Research has shown that errors in the Operating Room (OR) occur both within and between clinical teams [21, 22]. Quite often, errors result from a breakdown in coordination and communication between the OR sub-teams [23]. For example, the scrub nurse and the surgeon failing to anticipate and synchronize their actions so that a particular instrument is not available at a critical moment, leading to excessive bleeding or hemodynamic instability; or, the anesthesiologist acting unilaterally because he does not understand the immediate priorities of the surgeon. Other things that are known to distract and aggravate the mindfulness of the team include [24, 25]:

The impact of errors committed by non-surgical members of the team, such as OR nurses, orderlies, and perfusionists, during open-heart surgery, is not well known, but is likely to be significant [26–28]. Instructions from the attending surgeon and anesthesiologist to their assistants (or vice versa) can also result in errors (e.g. failure to administer anticoagulants leading to a delay in being able to commence cardiopulmonary bypass). Faulty communication and effective handovers to the team in the intensive care unit have been identified as a particular problem [29]. Another major source of error is the handover of responsibility for a patient by one health professional to another.

In similar complex environments, referred also as complex socio-technical systems, research about human factors has been a major contributor to enhancement of safety and reliability [30]. The importance of research about human factors research about systems in improving outcomes of pediatric cardiac surgery was highlighted in the Bristol Royal Infirmary Report [31], the Report of the Manitoba Pediatric Cardiac Surgery Inquest [32], and ongoing multi-national professional groups [33]. A key lesson from the Bristol and the Mid Staffordshire inquiries [34] is that once a professional group normalizes a deviant organizational practice, it is no longer viewed as an aberrant act that elicits an exceptional response; instead, it becomes a routine activity that is commonly anticipated and frequently used [35]. This process is known as “normalized deviance”. A permissive ethical climate and an inordinate emphasis on financial considerations in care can both contribute to managerial and clinician decisions to initiate deviance [36].

In pediatric cardiac surgery the expectations of families, administrators, and clinicians are uniformly high. Pediatric cardiac surgery has become a microcosm from which the wider medical community has sought to understand how to provide complex multidisciplinary care. Failures of units providing pediatric cardiac surgical care continue to occur with repeating themes including initial publication of apparent excess mortality from small units and the naming and shaming of surgeons involved [37]. Subsequent enquiries often highlight “system issues” including [37, 38]

Systems of clinical governance have generally focused on dealing with bad outcomes, and these suboptimal outcomes are generally not recognized in advance. Robust and widely adopted systems of risk stratification systems that allow cases to be classified on the basis of operative complexity and risk allow comparison of risk-adjusted outcomes between diverse pediatric cardiac units:

It is generally accepted that open and transparent reporting of outcomes on a regular basis is ideal, as is commonly done in the UK [39, 40]. Real time analysis and reporting of outcomes for internal purposes, to identify early trends and under-performance of the system, is possible, but difficult to achieve in practice [41].

Most applicants for training in cardiac surgery are high achievers with high self-confidence. These applicants are goal oriented and have a strong sense in their ability to control their actions and environment. They are used to subjugating their personal needs to those of their career, although the balance considered acceptable is probably changing [42, 43]. ‘Being’ a cardiac surgeon also brings a degree of positional power within the institution and status within the medical and wider communities that may be attractive to some. Cardiac surgeons need to be able to marshal the resources in the operating room and initiate rapid changes in management, which require mature and adaptive skills in the command and control of others. There are also some surgeons, many of them undoubtedly talented, who blur the margins between forceful behavior and demonstration of narcissistic personality. Narcissistic traits, according to psychiatric nomenclature, include [44]:

Other disruptive features include a tendency in some circumstances to externalize the reasons for failure where they exist, rather than taking responsibility or acknowledging the difficulty associated as a result of patient related factors. In extreme cases these behaviors might include throwing instruments, yelling, and diminishing members of the team.

