The impact of organisational and individual factors on teamcommunication in surgery: A qualitative study

Brigid M. Gillespie a,*, Wendy Chaboyer b, Paula Longbottom b, Marianne Wallis c

a Research Centre for Clinical & Community Practice Innovation & School of Nursing & Midwifery, Griffith University, Gold Coast Campus, Gold Coast, Queensland

4222, Australiab Research Centre for Clinical & Community Practice Innovation, Griffith University, Gold Coast Campus, Queensland 4222, Australiac Research Centre for Clinical & Community Practice Innovation & Gold Coast Health Service District, Griffith University, Gold Coast Campus, Queensland 4222, Australia

International Journal of Nursing Studies 47 (2010) 732–741

A R T I C L E I N F O

Article history:

Received 21 May 2009

Received in revised form 14 August 2009

Accepted 1 November 2009

Keywords:

Communication

Interdisciplinary

Operating room

Patient safety

Surgery

Teamwork

A B S T R A C T

Background: Effective teamwork and communication is a crucial determinant of patient

safety in the operating room. Communication failures are often underpinned by the

inherent differences in professional practices across disciplines, and the ways in which

they collaborate. Despite the overwhelming international support to improve team

communication, progress has been slow.

Objective: The aim of this paper is to extend understanding of the organisational and

individual factors that influence teamwork in surgery.

Design: This qualitative study used a grounded theory approach to generate a theoretical

model to explain the relations between organisational and individual factors that

influence interdisciplinary communication in surgery.

Setting and participants: A purposive sample of 16 participants including surgeons,

anaesthetists, and nurses who worked in an operating room of a large metropolitan

hospital in south east Queensland, Australia, were selected.

Methods: Participants were interviewed during 2008 using semi-structured individual

and group interviews. All interviews were recorded and transcribed. Using a combination

of inductive and deductive approaches, thematic analyses uncovered individual

experiences in association with teamwork in surgery.

Results: Analysis generated three themes that identified and described causal patterns of

interdisciplinary teamwork practices; interdisciplinary diversity in teams contributes to

complex interpersonal relations, the pervasive influence of the organisation on team

cohesion, and, education is the panacea to improving team communications.

Conclusions: The development of shared mental models has the potential to improve

teamwork in surgery, and thus enhance patient safety. This insight presents a critical first

step towards the development teambuilding interventions in the operating room that

would specifically address communication practices in surgery.

� 2009 Elsevier Ltd. All rights reserved.

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

* Corresponding author. Tel.: +61 7 5552 9718; fax: +61 7 5552 8526.

E-mail address: B.Gillespie@griffith.edu.au (B.M. Gillespie).

0020-7489/$ – see front matter � 2009 Elsevier Ltd. All rights reserved.

doi:10.1016/j.ijnurstu.2009.11.001

What is already known about the topic?

� C

ommunication failures contribute to nearly 70% ofsentinel events. � E ffective teamwork is essential in high-risk environ-

ments such as the operating room.

� T here are differing communication styles used by

various members of the surgical team which on occasion,lead to communication failures.

B.M. Gillespie et al. / International Journal of Nursing Studies 47 (2010) 732–741 733

What this paper adds

� T

his paper extends understanding of the root causes ofthe organisational and individual influences that impedeteamwork and communication in surgery. � T his paper uses a grounded theory approach to generate

a theoretical model to explain the relations betweenorganisational and individual factors that influenceinterdisciplinary communication in surgery.

� T his paper suggests that the use of a ‘shared mental

model’ in surgery has the potential to improve inter-disciplinary communication in surgery, and thusenhance patient safety in the operating room context.

1. Background

Internationally, the vital role of interdisciplinary com-munication is acknowledged as a critical determinant ofteam performance, and hence, minimizing errors and harmin healthcare (Dayton and Henriksen, 2007). It is especiallyimportant in high-risk environments such the operatingroom (OR) where there are complex interdisciplinaryinteractions among highly specialized professionals – thatis, surgeons, nurses, anaesthetists, and technicians. ORteams are, on a daily basis, confronted with potentialuncertainty inherent in surgery, sophisticated equipment,rapid transfer of information, and the patient’s condition.Thus, teamwork ideally involves the flawless synchroniza-tion of many small tasks that constitute the procedure.

Yet, while there has been strong support advocating theimperative for improved teamwork and communicationamong interdisciplinary teams in surgery, progress hasbeen slow, constrained by various contextual and histor-ical factors. The aim of this qualitative study was tobroaden our understanding of the organisational andindividual factors that influence interdisciplinary commu-nication in surgery.

