Challenges in Collaboration

In this category, the subcategories uncertainties, interdependency, and time constraints were recurring themes.

6.1.2.1 Uncertainties

The participants descripted a very complex and changing clinical practice. The quality and effectiveness of job performance were experienced as particularly challenging due to frequent changes and uncertainties in the daily surgical program, the lack of availability of required instruments, and the high degree of interdependency among the health professionals in the surgical teams and across units in the hospital. The participants experienced the uncertainty and changeable practice ambivalently. On the one hand, the unpredictability gave rise to great job satisfaction, while on the other hand, it was a source of frustration, with both perspectives being expressed by an experienced OR nurse:

“Our job is varied. You don’t know what you are going to do. The job is varied and unpredictable, and that is the reason why I find it attractive and satisfying to work in this operating room. For me it is a positive challenge. Of course, there are days where it is too much.” [OR nurse 5]

Through the observations and the interviews, it became obvious that the participants were proud of their task performance, while the emergent character of the work provided a great deal of meaningfulness to the health professionals, as expressed by an experienced AN nurse:

“We have responsibility for the scheduled surgical procedures and for the urgent procedures. We have tasks related to traumatized patients coming to the hospital, patients with cardiac arrest, or patients in need of immediately respiratory assistance. Anything…. Variation, I have always thought of it as enriching.” [AN nurse 14]

Frustrations related to uncertainty and coordination failures were clearly expressed by the participants in a surgical team performing surgical procedures:

“The surgeon asks the OR nurse “Why isn’t the patient in the OR now?” The OR nurse answers ”Always the same here. Perhaps the patients haven’t been seen by the anesthesiologist yet!” The surgeon shakes his head and says ”Incredible! What if the staff in the control tower at the airport didn’t know that the flight will land in five minutes? What would happen then? Incredible!” [Team 26]

When the health professionals described the unpredictability of their daily task performance, the challenges related to the lack of availability of instruments and surgical materials were very often mentioned, as declared by an OR nurse:

“The greatest surprise is whether we have the things we need. Are the instruments sterile or have they been used the day before? Lots of unforeseen things we can’t do anything about. We have to deal with whether we can operate on the patient or not. It’s really something you get annoyed about because it’s the same problem every time. You can’t help getting angry. You have to say “Sorry, we are delayed!”

or “Could we make some changes and move forward?” [OR nurse 3]

Sometimes, uncertainties and challenges arise in terms of having staff with the necessary skills present in order to complete the surgical procedures. In concrete terms, sometimes the surgeons are unaware of who should be their assistant until very late in the preparations for the surgical procedures, which can result in delays in surgery. Such challenges were expressed by several health professionals, for example, by a surgeon:

”You have to start from the beginning all the time. We have new staff that constantly need to be trained, and there is always the possibility of sterility rupture. I would like to say that I’m glad that the pilots are not new every time they are in their cockpit. Sometimes, I think we work unprofessionally in a hospital, even if it’s people we are dealing with – or as I usually say, “It is only people, we are dealing with!” We have to be focused, and sometimes I don’t want to be assisted by a student. One must concentrate on the core task, so if you also need to train an assistant in everything from avoiding striking the mask to something else, or if they don’t have the physical strength needed, it will be hard to finish, and it may well tip over!” [SUR 3]

Thus, the uncertainties in the collaboration in the OR had many faces, each demanding different actions from the health professionals. They had to perform these actions in order to maintain the surgical schedule and the flow in the OR.

6.1.2.2 Interdependency

At all times, the interdependency that exists among the health professionals in surgical teams and across units in the hospital was highlighted. The need for coordination and communication was highly emphasized, and the participants expressed their intentions to share knowledge and collaborate in achieving the common goal: high-quality care and high-quality patients’ outcomes. Every day, the health professionals experienced a high degree of interdependency in the surgical teams. When observing the preparation prior to surgery, it was clear that the health professionals were striving to do their best in terms of performing their part of the task. A pronounced perception existed that it was very important for the surgical procedures to be completed in a qualified manner, with everyone doing their best. This was expressed when an OR nurse reported on her efforts to be prepared:

”It is important for the teamwork that I am able to do my stuff. I must prepare.