These actions can be seen as intimidating and threatening to the psychological safety of other members of the team, hampering both the safety of patient care as well as the willingness of team members to speak up and to report failures of process and outcome [45]. Psychological safety is considered the cornerstone of enabling a culture of safety. Unchecked, such individuals tend to damage or destroy relationships within their working environment to the point where a serious breakdown^__either personal or professional^__is likely to occur. When recognized early, an understanding of the underlying complaints or frustrations needs to be addressed, in tandem with clear guidelines on what constitutes acceptable and unacceptable behavior. Often senior surgeons are involved, and the authority gradient makes those outside the operating environment reluctant to speak up and engage. These conflicts can only be resolved with meaningful commitment from such individuals and tackling the issues as a team problem. A calm analysis of episodes of unacceptable behavior might reveal genuine problems with training, competence, or cooperation on the part of team members. This candid discussion could improve the standard of care and lead to a reduction in the stress levels of the surgeon. Alternately, unacceptable behavior might give the surgeon and his or her colleagues an opportunity to reflect on their own levels of stress, be it due to occupational or personal circumstances.

The consequences of not acting are clear: a culture of blame and lack of psychological safety can lead to:

Expressions of frustration and real time verbalization of stress can have important functions such as communicating the urgency or seriousness of a situation, and some forms of disruptive behavior might even be tolerated by the team in the interests of doing the best for the patient. However, behavior that erodes the core concept of teamwork must be the concern of all members of the team, because ultimately it is the outcome of the patient that can clearly suffer [50].

Surgeons may overemphasize the contribution of a ‘good operation’ to successful organizational outcomes, and under-recognize the contribution of others, thus undermining trust within the team. It is easy to understand how this conclusion is reached, since a poor operation inevitably produces poor outcomes, but such logic is flawed. ‘Teamwork’ may be misunderstood as being simply a happy work environment where members do their best to help the surgeon gain a good outcome. This scenario, of course, can fail to deliver reliably good outcomes or a productive environment since leaders, including surgeons, are required to take collective responsibility for the known failings of ‘teamwork’, as articulated by Lencioni [51]. The ‘five dysfunctions of teams’ are well known to all in health care:

Teams that don’t invest in measures to build trust have a harder time making sense (sense-making) of what others are doing. They are intimidated by debate that is necessary to generate ‘healthy conflict’, avoid clarity and closure, and then have a hard time holding each other accountable through confronting difficult issues while focusing on outcomes.

Surgeons commonly specialize in pediatric cardiac surgery after completing a general surgery residency and then a 1–4 years adult cardiac surgery fellowship that provides a solid theoretical and technical base. Training in pediatric cardiac surgery then requires them to step back from a reasonably high level of autonomy for a further 2–3 years whilst gaining experience before commencing in a consultant (attending) post. This period of mentorship brings its own challenges and opportunities.

The closeness of working relationships between pediatric cardiac surgeons and pediatric cardiologists is an attraction to some and a problem for others. This relationship requires intense communication and negotiation and intersects with the care and managing of the relationship with the family. Although much of the subsequent discussion deals with mentoring of surgeons by surgeons, some of the most expert mentoring of young surgeons is performed by pediatric cardiologists who are one step removed and are able to see the whole landscape.

Low volumes of pediatric cases make it more difficult to acquire a critical mass of experience and sustain the multiple competencies required for complex operations in a short fellowship when compared to adult practice. Younger pediatric cardiac surgeons need more experienced surgeons to mentor and direct them, inside and outside the operating room settings, and at least for the first 5 years of independent consultant (attending) practice [42, 43]. This formal mentorship requires a significant investment on behalf of the senior surgeon, and inevitably brings different stress, as junior colleagues are mentored through more complex cases. During this time, the senior surgeon is essentially taking responsibility for the conduct and outcomes of the operation. Learning is seen as a rational, linear, and developmental process involving the learning of new knowledge and skills around which improved service can be delivered. The act of learning can be portrayed as being free from bias and politically neutral, but a more realistic view is that questions of power, hierarchy, and control are interweaved with the processes of learning and mentorship [42, 43]. This relationship between mentee and mentor can be mutually satisfying [42, 43]; however, at times it can be tormenting. The relationship requires frequent renegotiation for which frameworks do not exist. It is not uncommon for these mentee-mentor relationships to become strained as the junior surgeon transitions to independent practice.

Identifying and retaining the ‘joy’ of operating is, for many, something that requires active awareness and attention [52]. Thoughtful mentorship is required throughout a surgical career, and consultant (attending) surgeons operating together on difficult or rare cases is more than simply ‘sharing the load’ or ‘spreading the experience’. In some circumstances, consultant (attending) surgeons operating together is an uncontroversial way of

Successful individuals usually cite strong mentors. As most pediatric cardiac surgeons are not ready to take on the full range of emergency and major elective operations at the time they finish formal training and become attending surgeons, mentorship is key to developing their talent, supporting their intellectual and technical growth and development, as well as actively addressing technical weaknesses [42, 43].

