Resource and logistical constraints

Surgical team members highlighted the daily struggles they faced in having to cope with inadequate facilities, obsolete and malfunctioning laboratory equipment and overcrowded clinical areas. Taken together, these factors created unsafe environments. There were ongoing difficulties with obtaining basic medical consumables such as gloves, syringes, sanitisers and sutures. These items are frequently unavailable or only in limited quantities and are often of poor quality or the wrong size. Some essential items such as gloves are strictly allocated for specified periods or a particular shift irrespective of how patient needs for care unfold. Moreover, we heard reports that vital equipment that should be available in each theatre is sometimes shared or surgeries have to be relocated at short notice to theatres where equipment is available. This is typical of extreme deprivation of materials and equipment which is common in developing countries.15 47

I am supposed to work with gloves, especially there are gloves that you need when a woman retain placenta you go in it, but these are not there. So, you use the short one and blood covers all your hands (Consultant Surgeon 2 B)

Sometimes you have only one machine maybe 3 or 4 theatres and there are only two diathermy machines, and you have to move one from this theatre to the other so that you can have the case done (Peri Operative 5 A)

Team members reported that they adjusted to resource constraints by maximising the use of available resources in ways that can give rise to unsafe care. This practise was commonly referred to as ‘improvising’ and involved conscious deviations from standard guidelines and procedures. Examples included using disposable items more than once and generally ‘cutting corners’ to circumvent or temporarily ‘fix’ inadequate technology and equipment. Improvising also involved compromising on the quality of items. For example, expired vital drugs and poor-quality sutures that easily tear after surgery and expose patients to infection were used when management declined to fund replacements. These situations align with previous studies which have found that temporary ‘quick fixes’ and workarounds are often necessitated because of inadequate supplies, understaffing and malfunctioning equipment.11 12

Sometimes we don’t have the requisite equipment, materials at hand so that we will be able to perform surgery satisfactorily. You get to the theatre and it like what you get is what you use, we always improvise (Consultant Surgeon 2 B)

Like if we need a specific syringe or a sterile glove and that one is not there, you will be forced to use a disposable glove and therefore infection will set in. So improvising is common here and it is not helping (Surgical Ward Matron 1 A)

Transgressing normalised working boundaries

It was reported that the normalisation of unsafe practice makes it difficult to speak up about concerns. Healthcare professionals are primarily concerned with managing limited material resources for care. This makes it problematic to question long-established norms of behaviour that have been affirmed over many years and woven into the fabric of care delivery. When concerns are raised, they are generally not welcomed by colleagues and those in authority. This reflects strong social and group conformity48 that legitimises harmful ‘improvision’ and elicits silence when confronted with threats to patient safety.

Most of the issues have to do with people’s frustrations with things like equipment, rather than team issues like voice. Not that it doesn’t exist, but it is not recognised as a major factor because people will say but if I don’t have this or that to work with why should I worry about team problems? It is the least of their problems! (Manager, Consultant Surgeon 1 A)

Sometimes we are supposed to use something for patients ‘ one time’ but because we don’t get it, we will use it 3 or 4 times and …it becomes the norm such that if you want the correct thing done, people will say -ooooh you want to waste it [resources] – NO (Peri Operative Nurse Matron 1 A)

There are far less instrument at the ward for dressing wounds and managing patients and they have ‘ manufactured’ way of doing things [improvising]. So, if you come and you are not privy to that normal way of doing things then it becomes a problem for you (Surgical Ward Nurse 3 B)

The situation is reinforced by a steep authority gradient and leaders’ preoccupation with managing with severely limited resources. According to respondents, although they work together as a team, the strong authority gradient which underpins their work enables leaders to exercise strict control over how and when care is delivered.

…in the surgical team, we are all not the same – we are not at the same level. The surgeon is a doctor and a specialist… The scrub nurse might be a degree holder– so even if you are right, you are told to be wrong (Peri-Operative Nurse 3 B)

Power as in who is in authority, power as in who will find himself head of the team. And the way he or she sees things. That is how it must go (Senior Nurse Anaesthetist 3 A)

In addition, we found the onerous demands associated with managing with limited resources inclines heads of units, teams and departments to downplay and trivialise employee voice. Some senior managers showed little appreciation for employee voice and were not motivated to hear and act on concerns when they are raised.

I know attitude of seniors can inhibit voice, but such is not common in our system. My mistakes as a surgeon cannot make much difference, cause any much harm. The issue of harm is due to people not being listened to is somehow exaggerated. The problem we have is lack of resources (Manager, Consultant Surgeon 3 B)

Moreover, we found that surgical leaders apply coercive power to ensure economical use of resources and punish staff who do not manage to work within these constraints. For example, we heard reports that staff are sometimes required to squeeze blood out of gauzes for reuse in surgical dressings. Others are ostracised, reprimanded or punished for insubordination for raising concerns and trying to maintain patient safety standards against the economical resource use expectations of superiors.

