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Psychological Context, Individual Differences and Adjustment in Relation to Cardiac … 341
At present there is limited knowledge
regarding the assessment of surgical scars post
cardiac surgery. A recent study from China
involving a small number of patients highlights
scar assessment as an integral part of assessing
the aesthetic outcomes of cardiac surgery. For the
SCAR Comesis Assessment and Rating Scale the
median sternotomy group scored statistically
significantly higher than the non-sternotomy
group on the “overall impression” and “patient
question” with higher scores indicating less
patient satisfaction [6]. The results in another
paper [7], considering the psychological effects
of skin incision size in cardiac surgery, highlights
significant differences between the nonsternotomy and sternotomy approaches with
small incision patients having lower levels of
depression and anxiety symptoms and better
quality of life. Additionally, mean score differences of scar perception were markedly different
with non-sternotomy patients evaluating the scar
quality significantly better than sternotomy
patients.
According to NHS England and NHS
Improvement, mental health difficulties represent
the largest cause of disability in the UK, with one
in four adults experiencing at least one diagnosable mental health condition in any given year
[8]. The current evolving COVID-19 pandemic
also has physical, psychological and financial
implications for services, patients and their carers. In this context, routine screening of patient’s
emotional health and trauma histories would
assist the multi-disciplinary cardiac team to
understand the individual needs of the patient
and plan care accordingly both pre and postsurgery. Any assumption that one surgical
approach fits all does not account for individual
differences, psychological context and potential
adjustment issues. The challenge in the complex
decision making relevant to any surgical procedure is to consider how patient choice and other
factors that could influence adjustment and coping become incorporated in a meaningful, safe
and effective way.
The work I have undertaken within the cardiac specialty in addition to my personal experience has helped me to understand that
discussions about surgical incisions and the
remnant scars warrant attention during the consent process. Patients with a history of psychological and, or physical trauma, those
experiencing multiple disadvantage and, or social
isolation are likely to be at higher risk of postoperative adjustment difficulties including body
image issues, negative scar perception and
reduced adherence to medically informed rehabilitation advice. This understanding helps to
inform the development of models focused on
psychological preparation for cardiac surgery [9].
Endoscopic cardiac surgery incision s may have a
role to play in a sub-group of patients particularly
where, from a subjective perspective, a smaller
scar could reduce potential distress post-surgery.
From a clinical perspective, we will only
understand this through holistic assessment of
individual contexts and risk factors in addition to
further research in this area. Psychological
adjustment to both traditional surgical approaches and newer endosco pic techniques will be a
fertile field for future psychological research. As
Salzmann et al. conclude: “it seems important to
treat not only the heart but also the mind as well
to improve clinical outcomes after cardiac surgery.
” [9].
References
1. Rumsey N, Charlton R, Clarke A, Harcourt D,
James H, Jenkinson E et al. Factors associated with
distress and positive adjustment in people with
disfigurement: evidence from large multi-centered
study. In: Rumsey N, Harcourt D, editors. The Oxford
handbook of the psychology of appearance. (under
review).
2. Brown BC, Moss TP, McGrouther DA, Bayat A. Skin
scar preconceptions must be challenged: importance of
self-perception in skin scarring. J Plast Reconstr
Aesthet Surg. 2010;63(6):1022–9.
3. Ackerman MG, Sharipo PA. Psychological effects of
invasive cardiac surgery and cardiac transplantation.
In: Alvarenga M, Byrne D, editors. Handbook of
psychocardiology. Singapore: Springer;2016. https://
doi.org/10.1007/978-981-287-206-7_26.
4. Guler E, Schmid JP, Wiedemar L, Saner H, Schnyder U, von Känel R. Clinical diagnosis of posttraumatic stress disorder after myocardial infarction. Clin
Cardiol. 2009;32(3):125–9. https://doi.org/10.1002/
clc.20384.PMID:19301284;PMID:PMC6653086.
342 K. L. Green
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5. İyigün T, Kaya M, Gülbeyaz SÖ,Fıstıkçı N, Uyanık
G, Yılmaz B, Onan B, Erkanlı K. Patient body image,
self-esteem, and cosmetic results of minimally invasive robotic cardiac surgery. Int J Surg. 2017;39:88–
94. https://doi.org/10.1016/j.ijsu.2017.01.105. Epub
2017 Jan 29 PMID: 28143731.
6. Huang LC, Chen DZ, Chen LW, Xu QC, Zheng ZH,
Dai XF. The use of the Scar Cosmesis Assessment and
rating scale to evaluate the cosmetic outcomes of
totally thoracoscopic cardiac surgery. J Cardiothorac
Surg. 2020;15(1):250. Published 2020 Sep 11. https://
doi.org/10.1186/s13019-020-01294-w.
