Table 5 Examples of strategies used by surgical teams to manage the increased workload
Theme | Strategy | Example |
|---|---|---|
Scheduling for efficiency | ||
Anticipatory | Keeping elective and emergency theatres and pathways separate | Keeping elective and emergency theatres and pathways separate protected the scheduling of elective surgery and prevented delays in emergency surgery by having separate bed bases for each set of patients |
Having a ‘six-four-two weeks out’ rule for creating operating lists and allocating staff | The ‘six-four-two’ rule where surgeons and anaesthetists are assigned six weeks out, patient lists created four weeks out, staff and lists finalised two weeks out. If this cannot be fulfilled by two weeks, the theatre is offered to another service and anaesthetist is reassigned | |
Theatre managers, anaesthetists, surgeons and other members of the multidisciplinary team working collaboratively to plan lists | Planning of lists was done collaboratively with surgeons, anaesthetists and other members of the multidisciplinary team to maximise efficiency, minimise last minute changes and have an accurate estimation of timings to avoid overrunning or cancellations | |
Stand-by patients who are pre-assessed and ready to come in if there are cancellations | Increase pre-operative capacity to have a pool of standby patients ready to come in (e.g. not had breakfast) to reduce wasting theatre time if a surgery is cancelled | |
Looking at staff rosters in advance to anticipate necessary adjustments and allowances | Surgeons and anaesthetists look at staff allocation to the list ahead of time to anticipate pressures related to timing and level of supervision. For example, having an experienced trainee in theatre would determine operating time or allowances for anaesthetist to take unexpected requests such as assessing emergency patients | |
On-the-day | Renewed emphasis on strict start times for all theatre staff | All the operating team to meet promptly at the agreed start time to reduce late starts, late finishes and staff being idle waiting for others to arrive, enabling the day to flow as planned |
Filling in short gaps in lists with simple standby local anaesthetic (LA) or emergency cases | Space that has become available during the day may be filled with simple cases to optimise theatre time and staff that are available in normal working hours. A “quick LA” may also be arranged at the start of a list while general anaesthetic case reviews are taking place before the team brief | |
Communication and Coordination | ||
Anticipatory | Planned multidisciplinary team meetings to coordinate plans between disciplines or teams from different sites | Having an up-to-date knowledge of resources and demand was critical for optimising the allocation of staff and scheduling for theatres. Planned multidisciplinary team meetings were vital for these updates when it might not be easy to communicate ad hoc on the day itself when individuals are elsewhere |
More attention to detail in email chains and making sure all relevant people are copied in | Theatre managers emphasised the importance of attention to detail in email communication about changes to lists or staffing, to ensure all the right people were copied in. This prevented pressures of errors and confusion on the day. For example, the staff rota has changed but relevant staff haven’t been informed | |
Planning how and when to communicate plans with patients | Sharing with patients a realistic or slightly longer than anticipated waiting time, to prevent disappointment and additional workload for staff receiving calls from upset or chasing patients Implementation of a new policy to only inform patients of their scheduled date for surgery two weeks before to minimise the numbers of cancellations and changes | |
On-the-day | Adaptations in communication style when pressures increase | Speaking slower and softer when under pressure in theatre to focus the attention of others More use of closed-loop communication to check understanding in order to prevent errors or time delays |
Multimodal communication and increase in face-to-face contact | Although difficult when staff are in different theatres, participants emphasised importance of face-to-face communication when pressures are high to harness support and request help where needed | |
Using other means of quick communication | Use of WhatsApp for communicating changes and problems on the day to maintain streams of communication | |
Leadership | ||
Anticipatory | Increased emphasis on creating an environment of psychological safety | Being approachable and being explicit that people should feel able to speak up and communicate any concerns or questions. This was thought to improve performance, patient safety, staff wellbeing and leaders having good oversight of the situation |
Reinforcing professional autonomy within the team | Reinforcing professional autonomy so everyone felt equally valued. For example, one surgeon had a rule that doctors are not to take from the nurses’ trolley or store supplies there without asking them first. Having boundaries like this helped to prevent pressures arising from interpersonal difficulties within the operating theatre team | |
Adapting pace of work to the skills and expertise of the team | Knowing the skills and expertise of the team enabled leaders to be able to delegate, allocate roles suitably and take precautions. For example, notifying a surgeon of a new team member so they can plan to go more slowly or take special precautions | |
Staff support initiatives | Supporting staff by allocating mentors and organising team lunches to help build psychological safety | |
On-the-day | Being more directive and autocratic when communicating decisions and being willing to be unpopular | One anaesthetist explained that when they make a decision on the day about which emergency patient will get the theatre, they make it as near final a decision as possible and did not change their mind easily to limit errors and distractions based on last minute alterations |
Pausing operations to regain situational awareness | Stepping back from the situation and looking at the whole system rather than the person shouting the loudest. One surgeon described physically leaving theatre to take a breath, regroup and review with a fellow surgeon. Interviewees also described the importance of focusing on the patient or situation in front of them and not getting distracted by potential problems down the line that were beyond their influence | |
Staff member allocated as leader/coordinator of the day | ‘Of the day’ role for who was in charge of operations and resource allocation for that day (e.g. matron of the day, operational senior nurse of the day, ‘silver bleep holder’). This meant there was a designated person with decision-making authority whose role it is to troubleshoot everyday pressures | |
Providing support to staff on the day | Making sure the team were taking their breaks and foster an environment where staff feel able to question or ask for help. Clinical leaders would also organise additional debriefs or provide positive feedback at the end of a difficult day. This was to resolve additional stress and help prevent burnout | |
Teamwork | ||
On the day | Periodically regrouping and reviewing the plan and reallocating roles to manage changing pressures | Setting aside the theatre team hierarchy and empowering staff with the relevant skills and expertise to lead problem resolution in response to changing conditions and emerging pressures. For example, a healthcare assistant guiding an education team nurse covering staff absence on setting up the equipment needed in a particular theatre when surgical plans changed for the patient on the day |
Shared decision making and asking for help from others | Interviewees often expressed the importance of using the team and not feeling alone. Both nursing and medical staff emphasised the need to redirect or delegate to share out the workload when their own capacity was reached. Asking for help from others and sense checking to review difficult decisions were also key strategies | |