2. Literature review

OR teams are conventionally modeled on multidisci-plinary rather than interdisciplinary practices (Bleakleyet al., 2006). That is, where traditional professionalboundaries and intra-professional solidarity prevail overthe need for purposeful interdisciplinary interaction. Con-sequently, disciplines within teams tend to practise asseparate entities rather than as a cohesive unit. Additionally,the existing hierarchical and status differentials withinteams influence the level to which individuals shareinformation and interact with one another. Teamwork, inthe context of this professional hierarchy has been describedas the collective effort of a number of individuals who cometogether to perform a series of specific tasks (DiPalma,2004). Consequently, this task-oriented team model hashistorically focused on technical expertise and performanceof members with little emphasis on interpersonal beha-viours such as good communication, team coordination andleadership (Helmriech and Davies, 1996).

Clearly communication – defined as the transfer ofinformation and understanding from one person to another(Australian Medical Association, 2006), underpins team-

work in surgery. Effective interdisciplinary communicationis an essential prerequisite for cohesive teamwork in surgery– and its absence has been associated with devastatingadverse events that can impact on service delivery, patientsafety, and outcomes (Schaefer et al., 1995). Lingard et al.’s(2004) findings supported the belief that cross disciplinaryconflict made collaboration difficult, and consequentlyimpeded effective communication and teamwork. Suchconflicts plainly have implications for clinical efficiency,novice socialisation and patient safety (Lingard et al.,2002a,b; Michael and Jenkins, 2001; Timmons and Tanner,2004). Data collected by the Joint Commission in the US onAccreditation of Healthcare Organisations indicated thatpoor communication contributed to nearly 70% of sentinelevents during 2005 (JCAHO, 2007). In Australia, about 50% ofadverse events in Australian hospitals occur as a result ofcommunication failures between healthcare professionals,in particular, nurses and doctors (AIHW, 2007). Commu-nication failures represent the disconnect between theparticular communication practices used across profes-sional disciplines and the specific collaborative expectationsand work process improvements (Bleakley et al., 2006). Insurgery, such disparate collaborative expectations are oftenreflected in suboptimal teamwork practices.

Some studies have described the substantial discre-pancies in perceptions of teamwork were held by surgeonsand nurses (Makary et al., 2006a,b; Sexton et al., 2000).Surgeons rated the teamwork of others as good, whilenurses perceived teamwork as poor. Such differencesunderscored the disparity in perceptions held by thesedisciplines with regard to effective teamwork. It appearsthat there are fundamental disparities in the way thatnurses and doctors are trained to communicate (Leonardet al., 2004). Nurses are taught to communicate in verybroad narratives in their descriptions of clinical scenarios.Conversely, doctors are trained to be very succinct, andquickly get to the crux of the situation. These elementarydifferences in styles of communication used by variousgroups of healthcare professionals have been associatedwith communication failures (Lingard et al., 2002a,b), andhence impede team cohesion.

Within the OR context, there is the persistent effect oftime pressures, workload, and competing workflowpriorities, limiting opportunities for interdisciplinarycommunication, especially during preoperative prepara-tions (Gillespie et al., in press). Lingard et al. (2005),Lingard et al. (2006a,b), Lingard et al. (2008), and Lingardet al. (2002a,b) series of studies conducted in Canadaindicated that critical information was passed on in an adhoc, often reactive manner – culminating in communica-tion failures that have the potential to result in adverseevents. Consequently, it is essential to target teamworkvis-a-vis communication practices as a means of improv-ing patient safety.

3. Methods

3.1. Objective

The aim of this qualitative study was to betterunderstand the organisational and individual influences

Table 1

Number of participants interviewed and method of interview (N = 16).

Interview # Number of participant(s) Method of interview

1 3 staff nurses Group

2 1 anaesthetist Individual

3 1 surgeon Individual

4 2 nurse managers Group

5 4 staff nurses Group

6 1 surgeon Individual

7 3 staff nurses Group

8 1 anaesthetist Individual

B.M. Gillespie et al. / International Journal of Nursing Studies 47 (2010) 732–741734

that shape interdisciplinary team communications insurgery. Such an understanding is important as it willinform the identification of interventions that wouldimprove communication practices used by surgical teams.A grounded theory analysis of a subset of interview dataspecifically based on questions around the use ofprebriefings in surgery is reported elsewhere (Gillespieet al., in press). This paper reports the findings of the threethemes that emerged in relation to questions aroundteamwork and communication.

3.2. Design

Qualitative interviews were conducted and a groundedtheory approach to analysis underpinned by Strauss andCorbin’s (1990) methods was used to generate a theorythat identified factors which influenced teamwork amongsurgical teams.