7. Piarulli A, Chiariello GA, Bruno P, et al. Psychological
effects of skin incision size in minimally invasive valve
surgery patients. Innovations. 2020;15(6):532–40.
8. NHS England and NHS Improvement. Adult and older
adult mental health. 2020. https://www.england.nhs.
uk/mental-health/adults/
9. Salzmann S, Salzmann-Djufri M, Wilhelm M, et al.
Psychological preparation for cardiac surgery. Curr
Cardiol Rep. 2020;22:172. https://doi.org/10.1007/
s11886-020-01424-9.
Leadership, Interpersonal Dynamics
and the Adoption of Minimally
Invasive Endoscopic Mitral Valve
Surgery
Megan Joffe
Abstract
In any field, individuals and teams who
implement innovative practices in the workplace face personal, professional, and organizational challenges when they try to encourage
widespread adoption of new ways of working.
In surgery, where success has historically
depended on continuous learning and safe,
well-governed adoption, the challenges of
introducing disruptive, innovative approaches,
are particularly marked. The objectives of this
chapter are to explore the challenges faced by a
group of early adopters of minimally invasive
mini-mitral valve surgery (MIS) in the nationalized health system in the United Kingdom
and to outline the lessons learned so that
surgical innovators of the future might better
prepare their own implementation efforts. It
demonstrates that key to understanding the
lessons of these innovative practitioners is a
recognition of the psychology of behaviour
within organisations and how it influences the
adoption of new techniques. While training
together as a team has been shown to be a key
factor in successful implementation (Edmond-
son et al., Administrative Science Quarterly
46:685–716, 2001) less attention has been paid
to the personality of the individual surgeon,
and the behaviour of groups of surgeons, and
how organizational and collegial politics are
navigated to gain support for the implementation of innovative practice. A key finding of
this study was that an understanding of
psychology rather than a one-dimensional
focus on the science, that is on the surgical
procedure and its value, would be beneficial to
the implementation process. This chapter aims
to highlight the contextual, organizational and
team issues faced by this group of surgeons
and to explore how these link to key concepts
in organizational psychology, such as team
and organizational dynamics. Individual surgeons’ behaviourial reflections are also linked
to the concept of learning agility to highlight
where lessons can be learned.
Keywords
InnovationOrganizational psychology
Learning agilityTeamPsychological safety
M. Joffe (&)
Organisational Clinical Psychologist, Edgecumbe
Group Limited, Bristol, England
e-mail: megan.joffe@edgecumbe.co.uk
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
J. Zacharias (ed.), Endoscopic Cardiac Surgery,
https://doi.org/10.1007/978-3-031-21104-1_24
343
344 M. Joffe
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1 Introduction
1.1 Background History of MIS
in the United Kingdom
Minimally invasive mitral valve surgery
(MIS) was introduced to the United Kingdom
National Health Service (NHS) 24 years ago
following interest created by American surgeons
in the mid-1990s who first experimented with
dogs using long instruments to reach the heart
through the ribs, rather than the breastbone,
before introducing it to humans [1]. Since then,
techniques have developed rapidly. Benefits of
MIS for patients include less pain, faster recovery, and smaller scars. The advantages for the
hospital include shorter length of stay [2], and
benefits to patients increase the appeal of the
service, and in time, the realization of greater
income which may be an incentive in both privatized and nationalized systems. Indeed, there is
an economic imperative to adopt new technologies for sustained competitiveness [3] notwithstanding the need to keep up with the latest
treatment options. In the UK, many units
implemented MIS techniques, following the
pioneering US surgeons, but by early 2000 all
had reverted to traditional sternotomy surgery,
despite MIS gaining traction in Europe [4] and
the US [5].
Nevertheless, in the early 2000s, a small
number of UK cardiac surgeons, keen to adopt
MIS techniques safely, honed their nascent
interest in these procedures through independent
training and mentoring in Europe. They returned
to their units to reintroduce MIS in what was
experienced as an unwelcoming, and at times,
hostile national and organizational climate.
