Teamworking in cardiac surgery at St. Luke's Hospital

Abstract

Team performance in the cardiac surgical setting has wide ranging and far reaching consequences. Cardiac surgery is on the increase due to a higher incidence of ischemic heart disease as well as due to improved methods of diagnosis. It comes as no surprise that cardiac surgery has become a top priority of the Maltese health service. A well-functioning cardiac surgical team ensures success in cardiac operations, resulting in a good turnover and therefore keeping waiting lists to a minimum. In view of this, the study aims at assessing the level of teamwork within this complex setting in order to promote and adopt better team collaboration which enhances performance. Thus the study investigated key process in teamworking namely role clarity, cohesiveness, communication, collaboration, participation and effectiveness. The target population included professions participating in open heart surgery at the Main Operating Theatre at St Luke's Hospital. Data collection was carried out using triangulation of methods to improve the validity of the study. The methods used were self-report questionnaires and semi-structured face-to-face interviews for surgeons and anaesthetists whereas perfusionists, theatre nurses and anaesthetic nurses participated in focus groups.

Results revealed that team members understand the benefits of teamwork. They are aware of their roles and share a healthy level of role flexibility. However they lack full understanding of each other's roles, adversely affecting team members' behaviour. Team members identify the consultant cardiac surgeon as the team leader. In general, the team has a good level of cohesiveness, manifested by the good working relationship. Team members are also committed to good quality patient care. However, the team fails to collectively audit its performance. There is also commitment to team goals and objectives related to patient care:- Problems in communication are mostly related to the administration of operating theatre lists. Adequacy of briefing and debriefing methods is contested by anaesthetists and non-medical team members. However the good level of intraoperative communication is attributed to standardised working practices. Team members collaborate well with each other. Most of the non-medical team members comply with decisions made due to the perceived status-gap, whereas anaesthetists admit of being less compliant to decisions they strongly oppose. However such incidents are very rare. Participation in decision making is centralised and limited to the medical/surgical professions. Decision makers however accept their decision to be questioned by other members of the team. Nevertheless, non-medical team members are reluctant to do so.

In relation to effectiveness, the team suffers lack feedback. Team members perceive the team as responsive and efficient during routine cases but may be less so in emergency situation due to limited exposure to certain procedures. Conflicts related to patient management are perceived by the medical/surgical team members as managed cognitively, however other team members see them as unmanaged. Recommendations for management and clinical practice include • Establishing of effective communication in patient care • Organising regular departmental meetings to address areas of disagreement as well as to ensure optimal organisation of cardiac operations • Establish shared effort in achieving quality of care • Inclusion of anaesthetic nurses in the team by establishing role clarity in this professional group. • Presenting the Cardiac Surgical Team as a model for other multidisciplinary teams working at St Luke's Hospital, should the other recommendations be implemented and proven successful. A recommendation for further research includes the evaluation of the impact these recommendations would have on the professionals involved in cardiac surgery. In conclusion, despite highlighting several team processes which may be improved to ensure better team effectiveness, the cardiac surgical team in Malta appears to have successfully functioned as a team despite the workload that has steadily increased over the years.