Introduction

A recent article in APSF by Jeffrey Cooper, PhD, highlighted the importance of considering the relationship between certain dyads in the operating room, specifically between anesthesia professionals and surgeons.¹ The article discussed implications for patient safety, and the potential for patient harm due to relational degradation in this dyad. However, we suggest that an equally important dyad to consider is that between anesthesia professionals. External pressures have the potential to bleed into our operating rooms, and influence our experiences at the point of care. Therefore, it is most important to create a satisfying work environment for all team members so that collaborative care can translate into improved patient safety.

Optimizing Our Teams

There is a growing body of research that give us insights on how we can promote better team performance which can lead to enhanced patient care.

Collective Intelligence and Teaming

The performance of teams is only moderately connected to the individual intelligence of its members.² Woolley et al. found empirical support for a collective intelligence factor (c-factor) that explains a group performance. Specifically, this c-factor is “not strongly correlated with the average or maximum individual intelligence of group members, but is correlated with the average social sensitivity of group members, the equality in distribution of conversational turn-taking, and the proportion of females in the group” (which is likely also related to social sensitivity).³ Teams with members who can be socially sensitive, encourage all members to participate in the conversation, and value input from all team members may function better as a team.

The nature of the operating room setting requires unique modes of team interaction. Much of the research on teams assumes stable membership among team members, which allows them to practice and hone their team performance over time. However, in the perioperative context, each case may represent a unique combination of clinicians who have worked together with varying degrees of frequency. While some teams enjoy stable membership, others have a frequently changing mix of anesthesia professionals, surgeons, and trainees. Researchers have referred to this concept as “teaming” which requires relative strangers to come together quickly to perform challenging tasks with little or no time to practice. Edmonson describes teaming as “teamwork on the fly,” which is apropos for the situations in the perioperative space.⁴ A critical component of teaming is psychological safety, which is the belief that the team is a safe place for interpersonal risk-taking, and describes an environment of trust and mutual respect. In the perioperative context, this risk-taking may include speaking up when a team member has a concern about patient safety or disagrees with a care decision. Successful teaming also requires situational humility, which acknowledges the difficulty of the task ahead, and understands that it cannot be solved alone.⁴ Situational humility leaves room for all members of the team to make a contribution to the end goal. In the face of uncertainty and ambiguity—both central features in the current health care environment—situational humility fosters an environment that encourages teams to engage in more learning behavior. However, if one member within the team retains an authoritarian or dictatorial leadership style, they risk not only suppressing valuable input that might increase patient safety, but also devalue other members of the care team.

The Role of Stereotyping

When a person is dealing with another person who is unknown to them, they often look to cues and stereotypes to try to anticipate how that person will behave. Stereotyping is a mechanism for reducing perceived uncertainty. For example, if an anesthesia professional is working with a surgeon that they do not know, they may rely on stereotypes about surgeons or specific specialties to try to navigate this new relationship during the case. If these stereotypes or assumptions are incorrect, they can lead to communication errors and threats to patient safety. Nurses, physicians, and other members of the care team who are familiar with one another within the hospital setting may have built trusting working relationships. However, when the people in those roles are unknown to each other personally (which is common in large organizations) inaccurate stereotypes can be increasingly detrimental. External pressures, intra-organizational power struggles, and professional clashes have the potential to saddle members of the care team with negative stereotypes regardless of the characteristics of the individual. This stereotyping can create a mistrusting and threatening environment before the case begins. When a threat to safety is perceived, then self-preservation, not collaboration, can become the norm.

Role Ambiguity

As the roles of health care providers evolve and change, they also bring new questions about exactly what functions each team member should fill.

The lack of clarity about how each team member can best contribute or what functions each team member should serve can lead to role ambiguity.

Role ambiguity is “the extent to which one’s work responsibilities and degree of authority are unclear.”⁵ Role ambiguity is a determinant of occupational stress, and is associated with anxiety, burnout, depression, job dissatisfaction, dissatisfaction with supervision, and dissatisfaction with co-workers among other negative outcomes.⁵ High levels of burnout and stress have been reported among both physicians⁶ and advance practice providers (APPs).⁷ Therefore, it is imperative that we work to reduce sources of distress such as role ambiguity, and identify the strengths that each type of practitioner can bring to the team and to the bedside. By understanding which team configurations produce the best outcomes, we are better positioned to help each member see the unique value and contribution of the others, thus reducing role ambiguity, and creating an environment of appreciation, mutual respect, and psychological safety. Efforts should be made to clearly identify what functions each clinical professional should serve, in order to reduce friction in areas of possible overlap and maximize team performance. A clear plan that is developed mutually can help the physician, APP, nurses, and technicians understand how their efforts support the team.

