The all-too-familiar stress of team ‘unfamiliarity’

SurgicalPerformance data reveals that ‘Team Unfamiliarity’ directly correlates with increased complication rates, to the tune of 30%. 4 nurses share their unique lived perspectives.


Within SurgicalPerformance there is an entry field labelled “Familiarity of the team”, and for many this may seem like an irrelevant section not requiring input, but data shows that it has a greater importance than many may perceive. Not only has the data gathered from SurgicalPerformance been able to demonstrate a 30% increase in complication rates as a result of team ‘unfamiliarity’, this is also a well researched area academically.

We’re diving into this topic of Team Familiarity in greater detail, and aim to not only provide quantitative data but also qualitative insights gathered from a variety of perspectives. Because although the data on SurgicalPerformance is a direct reflection of the surgeon’s experience, their surgical team also has intimate knowledge of this dynamic and its impacts.


Understanding ‘Team Familiarity’ from a Nurses perspective


In our article, “What’s your glove size, Doc?”, SurgicalPerformance founder Dr. Andreas Obermair provided an anecdote on his experience of working with a completely unfamiliar team. From this perspective we’re able to understand how it feels as a surgeon to enter into a theatre and be welcomed with new faces. But, what do your teams think of the situation?

We have interviewed a selection of theatre nurses to understand their experience of working in familiar and unfamiliar teams.


Q1: What has your experience been with respect to the importance of Team Familiarity in surgery?


Nurse 1: When surgeons are familiar with their team they definitely appear more relaxed and confident with how their day will go. When there are new team members I feel they don’t respect/ lack trust in the new team.


Nurse 2: When working with my familiar team I am not having to ask as many questions of the surgeons and how they do things, which makes it run a lot smoother. Working in ENT and with kids frequently, from as young as 10months at times, we always have the same team and are very aware of what’s going on in our surroundings – we can even pick up the sounds of the anaesthetic machines which means we have this advanced knowledge of what’s happening, what needs to be done, and how each in the team will respond if complications arise. Picking things up very early in this way allows us to anticipate outcomes and mitigate impacts. 


Nurse 3: My experience with theatre teams has been with regular familiar teams with good communication as well as transient teams with poor communication. Team familiarity in my opinion is the foundation for good communication which results in good patient outcomes. Having a familiar team and knowing your teams’ strengths and weaknesses allows for good planning at the beginning of surgical lists which is critical in high acuity cases. The familiar aspect to a team promotes good open communication which then allows us to anticipate potential outcomes, further educate our teammates, optimise task management, and provide better outcomes for our patients.


Q2: What have you observed in relation to Team Familiarity’s impact on complication rates, length of surgery, blood loss and other clinical measures?


Nurse 1: In my experience, length of surgery is shorter when working with a familiar team, the surgery is generally smoother and more controlled which can have a great impact on outcomes.


Nurse 2: If there’s a familiar team, members can predict what instruments or steps are coming up to be well prepared if any complications may arise. This helps immensely, having equipment already on the sterile table or room can help reduce time wasted.


Nurse 3: We have a list of surgeries on Friday’s where all but one team member is the same, and because the majority of the team is so familiar & in sync we are able to anticipate each other’s actions and have the ability to forward think on potential outcomes, minimising the communications required. You cannot prevent blood loss, but when you’re working with someone familiar you have an understanding of what they need, how they like to work and this allows you to anticipate actions and respond to complications with speed and ease. Familiarity allows for streamlining and leads to increased efficiency.


Nurse 4: Things I have observed during my time in the operating theatre that are impacted by team familiarity is length of surgery times. This I believe comes down to good communication and situational awareness. The teams I work with on a regular basis take into consideration the complications we may encounter for the day as well as implement strategies to help us if these arise, a plan B is always discussed. Having a backup plan allows for a less timely transition and everyone is aware of their role and tasks.


Q3: What is the impact on mood, morale and professional satisfaction?


Nurse 1: If the team has unfamiliar members or inexperienced members, Surgeons and other team members can get frustrated and stressed. If the team however

 are all very familiar, the day will run smoothly and members of the team appear happy/ at ease.


Nurse 2: When working with a team that you know, the morale and mood is lighter and generally more positive and communication is easier


Nurse 3: Immediate impact, much more relaxed, communication is much more open around what’s required across the whole team and with the surgeon. Everything runs a lot smoother and you can feel this. It cuts down the time to communicate needs/requirements prior to commencing, and all the team feels more relaxed. You always feel much more satisfaction when you feel respected and like you’re doing a good job, which is easier to do when you’re with a familiar team.


Nurse 4: From my opinion morale is high with a familiar and regular team. You work closely together and know each other’s strengths and weaknesses. A few of us have worked together for many years so we work together like a well-oiled machine. The professional satisfaction is seeing the smile on everyone’s face when they know who their team members are for the day, it’s a feeling of ease and knowing you have good support for whatever the day entails.


