In the Literature
Jan 2010

Perceptions of Teamwork in the OR: Roles and Expectations

Allison L. Grady
Virtual Mentor. 2010;12(1):24-26. doi: 10.1001/virtualmentor.2010.12.1.jdsc1-1001.


Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J Am Coll Surg. 2006;202(5):746-752.

Teamwork—the word brings to mind motivational speeches, great sports teams, and corporate slogans. In fact, the word has almost become a cliche—overused, unoriginal, and diluted in meaning. But in the field of medicine, as Makary and colleagues note in “Operating Room Teamwork among Physicians and Nurses: Teamwork in the Eye of the Beholder,” teamwork is not just a buzzword or fuzzy concept [1]. Rather, it “is an integral component of a culture…and, accordingly, is an important surrogate of patient safety” [2]. Makary et al. focus specifically on the operating room (OR), providing pointed insight into an environment that requires many players to be involved in a single high-stakes procedure.

The operating room has long been known to be hierarchical. Led by a physician-surgeon, anesthesiologists (also MDs), nurses, certified nurse-anesthetists, and surgical technicians all play important roles in successful surgery on an unconscious patient. Due to the high professional-to-patient ratio, the importance of maintaining a sterile field, and the need to complete the surgery in a timely fashion, leadership, direction, and communication are all vital to a well-run OR. Traditionally, the physician-surgeon has given orders and dictated the pace, an approach that has not always proved to be ideal. In 1998, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) identified “breakdowns in communication as the leading root cause of wrong-site operations, and other sentinel events” [2]. To help correct this problem, JCAHO and the Institute of Medicine recommended that hospitals “promote effective team functioning” and “measure culture” [2]. No specific tool has been designed to achieve these goals in the OR.

Makary and colleagues set out “to measure teamwork in the surgical setting…to compare ratings of teamwork within and between OR caregivers” [3]. Using the Intensive Care Unit Management Attitude Questionnaire as a template, the authors created the Safety Attitudes Questionnaire. Particularly interested in the ratings that OR staff members gave each other, the authors asked responders to describe on a scale of 1 (very low) to 5 (very high) the quality of communication and collaboration they had experienced with surgeons, anesthesiologists, surgical technicians, certified registered nurse anesthetists and OR nurses [3]. The survey was sent to all OR staff of Catholic health systems in 16 states (for a total of 60 hospitals) and had a response rate of 71 percent, with 79 percent of nurses returning the completed survey, and 67 percent of certified nurse anesthetists participating. The other disciplines fell between these two percentages.

The survey results showed a major difference between physicians’ and nonphysicians’ perception of teamwork. Makary et al. found that, while physicians rated their disciplines the highest for teamwork, they were given the lowest ratings by their colleagues. OR nurses were awarded the highest marks for teamwork by others. OR nurses gave teamwork with surgeons an average 3.53, while surgeons rated OR nurses at an average 4.42 [4]. The authors also found that each discipline perceived its members as effective team workers and that the majority of physician-surgeons believed that “everyone in the OR is doing a good job in terms of teamwork” [4].

The most striking finding from this study was how differently nurses and doctors viewed communication and teamwork. The authors suggest that this could be part of a long-standing discrepancy between nurses and physicians with regard to “status, authority, gender, training, and patient-care responsibilities” [4]. They also astutely point out that the disconnect between the professions may have less to do with these historical problems and more to do with the fact that they have different definitions of teamwork. In the discussion portion of the survey, “nurses often describe good collaboration as having their input respected, and physicians often describe good collaboration as having nurses who anticipate their needs and follow instructions” [4]. These differences are significant, because if nurses do not believe that physicians value their input, and if physicians expect nurses to be focused on the surgeon, then the likelihood is slim that nurses will speak up when they sense something going wrong with the patient. This hesitancy to voice concerns or confront a surgeon—for whatever reason—leads to greater career dissatisfaction, compromised patient safety, and poorer patient outcomes.

This study, while interesting, was also limited. The authors acknowledge that “perceptions of communication can vary over time and can be influenced by acute events within the OR” [5]. This variable is, to me, the most significant and has the greatest chance for affecting opinions. Another limitation the authors point out is that these responses to the survey are possibly “tainted.” In other words, many hospitals have already initiated patient-safety measures that may have had an effect on the way staff and caregivers described effective communication [6].

Overall, I think that the authors have identified an important aspect of the culture of the OR—communication—and have demonstrated how that culture can adversely affect patient outcomes and safety and lead to higher levels of professional dissatisfaction among OR staff. I would be interested in a study that took this research to the next level by suggesting ways to change the culture of the OR. The authors do discuss a program at Johns Hopkins in which pre- and post-surgery conferences bring caregivers together beforehand to discuss the expectations and goals of the surgery and, following the procedure, to debrief and share impressions of the case. I believe that this could be helpful, but the climate of each OR is different, and I would be interested in seeing the outcomes of various approaches measured.


  1. Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J Am Coll Surg. 2006;202(5):746-752.
  2. Makary et al., 746.

  3. Makary et al., 747.

  4. Makary et al., 748.

  5. Makary et al., 750.

  6. Makary et al., 751.


Virtual Mentor. 2010;12(1):24-26.



The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.