The Path Forward

The COVID-19 pandemic has provided incomparable pressure to the perioperative team and has laid bare the underlying nature of the relationships among members of the care team. Under stress, one’s ability to disguise and bury relational damage can become more difficult. Teams that were cohesive and trusting beforehand may pull together more, while those that were not, may have a tendency to fracture under the pressure. What shall we do, both in the near-term and as we re-emerge from this pandemic?

First, we need to routinize the concept of micro-empathy with teammates into our daily interactions. The concept of micro-aggressions in the workplace has been a subject of recent focus. Originating in studies of racial discrimination, the concept of micro-aggression has been more broadly applied in the health care setting.⁸ The premise is that small acts of disrespect, insults, aggression, or hostility can occur frequently and have the ability to degrade and demoralize employees. We propose the need to institutionalize the practice of micro-empathy, or small and deliberate acts of consideration, concern, and respect. We suggest that micro-empathy can occur through small acts of listening and concern which have an important cumulative effect over time, building relational capital among team members. Just as we have implemented surgical safety checklists, we need to implement micro-empathy into our routine operations. While showing empathy when a team member experiences an obvious hardship is critical, we need to initiate frequent conversations that allow us to show empathy for the stresses of the day or week before they take a cumulative toll. The Circle Up model⁹ suggests that this routinization can occur during daily huddles, by asking questions such as:

• “Reactions to today?”
• “What helped your team work well together?”
• “How could our work be 1% better?”
• “How did the shift affect you personally?”

This is likely to be most effective when the team has prioritized building trusting and open relationships.

Additionally, we need to ensure team building early on in professional careers. We should train together. Across the nation, trainees from different disciplines oftentimes do not train together. Health care could be better served by intentional collaborative education, not only on the art and science of care itself, but on the foundations of highly reliable teamwork.

In conclusion, many anesthesia professionals report collegial and rewarding work environments, with mutual respect toward one another. A patient deserves the very best care, and we suggest that this occurs when all members of the care team work together in harmony using their diverse skill sets and training, pooling their collective intelligence to create smart teams that result in the highest quality delivered care. While we unite against the common and formidable enemy of disease, we must take care of each other. It is only then that we will achieve APSF’s vision, “That no one shall be harmed by anesthesia care.”

 

Katherine A. Meese, PhD, MPH, is assistant professor, Department of Health Services Administration; Director of Research, UAB Medicine Office of Wellness; and Program Director, Graduate Certificate in Health Care Leadership at the University of Alabama at Birmingham.

Matthew Sherrer, MD, MBA, FASA, is assistant professor, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham.

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The authors have no conflicts of interest.

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References

1. Cooper, JB. Healthy relationships between anesthesia professionals and surgeons are vital to patient safety. APSF Newsletter. 2020;35:8-9. https://www.apsf.org/article/healthy-relationships-between-anesthesia-professionals-and-surgeons-are-vital-to-patient-safety/. Accessed April 9, 2021.
2. Mayo AT, Woolley AW. Teamwork in health care: maximizing collective intelligence via inclusive collaboration and open communication. AMA Journal of Ethics. 2016;18:933–940.
3. Woolley A, F Chabris C, Pentland A, et al. Evidence of a collective intelligence factor in the performance of human groups. Science. 2010;330:686-688.
4. Edmondson AC. Teaming: how organizations learn, innovate, and compete in the knowledge economy. John Wiley & Sons; 2012.
5. Psychology Research and Reference. (2019). Role ambiguity. https://psychology.iresearchnet.com/industrial-organizational-psychology/job-satisfaction/role-ambiguity/. Accessed April 9, 2021.
6. Meese KA, Borkowski NM. Do no harm, except unto thyself. Anesth Analg. 2017;125:1840–1842.
7. Kapu AN, Card EB, Jackson H, et al. Assessing and addressing practitioner burnout: results from an advanced practice registered nurse health and well-being study. J Am Assoc Nurse Pract. 2019;33:38–48.
8. Molina MF, Landry AI, Chary AN, Burnett-Bowie S. Addressing the elephant in the room: microaggressions in medicine. Ann Emerg Med. 2020;76:387–391
9. Rock LK, Rudolph JW, Fey MK, et al. “Circle Up”: workflow adaptation and psychological support via briefing, debriefing, and peer support. NEJM Catalyst Innovations in Care Delivery. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0240. Accessed April 15, 2021.