3.3. Setting and participants

The setting was an OR department in a large publichospital in southern Queensland, Australia. Potentialparticipants included in the sampling frame were sur-geons, anaesthetists, nurse managers, and clinical nurseswho practiced across various surgical specialties whichincluded orthopaedic, neuro surgery, ophthalmology,general and vascular surgery, gynaecology and urology,were interviewed. We sought to obtain divergency inparticipants in order to obtain a variety of perspectives onsurgical teamwork. Participants were initially approachedif they displayed an interest in the study when they wereinformed about it or were recommended by otherpotential participants (snowball sampling). As this studysought to identify personal and organisational factors thatshaped teamwork in surgery, ongoing selection of parti-cipants was based on their ability to render useful insightsinto these phenomena. Based on their personal preference,participants were either interviewed in groups or indivi-dually.

3.4. Data collection

Demographic data were collected in relation toparticipants’ age, years of clinical experience, and profes-sional and/or clinical role. Eight semi-structured inter-views were conducted with 16 OR team members fromnursing, surgery and anaesthetics. Of these, four groupinterviews were conducted with nurse managers and staffnurses who worked across various surgical sub-specialtieswhile the other four were conducted individually withmedical staff (two surgeons and two anaesthetists)(Table 1). In order to be responsive to participants’preferences, we undertook both group and individualinterviews. Group interviews were conducted with nurseparticipants who belonged to the same staff category todiffuse potential status differentials, and ensure grouphomogeneity (Klueger, 1994). Medical participants wereinterviewed individually as there were constraints inrelation to their availability. Nurses represented themajority of interviewees; however, they also had the

highest professional representation in this OR. Accord-ingly, the numbers of doctors and nurses interviewedreflected these proportions across disciplines.

A general interview guide was used, directed by a set ofquestions identified through the literature. These semi-structured interviews involved outlining a set of issues tobe explored with each participant (Patton, 2002). As thestudy progressed some questions varied as a consequenceof the iterative nature of qualitative research. That is,consistent with grounded theory, new questions wereasked, based on emergent findings. Interviews exploredissues surrounding strategies currently used by interdis-ciplinary teams to enhance teamwork, as well as identify-ing impediments to communication and teamwork inrelation to the individual and the organisation. Thequestions asked were open-ended, starting with thegeneral issues and moving to more specific issues. Forinstance, some of the interview questions were: ‘‘What are

some of the barriers to communication and teamwork in

surgery?’’, ‘‘Are there any organisational factors that may

have an indirect influence on the ways in which teams

communicate?’’, ‘‘What individual and/or team character-

istics promote effective communication?’’, and, ‘‘How do you

think communication could be improved among team

members?’’ Data saturation was evident in the way thatno new information was forthcoming during later groupand individual interviews. All interviews were conductedby the first author in a quiet location, lasted 45–60 min,and were digitally recorded for later transcription.

3.5. Ethics

Ethical approval was given by the hospital and theuniversity ethics committees. Confidentiality and dataprotection were adhered to as minimum standards.Participants were given an invitational letter detailingthe study’s aims, procedures, potential risks and benefits.Participants signed a consent form and completed a briefdemographic profile.

3.6. Data analysis

Familiarization with the data involved listening torecorded interviews and repeatedly reading the tran-scribed data (Lacey and Luff, 2007). Interview data weremanaged using Microsoft Word. All interviews were coded(line-by-line) and categorized using constant comparativemethods as described by Strauss and Corbin (1990). Opencoding was used as a process of breaking down, examining,

B.M. Gillespie et al. / International Journal of Nursing Studies 47 (2010) 732–741 735

comparing, conceptualising data in order to recogniseemerging patterns, as a form of thematic analysis (Straussand Corbin, 1990). Different colours were used for codingsections of each transcript that contained content of asimilar nature. The codes were further explored andgrouped under common headings, or categories, that bestdescribed the content of the data. Further review of the listof categories involved sorting and identifying those thatcohered together meaningfully such that they representedan overarching theme (Braun and Clarke, 2006).

The decision regarding theme identification was basedon repeated occurrences of dialogue with similar content,both within and across interviews. Metaphorical descrip-tions which served as symbolic constructions of individualmeanings and experience (Ryan and Bernard, 2003), werealso used in theme identification when they answered acrucial aspect of the overall research question.

The extracted themes and their corresponding expla-natory data were cross-checked between the researchersto ensure consensus. Finally, a concept map, representingthemes and their related categories, was constructed toorganise the data, and thus illustrate the findings using acause-and-effect schema (Levinson, 2006).

