Human factors
Enhancing culture and teamwork in theatres
Dora Bilan explains why the adoption of non-technical skills is essential for ensuring effective and efficient operating theatres and discusses the need for strategies to help minimise the high-pressure environment of the workplace.
In the operating theatre’s specific and high- pressure environment, efficiency, effectiveness, and patient safety are paramount. The technical skills of the operating theatre team are recognised and expanded to protect patients from harm, neglect or even death. All teams make sure that each surgery step is correct and based on evidence-based practice to prevent incidents that can affect the patient and the team. It comes with competence, clinical expertise, communication skills and life experience.1 The operating theatre, with its specific
environment, demands precision, coordination, and efficiency.2
While technical skills are
essential for safe surgical outcomes, increasing attention to non-technical skills (NTS) can enhance surgical team performance and improve not only patient outcomes but also the operating theatre’s performance. Non- technical skills encompass cognitive, social, and personal resource skills that complement technical competencies and support safe and effective task performance. These skills
include communication, teamwork, leadership, decision-making, situational awareness, and stress management. By embedding non- technical skills into the culture of the operating theatre, healthcare institutions can create a more collaborative, resilient, and safety-oriented environment for patients and the team. Traditionally, operating theatre culture has been hierarchical, with clear divisions between roles – surgeons, anaesthetists, scrub nurses, circulating nurses, and operating department practitioners (ODPs). While role clarity is important, such hierarchies have often stifled communication and discouraged team members from speaking up, particularly when concerns about patient safety arise. This dynamic or hierarchy can lead to errors, miscommunication, human factors issues and a lack of cohesion.3
Furthermore, the
stress and pace of surgical procedures can create an emotionally charged environment, contributing to burnout, disengagement, and ineffective teamwork. In such conditions, a strong culture grounded in mutual respect,
open communication, and shared responsibility becomes essential.4,5 Recognising the toxic environment can only bring the change that the operating theatres need to maintain good working conditions, to make sure the workload will not overwhelm the team. A toxic operating theatre environment refers to a workplace culture characterised by poor communication, disrespect, bullying, blame, hierarchy, and lack of psychological and emotional safety. In many toxic theatres, a rigid hierarchy persists, where senior nurses, surgeons or consultants dominate the environment and junior staff feel unable to voice concerns or raise questions.6 These environments impact not only the well-being of healthcare professionals but also jeopardise patient safety and the quality of care provided. Regardless of the technical proficiency of clinical staff, the human and relational elements of teamwork are frequently disregarded, sometimes resulting in dysfunctional team dynamics. Bullying and incivility are also markers of a toxic environment. According to NICE, this behaviour can be easily de-escalated by planning by every team member in any clinical setting.7 Staff subjected to repeated negative
behaviours may experience anxiety, stress, burnout, and even post-traumatic stress symptoms. Over time, this leads to high turnover, low morale, and reduced engagement from staff. Recruits or students placed in such theatres may become disillusioned early in their careers or internalise unhealthy norms as standard behaviour. In the operating theatre environments, blame
culture often replaces constructive learning that should support nurses and other medical professionals to develop a peri-operative career.8
When mistakes occur, sometimes
individuals are blamed rather than the system being examined for contributing factors such as cultural differences. This discourages discussion, learning in a safe environment and
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