Great Collaboration

In this category, the subcategories professionalism, communication, and respect were recurring themes.

6.1.1.1 Professionalism

Generally, the health professionals described the importance of a shared understanding of the core task, respectful and accurate communication, and a high level of professionalism as essential elements of a great collaboration. A consensus existed about the core task and the shared goal: to perform high-quality treatment and care for patients undergoing surgery. This was expressed by an OR nurse during a focus-group interview:

”We are collaborating to perform the best possible pathways for the surgical patients.

The patient is always at the center. The surgical procedures and the followed pathway are for the patient. That is what it is all about!” [OR nurse 29]

At the morning planning meetings, during preparation for surgery, and during coffee breaks, the health professionals discussed professional issues. Many of them expressed professional pride and professional commitment. They also understood great collaboration as something that helps to enhance professionalism and make each other better, as described in a focus-group interview by an OR nurse:

“If you have a great team, it will affect your professionalism, because you just get more energy and you remember a little better and think a little differently. Maybe you also come up with good ideas.” [OR nurse 34]

To establish a great collaboration, professionalism is needed. Professionalism within a complex and specialized context, such as the orthopedic surgery areas, is typically described by the involved health professionals, as having specialized knowledge about surgical procedures, instruments, surgical techniques, and patient-related orthopedic challenges. But other skills, such as the ability to collaborate, awareness of the

situation during surgery, and an accessible personality, were also emphasized. This was demonstrated in the dialogue between the OR nurses during preparation for surgery when they discussed how to be an excellent collaborative partner as an OR nurse:

The circulating nurse (CN) says, “To be a great OR nurse, you most know the surgical procedures, what is going to happen, what we are going to use, and you have to know the surgeon’s preferences.” She then asks the surgical nurse, ”What is a great OR nurse, in your opinion?” The surgical nurse (SN) answers, ”You can be a very skilled surgical nurse, but if you can’t cooperate, it is not worth anything!

In addition, you must be able to reflect on what is happening along the way. One must be able to argue and stand by your choices. Moreover, you must know what to do if there is something urgent, you must come up with suggestions for how to solve it. You must also engage in what is happening at any time.” Then she adds, laughing, ”Finally, you must have humor, and I have!” [Team 12.2]

There was broad consensus among the health professionals that it is essential for a great collaboration that the members of the surgical teams are prepared, equipped with specialized knowledge about surgical procedures and exhibit awareness of the situation. The necessary knowledge and essential skills are also required for health professionals to provide qualified and safe treatment for patients. However, this angle was articulated less frequently.

Another important and recurring factor related to a good collaboration was the atmosphere in the room, which was expressed in different ways, here by a surgeon:

“A great collaboration is when the nurses, all of them even the AN nurses, are prepared, and know what it is about. Surgeons can also be unprepared, I know, but it is important. You may be annoyed, if someone says: “Oh, we didn’t know” or

“We didn’t think so!” The patient can actually hear when someone says: “We didn’t think so!” Nurses should also be aware of what is going on. They must be attentive, they don’t have to attend to the surgeon’s every need. It has nothing to do with it, but they must follow the process. And then of course, there shouldn’t be too much talk in the OR! It can confuse the patient and create an atmosphere that is not conducive to concentration. I have been in the business for several years, going to the OR is a part of my life, and it is a part of a great collaboration to have a good atmosphere. So, I try not to be to mad if someone is unprepared and annoys me, and I try to avoid letting it shine through too much, because it doesn’t promote the process.” [SUR 3]

A relaxed and familiar atmosphere was experienced as an indicator of a great collaboration, since the atmosphere impacts the individual’s sense of safety and trust.

However, this may have a downside, as expressed in the situation above. In that case, the surgeon highlighted the negative impact of an atmosphere that is too relaxed or

too familiar, with health professionals joking and using small talk, and who are not aware of the patient’s need for seriousness and tranquility. This challenge was often dealt with in interviews or contexts where several health professionals were gathered.