3.7. Rigour

In this study, rigour was considered in relation totrustworthiness, auditability, transferability (Guba andLincoln, 1994). All members of the research team wereinvolved in data analysis to establish trustworthiness.Preliminary findings were taken back to participants toclarify and confirm (i.e., ‘member-checking’), thus con-tributing to trustworthiness. Memos connecting codes topieces of verbatim supported the emergent categories, anddemonstrated an audit trail in the decision-making

Diagram 1. Fish bone schema illustrating cause-and-effect influences o

process. Participants were selected based on their exper-tise in the OR context, and on this level, there may beconceptual transference of findings to other similar ORsettings as surgical team members may identify simila-rities in relation to experiences, attitudes and situations.

4. Findings

A total of 16 participants agreed to be interviewed andincluded 12 nurses, two surgeons and two anaesthetists.Participant’s age ranged from 25 to 63 years; the averageage was 44 years (SD = 12.6), and years of experienceaveraged 15.8 years (SD = 13.2). Three themes emergedfrom the analysis of interview data; ‘interdisciplinarydiversity in teams contributes to complex interpersonalrelations’, ‘the pervasive influence of the organisation onteam cohesion’, and ‘education is the panacea to improvingteam communications’. Themes are described below, withcategories italicized. Diagram 1 shows the relationbetween themes and categories. The ‘fishbone’ diagramuses a cause-and-effect schema and thus was consideredappropriate for illustrating the root causes of interdisci-plinary teamwork problems in a cogent visual format(Levinson, 2006).

5. Interdisciplinary diversity in teams contributes tocomplex interpersonal relations

The theme, ‘interdisciplinary diversity in teams con-tributes to complex interpersonal relations’ was describedin terms of interpersonal and social aspects that shapedteam behaviour in surgery. ‘Interdisciplinary diversity’shaped communications among team members, theoccasion, and the content of those information exchanges.Subsumed in this theme, were four interlinking categories,

f organisational and individual factors on teamwork in surgery.

B.M. Gillespie et al. / International Journal of Nursing Studies 47 (2010) 732–741736

professional culture and mores, professional leadership,

interchanging team membership and the primacy of sub-

specialization.The dominant influence of professional culture and

mores on team dynamics was evident in participants’ senseof professional identification, and was manifest in a highdegree of independence, which, on occasion, limited theimpetus for interprofessional collaboration. One surgeoncommented on the historical emphasis on individualism insurgery,

Surgery has always been a bit of an autocraticenvironment where the surgeon waltzes in. . . workingtogether is difficult and trying to teach surgeons not tobe silo is a difficult thing. . . surgeons have been lonewolves. For a theatre to work that has to be one team,it cannot be three individual silos. . . (Surgeon, Inter-view 6)

Nonetheless, a ‘‘silo’’ mentality was not a characteristicexclusive to surgeons – this notion was also confirmed bynurse participants who acknowledged a three teamtripartite,

There are three teams, the anesthetic team, the surgicalteam and the nursing team. . .nurses think of them-selves as the nursing team not part of the neuro teamnecessarily. . . (Registered Nurse, Interview 5)

Having three distinct teams was perceived by mostparticipants as being advantageous as this enabledindividuals to work cohesively together under pressure.For example, during emergency situations,

It means that you can step into a trauma [case] andthings will be done without us having to actually speak.You know what needs to be done, because it is doneuniformly. You don’t have to speak you just do itbecause you see what needs to be done. It iscommunication but it is not verbal communication.(Registered Nurse, Interview 7)

In some instances, it appeared that even when staffwere unfamiliar with each other, and had not workedtogether as an established team, they were still able tocoordinate their actions and strategize accordingly. Thistacit understanding between team members also under-pinned decisions about surgical and anaesthetic equip-ment requirements that were made independently bynurses and medical staff, respectively, based on surgeons’preferences, preoperative assessments, and ‘‘routine’’expectations for a given procedure. Thus, while theapparent demarcation of individual roles often limitedteam dialogue, it concomitantly contributed to teamefficiency and performance. In spite of this, having definedroles within surgical teams did not always mean thatmembers were able to develop shared understandings.