Low volumes of pediatric cardiac cases and financial incentives lead a significant proportion of practitioners into mixed adult and pediatric practice. This increased work can make it difficult to contribute to the non-operative elements of the pediatric cardiac surgical service, including mentoring and the development of the service and its personnel. It does bring advantages through cross-pollination with adult practice and participation in the innovations learned in the high volume settings of adult cardiac surgery. Diversity in the models of engagement (i.e. mixed adult practice vs. pediatric only practice) is a good strategy and assists in construction of a sustainable roster. Such individuals also bring with them the expectations of conduct in the operating room from the adult context that may be more hierarchical than the pediatric environment. It also, however, might lead to a lower overall number of pediatric cardiac surgical cases that must be factored into the overall competency in the early career of a surgeon.

We are well attuned to the need for management of challenges early in the career of a pediatric cardiac surgeon, but transitions at the other end of the career remain an important issue as well. In an ideal setting, older surgeons would be retained in the system to guide and coach younger colleagues to:

These older more senior surgeons would consciously create space to allow development of their younger colleagues; however, this strategy involves a level of clarity in planning and dialogue that is sometimes difficult to achieve. Since ending a career well is an important transition and many now have an expectation of working into their 70s, these considerations require close planning, attention, and candid conversations.

Pediatric cardiac surgery involves long and complex operations. All proceduralists will have observed that not all teams have equal capability. Some teams seem to be able to complete complex tasks with ease and in a good spirit whereas other teams show disharmony and conflict, sometimes with inferior clinical outcomes. Understanding what enables one team to perform more effectively and reliably than the other remains elusive and learning from ‘mistakes’ is difficult [53]. An obvious approach is for more harmonious and functional teams to work more closely with members of less functional teams in the hope of modeling better behavior of the team. Major operations that require additional hands present a natural opportunity for this cross fertilization. However, such cases in and of themselves are most likely to be stressful for all concerned and might not be ideal cases for illustrating good team dynamics.

Situations where known issues with individuals or combinations of individuals exist may create stress in anticipation because of the internal perception by many members of the team that they will need to rise above the usual input to achieve a good outcome. These expectations of ‘compensating’ for the other members of the team can be distracting and undermining. The challenges for the operating team are [54]:

In instances where things go wrong, surgeons may become tense or angry, and fail to perform at their best. Collective responsibility would imply that that scrutiny of the conditions triggering these states, including an the individual performance of each member of the team, is important for every member of the team [55]. Systems theory suggests that the overall performance of the team is related to the individual performance of each member of the team; however, some surgeons can feel quite put out when poor outcomes are attributed to them when other members of them performed poorly [56].

All members of staff experience the stress of ‘doing’ cardiac surgery. The surgeon carries with them the shared responsibility for the patient through the postoperative period and the lifetime of the patient. The unrelenting nature of the work, with very little ‘down’ time completely off call, and the need to routinely participate in care on the nights and weekends, generates ongoing occupational stress. A natural tension exists between:

This tension can be addressed by better sharing of work arrangements between surgeons. Yet, even when such arrangements exist, most pediatric cardiac surgeons report that they are never truly ‘off call’ unless they are out of the city and in some cases out of the country. Vacations are interrupted by the demands of transplantation are common. With high levels of application to work, it is not surprising that surgeons report high levels of job satisfaction but also high rates of burnout [7], family discord, and the associated susceptibility to error and poorer outcomes [57]. High rates of self-reported de-personalization and emotional exhaustion are key findings. Difficulties in negotiating a home-work life balance [42, 43] and failure to look after one’s own health are common manifestations of the burnout complex. Interestingly, in cardiac surgery, and particularly pediatric cardiac surgery, most of these aspects of the work are accepted as ‘part of the job’, but it is the apparently ‘minor’ factors that become incendiary, such as tardy members of the team, poor scheduling, and cancellation of cases because of constrained resources in the Pediatric Cardiac Intensive Care Unit (PCICU). These “incendiary factors” lead to flow-on implications of rescheduling patients and further upending the balance of their clinical and non-clinical priorities [58]. The cost of re-scheduling a case has far-reaching implications on the patient and the family of the patient, and often for the surgeon and the family of the surgeon.