Because you can feel it immediately if something is new and you haven’t seen it many times before. Then, perhaps I will be horsing around thinking “What is that for a handle?” Then, some surgeons will sigh! I will say to myself “Come on, you can do better!” What I am doing is writing and drawing in a notebook every day before going home how best to “prepare the surgical tables” by looking at my colleagues and by looking at the schedule for tomorrow. Then, I will study the drawings and my notes at home and learn. When I arrive in the morning, I am as prepared as I can be.” [OR nurse 31]

The interdependency between the health professionals in the OR had many forms, such as collaborators being prepared and competent, as in the above examples.

Another form of interdependency was associated with a timely exchange of knowledge, information, and prescriptions, as expressed by a surgeon:

“There are a lot of instruments that OR nurses need to catch from outside the OR.

Often, they are running in and out of the room, saying they didn’t know this and that. But it is also because of us [surgeons]. We are the ones doing the prescriptions for the preparation of the surgical procedure. And often the prescription is not applicable – we change our decisions during the surgical procedure and therefore it is not possible for the OR nurses to be appropriately prepared – because we don’t know what solutions we will end up with. I am relaxed about this, it is just the way it is!” [SUR 3]

However, feelings associated with frustrations, anger, and resignation were also reported when talking about interdependency and having to depend on collaborators with whom you aren’t familiar, as described by another surgeon:

“It is very challenging for the collaboration that we, as surgeons, are like gypsies, one day here and one day there. We aren’t familiar with the nurses, not at all. It is impossible due to the way our work is organized. Today, I am with a colleague, but otherwise we never speak with any colleagues. There is a big difference between whether we are operating with a colleague where we can engage in professional sparring along the way or if we are with a student who doesn’t know what is going on. I am rarely in this unit; therefore, I have nothing to say, I am never involved in the decisions.” [SUR 4]

6.1.2.3 Time Constraints

Time is a non-deniable factor associated with the performance of surgical procedures in the complex and specialized OR. The health professionals talked about time in many different terms, such as “time for the first patients to be in the OR in the morning,” “time of incision,” “time for the transition of patients in the OR,” “time for the preparation of surgical procedures,” and “time for patients to be anesthetized.” They also described time as being constraining and challenging, since the demands of all these different

“times” were to be as soon as possible and as short as possible. For example, a mention of the time made in the surgical team:

The SN was preparing the tables for surgical procedures and she was telling her newly employed colleague, the CN, that time was an issue today. She claimed “We have used too much time for the morning meeting today. We have to hurry, we have just been scolded for it. They have just checked our “time of incision” every Thursday and only three out of 50 patients have been on time. It doesn’t work.

Today, we must focus and be on time!” They work quickly on the preparation and talk together about an upcoming course. [Team 14]

Having to work under time pressure while at the same time experiencing that the work is done ineffectively was one way of describing the challenges related to time. Different initiatives and structural changes intended to manage the time constraints had been introduced, but time and efficiency remained challenging, as a surgeon explained:

”We have had challenges with the time in this unit for several years. We are always late, and it is not effective at all, but the collaboration is okay. A lot of initiatives for improving the efficiency have been introduced during that time without success, and people don’t care anymore, it can’t be better.” [SUR 11]

Another point of view was that time in the OR was filled with unpredictability that one must navigate in the best possible way. There was a lack of control, but by working together, the tasks would always be completed. An OR nurse reflected on this point of view:

“Time is very important here for us. When performing complex surgical procedures, the time for preparing patients for anesthesia is very long, and we also have time for preparing the table with surgical instruments, and sometimes the patients must have an analgesic blockade after surgery. Thus, we are occupying the OR for hours, and a lot of time is wasted, so we are using the OR too little for surgical procedures. But I do not feel time-pressured, like when I was on the ward, where I was pushed not to accomplish my tasks. I accomplish my tasks. Maybe, I am not finishing what was expected, but I don’t go home and still have lots of tasks I haven’t completed.” [OR nurse 5]