The categories interchanging team membership and theprimacy of sub-specialization were illustrated in the waysparticipants described the fluidity of teams, that is, wheremembers, especially nursing staff, moved in and out ofdifferent surgical teams. Nurses described the divergencein the specialties they worked, the times they worked, and

their daily work schedules were characterized by inter-ruptions. This limited opportunities to meet and formregimens of shared practice and knowledge. Movingbetween various specialties sometimes made it difficultto become familiar with the nuances of individualsurgeons. One senior nurse commented,

Nothing upsets me more than walking into a case whereI don’t know the doctor and I have been doing this for 38years and although I know most things, each doctordoes something different. What I find the most stressfulis somebody else who doesn’t know as well. (RegisteredNurse, Interview 1)

Medical participants perceived discontinuity of nursingstaff as problematic because there were occasions whennursing staff involved in the surgical list lacked thenecessary knowledge of the procedure and its associatedinstrumentation, and the individual preferences of thesurgeon and/or anaesthetist. The primacy of ‘‘sub-specia-lization’’ was considered by medical participants as crucialfor the smooth running of the list:

You have to have nurses that sub-specialize into thoseareas because in order for everything to work well intheatre the nurse has to know her [sic] specialty andthere is nothing more disruptive than someone saying‘‘I have never done this case before, I don’t know thename of the instruments’’, and you can just see it allfalling down. (Surgeon, Interview 6)

Situations where nurses were unfamiliar with boththe procedure and the surgeon intensified the potentialfor interdisciplinary conflict, and thus hampered effec-tive communication and teamwork. Clearly, working insurgical lists with regular, competent staff, contributedto good communication and teamwork. For the majorityof participants, working in established, specializedteams implied a familiarity with the nuances ofprocedure and the surgeon and/or anaesthetist, as wellas knowledge of the strengths and limitations of otherteam members. Hence, teams worked in anticipatory, co-operative ways which enabled the surgical list to runefficiently, even when the operations were complex andprolonged.

In illustrating the category, professional leadership, therewas variation in among surgical team members’ perspec-tives vis-a-vis the quintessential qualities required forgood leadership,

A strong leader should lead from the front, and shouldnot expect any of the team to do things that he [sic] isnot able to do himself [sic] . . . there can only be onepilot in a cockpit, one chief surgeon in a case. Most ofthe time you [surgeon] need to be willing to take theresponsibility for that patient, that decision, thatclinical case. . . (Surgeon, Interview 3)

It appeared that leadership was considered inexorablylinked to the level of responsibility and decision-makingrequired to perform the task in question – surgery, andthus, was overtly underpinned by professional identity. Incontrast, nurse participants described leadership in terms

B.M. Gillespie et al. / International Journal of Nursing Studies 47 (2010) 732–741 737

of the ability to communicate effectively with others indelineating role expectations:

If someone is taking on a senior role then everyoneshould know what their role is as soon as possible, andestablish others’ roles and what is expected of them,then you are more able to contribute more effectively. . .

you have to be upfront about your strengths. (Regis-tered Nurse, Interview 1)

6. The pervasive influence of the organisation oninterdisciplinary team cohesion

The second theme, ‘the pervasive influence of theorganisation on interdisciplinary team cohesion’ describedthe omnipresent ways in which organisational cultureimpacted on team dynamics in surgery. Decisions made inregard to organisational policies, albeit at the strategiclevel, profoundly influenced clinical practice amonginterdisciplinary teams. Three entwined categories, culture

of blame, haphazard implementation of a prebriefing protocol

and finite resources were encompassed in this theme.The category, culture of blame was perceived as being

perpetuated by the organisation through its emphasis onpolicies which, on occasion, gave rise to interdisciplinaryconflict. One medical participant stated,

A blame culture persists and the fact that the first jumpis to write an incident report. . . Why don’t we talk thisthrough that would be a much better way than theblame game? Many issues are escalated rather thandiffused and that is being promoted not only betweennurses and doctors, but doctors and doctors, and isdetrimental to teamwork. (Anaesthetist, Interview 8)

Such policies were seemingly perceived as tools forapportioning ‘‘blame’’ rather than as an opportunity forlearning – albeit that they were introduced for the‘‘greater good’’. Consequently, their use was viewed ashaving a discordant influence on team communication,culminating in dissonant attitudes among the variousdisciplines.

The categories, haphazard implementation of a prebrief-

ing protocol and finite resources illustrated the bureaucraticapproach used to introduce patient safety initiatives, suchas a prebriefing protocol, and the human and materialresources allocated to ensure its uptake in the clinicalenvirons. Participants perceived a lack of support from theorganisation in relation to the allocation of sufficientresources needed to properly implement and sustain suchinitiatives, which became enshrined in hospital policy.Senior nurse participants described the organisation’semphasis on ‘‘increased productivity’’ and a lack ofadequate nursing staff meant that often, lists were runningwith only ‘‘skeleton staff’’. Thus, the addition of performinga prebriefing check at one of the busiest times during pre-surgery preparations only intensified the stress experi-enced by nursing staff in particular.

