Many surgeons don't listen to nurses, say non-nurses

May 5, 2006 -- Today a number of web sites ran a HealthDay News piece by Karen Pallarito about a new study suggesting that surgeons' OR teamwork is poor. The Johns Hopkins study stresses that the hierarchical structure that can prevail in ORs may discourage nurses from speaking up about errors and other key care issues, endangering patient health. The piece does a fairly good job of bringing out these important findings. However, we can't escape the irony that the piece relies entirely on expert comment from the study's principal investigator, Hopkins surgeon Martin Makary, and a non-nurse project director at a patient care non-profit group--even though one of the other study researchers was Hopkins director of surgical nursing Lisa Rowen, RN, DNSc. In fact, the article was sufficiently nurse-focused that the MSN site's headline for it was "Nurses Give Surgeons Poor Grades on Teamwork in OR." Wouldn't it make sense--in an article about the importance of listening to what nurses have to say--to ask what nurses have to say? One thing a nurse might have noted that the piece does not is that the effects of such poor work environments can extend well past the immediate clinical interaction and contribute to other systemic problems, including nursing burnout and high turnover.

The new study appears in the May 2006 issue of the Journal of the American College of Surgery. The piece explains that it underlines the need for good teamwork in the operating room, because an atmosphere that discourages good communication can lead to dangerous errors. However, the piece notes, ORs have historically been governed by a communication-inhibiting "pecking order" headed by the surgeon. Right off the bat, the piece asks readers to imagine that they are going "under the knife," but the surgeon "intimidates the anesthesiologist and marginalizes his nursing team," so that a scrub nurse who sees an error is afraid to speak up. Good point, except that nursing teams do not belong to the surgeon, as the piece's use of "his" implies. Instead, despite the obvious power imbalance, nurses are autonomous professionals focused on the patient. Moreover, most anesthesia in the U.S. is now given by nurse anesthetists, like the 121 who were respondents in this survey, and some surgeons are female, like Hopkins chief of surgery Julie Freischlag, who was one of the researchers in this study.

Moving on, the piece explains that the researchers based their study on more than 2,000 surveys completed by OR personnel in 16 states. Hopkins surgeon Makary sums up the findings: "Basically, the surgeons thought there was great teamwork and the nurses thought there was terrible teamwork." Surgeons got the lowest marks for teamwork, while scrub and circulating nurses got the highest ratings. The piece notes that the researchers adapted a survey first designed to measure the safety practices and communication of airplane flight crews, an industry which reportedly has had similar safety issues caused by the reluctance of members of the flight crew to challenge the pilot.

Providing context, the piece notes that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has found communication problems to be the "most common cause of deaths and serious injuries reported in U.S. hospitals." Examples include surgeries on the wrong patient or the wrong part of the body. The piece quotes Fran Griffin, project director at the Institute for Healthcare Improvement in Massachusetts, who notes that "nurses are generally trained to work in teams with each other, and with the other disciplines...whereas the surgeons are trained to be sort of the captain of the ship." She argues that this means that if the surgeon is not open to communication, others will feel too intimidated to speak up with their concerns.

The piece concludes with some ideas for improvement. To his credit, Makary calls the findings a "wake up call for physicians," and says "we need to do a better job as surgeons promoting teamwork." The story notes that some "cultural reforms" are underway, pointing to a JCAHO proposal that U.S. hospitals conduct annual assessments of their "safety culture." At Hopkins, all members of the OR team now participate in a "pre-surgery briefing," modeled after flight team cross-checks, to get acquainted and discuss goals and concerns.

The piece again turns to Griffin, who stresses that the surgeon "must be the one" to encourage input from others, presumably because no one else would have the juice to do so. Griffin also urges hospitals to "start small" with the most willing surgeons, rather than "the surgeon in your operating room who's the most difficult to deal with and has a reputation for yelling at people and throwing things across the room." Such recalcitrant surgeons, evidently, must be brought along slowly through "[p]eer pressure" as the tide shifts. We see the argument, and we have no doubt that non-surgeons would be more likely to speak up if a surgeon encourages it. Introducing formal reforms slowly may make sense in particular environments.

But at least as presented here, Griffin's comments seem far too tolerant of abuses that are causing patients, nurses, and others real harm right now. Such abusive behavior is a significant factor in the nursing crisis, as Gordon has shown. Surgeons should be required (not just timidly requested) to allow input from others, and those who yell and throw things should be disciplined for that misconduct just like any other worker would be. Imagine an attorney, for instance, being asked to tolerate a colleague's yelling and throwing until some undefined level of "peer pressure" has built up way off in the future. Even the suggestion that surgeons must be the ones to invite input subtly reinforces the idea that they are and should be in charge, that it is still a matter of their discretion rather than a requirement--in essence, that they should evolve toward benevolent despotism. However, that is not only inconsistent with proper collaboration with other autonomous professions like nursing, it is not in patients' interests.

In these respects, it might have been helpful for the reporter to seek expert input from the group of professionals whose expert input is the main subject of the article: nurses. Of course a nurse expert might have said the same things Griffin did. But we'd like to think he or she might at least have included some hint that teamwork cannot be a matter of physician discretion, and that the effects of poor teamwork are not limited to the care of the immediate patient.

We thank Ms. Pallarito and HealthDay News for this important, though flawed, report.

See the HealthDay article "Nurses Give Surgeons Poor Grades on Teamwork in OR" that was posted on May 5, 2006 on the MSN website.

Articles about study also appeared on the Forbes magazine website and in the Johns Hopkins University Gazette.