Ethnography of Operating Room Culture and Team Dynamics

Introduction

The cultural scene explored in this ethnography is an operating room. The individual participants in a typical operating room setting are: primary surgeon, second surgeon, surgical assistant, surgical technician, anesthesiologist, nurse anesthetist, scrub nurse, and a circulating nurse. There is also a holding room nurse and a recovery nurse — not specifically inside the operating room but involved nonetheless in the surgery and recovery. The participants require highly specialized training to be able to perform their chosen roles successfully. The common goal of all these individuals is the successful performance of an invasive medical procedure, generally for the purposes of improving or even saving a life. The patient is, for the duration of the procedure, the total focus of every person in that room — years of experience and dedication devoted to those hours in which a human life is genuinely and quite literally in their hands.

Throughout the course of this paper, I hope to elucidate not only the specific function of the aforementioned individuals but also the value they have ascribed to their individual roles. Through firsthand observation, I had the unique privilege of observing two surgical procedures, one of which is used as a vignette below. I also had the chance to meet and interview several of the regular participants in my chosen cultural scene, which provided invaluable information in truly understanding what I was experiencing as a member of the scene. Retrospectively, I am able to look back on the experience and consider what I might have done differently, as well as what factors may have influenced not only the data but the experience itself. Finally, I hope to reflect on this learning experience, appraising the social, cultural, and psychological value of my newly acquired knowledge.

The best and most succinct description of my chosen scene was offered by the surgical technologist I had occasion to speak with: "In the OR, we're like a single organism, all connected, working towards one goal — the successful completion of which is central to our continued existence." Initially I did not understand how that could be true when the diverse and complex roles of each participant demanded autonomy and expertise in their own right. However, after observing a procedure, the analogy made perfect sense. Once in the midst of a procedure, it is as though each participant is anticipating the needs and actions of every other participant. They are prepared for the best, worst, and most likely scenario, and act as a single-minded, flawless, and precise unit.

Cultural Description of the Operating Room

The most striking aspect of this whole event is that these teams are not always assembled from the same people. Nurses, anesthesiologists, and surgeons are all interchangeable depending on the procedure, the day, the time, and the relative urgency of the situation. Essentially, each individual must know their role in any procedure so thoroughly that, regardless of who comprises the rest of the team, they are able to function with the same level of confidence and expertise. Understanding how operating rooms are organized helps illustrate why this adaptability is so critical to patient safety.

A day in the life of an operating room is not terribly indicative of the social scene in which I am interested. The room is simply a sterile space with technical equipment until it is in use. Then, as though elevated to something more than floor, walls, and a ceiling, it takes on a surreal energy — alive with the hurried, hushed movements that will decide a patient's longevity. An operating room will see several surgical procedures on a given day, nearly analogous to a revolving door, holding a diversity of procedures as well as outcomes. In the quiet between procedures, it is simply a room.

In this setting, categories are predetermined and very clearly defined, organized according to job and tenure within that field. As I had anticipated, it was the primary surgeon who led the carefully choreographed procedure — conducting, if you will, a multipart orchestra in which all players have vital roles. The primary surgeon was responsible not only for successfully achieving the surgical goals but also for assessing the relative efficacy of the anesthesia, the patient's vital statistics, and directing the secondary surgeon, surgical assistant, surgical technologist, anesthesiologists, nurse anesthetist, and scrub nurse. This included determining what order to utilize chemical agents, when to retrieve sterile instruments, and requesting additional materials as well as the removal of waste materials and no-longer-needed instruments.

With that level of control comes the heavy responsibility of being largely accountable for the success of the procedure and the life of the patient. Though it was undoubtedly the primary surgeon who held the role of leader during the procedure, without the careful preparation of the surgical technician and the dedication of every other person in that room, no successful surgical procedure would be possible. The primary surgeon is in charge and will ultimately be the first held to account if something goes wrong, but his actions are very nearly of equivalent value to those of the other individuals physically acting upon the patient.