Medical participants, while acknowledging the impor-tance of patient safety initiatives, expressed concern inrelation to the apparent disregard for their input during theorganisational introduction of a structured prebriefing

protocol prior to the commencement of surgery. Onesurgeon commented,

We need to insist that a system is in place, not rigid, nottrying to dictate from above with this motherhoodattitude to surgery. . . I need to be sure that I am doingthe right thing; each person has to have a system thatworks. . .if your check system is the same, and then it isuseful. If you are going to make a ritual of it then it is notuseful. (Surgeon, Interview 3)

Evidently, medical participants used their own check-ing systems, which they enacted prior to the organisationalintroduction of prebriefings. However, checking systemsvaried among surgeons, and the subtleties therein werenot always explicitly communicated to nursing staff. As acorollary of a perceived lack of clarity, nurse participantsstated they would, on occasion instigate this check, even inthe absence of the surgeon. This occasional uncertaintyfuelled interdisciplinary conflict between members of themedical and nursing staff in relation to ‘‘who’’ is ultimatelyresponsible for the prebriefing, and ‘‘when’’ this check isperformed. One nurse declared,

If this is a surgeon driven thing, why should we take theresponsibility, because if the wrong leg is cut off, thenwe did the final check, the surgeon wasn’t there, are wethen responsible? (Registered Nurse, Interview 7)

Yet, identifying the correct surgical site was notconsidered by the majority of nurses across the groupinterviews as a burden of responsibility – this aspect ofpatient safety was the responsibility of the entire team, asit was ‘‘second nature to double-check everything.’’

7. Education is the panacea to improving teamcommunications

The theme, ‘education is the panacea to improving teamcommunications’ centered on the provision of education asa means to increase collaboration and acceptance amongteam members. Education was described by participants asthe universal remedy that provided the impetus for a moveaway from historically entrenched team attitudes andbehaviours. Included under this theme were three inter-connected categories; education changes culture, educa-tion improves communication, and education increasesprofessional understanding.

The categories, education changes culture and education

improves communication emphasised the need for earlyenculturation in the use effective communication strate-gies and teambuilding techniques during the formativeperiod of professional learning – that is, during studenttraining.

Again culture will be slow to change so we have to holdtight and I think education is a key at a young level.With team building you have to get to the medicalstudents and it has to start from there and be continualupdates. Start with the young. (Surgeon, Interview 6)

Many participants believed that there was little to begained by trying to re-educate some of the ‘‘older nurses

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and doctors’’ – a case of too little, too late. Rather,education to change the culture of surgical teams would bebest addressed by targeting the younger doctors andnurses – to this end, interdisciplinary education wasperceived to more likely have an enduring effect on teamcommunication and cohesion. Notwithstanding this,participants affirmed that initiating changes in teamculture is often slow and onerous; although ‘‘the wayforward’’ was through ongoing education programs,

You need to start with education programs and theyshould include communication courses. . . education oneffective communication and teaching young ones tonot be scared. . . (Registered Nurse, Interview 5)

Still, some believed that education was also importantfor building and maintaining professional understandingamong doctors and nurses. Education within the organisa-tion needed to address issues such as conflict resolution inthe clinical environment when there are differences inprofessional role expectations:

I think there needs to be more education on how do youdeal with a problem in the first place if there is noresolution, and then go to that next step. (Anaesthetist,Interview 2)

This comment reflected the attitude of many of themore senior team members across interviews vis-a-vis thelack of available educational strategies that could beenacted at the organisational level. There was a palpablerecognition among participants concerning the crucial rolecommunication played in creating cohesive teams. Nurseparticipants in particular, discussed the differences incommunication styles used by the various disciplines, andthe importance of understanding such differences.

The category, education increases professional under-

standing was reflected in participants’ comments aboutindividuals’ personalities and roles within the team, andthe ways in which these interfaced with others duringsurgery. The majority of participants believed that newstaff entering the OR environs needed ongoing supportboth at the organisational and departmental levels. Withinthe OR, there were some education strategies that hadbeen instigated at the departmental level:

We have a booklet [in anesthetics] which has all thereadings and was written by one of the previousanesthetic girls [sic] for nursing staff when they comein. So they [nurses] are supported and educated intotheir role. . .. (Anaesthetist, Interview 8)

However, at the organisational level, limited funding inrelation to staffing and the push to ‘‘increase surgicalthroughput’ meant that there was little time to allow staffto attend hospital-based training programs. Additionally,senior nurses, in many instances, were unable to come ‘‘offline’’ to provide additional educational support to newstaff.