Today there are over 10 units undertaking cardiac MIS, but the approach remains a minority
interest and its successes are uncelebrated.
Informal figures indicate that MIS mitral valve
surgery constitutes approximately 8% of mitral
valve cardiac surgery in the UK while in Germany, with a population only slightly larger than
the UK, it represents 55% [6]. With the
establishment of the British and Irish Society of
Minimally Invasive Cardiac Surgery (BISMICS),
MIS has achieved a higher profile and there are
reportedly signs of support from professional
bodies e.g. the Society of Cardio-Thoracic Surgeons (SCTS) and the wider surgical community.
Despite the higher profile, there remains a degree
of institutional inertia which continues to present
a barrier to attracting junior surgeons to the subspecialty, and to making MIS more widely
available to patients, despite individual surgeon
experiences being positive with good patient
outcomes, and patients reporting high satisfaction with the procedure and outcome.
Surgical innovation typically struggles to
report evidence along traditional lines, such as
randomized control trials (RCT), and the surgeons in this study struggled in the early stages
of the surgical develo pment process, as outlined
in the IDEAL framework [7] to produce such
evidence. This presented as a significant, but not
untypical barrier, to gaining collegial and organizational support. Notwithstanding this, adoption of minimally invasive surgery is well
documented in other surgical specialties. Why
then has it been a struggle for MIS to gain traction and become as popular a procedure in the
UK as it has in Europe or the United States?
This chapter is based on the research outcomes from a qualitative study of the experience
of nine surgeons, early adopters of MIS, in the
UK. Early adopters are those keen to adopt a new
product or technique before the majority [8].
What makes the experience of these nine surgeons unique is that their learning was achieved
against a backdrop of intense scrutiny in cardiac
surgery, which has low margins for error, and
strong collegial skepticism, the latter being typical of most innovation efforts. A small number
of the nine reported conditional support from a
few colleagues and their organizations but the
majority reported active resistance, in the form of
public criticism of their ethics and motives;
suspicion about outcomes in the absence of
RCTs; lack of funding for necessary equipment;
resistance to requests to train and form stable
Leadership, Interpersonal Dynamics and the Adoption of Minimally Invasive Endoscopic … 345
operating teams, and lack of curriculum support
for training junior surgeons. Although they did
not perceive the lack of support and criticism as
personal, these factors were significant hurdles.
Within this context, introducing MIS mitral surgery has proven a bumpy ride, with some distance yet to go, proving that introducing new,
innovative technology into complex organizations is more difficult than expected. A key
finding of the study was that an understanding of
psychology rather than a one-dimensional focus
on the science, that is on the surgical procedure
and its value, would be bene ficial to the implementation process.
Psychology is defined as the scientific study
of the mind and how it dictates and influences
our behaviour, from communication and memory
to thought and emotion [9]. Broadly speaking, as
a group, surgeons are not typically known to
have an interest in the psychological aspects of
work, although this has been changing with the
greater focus on human factors and the role these
play in the healthcare system including an
interest in a wider range of solutions than
checklists, protocols or training [10]. Research
has begun to explore the complex relationship
between human behaviour and technology, tasks,
environment and organization [10].
Human factors support the delivery of patient
care by “enhancing clinical performance through
an understanding of the effects of teamwork,
tasks, equipment, workspace, culture and organisation on human behaviour and abilities and
application of that knowledge in clinical settings”
[11]. The experiences of the surgeons in this
study demonstrate the relevance of understanding
how individual, group and organisational behaviour, in other words, psychology, affect the
successful introduction of change and implementation of innovative technology. As
Edmonson [3] has pointed out, introducing new
technology has disrupting effects on relationships
AND what she calls “organizational routines”,or
ways of working. The surgeons in this study
reflected that understanding organizational relationships and behaviour, and the politics and
power dynamics underlying these, is potentially
more important than many innovators
acknowledge given that they are often in the
thrall of the technology.
This chapter now focuses on a brief description of the national context within which the
implementation journey started. It then goes on
to describe several features of the nine surgeons’
experience and how relevant psychological theory can help to explain those features. Lessons
are drawn that it is hoped will help surgeons who
wish to introduce innovation in the future.