Q4: Does this impact increase with increased unfamiliarity?


Nurse 1: Definitely

Nurse 2: The mood and morale are different with unfamiliar teams. It’s not a bad thing working with unfamiliar teams, it’s just unfamiliar which is sensed throughout the team. Stress can be heightened without the familiar support as well which can affect the communication of the team and negatively impact planning of surgical lists.


Q5: Does the impact increase incrementally or exponentially with every unfamiliar team member in your opinion?


Nurse 1: Depends on the ratio of unfamiliar members to familiar and certain surgeons. Some people can adapt with unfamiliar teams.


Nurse 2: I think this is very dependent on the personality, role and experience of the unfamiliar members. A new surgeon or a new scout nurse can both have vastly different impacts on the overall running of the theatre. 


Nurse 3: The more unfamiliar the team, the more talking required, the slower things go. You’re unable to anticipate how surgeons/anaesthetists like to work, and the more that the overall team is unfamiliar the less efficient and flowing is the surgery.


Nurse 4: In my opinion it differs. I notice incremental impacts with slight changes to team members. The team member may not frequent the theatre on a regular basis but has worked with us previously in the past as opposed to exponentially where team members are joining us for the list who have had little to maybe no exposure to the specialty.


Q6: Does Team familiarity become more important with more complicated cases or newer procedures?


Nurse 1: I definitely feel the more complicated the case the better the outcomes if the team are familiar. Troubleshooting is much easier, the team can predict equipment/outcomes. Time isn’t wasted looking or describing what things are/how to use it.


Nurse 2: Yes, these can result in high tension and increased stress. Knowing the team you are working with and knowing you can rely on them makes this a smoother process 


Nurse 3: Definitely. Any complications or a complex case then you want a familiar team.


Nurse 4:  Yes definitely. With a familiar team everyone knows their role, communication comes more naturally and there are no unfamiliar hurdles you must face apart from the complicated case or new procedure that the whole team is facing together. Personally facing a challenge with a team you know and work well with is going to be a lot less stressful and challenging compared to a team who is unfamiliar. Unfamiliar teams lack adequate communication, you’re unaware of your team’s strengths and weaknesses and your role becomes more task focused instead of patient focused.


Q7: What are some of the factors/pressures that lead to less familiar teams being formed?


Nurse 1: Staffing has a huge impact. Inconsistent shifts – rotating rosters. When there’s too many off sick, staff get shuffled around.


Nurse 2: New staff, new consultants, sick leave, need to expose and support newer nurses, scheduling conflicts, on call rosters


Nurse 3: Understaffing is a pressure we are facing in these times of covid which is leading to less familiar teams being formed or familiar teams being split to accommodate skill mixes in other surgical lists.


Q8: What sort of ratio do you have between surgery with a familiar team makeup vs less familiar?


Nurse 1: Very day to day dependent due to sick calls. But they do try have at least 3:1 (3 familiar:1 unfamiliar)


Nurse 2: I do the majority of my work with less familiar teams- that is mostly my preference, slightly less important for anaesthetic nurses and I like to do something new every day + I’m quite flexible in new theatres


Nurse 3: I believe I work within teams that are quite familiar, it is only rarely I find myself in a completely unfamiliar team. There are always adjustments to the teams depending on different circumstances however generally the teams are majority familiar.


Q9: Can you give an example of a case you were involved in or have heard of where reduced Team Familiarity contributed to complications or stress?


Nurse 1: A while ago I relieved a scout for dinner for a surgical case which had already gone for around 10hrs. That case had around 5-6 different nurses in it. The room was a mess and you could tell everyone involved was stressed.


Nurse 2: I have been in a case where I have been the only familiar Nurse in the team. There were no complications thankfully, however the stress that I felt was immense. I noticed my situational awareness was heightened as I was lacking the support from the unfamiliar team members. I felt as though I was carrying the weight of the team on my shoulders, the weight that is normally distributed and not felt through familiar team members.


Q10: Finally, can you share an example where Team Familiarity contributed to a truly excellent outcome for all in what was a challenging case?


Nurse 1: High acuity lists come with many challenges and challenging cases. The familiar team I work with always just steps into action when required for these cases. We have excellent outcomes because we effectively communicate, learn from each other, and most importantly support each other as a team.


As we can see from these insights, the nurses and collective surgical team pick-up and feel the same impacts from team familiarity. It is an area that can be overlooked or disregarded, and yet the day-to-day experiences and data support that it is a critical factor in patient outcomes, and an area that can provide either great satisfaction or stress for each member of the team.

We’re excited to be highlighting the experiences of different team members and aim to open the dialogue around how we can enhance team familiarity and lead to better surgical outcomes overall.