Participants also explained the need for education inmanaging the myriad of different personalities that makeup surgical teams. Many of the lesser experienced nursesexpressed the need for workshops in order to assist them

in dealing with ‘‘difficult personalities’’. Lesser experiencedparticipants identified instances where there was distinct alack understanding for such differences, which increasedthe opportunities for miscommunications – accordinglythis had a detrimental effect on teamwork. Conversely, themore experienced staff nurses believed that they had, overtime, developed the skills needed work cope with, andaccept the differences in individuals’ personalities. Thus,they were able to tailor the ways in which theycommunicated.

8. Discussion

In this study, three themes emerged as being key toeffective communication and team cohesion; ‘interdisci-plinary diversity in teams contributes to complex inter-personal relations’, ‘the pervasive influence of theorganisation on team cohesion’, and ‘education is thepanacea to improving team communications’.

The first theme revealed that disparities in professionalorientation were explicitly underpinned by historicaldifferences between nurses and doctors in relation togender, authority, and patient care responsibilities – andcontributes to ‘uniprofessional identification’ (Bleakleyet al., 2006). In our study, this notion was exemplified bythe disconnected nature of team communications. Parti-cipants dichotomized their roles within the team, reinfor-cing the notion that teamwork behaviours in surgery arelargely informed by professional culture and identity, andlevel of responsibility. Ideally, OR teams should be unitaryand cohesive to maximize their performance (Edmondson,2003). Our findings extend the notion of professionalindependence in surgery – which has been described inprevious work in relation to clinical expertise (Leonardet al., 2004). Paradoxically, professional independence isboth an advantage and a limitation vis-a-vis communica-tion practices. One of the advantages of professionalindependence is the tacit knowledge team memberspossess in relation to standard regimens of care – thusallowing team members to perform their defined tasks in acoordinated, seamless manner. Nonetheless, the focus ondemarcated individual roles does not tend to encourageteam talk about procedural requirements. Conceivably,this uniprofessional approach to communication is anobstacle to team cohesion and performance.

Minimal information exchange as an accepted practicein OR culture – is considered a defensible strategybecause safety is perceived in relation to personalcompetence. Yet, with the use of minimal communicationamong team members, inconsistencies and missinginformation have a tendency to remain undetected(Lingard et al., 2006a,b). Given that inconsistencies occurinfrequently, it is reasonable to assume that teammembers would perceive their communication processesas largely reliable. Nevertheless, inconsistencies becomediscernable during emergent problems, such as whenthere is more blood loss than expected during surgery andit is obvious that insufficient blood products have beenordered. Clearly omissions in team communication vis-a-vis checking and confirming information using standar-dized processes compromise patient safety (Lingard et al.,

B.M. Gillespie et al. / International Journal of Nursing Studies 47 (2010) 732–741 739

2006a,b). Without standardized communication pro-cesses to cross-check information sources, there is nosafeguard against capturing latent errors – that is, failurescreated as a result of decisions taken at the higherechelons of the organisation (Reason, 2005).

The second theme illustrated the impact that organi-sational context had on teams’ communication practices.Our findings described participants’ general lack ofconfidence in the organisational context in regard toresource allocation and the introduction of patient safetyinitiatives mandated to improve team communications.Conceivably, bureaucratic decision-making vis-a-vis pol-icy design and resource allocation was ostensibly farremoved from the front-line activities of surgical teamsin the OR. In our study, a culture of ‘‘blame’’ was notconducive to effective teamwork; and it appeared thatthe organisation did not promote a culture of collabora-tion. That is, considered communication, debate andfeedback, and hence challenges a culture where scape-goating and control are valued over learning from error(Bleakley et al., 2006). A collaborative culture is informedby reflection on recent history, and there is an acceptanceof an inevitable degree of uncertainty as safety initiativesare implemented to change practice – acknowledgingthat over time, protocols themselves must change.Essentially, this must be done collectively, and under-pinned by a respect for difference among clinicians.Tolerance of differences provides the impetus for livelydiscussion about the quality of safety practices (Bleakleyet al., 2006).

The third theme described education as central tochanging culture and increasing understanding amonginterdisciplinary team members. Notably, the majority ofour participants believed that teaching older clinicianscommunication skills was futile: For older clinicians,developing effective interpersonal skills was not necessa-rily emphasised during their formative socialisationperiod, and perhaps reflects traditional biomedical trainingwhich focused on developing technical skills in isolation ofinterpersonal capabilities (Helmriech and Davies, 1996).That said, the goal of any education strategy shouldultimately engage deliberate and ongoing changes thataddress interdisciplinary communication practices, thereis an important initial step. Changing entrenched clinicalpractices depends upon attitude change (Bleakley et al.,2006). Still, only when attitudinal change is accumulativeis it possible for the emergence of a new culture (Genn,2001). Good teamwork starts with a set of attitudes andvalues. Our participants’ teamwork behaviours werecharacteristically modeled on notions of multi-profession-alism. Without first valuing interprofessionalism overmulti-professionalism, it is impossible to progress acollaborative culture, one that is founded on work-basedlearning (Bleakley et al., 2006). Participants also acknowl-edged that culture change would proffer sustained changeonly if education occurred during the formative trainingperiod. Necessarily, though interdisciplinary educationneeds to be incorporated into professional developmentprograms, it must also be embedded into medical andnursing undergraduate curricular. Education programsthat emphasize skills in leadership, communication, and

conflict management are critical for collaborative practice(Clark, 2006).

