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The study has been carried out in an orthopedic surgery clinic in a university hospital in Denmark. The clinic was part of a large ethnographic study conducted in 2010 exploring the functions of surgical assistants and perioperative nursing (Sørensen, 2011). That study recommended further studies of the adaptive capacity in interdisciplinary surgical teams in order to improve teamwork in the operating room and thereby improve the quality of patients’ outcomes. Contact was established, and agreements were made between senior management and the researcher(s) in 2013, as well as between the specific frontline managements and researcher in 2014. The vice director of human resources at the orthopedic surgery clinic acted gatekeeper, while the nurse managers were the closest daily cooperation partners. The orthopedic surgery clinic is divided into four surgical units, which are located in different geographical areas of the region. These units conduct orthopedic surgical procedures of different levels of complexity, which are divided into different sub-specialties:

arthroplasty (replacement), trauma and fracture management, foot and ankle, shoulder and elbow, spine, children and reconstructive surgery, and hand surgery. Contextual

4 The term “participants” is used when describing the ethnographic fieldwork and the organizational intervention. The term “respondents” is used when describing the measurement of relational coordination and safety culture using surveys.

variation was ensured by recruiting teams from two geographically different locations that work at different levels of complexity within the same organizational setting.

PHASE I was conducted in Surgery Unit I and Surgery Unit II. They were mainly selected based on differences in the level of complexity, as presented in the following.

Subsequently, they differed from each other in terms of the level of uncertainty, that is, they differed according to the proportion of surgical procedures carried out as scheduled or emergency surgical procedures. PHASE II and PHASE III were only conducted in Surgery Unit II. This decision was made partly to match the time and resource framework established for the research process and partly to accommodate a managerial need for change within the organization.

In order to describe the diversity between the two units, data reported from all orthopedic surgical units in Denmark to a national clinical surgery database has been consulted (The Danish Hip Arthroplasty Registry, 2015).

The four surgical units in the region all differ from each other (Table 2). Almost all the hip arthroplasties performed in Surgery Unit I are categorized as primary hip surgical procedures (364 primary hip surgical procedures and only 13 revision hip surgical procedures in 2015), while almost all the hip arthroplasty surgeries in the region that are categorized as revision hip surgical procedures are performed in Surgery Unit II (78.5% of all revision hip surgical procedures performed in the region in 2015).

Table 2 Reported primary and revision hip arthroplasty operations, as adapted from the Danish Hip Arthroplasty Registry (2015).

The diversity between the units is also supported by Table 3, which demonstrates the case mix for surgical procedures in the units in terms of for hip arthroplasties during the same period. The case mix is a term used in clinical databases that serve, as an information tool for understanding the complexity of health care delivery.

In this table, which presents the case mix for patients undergoing hip arthroplasty, the patients’ relevant demographic factors, such as gender, age, primary arthroplasty, severity of arthrosis, and comorbidity⁵, are included. Primary arthroplasty is included as a factor describing the case mix, since primary arthroplasty is a less complicated surgical procedure than revision arthroplasty. Whether one or both of a given patient’s hips are affected by arthrosis is a factor that provides, an indication of the severity of the arthrosis. The age and comorbidity are both dimensions that are considered when a patient’s ASA score⁶ is assessed by anesthesiologists prior to surgery. The frequency of patients undergoing surgical procedures with a comorbidity is highest in Surgery Unit II (47.9%) and lowest in Surgery Unit I (21.8%), while the patients are elderly in Surgery Unit II (55.3% of the patients are older than 70 years) than in Surgery Unit I (46.2% of the patients are older than 70 years).

5 “Comorbidity” is the medical term used to indicate the presence of one or more additional diseases. In this case mix table (Table 2), it covers other diseases in addition to arthrosis.

6 The ASA score is a physical status classification system stated by the American Society of Anesthesiologists (ASA), which is commonly used and known worldwide to assess the fitness of patients prior to surgery.

Case Mix for Surgical Procedures (Hip Arthroplasty) 2010 – 2015 Woman

Given that the level of complexity involved in the revision hip surgical procedures is higher than the level of complexity involved in primary hip surgical procedures, it can be stated that:

Surgery Unit I is the regional unit in which the level of complexity is estimated to be lowest. It also has the lowest percentage of comorbidity (21.8%), the highest percentage of primary arthroplasty (65.2%), and the lowest average age (46.2% of patients were older than 70 years).

Surgery Unit II is the regional unit in which the level of complexity is estimated to be highest. It also has the highest percentage of comorbidity (47.9%), the lowest percentage of primary arthroplasty (28.4%), and a high average age (55.3% of patients were older than 70 years).

Each of the surgical units had a management group (frontline management), including a nurse manager and a surgeon manager, and each of the units had several employed operating room nurses and nurse assistants, as illustrated in Figure 8.

Figure 8 Organization diagram showing the management and organization of the surgical units.

The surgeons were employed by the senior management, which meant that the surgeons performed surgical procedures in all four units, and they thereby collaborated with a large group of collaborators in various clinical settings. The anesthesiologists and nurse anesthetists, who were also part of the surgical teams, were employed in another unit, namely the anesthesia clinic, which was organized in a similar way. The main consequence of this organizational structure was that the health professionals (surgeons, OR nurses, AN nurses, anesthesiologists, nurse assistants, and surgeon assistants) worked together in the same operating room but referred to different senior managers and different frontline managers.