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Detailed comparison of the notes for all the observed sessions, allowed the construction of a typical work sequence for an operating session. A concise version of this sequence is first presented in order to provide the context for a detailed description of the findings which follow.
6.2 Typical work sequence from the observed operating sessions
The theatre staff, both nurses and operating department practitioners, arrived at various times in the theatre to which they had been allocated. They proceeded to check, clean, and position the furniture and equipment of the theatre. This work was undertaken by all persons present, irrespective of grade, and appeared to the observer to follow no particular sequence. The staff seemed to gravitate towards which ever tasks were seen to require their attention. Attempts to organise the work in terms of allocation of persons to specific tasks, or sequence of priority were rarely seen, as were any verbal communications in the course of the preparations. Staff appeared instead to move intuitively to their work.
The checking and preparation of the theatre reflected similar activity on each occasion. The operating table and trolleys were wiped with damp cloths, equipment, including diathermy, suction, and lighting were tested, and prepared for use. The checking of these items did not follow a pre- determined checklist, instead staff appeared to prepare them to their own satisfaction. Instruments and equipment were prepared in the laying up area for the cases on the list. Instrument sets and their accompanying supplementary items were placed on trolleys in readiness. Staff used a card system to assist them in this element of preparation, as an aide-
memoire of the surgeon's requirements.
During this period, the anaesthetic assistant, either a nurse or an operating department practitioner, prepared and tested the anaesthetic equipment, both in the anaesthetic room and in the theatre. It was unusual for there to be any communication between the anaesthetic assistant and the theatre staff as they proceeded with their various preparations.
Once all was prepared to the satisfaction of those present, the next step was to await, or locate, the surgeons. It was unusual for any action to be taken to get the operating list underway until the surgeons had been seen. This was usually due to a lack of certainty regarding the composition of the operating list. It was recognised that the surgeon may make changes
to the order for a variety of reasons, and it was therefore considered unwise to send for the first patient as advertised on the list, in case the order had been altered.
Once the list order had been verified with the surgeon, the first patient was sent for, usually, but not always, by the anaesthetic staff. The theatre scrub staff negotiated between themselves, to establish who would scrub for the first case. No formal allocation of cases to personnel was seen during the period of observation. The practitioner who had agreed to scrub for the first case prepared to scrub and don sterile gown and gloves, and the practitioner who had, by default, taken the circulating role went to the laying-up room to open the sterile instrument packs, and assist the scrub practitioner to lay up the trolley. This process appeared to follow a routine structure in nearly all cases, regardless of the theatre or staff. First the circulating person assisted the scrub practitioner to complete the donning of the sterile gown, and then handed sterile items to the scrub practitioner, using an aseptic technique. Once the trolley was prepared, swabs, instruments and other items were counted, and the results of this counting are marked up on a board.
During this time, the anaesthetist and the anaesthetic assistant were engaged in anaesthetising the patient. When the surgeons arrived in the theatre, they tended to remain in their own group. There was little communication between the surgeons and the theatre staff, and that which was observed was of a light and inconsequential nature. Although discussion of the cases on the list was seen to occur, it was by no means the norm.
When the patient was wheeled into theatre, the mode of transfer from the trolley to the operating table, also followed a routine pattern. The anaesthetist co-ordinated the move, and all parties attended to their instructions. All free staff then positioned themselves around the table ready to assist, and adopted the appropriate positions without having to be asked or directed. The anaesthetist co-ordinated the move on the count of
three. Once this was complete all those involved in the transfer assisted to secure the patient and then returned to their previous tasks.
When the surgeons had scrubbed and donned sterile gowns and gloves, they approached the patient, and circulating staff removed any blankets and coverings, in order to reveal the operative site.
The surgeon then took the antiseptic solution to be used to prepare the site from the scrub practitioner (frequently without verbal communication). There then followed a draping procedure with the connection of diathermy and suction apparatus, which also followed a routine pattern, and following a check with the anaesthetist (also routine) the surgery proceeds.
Throughout the surgery the scrub practitioner handed the surgeon the instruments required. Sometimes these requirements were anticipated, but more often the instruments were asked for by name. The circulating person kept the scrub practitioner supplied with swabs and supplementary items, and recorded these additions on the board.
At the end of the operation the dressing was applied, and the drapes removed. The transfer of the patient back onto the trolley or bed followed the same pattern seen at the beginning of the procedure.
The patient was taken out of theatre to the recovery unit, and the theatre prepared for the next case. The next patient was usually sent for during the closing stages of the previous case, usually by the anaesthetic assistant, at which point the process began again.