Overall, our findings suggest that shared mental models

(Mathieu et al., 2000) may have clinical utility in surgery.Participants in our study described instances where,during critical situations, they were able to coordinateand strategize during situations that change unexpectedly.Essentially, using a shared mental model enables the teamto discuss the next contingency, and is not heavily relianton pre-existing knowledge – thereby reducing thepossibility of omissions and inconsistencies in commu-nication. This is especially important in surgery, wherechanges in patient condition occur on a moment-by-moment basis, consequently optimal teamwork is essen-tial. Previous work has demonstrated the associationbetween poor teamwork and a higher rate of surgicalcomplications (Aggarwal et al., 2004). Undoubtedly, teaminstability limits the opportunity for surgical teams todevelop a shared mental model, and thus impactsnegatively on team communication and performance.Organisational issues such as heavy clinical workloads,the need to increase productivity, and time constraintscreate conditions that potentially impede communicationpractices. In this instance, shared mental models becomecrucial to team functioning because they allow teammembers to predict information and resources needs ofother team members.

The use of structured communication methods such aspre- and post-surgical briefings enables surgical teams todevelop shared mental models in the clinical milieu. Theuse of prebriefings in surgery enables team members, whooften come together on an ad hock basis, to becomefamiliar with the patient’s history and specific proceduralrequirements (Makary et al., 2006a,b). Team prebriefingsprovide opportunities for interactive communication,where members can give feedback, identify areas ofconcern in relation to important safety and operationalissues, and establish guidelines for workload distribution.Post-briefings provide team members with opportunitiesto identify any deviations from the surgical plan and touncover any defects that may not be apparent at the timeof the surgery. Post-briefings encourage a culture oflearning that involves action, reflection and revision(Makary et al., 2006a,b).

8.1. Limitations

We acknowledge this study has several limitations.First, the single locale in which the study was conductedlimits the extent to which findings may be generalisedbecause the doctors and nurses working in this hospitalmay in some way, be unusual. Notwithstanding this, therewas representation of the various disciplines that compriseinterdisciplinary surgical teams, and subsequently per-mitted diverse professional perspectives. Moreover, ourfindings are consistent with various other studies ofcommunication in surgery (Lingard et al., 2006a,b). Second,the dissimilar methods of interview used for nursing andmedical participants may have given rise to differentdynamics during interviews. However, similar issues wereexplored during these interviews and data saturation was

B.M. Gillespie et al. / International Journal of Nursing Studies 47 (2010) 732–741740

achieved. Further, the variety of interview techniquesresponded to participants’ preferences. Third, the dispro-portionate number of doctors interviewed as comparedwith nurses may not adequately represent medicalparticipants’ perceptions. Finally, we have identified anddescribed individual and organisational factors thatovertly impinged on interdisciplinary teamwork; never-theless, there may be other influences not explored in thisstudy.

9. Conclusion

In surgery, effective communication is vital, and itsabsence is evident in poor transfer of critical information,impaired decision-making, and may ultimately lead topatient harm. Undoubtedly surgical teams are part of awider system of processes and relations that produce thekinds of errors traditionally headlined in the patient safetyliterature, such as wrong site surgery. Further, such eventsmay be tacitly connected to less visible communicationfailures in surgical teams as a result of embeddedorganisational practices and uniprofessional identityissues. Clearly, there are challenges associated withenacting communication practice changes both at theorganisational and individual levels. Research on trans-forming the practices of health care providers in respect toteambuilding interventions that promote the use of sharedmental models in surgery would be timely and useful.Good communication is an integral component of theculture of teamwork and as such, an important surrogate ofpatient safety.

Acknowledgments

Brigid Gillespie acknowledges the financial support ofthe Research Centre for Clinical & Community PracticeInnovation, Griffith University.

Conflict of interest. There is no conflict of interest.

Funding. This research was funded by Research Centrefor Clinical & Community Practice Innovation, GriffithUniversity.

Ethical approval. Ethical approval was given by the GoldCoast Hospital ref # 200801. Griffith University ref # NRS/12/08.

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