2 The National Context
The early 2000s in the UK was a time of intense
scrutiny of cardiac surgery. The Bristol Inquiry
[12] (2001), reporting on the tragic outcomes in
paediatric cardiac surgery (1991–1995), together
with other tragedies involving individual surgeons with poor patient outcomes, attracted
media interest and threatened surgical endeavour
that was not fully evidence based. Technically,
MIS is a challenging procedure and does not lend
itself to the questionable “See one, Do one,
Teach one” school of medical training. The
development of complex surgical motor skills,
perceptual-motor co-ordination and effective
motor schemas required in MIS take time to
acquire [13] and the misplaced confidence of a
few surgeons, after seeing one and then doing
one in the early years of MIS in the UK did not
serve the MIS cause. The professional and the
social context became increasingly skeptical,
even hostile to innovation, and systemically risk
averse.
The surgeons in this study were members of
several systems each embedded in other, larger
systems. They were members of the consultant
group of surgeons in their hospital; each of the
surgeons is also individually affiliated with the
Royal College of Surgeons and regulated by the
General Medical Council. The hospital in which
they each work is part of the larger NHS influenced as it is by the social and political context in
which it operates. While it was recognized that
the NHS was always going to be cautious in
accepting MIS and that, in practice, surgical innovation is not easy even with collegial and
346 M. Joffe
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managerial support, cardiac surgery’s unfortunate history resulted in heightened caution and
even mistrust of surgical motivation and
innovation.
Personal and professional risk to implementing MIS was increased when, partly because of
the Bristol scandal, national scrutiny of cardiac
surgeons was introduced in 2005, with systems
that reported patient outcomes by individual
named surgeons. While this was intended to
provide public reassurance, it received a mixed
reception. National bodies (e.g. SCTS) championed the initiative [14] but individual surgeons
reported being less enthusiastic and even fearful
and the process had the unintended consequences
[15] of dampening surgical motivation to innovate or to take on higher risk patients, even
though the data was risk adjusted.
Funding for innova tive cardiac surgery faced
(and continues to face) challenges, not least
because of competition from industry supported
trans-catheter procedures, usually conducted by
cardiologists. The suggestion that cardiac surgery
in general was being cannibalized (i.e. competed
against) and might soon be redundant also made
it difficult to persuade others of the value of MIS.
Notwithstanding these competitive challenges,
evolving research suggests that stents do not
confer as long a result as originally expected,
compared to coronary surgery [16], and given the
increasing demand from patients and the vast
need for treatment in the undeveloped world,
MIS cardiac surgery is reported to have a bright
future if innovation is adopted widely [17].
2.1 Psychology and Lesson
The complexity of these various contextual
issues seems to have created a shared mindset
that innovation, with its associated risk in cardiac
surgery, was not worth the risk. The priority
became to reduce risk and perform [18] i.e. to
deliver outcomes in the traditionally accepted
mode of open surgery rather than to innovate.
The personal risk associated with pursuing an
interest in MIS against this backdrop was high,
with strong potential for being either a hero or a
villain. The easier option was, as one surgeon
said, to take “the middle road where you can be
assured of a decent life and you won’t appear on
the front pages of the tabloids”.
Individual surgeons are unlikely to be able to
affect the national context but within this national
context is the organizational context in which the
surgery takes place. Here there is space for
influence.
3 The Organizational Context—The
Hospital
Whereas MIS is seen by those offering it, especially in the US and Europe, as an opportunity to
offer advanced patient care, attract patients to
your hospital and boost organizational reputation
and income, in the NHS, interviewees suggested
that MIS was often seen as problematic. The
political cycle with changing ministers and NHS
strategies, coupled with the rapid turnaround of
hospital chief executives and shifting commissioner demands, create an unstable climate for
innovation. Locally senior and middle management incumbents also change jobs rapidly. Getting senior management support can therefore be
difficult given this background. Moreover, many
surgeons’ typical lack of interest in the financial
and operational aspects of organizational functioning that would help create rapport and
understanding with management, also presents a
challenge. The introduction of professional
management in the late 1990s and in early 2000,
into the NHS, with its focus on targets and productivity, led to some criticism that management
was more important than technical expertise,
resulting in surgeons possibly feeling they had
less authority. The importance of senior management suppor t [19] in innovation is a key
factor in successful implementation as it offers
organizational legitimacy for the innovative
effort.