6.3 Categorisation of findings
The main findings of the ethnographic study are now presented using the main category headings derived from the data analysis. These provide the framework for the presentation of the findings.
The organisation of multiprofessional team working in the operating theatre toward the achievement of its common goal was of particular interest in the present study, not only because of the key question of identifying the nature of team work in this context by comparison with existing models, but also because the main areas of conflict, identified in phase one of this study, centred on list overrun, changes to order, and other issues connected with the management and organisation of work. Therefore in this initial section a description is presented of the data which refer to organisation, leadership and co-ordination of work in the theatre, and its consequences.
Although the multiprofessional theatre team has been presented in management literature as a close-knit group of surgeons, nurses and anaesthetists working as one towards a common goal, in practice the professions were observed only to come together for the immediate period of surgery. The preparatory work required before surgery can take place is considerable, and during the observational phase of this study this initial work was undertaken by all members of the multiprofessional team. However, only the nurses and ODPs undertook preparations within the field of observation. Medical preparations mainly took place outside the theatre.
6.3.1 Organisation of the work of the theatre team
Throughout the period of observation, one of the most striking features of the organisation of work, and particularly in the initial preparation of the theatre, was its routine nature. Almost exactly the same pattern and order of work was carried out in each of the observed sessions. The cleaning and checking of the theatre, the preparation of trolleys for the list, the negotiation between practitioners as to who would take each case, the donning of sterile gowns and gloves, the counting and recording of equipment used, were similar in all observed sessions. The following extracts from the observation notes, made seven months apart, show the similarity of reports in the opening comments.
Initial preparations follow the usual pattern. The theatre is prepared by two nurses and one ODP. No one is directing the work, they all seem to gravitate to tasks that need to be done without any obvious plan or order.
A similar entry continues the theme of apparently unstructured work, adding the absence of verbal communication:
[Theatre staff] begin the tasks of checking the equipment, and pushing it into position. They do not communicate with each other, or refer to any check list or protocol
The unvarying nature of this initial work of preparing the theatre environment was surprising even to the ‘insider’ researcher. The staff seemed not to follow any particular plan. Within the nursing/ODP group each member made a contribution to the shared objective of preparing a safe environment for surgery, although no individual had a unique role within the group. Instead, any available person was seen to turn their hand to what ever needed to be done to achieve the objective. Although the work pattern lacked any discernible structure, a great deal of what was observed was revealed at informal interview to be procedure taken from protocols, guidelines and other directives. Therefore it could be argued that a degree of uniformity of process was to be expected.
This type of activity, categorised as ‘self-allocation of work’ in the initial analysis, was readily observed in the preparations for the morning or afternoon operating sessions. However, it also applied to working practices observed throughout the day, when the whole multiprofessional team was present. Rarely was any individual group member observed to formally organise work, in terms of allocation of persons to specific tasks, as might be expected in industrial models of team working, nor was any evidence seen of attempts to organise the sequence or priority of the work. To the observer it appeared that the staff moved intuitively to their work. A staff nurse, offered the following observation in defence of this system:
"..we've all worked here a long time, and you get to know what needs doing, and how to do it."
Her statement carried the implication that a routine and the skills needed to accomplish the work were acquired experientially. When asked how new or inexperienced staff members coped without experience or formal guidance, she replied:
"They are never on their own, they are always with a more senior member of staff. We show them what needs to be done, they soon get used to it."
This apparent lack of formal organisation was not attributable to the lack of availability of a senior person able to take charge, or to a lack of knowledge of what needed to be achieved. In conversation with staff members of various grades, when asked what they would do if they were in charge of an operating theatre, almost identically structured responses were given, specifically: that they would organise staff, allocate work, check equipment, allocate breaks and send for patients. In these accounts, effective communication was accorded the highest priority by participants, after patient safety. Regardless of these statements, evidence of any such systematic approach was rarely observed. Indeed, discussion with theatre staff revealed the perception that formal organisation was unnecessary: Katherine, a grade E staff nurse explained why:
"We have been working here a few years now. We don't really need anyone to tell us because we are used to it. We know what to do and just do it."
Whilst the need for formal leadership was not recognised by some participants, others considered it to belong to earlier more hierarchical methods of management which have since been superseded. An example
of this view was provided by a senior sister in a discussion of previous systems of working:
Sister: "Yes, we all get on and speak freely to one another. …much better than the old days. No one would wish to go back to being ordered around by bossy old sisters. At least these girls are allowed to make their own decisions…we were not allowed to do anything."