6.1.1.2 Communication

One of the key issues in the OR is to ensure that the day’s schedule of surgery is completed. To succeed in this, frequent, accurate, timely, and problem-solving communication must take place between surgeons and OR nurses. The OR nurses needed to reflect upon when the communication was timely. As described above, professionalism in OR nursing is based on specialized knowledge, the skills needed to collaborate, and an awareness of the situation. In order to perform this role in a qualified way, the OR nurse must turn to the surgeon several times during the day to obtain information, discuss possible solutions and plan the surgical procedures for the next patient due to undergo surgery, as expressed by an OR nurse:

“If something regarding the surgical procedures for the next patient is unclear, you have to catch the surgeon. Because maybe they are not the one who has done the prescription, and therefore they are not prepared to perform the surgery on this patient. I need to think about, when to catch him and say, “What about this patient?”

If I catch him at the wrong time, he can’t manage and perhaps he is left wondering

”What is she talking about? I am concentrating on this!” The best time to ask is in the morning, when the surgeon arrives in the OR. If I am prepared to present the problem, it can be in the mind of the surgeon while operating on the first patient.

He may think about the solution and inform me in time. You shouldn’t disturb the surgeons too much, they need to concentrate, and you must respect that. You have to wait to ask your questions until they are ready!” [OR nurse 3]

The understanding of communication as timely was not just a question of whether the communication in question was delayed or initiated prematurely. It was equally an understanding of whether the communication would cause a disturbance or not at the time when it was initiated. These perspectives about the timeliness of communication were also involved in the discussions during a focus-group interview, as expressed by a surgeon:

“You should never contact the surgeon at the beginning of the surgical procedures.

I have been told this by an experienced OR nurse. You must wait until “his shoulders are dropped.” Because only then does he have a handle on what he's doing. Then you can ask the questions about everything else.” [SUR 1]

Problem solving is considered an essential part of performing high-quality surgical procedures in the OR. Questions about how best to solve problems and how to communicate in the surgical teams when shared decision making was needed were expressed often and clearly by the health professionals, although many described it as

challenging due to different approaches to addressing complex and acute situations, interpersonal dynamics, and the tone of voice in the OR, as described by an OR nurse:

“It is very important that we speak properly to each other, no matter how hectic the situation is. The tone of voice in the OR is surprisingly special, but you get used to it. I don’t like it when people shout. It is important that we help each other, and we function as a team. Nobody is more important than any other person there. I also appreciate that we don’t point fingers at each other. We have to talk to each other, we must have a dialogue and help each other. I like that we constantly have a dialogue about what is going to happen! For the most part, we are good at the planning part. But there are just some combinations that do not work quite so well!

And it marks you immediately. It does! In reality, it depends on individuals. And one can also notice that there are some surgeons and some OR nurses that doesn’t fit together! Then the surgeon is right up in the red zone even before we start, and it spills over! I don’t like it at all. [OR nurse 33]

A problem-solving way of communicating was considered to be an appropriate way to take responsibility for the joint core tasks as well as for shared decision making. This was observed not only in tense situations, but also in daily conversations, where solutions to surgical problems had to be found quickly. This consideration was expressed by an experienced OR nurse:

”If I see a problem, I try to ask ”What can we do?” instead of talking about the problems again and again, but without doing anything. I would rather come up with a proposal for a solution and say, “Can we try to do so and so?” in order to get something through. Again, you all have to take responsibility for what to do to solve problems!” [OR nurse 3]

However, diversity appeared again, because a finger-pointing, blaming, and shouting form of communication was also observed in the surgical units and expressed by the health professionals during the interviews. In such situations, the health professionals debated whether they should confront their colleagues about the inappropriate behavior or simply let it pass. A useful example in this regard was expressed by an OR nurse during a focus-group interview:

“Once I was the coordinating nurse and a surgeon came to my office. He was very angry and shouted at me, because his patient wasn’t called to the OR. I chose to close my ears. When he was gone, I called his manager. I told him about the situation, what had been said, and that I wanted him to know, how the decisions were made, and then I asked him to manage the situation themselves.” [OR nurse 6]

6.1.1.3 Respect

Respect for each other’s professionalism is considered crucial for great interdisciplinary collaboration, including respect between professions and between different specialties. Respect could be expressed in different ways, and it could also be lacking. Respect was described very shortly and simply in this statement from an anesthesiologist during a focus-group interview:

”What characterizes our teamwork is a great respect for each other’s professionalism, but sometimes it is missing. Respect, I think, is such a great keyword!” [ANE 3]

Mutual respect and the way it was expressed during the everyday life in the OR varied.