MIS procedures proved in this context to be
an operational challenge for those who did not
join customized units. MIS procedures typically
take longer than open access surgery, thereby
occupying valuable theatre space; they are not
Leadership, Interpersonal Dynamics and the Adoption of Minimally Invasive Endoscopic … 347
readily standardized making it difficult to train
others quickly or delegate to less expensive staff
to perform; no tariff changes were made and
although some instrumentation was reusable, and
manufacturers were helpful, considerable cost
and time was added to each case. One surgeon
made the point that managers do not see patients
in clinic and so cannot readily appreciate the
benefits of the surgery, seeing it instead as a
costly exercise associated with high risk and
disruption. There were also staffing implications,
as MIS requires anaesthetic and theatre staff
competent and confident to support the specific
MIS needs. The surgeons described the challenge
of convincing theater management of the need
for stable teams when management was promoting the idea of interchangeable and multiskilled theatre staff in the interests of
productivity. From a financial and productivity
perspective the organizations were not incentivized to support MIS.
As reported through the interviews, where
surgeons adopted a managerial perspective, and
worked collaboratively with managers, progress
was easier than when they did not. The surgeons
in the study recognized that they were not independent operators, but rather worked within a
larger system, i.e., the hospital. While they all
acknowledged that senior management support
was necessary for their project, their experiences
of securing that support varied. Those who
worked in a custom-built unit or were specifically appointed to lead an MIS program in a
larger hospital, were in the good starting position
of h aving organi zational legitimacy. Where the
surgeon was a lone voice for MIS, skepticism
was extremely difficult to overcome, and the
individuals had to make a business case requiring
collegial endorsement and conduct deft negotiation for which surgeons do not typically have the
training, skills, or patience.
Significantly, most of the participants were
early in their careers with, what they said was,
little “political clout” at that early stage so persuading the senior establishment (managerial and
surgical) of their cause proved frustrating. For
those who could, it proved helpful to secure the
support of a senior surgical colleague who could
provide an extra voice and be the champion in
political and managerial discussions, acting as a
“shield”.Toinfluence senior management and
garner support, another said that he deliberately
invited the most senior managers to work with
him on the business case, thereby exploring the
organisational constraints and consequences
together. Another was buoyed by the feeling that
he had had the support of the chief executive.
A fourth said that he initially resisted productivity pressure to perform more than one case a
day so that he and the team could reflect and
learn from each case. A fifth reported having to
resist pressure from an anaesthetist to work more
quickly to finish in time.
3.1 Psychology and Lesson
The instability in the organizational context,
described above, makes it all the more important
to form a strong local “guiding coalition” [20]—
a group of stakeholders in the hospital who
champion the innovative effort. The risk of losing
an advocate is reduced because the initiative will
not be dependent on only individual.
Contextualizing the experiences and examples
above through the lens of the Primary Colours
Model of Leadership [21] is useful. This model
describes the three major capabilities of leadership as being strategic, operational and interpersonal and these overlap with one another with
Leadership at the center. The strategic domain is
further divided into setting strategic direction,
creating alignment, and planning and organizing;
the operational domain into planning and organizing, team working and delivering results, and
the interpersonal domain into creating alignment,
building and sustaining relationships, and team
working. While few of the surgeons in this project intentionally focused on accomplishing all
three major tasks, the actions they took did fall
into these categories, thereby underlining the
utility of this model in understanding the different domains of leading innovation. For example,
some surgeons through the deliberate engagement of senior management, sometimes with the
help of a surgical advocate in the MIS strategy,
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were setting the strategic direction and creating
alignment, some more successfully than others.
Planning and organizing was at the center of all
the surgeons’ activities including a focus on
governance, developing their own skill over time
and the skills of the team. Delivering results was
the outcome which justified the activity and
arguably was the most important task, often
achieved through deliberately managing the
pace, rather than acquiescing to operational
(productivity) and individual demands for speed.
Results delivery was supported through team and
individual critical reflection about the technical
aspects of the operation in the inte rests of seeking greater efficiency and effectiveness during the
surgery. The surgeons seemed to pay less attention to the interpersonal domain, from a strategic
perspective. For example, although some of the
surgeons successfully engaged with managers,
for others less attention seems to have been paid
to creating alignment with colleagues and with
management with their intended direction
(MIS) in the run up to implementation, focusing
instead on the detailed planning and preparation.
Ignoring the challenges from their colleagues
(see next section) and ploughing on regardless
might, in retrospect, have been in their short-term
interests because had they not done so they might
not have embarked on MIS. It can be argued that
for some, it did not serve their long-term interests
either, because they are still struggling, to an
extent, to raise the profile of MIS.