The surgeon I was able to interview was initially unsure how to define the way he found meaning in his work. "It needs to be done — I have the ability and training to do it." There had to be more, though. Why did he choose to train for this particular role in so draining and stressful a position? He reflected:

"I've always been curious — beyond curious — about how it is that a collection of cells and chemicals comes together to make a person. That curiosity never abated no matter how many answers I found in school. There was no other career choice for me. I am validated for every hour of study each time I see a patient going out those hospital doors better than when they came through them. Conversely, every time I encounter a patient who I know will never go through those doors under their own power after being on my table, it is that much more urgent to learn and continue learning, so that if I ever encounter similar problems I can make sure the patient comes out of it alive and healthy. Knowing that I can never have an off day, that I must always strive relentlessly for perfection — it's the lazy way of making sure I get the most out of life, I guess."

Roles and Meaning: Interviews with Key Participants

Modest and self-aware, this surgeon understood the full responsibility of his position yet was humble — not at all the way I had initially imagined that someone holding such power would view their role. He found meaning in his ability to affect the outcome of a patient's life while still understanding that not all things were within his control. His view of being a primary surgeon appeared integral to the way he evaluated the success of his own life — not a stance to adopt lightly or with anything less than total commitment to one's profession.

The anesthesiologist is responsible for ensuring that the patient's vital signs remain within healthy parameters, and that anesthetic levels are high enough to prevent consciousness and pain yet not so high as to cause permanent damage or death. The anesthesiologist must have a functional knowledge of the procedure in order to anticipate the biochemical effects of each surgical movement and remain prepared to adjust chemical levels accordingly. When asked why he had chosen this specialty, he explained:

"Well, it's quite simple, really. When I was a teenager I fell off my skateboard and broke my leg quite badly. I was hurt bad — never really grasped pain until that moment. The bones in my leg needed to be surgically set. All I cared about at the time was not feeling the pain anymore. Finally the anesthetist came in and knocked me out. I have never been so grateful for a needle in my entire life. If I can give that reprieve, however briefly, to another person who is in pain or who would be in pain without me — that's good enough for me."

He understands pain and how devastating and demoralizing it can be, especially when a person is completely helpless to alleviate it. The meaning he finds in his work is the knowledge that he can spare others from that sense of helplessness. Having experienced firsthand the reprieve his profession offers, his personal barometer of success is simple: if there was no pain and no lingering side effects, then there was success.

I was also able to interview the surgical technologist. She occupied many of the duties I had always believed were held by the head nurse. In fact, the role of the surgical technologist entails not only a detailed knowledge of the procedure but also an ability to anticipate a surgeon's need for different tools, set up the instrument table in precise order, and ensure that in an emergency, access to necessary corrective instruments and supplies is as close to immediate as possible. When asked about the meaning she found in her position, she said:

"Well, what I do is not terribly glamorous and doesn't come with a great title. Lots of times people think I'm like a dental technician. Really though, I like to think that I lay the immediate groundwork for the procedure. I get everything ready and set it up. The highest compliment I can be paid is if the surgeons and other experts in the room never have to look for an instrument before they grab it — never have to ask for an instrument because it's always there waiting."

This was particularly interesting. Rather than emphasizing the knowledge her role required, she took pride in people not noticing the results of her work. Perhaps she is, in a quiet way, the one truly in control in the room. Without her attention to detail and commitment to first-time perfection, procedures would take longer and might be markedly less successful.

Speaking with these three key participants, it became clear that there was no room for ego in the operating room. Each person knew their role and understood the significance of working seamlessly with the rest of the team. There was no indication that any of them were filling these positions in search of glory. They had spent years working toward the ability to act quickly and effectively in correcting physiological problems with as little inconvenience and discomfort to the patient as possible — each driven by a personal standard of excellence, and none apparently unaware of the precious commodity that complete strangers entrust to their expert care every single day.

Conclusion

The most important thing I took away from this experience was the need for effective communication and the ability to trust absolutely in your team — to hold genuine respect and admiration for colleagues you might work with only once every few weeks, or have never worked with before. These participants must be so thoroughly practiced in their field that their ability to perform with accuracy and efficiency is unaffected by whoever they happen to be working with at the time, regardless of any potential personal history between them. There was no ego, no struggle for control or power — just the single-minded desire to perform the task each knew they must, to the very best of their ability.