The health professionals experienced a high degree of mutual respect most of the time, although situations were also observed in which respect was missing, or hostility occurred. In such situations, it became clear that the shared goals of the task faded, and more functional goals appeared, as expressed by an AN nurse in a focus-group interview:

“Sometimes, it all comes together, while other times we work in our own camp. We can’t come through or above boundaries to each other. These days are the frustrating days. The other days are going well.” [AN nurse 16]

This statement was supported by an anesthesiologist in an interview:

“When you have to deal with lots of changes and uncertainties, mental surplus and focus on a shared goal are needed. From an anesthesiologist’s point of view, one must have a helicopter view of the OR, but sometimes you are against forces that are only looking at their own OR. That is a challenge, and a dilemma you can be caught in. If you only have eyes for your own patients, and the rooms for surgery are limited, then some sort of fight between sections may occur. That is my experience. Then it is difficult to predict the schedule of surgery, since you have many changes in the schedule during the day and some patients are going to wait for surgery for a long time.” [ANE 3]

When the health professionals were talking about these issues, respect, and familiarity were often mentioned being connected. To make decisions, to be flexible, and to be safe and speak up, were all considered easier when the members of the surgical teams were familiar with each other, as described by an OR nurse during a focus-group interview:

“When we are familiar with each other. You know who you are dealing with, and you also know, when you are allowed to do something, and when you will get smacked. It means everything to me! Talking together and listening to each other.

Then, they [surgeons] get the most out of me. Then, I will work ten times better.

Feeling unsafe and uncomfortable, it won’t go particularly well. If the surgeon is familiar with his staff – professional and personal, he wouldn’t need to use his energy to think ”I must keep an eye on this and that. I have to make sure it is all right.” Then, he can use his energy on other things. If we know each other, we use less energy worrying. You can even have a great time on the job – and it has a great effect, it makes me feel safe!” [OR nurse 34]

During a focus-group interview, an OR nurse with many years of experience in the operating room talked about the mutual respect between nurses and surgeons, when they know each other very well due to several years of collaboration:

“It is a sort of human acceptance of each other. It means something to me – very much. Because you feel equal in one way or another. When you can talk and socialize a little, and so… I choose my fights with care. There must be something to build on. I mean trust and so on. Trust and respect. And you have to assume, that the other person is responsive to what you are going to say. If you expect to meet a wall, then you don’t go for it. You will pull back. You don’t want to waste energy on such cases.” [OR nurse 30]

Repeatedly, the health professionals mentioned individual factor when reflecting on the issues of respect and great collaboration. Individual factors such as temper, mood, engagement, and the ability to cooperate were all considered to influence the experiences of teamwork. This diversity was expressed by a newly employed OR nurse:

”In our group of nurses, a kind of old-fashioned hierarchy exists. Somebody has status, and somebody doesn’t. Experience gives status. Someone who is very experienced has dignity. But someone could be very experienced and very testy, and they don’t have much status, I think.” [OR nurse 33]

The individual factors considered to impact on the collaboration showed up in different ways. Experienced colleagues who were willing to share their experiences were described as role models and experts who exhibited dignity, which positively impacted the teamwork climate. Yet, dealing with individual factors could be challenging, as expressed by another experienced OR nurse:

”It is hard to tackle, if a surgeon from one moment to the next changes attitude, from being honeyed to be uncomfortable with a colleague. It's hard to tell him "Do you know that it's actually very unpleasant when you exhibit those sudden mood changes when we are operating? It is difficult to deal with. “I do not know if he is actually aware of it.” [OR nurse 3]