The skills of influencing, negotiating, and
lobbying are of considerable benefit in creating
alignment whether they are held by the individual surgeon or by a colleague who is more skilled
in these areas, notwithstanding the guiding
coalition. Working as a pair of surgeons cocreating alignment and sharing responsibility can
provide reassurance to management that there is
more than one person interested in pursuing innovation. The time and effort including the
expensive outlay for equipment etc. is mitigated
to an extent if there is more than colleague
interested in implementing the initiative. It is far
easier to champion a widely supported program
than one in which one person shows interest.
Where the preparation has involved the
establishment of a small but influential internal
guiding coalition [20] with the necessary political
skills and organizational power to champion the
initiative and support the implementation this
reduces the burden on the individual surgeon
who is more often than not focused on the
technical aspects of the innovation.
Finally, the leadership aspect of the model
provides a unifying force. Leadership is a process
in which an individual influences the group to
accomplish the common goals and targets and is
based in the relationship between the leader and
the follower rather than simply in the position.
Understanding yourself through actively seeking
and receiving feedback; creating the conditions
for success, inspiring confidence and trust,
focusing efforts on priorities; enabling individuals and groups; and helping people to learn, are
all aspects of leadership. Leadership will be
discussed further in the sections below The the-
atre Team and The individual surgeon.
4 Collegial Support
Strategic rather than purely technical surgical
support from your surgical colleagues and other
specialties, such as anaesthetists and intensivists,
is obviously important and can help or hinder
implementation efforts in overt and/or covert
ways. A major trap, perhaps due to naivete, or to
over-confidence, is to assume others will be as
passionate as the innovating surgeon is about
innovative practice.
External collegial support seemed easier to
come by than internal collegial support for some
of the surgeons in this study. Other than in
custom-built units where surgeons were specifically employed to develop an MIS program,
finding local collegial support proved a challenge. While questions from colleagues were
expected, the nature of some of the challenges
was not. Examples from this study demonstrate
that collegial challenge can take many forms
from implied to explicit lack of support and, even
threat. This was summed up by one interviewee’s
comment that “implied threat is voiced when you
are asked if you can do the surgery, and then
Leadership, Interpersonal Dynamics and the Adoption of Minimally Invasive Endoscopic … 349
explicit threat can be assumed when you prove
you can because you are then viewed as competition”. An illustrative example that con-
tributed to the skeptical collegial climate was of
experienced surgeons who had attempted MIS
unsuccessfully and who then “rubbished” MIS as
a procedure. Yet another surgeon reported being
told by a more senior colleague as he was
scrubbing for his first case “ if something goes
wrong, I won’t support you”. More insidious
sabotaging was evident in the example of a
consultant colleague writing to a senior medical
manager suggesting the MIS surgeon’s work be
scrutinized. Challenges also came from supporting consultants (e.g. intensivists) about the length
of time operations were taking. Only one interviewee offered that a senior colleague had said to
him “let me know how you are getting on and if
you need help”.
Comments, reported by this small group of
surgeons, make it clear that some surgical colleagues felt threatened by this new technique and
those who practised it. This is common in those
who feel less willing to engage with innovation,
often referred to as “ late majority” or “laggards”
[8]. However, it would be naïve to overlook
subtle psychological pressures such as professional jealousy and interpersonal rivalry for
patients and for reputations, as these factors are
also likely to have affected the willingness of
some to offer collegial support.
The potential cost to the patient of even the
smallest mistake in MIS, while extremely high,
might be mitigated by reverting to open surgery
but the surgeons made the point that the associated criticism would not serve the MIS cause.
Whereas similarly serious mistakes might occur
in open surgery, a mistake in MIS attracted disproportionate criticism and led to comments
which confirmed the naysayers’ view that mistakes were due to the minimal access and that
MIS was dangerous. This is an illustration of the
effect of confirmation bias [22] the tendency to
use new data and evidence as confirmation of
one’s extant beliefs, which is a strong barrier to
positive support for implementation of innovative practice.
4.1 Psychology and Lesson
Typically, surgeons in the NHS with similar
interests are jointly responsible for service
delivery but they are not necessarily dependent
upon one another to achieve their individual
purpose or aspiration. Group members are to a
degree reliant on one another for support to have
a program of work which allows time for their
special interests as well as their other work in
support of the wider service. They are potentially
more dependent on their multi-disciplinary team
to achieve their purpose.