Thus, during observation and informal interview, a tension could be identified. At interview there was agreement between accounts given that the person in charge of a theatre should organise the work, check equipment and send for patients. However, the same group defend their position of not needing supervision due to their knowledge and experience. The need for a person to allocate work, or “tell people what to do” was not recognised. Instead the group approach focussed on dealing with contingencies as they arose, rather than detailed planning. In this way the individual must rely on his or her own discretion in order to deal with problems as they arise, rather than turning to a supervisor for instruction as described in industrial models of team working. These responses suggest that the nurses/ODPs associate a designated person in charge, with being overseen and being ‘told what to do’ rather than arriving at their own decisions. In terms of team models, the staff in this sample wished to divorce themselves from work group structures which they considered dated and connected with negative views of hierachical team supervision which undermined the preferred style of collegiality.
This is not to say that no sort of allocation of work existed in the nursing/ODP group. Even though formal allocation of work was difficult to observe, informal division of work was frequently demonstrated. The decision of who should undertake the scrub role for cases on the list was seen to be a matter of negotiation amongst the nurses and ODPs. They would decide, sometimes at the last minute, who should be assigned to
each case. These decisions were not passed on to any more senior staff, but remained between those directly involved with those roles.
At the scrub sink I asked Monica, an E grade scrub nurse, how decisions were arrived at regarding who would scrub for which cases during the list.
Monica: " We just work it out between us."
Interviewer: "So the decision of who takes which case is really up to you?"
Monica: "Yes, unless someone comes and tells us they want us to scrub for a particular case."
Interviewer: "Why might that be?"
Monica: "I don't know, sometimes they do."
Interviewer: "Does anyone organise your daily work then?….assign cases or jobs to you?"
Monica: "Sometimes, but not usually. We have been working here a few years now. We don't really need anyone to tell us because we are used to it. We just know what to do.
Once again, the recurring theme amongst the nurses and ODPs in the sample revealed that an industrial ‘supervised work group’ model is rejected as restrictive and redundant. Length of experience, and technical skill were considered to obviate the need for formal organisation. This system of work allocation, by peers as the need arose, was effective at least up to a point. However, on occasion, these locally arrived at decisions failed to take into account the time at which shifts ended, leaving practitioners scrubbed at the operating table at the end of her shift. On others it meant that staff on late shifts could not be re-deployed elsewhere within the department, because they were scrubbed. Therefore, although this arrangement worked at one level, specifically in that it allowed for work to be completed by the immediate team, it disregarded the needs of the larger department. It also resulted in unplanned overtime for some staff.
The following extracts illustrate some of the difficulties encountered by staff in attempting to co-ordinate their work. Alicia, an E grade staff nurse explained:
Interviewer: "Will you be doing the first case?"
Alicia: " I should think so. Janet [E grade staff nurse] is on a late shift, so she should do the last one. I hope that there will be someone to circulate for her because I need to be away by five today.
Interviewer: "Is that the end of your shift?"
Alicia: " It's supposed to be, but we always overrun on a Wednesday. I am fed up with staying back, but there's never anyone to take over."
Overrunning of theatre lists was identified as a specific cause of conflict in phase one of this study. This extract demonstrates the frustration of the staff nurse, not only at the perceived inevitability of a late finish to her shift, but also her resignation to the fact that the list would overrun. Her concern was with the provision of staff to relieve her in order not to finish her shift late, rather than focussing on the issue of managing the overrun. The root cause of the conflict therefore, remains to be addressed. The manner of local work organisation itself contributed to the conflict, as it resulted in unwanted and unplanned overtime. Although respondents appeared to welcome an autonomous approach to work allocation, the negative aspects were also identified. In addition it was observed that not only did the immediate theatre team ignore the needs of the larger department, the managers seemed not to recognise the needs of the theatre as demonstrated by the reported lack of staff rostered on a late shift sent to take over and allow people to finish their shift on time. This provides a clear example of conflict connected with the late running of lists, although this time the area of conflict is seen to exist between the nurse and the departmental management rather than between members of the professional groups.
6.3.2 Lack of correspondence between grade and work activity
The rejection of a hierarchical system of supervision by nurses and ODPs within the sample, suggests a dissonance with the way in which nursing is organised as a structure with various levels of seniority, and begs the question of how such a tiered system can be reconciled with a staff group all with similar skills and experience, who respond to situations as they arise. During observation and subsequent analysis a sizeable category developed under the label 'lack of correspondence between grade and work activity'. A key theme of work organisation observed within the theatre can be described as focusing on ensuring that what needs to be done at a specific time is done, as the contingency arises. During the period of preparation, and throughout the entire working session, there was no clear correspondence between the grade of staff and the work undertaken. Whereas in other models of team working, a supervisor might perceive a