Teamwork in the operating room

The Challenge

Working in an Operating Room environment is highly stressful team operation. Renier de Graaf hospital in Den Haag commissioned a design team at TU Delft to see how teamwork in the OR could be improved to reduce stress and medical errors.

The Outcome

After observational studies of surgeries using contextual inquiry techniques, the concept of ”cognitive load” was used to explain differences in OR roles. A post-surgery evaluation tool based on this theory was designed.

Skip to: Research: Teamwork in the Operating Room, Product Development: Cognitive Load as Communication Tool, Outcome: An Evaluation Tool, Gamified Surgery: Communicating the Product

Teamwork in the Operating Room

Our team first donned scrubs and headed into the operating room to observe several hip arthroscopy operations performed by the Renier de Graaf team.

Since operations are complex activities, we used the method of contextual analysis to process our observation results. This involves breaking down the activity into various aspects: physical space, interactions and policies and cultural norms observed.

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This physical model showed an activity where some actors moved around continually, acting as a conduit between those who were mostly static. This affects the team interactions and different actors’ awareness of each others tasks.

Flow Diagram Combined - Revised 6_11_2105

detail flow diagram

The model above shows the flow of interactions between team members before, during and after the operation.

Through all these models, we found a common theme – work was not distributed equally among OR team members. Obviously each role and its responsibilities are different, but beyond that there was a severe imbalance in the cognitive load experienced by different OR team members.

Cognitive load is a function of the number of different inputs and outputs a person has to balance when performing a task. The surgeon – who must operate on the patient, communicate with the rest of the team and keep an eye on operation progress – is heavily overloaded. The circulating nurse, who must constantly move around the room performing tasks, co-ordinating artifacts and communicating between actors, is also heavily overloaded. Whereas the anaesthetist and radiologist are ”underloaded” – they have little to focus on, and so lost concentration and lose track of the operation. This leads to breakdowns in teamwork as the ‘underloaded’ members are not ready with the ‘overloaded’ members need them.

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graph of perceived cognitive load of different OR team members over the course of an operation
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example of cognitive overload during an operation

Cognitive load as a communication tool

We presented our mapping of cognitive load to OR teams. We found that not only did they agree with the cognitive load graph as an analysis of the OR situation, but, surprisingly, the idea of ‘cognitive load’ in general sparked enthusiastic and meaningful discussions in the team about the operations. The teams felt that cognitive loading was something they could ‘feel’, and recall more easily than their exact thoughts at each moment of the operation, so found it natural to discuss. They also felt that they could freely discuss it with their colleagues more easily than describing ‘stress’, or ’emotion’, which carried some stigma.


Taking this idea further, we then asked each OR member in the session to draw out and annotate their cognitive load during an operation, and to estimate with their colleague’s cognitive loading was. After this exercise, we discovered that the team had very little idea of what other people were feeling at different points in the operation, and so often unwittingly contributed to each others stress.

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Because of the value of this technique seen in the user feedback sessions, we decided to turn the concept of cognitive load itself into a product: a post-operation evaluation tool.

An Operation Evaluation Tool based on Cognitive Load

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We took the concept created with the OR team and developed it into an idea for a pre- and post- operation evaluation tool based around cognitive loading. The concept can use either a smart whiteboard or a low-tech pen and paper – in either case, each team members can draw their experienced cognitive load, and annotate it with notes and suggestions for improvement.

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marking a ‘problem sticker’ on an identified issue
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evaluating what caused the problem through assessing cognitive load

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‘solution sticker’ added to the graph
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a ‘solution sticker’ details a proposed solution to the problem, with a focus on collaboration

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Explaining the tool: A Gamified Surgery

TU Delft is further developing an evaluation tool based on this concept. During the development, we found while surgical professionals immediately ‘got’ the idea of cognitive load in the OR, the concept was more difficult to demonstrate to other stakeholders.

A ‘demonstration game’ was devised to illustrate the unequal distribution of cognitive load during a surgery. Players have to collaborate to complete a ”buzzwire” game, each in roles designed with the ‘cognitive loads’ of surgeon, scrub nurse and radiologist.


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