In exploring why the MIS implementers were
not offered greater collegial support, notwithstanding the contextual issues, it is useful to
consider the competitive nature of surgeons and
how this can affect group cohesion and interpersonal dynamics. Cohesion describes the
extent to which people are drawn to work in a
group and contribute effort to the work it does.
Group dynamics are the effects of individual
team member’s motivations, interests, behaviors
and roles on each other and the larger
group. These effects are often, but not always,
unconscious, and they can combine to provide an
unhealthy psychological climate with challenging, tricky interpersonal consequences.
Surgeons are well known for being competitive individuals—simply succeeding through
competitive entry into medical school and surgical training requires determination, goal-focus
and a competitive spirit. This competitiveness
does not simply dissolve in qualifie d and established surgeons. Competitiveness is one of the
psychological and/or behavioral factors which
influence the group and its dynamics.
Rivalry, whether public or in the shadows, has
the positive potential to increase motivation but
also to affect group dynam ics by creating interpersonal friction and obstructive behaviour.
Whether the rivalry is in the interests of personal
reputation, private practice or is located in professional jealousy, it should not be ignored. How
the innovating surgeon frames the implementation of the new technology and the way it
impacts their own and others’ work is important
350 M. Joffe
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and has the potential to help or hinder its success.
When individuals feel excluded or threatened by
another colleague’s ability to attract patients
away from them, particularly if the other colleague is younger than they are or where the
younger colleague has not engaged with them,
the more experi enced colleague might respond
by under-mining or even by sabotaging innovation efforts.
Engaging, actively and personally, with surgical colleagues and those in supporting specialties, is essential. Consulting with them on a
one-to-one basis exploring their views and
specific concerns and acknowledging these suggests that you care not only about yourself and
your initiative but about the group. Keeping them
updated and communicating as much as possible
so that colleagues are not surprised by your
activities is time consuming but important. As
very likely a younger surgeon, it is important to
be aware that one’s more recent training in newer
procedures might threaten more established surgeons at an advantaged stage in their career and
one should take active steps to minimize such a
threat. Failing to do so might result in deliberate
or unconscious attempts to undermine your personal credibility and that of your initiative. Much
goes on in the shadows of teams and while collegial collusion, cliques and competition are
almost inevitable in most groups, the more one
communicates and is open and transparent the
easier it is likely to be to navigate through
successfully.
The experience of surgeons who started MIS
as a pair appeared to be better than those who
started on their own. Based on this research, a
buddy system is useful in the initial learning
phase to share both the pressure and learning
involved in success and/or failure and ensures
there are two people who can meet with other
colleagues, explain what they plan to do and
what governance processes they have in place.
The time needed to engage with peers should not
be under-estimated. Neither should the time
needed to engage and develop the operating
theatre team be under-estimated.
5 The Theatre Team
Trust, achieved through shared experience of
working together, is essential to the development
of interdependence which is important in all
surgery, but significantly so in MIS. Given the
need to focus on a very narrow field of surgical
vision in MIS, situational awareness is the
responsibility of the team rather than one single
surgeon. How the theatre team works together in
MIS was noted by the surgeons, as a significant
factor in the success of MIS surgery. The surgeons made much of how they helped the team
makes sense of their task. They emphasized that
the team was there for the patient and that the
surgeon was reliant on them to inform him—“be
my eyes and ears for the sake of the patient”—
rather than that they were simply there to meet
the surgeon’s ends. Put simply, the team makes a
genuine contribution rather than being a set of
readily interchangeable cogs there to perform a
task. This encourages team cohesion.
The surgeons in this research grappled with
whether the MIS procedures should be branded
as “special”, thereby needing a specially trained
team, or whether MIS should be simply another
surgical procedure. Ideally, they would have
preferred to establish a stable team which trained
together and then worked together to develop the
necessary trust and interdependence. Trust is
necessary for establishing psychological safety
i.e. a shared belief held by members of a team
that the team is safe for interpersonal risk taking
[23]. Psychological safety allows team members
the confidence to take on the responsibility of
working in an MIS cardiac theatre which
includes feeling confident to ask a question
and/or voice a concern.
Although most had a stable team for the initial
training, they cited the development of a longterm stable team as one of the biggest challenges.
Following the initial training, surgeons had in
some situations to adapt to working with a wide
range of theatre staff and with teams where there
was no previous collective learning. This was not
the case for those customised units who were
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