A matron told me I could use only one pack of gauze for the case, but I needed more to work with. There was blood all over and we had to mop and clean with the gauze. But she kept telling me I should use only a pack of gauze. And I didn’t know what to do but like she said I have to manage with it (Senior Peri Operative Nurse 5 A)

Sometimes if you stand by your point and it is reported, you are given a query letter. Should I be the one to say it for them to take me on? (Peri Operative Nurse 2 A)

We found that the daily stress associated with having to work with unserviceable and malfunctioning equipment engendered unsafe care and employee silence. For example, we heard reports of surgeons using inappropriate instruments in ways that risk safety as well as surgeons becoming so frustrated with malfunctioning instruments during procedures that they threw them away. Previous studies have found problems with surgical instruments as a source of stress13 14 with surgeons sometimes engaging in unsafe practices which is rarely criticised.49 50 We found that team members are hesitant about making suggestions about improving safety to surgeons who are already struggling with equipment and making the best of what they had. And surgeons on their part tended to disregard suggestions about how care could be improved.

Sometimes the surgeons can throw away the instrument. some will also break the instrument and tell you – this is not the instrument I need, get me a better or the right instrument. He can just throw it away. So, whether it hits you or not (Senior Peri Operative Nurse 5 A)

Maybe you are telling the surgeon something, and he is struggling with the instrument, he will not listen to you (Peri Operative Nurse 3 B)

Resources are not available, so the lead surgeon is probably looking at how he does something which works and not necessarily how it is done internationally. So even though what he is doing is not necessarily right he probably wouldn’t listen to anyone because he just wants to do what he does which is safe for the patient. So, if anyone makes a suggestion you are likely to ignore them (Specialist Surgeon 4 A)

High workload and unsupportive atmosphere for raising concerns

Both hospitals have a high patient to staff ratio with long lists of daily scheduled surgeries. Each theatre undertakes seven to eight surgeries daily and wards are always full of patients being prepared for surgery or recovering. Stress from such an intensive workload and inadequate working space creates an unsupportive atmosphere for voicing concerns.

Yes, there is excessive work demand, if you pick the list of cases [surgeries] today like 8 cases in one theatre so we need to be working briskly and it can be hostile (Consultant Anaesthesiologist 3 A)

…the day that the list is short everybody is friendlier but when you have a long list there is potential acrimony (Resident Surgeon 1 A)

Attending to so many patients within a limited time frame makes it difficult for team members to comply with safety standards or raise concerns with colleagues when these are not met. This reflects how high workload leads to poor care and silence. Beyond the tendency to remain silent, team members reported how high workload and stress in surgical units engenders harsh voice and responses. Raising concerns even in a ‘cordial manner’ sometimes led to negative reactions. The stress resulting from high workload takes a toll on personal resources such as physical energy and emotions34 leading to an unfriendly and hostile voice atmosphere and failure to act on patient safety concerns.

You know sometimes the stress of work – the person is looking at workload and also looking at what you are doing which he thinks is not in the right channel. The tendency is to flare up. They easily get pissed off (Peri Operative Nurse 5 A)

It was a difficult operation, after doing it we realise that we had turned the intestine upside down then I drew his attention [the lead surgeon]to it. He said oooh the child’s prognosis is not good and coming to do all that is going to be very difficult. So, we left it like that (Resident 4 B)

Silence as avoidance of additional work

We found that overwhelming workload inclines many team members to remain silent to avoid the burden of having to take on additional work to remedy threats to patient safety . Similarly, it was reported that some surgical leaders tended to disregard or trivialise concerns due to the implications of having to take on the burden of the additional responsibilities required to deal with the situation.

We had a very difficult case that took about 8 hours and in the recovery room we realise there was a problem, so we went to call this boss. But going back to look for another blood for the additional procedure will even be another headache. He [the boss] just told us - at this point there is nothing he can do. So, we left it so (Resident 5 A)

Sometimes you are too stressed, that is one of the reasons why you may not like to go an extra mile. If I tell my boss that we should do it this way, we are going to spend another one hour on the ward. But I am tired, so fine we will just do it the way he wants it done even though I know it is not the right way or the best… So, if your boss says it is a hopeless case well you leave it (House Officer 1 B)

Some people go about the work at baseline level because they are just not satisfied with number one –lack of basic things to work, remuneration. So, they just perform basic functions they don’t want to do anything out of their way. They will never speak - they have nothing to say about anything. Just come and do the barest minimum and go away (Senior Specialist Surgeon 2 A)

Responses revealed that speaking up about patient safety concerns is a strenuous and taxing act for observers of unsafe care and for colleagues who are already overwhelmed with work. This reflects the inclination to conserve and refrain from investing further resources when experiencing persistent loss of personal resources such as energy and emotions.34

You see! when you are tired with a lot of workload you don’t feel like talking. The little energy you have you will rather reserve it for something else rather than talking which of course might not be taken at the end of the day so why bother yourself to talk (Senior Peri Operative Nurse 2 A).