Dr. Richard Sherry, a Clinical Psychologist, proposes a change of approach in surgical care that considers psychological human factors in efforts to reduce surgical site infection and the risk of complications. He calls for a change in how human behaviour is considered – with emotional milieu being viewed as significant as the interaction of microbes.
New research is highlighting the impact of toxic work cultures and the pervasiveness of these issues throughout surgery. There is also evidence that staff issues and burnout can impact patient care and rate of complications.1 Better care of the health and emotional well-being of staff has a direct link to better outcomes for patients and, therefore, can lead to a reduction in complications including infections. Positive cycles of health for both staff, as well as patients, necessitates understanding and ensuring a positive direction of development. A vital question emerges: how can we work to create these positive and healthy surgical environments?
To give some historical background and context, breakthroughs in the understanding of histology and pathogens, as well as disease surveillance, began with Ignas Semmelweis, the Hungarian obstetrician and physician in Vienna, during the 1800s. He is credited with developing the medical imperative of hand washing and working to stop unnecessary cross contamination.2
Observing the significant reduction in patient deaths and instances of infection highlighted the first dawning awareness of the impact on patient health, where microbes could be now more clearly conceptualised. Changes within these practical approaches also addressed the profile of surgical risk and patient safety for infection — marking a breakthrough in the reduction of mortality and surgical complications.
Moreover, additional medical innovations were able to open up, for example, the use of antibiotics, improvements on surface design (and materials), use of cleaning and sterilisation of surfaces, innovations in surgical tools, use of disinfectants, operating design, and surgical safety — all contributory factors in infection occurrence once this initial change was able to be systematically introduced and accepted.
However, despite these improvements, infection continues to be a major problem and current research highlights that infections in surgery impacts the NHS at a cost of £700 million a year and surgical site infections continue to occur.3 So, what else may account for these persistent rates of infection?
Psychological contamination
There are invisible worlds until we are taught how to see them and understand their unique and special ecosystems and, until we have this knowledge, we will be ignorant of their meaning and impact. As with invisible microbes, the medical environment has largely regarded human behaviour to be one of these equally intangible and misunderstood phenomena.
This paper would like to change how human behaviour is considered and these initial steps advocate for the emotional milieu to be as significant as the interaction of microbes. Both are essential factors to be 'seen' and understood as necessary factors of effect within surgical care.
1. First, belief systems affect perception and then alter actions. In many psychological surgical assessments I have undertaken, I have observed the impact of psychological belief systems (about the patient themselves and their perception of the world), which directly contributes to self-sabotaging health behaviour. In extreme cases, without professional intervention, negative self-beliefs can jeopardise the operation's safety outcome. For example, the patient's negative self-appraisal may manifest through their acting out with high-risk socialising (as seen during recent post COVID conditions) before their surgery — making their risk higher and increasing multiple kinds of infection risks, while reducing their overall health and resiliency.
2. Second, the presence or absence of empathy is one of the foundational determinants for staff, as well as patients, to feel safe. This, in turn, profoundly affects all aspects of the other psychological behaviour in terms of interaction within the surgical environment, and interaction with everyone within these environments. Simple steps, such as helping connect empathetic concern for the patient's well-being, will support staff in their thinking about — and engagement with — patients and each other.
3. Third, the first two principles will impact on health-related behaviour for both surgical staff, as well as patient engagement. Strongly encouraging positive health-related behaviour and self-care — such as pre-surgical isolation, hand washing, ensuring good sleep and nutrition — all change the patient's potential risk profile. These psychological factors frequently manifest in the patient's pre-operative or post-operative risks, particularly if the patient escalates their risk taking to where it impacts their surgical preparation or recovery plan.
Neglecting the importance of these human factors can lead to avoidable complications and must be considered within a systems approach to care, well-being, and outcome.
'Contamination' is not just important for viruses or microbial processes: 'Psychological contamination' should be included as an essential part of the improved approaches to risk prevention in all aspects of surgical training and ongoing CPD. Mindset matters — especially to prevent risk. Making every possible effort to guarantee the best outcome for all should be the priority when it comes to addressing surgical site infections, tackling issues of hand washing, and minimising patient mortality or unnecessary periods of illness.
Regression and dependency: If this positive engagement is not supported, then the disaffected (antithetical) emotional responses are likely to passively emerge — whereby the patient might be expecting the surgeon and surgical team to take the entirety of the pressure of the risks and potential problems. This automatically establishes an adversarial dynamic where the patient then disengages with their own care and pushes this on to the responsibility of the surgeon and the surgical team. This is a major risk for derailment, stress, burnout, and serious risk of complication.
Immaturity creates unnecessary conflict and increases burnout: This is a kind of emotional contaminated process stemming from misalignment and other communication problems that can escalate to feelings of anger and betrayal. If these emotional triggers continue, these can contribute to enactments of rupture and emotional contagion. If such a precedent is opened, this is likely to sabotage much of the hard work and mutual cooperation that would otherwise support a positive and productive working alliance that is necessary for a long, fulfilling, and productive surgical career (as opposed to the increased risk of surgeon and surgical team mistakes and burnout). The stepwise escalation of risk forms a major ingredient of ruptures of safety, negligence, and other negative directions of patient complication — where not only the patient is put at risk, but the surgeon and surgical team are just as vulnerable.
Psychological contamination: When considering human factors within the dynamic surgical environment, the psychological impact of human behaviour needs to be contextualised. What I hope to illustrate is that infection control can be influenced through preventative behavioural change with the guidance and principles outlined within this article.
In order to properly influence preventative behaviour, the psychological state of mind of the staff, as well as the surgical patient (or their family), needs to be addressed. We need to understand the social and emotional defences against the anxiety4 that can lead to a triggered emotional response, which can create higher-risk behaviour. Surgery understandably elicits fear in all concerned. The maturity and compassion in how this is managed will make considerable differences in how reactions evolve and how these are understood and responded to.
In my own experience, I have witnessed a significant divide between the physical/ medical and the psychological/mental health aspects, where the exploration of their interaction in a meaningful way is often overlooked. I have seen a consistent trend in teams with a phobic avoidance of looking at (or dealing with) these aspects — with the medical side looking solely at medical health aspects, and mental health teams focusing only on the psychological factors. In short, there is a reluctance to explore these components and how these human factors interconnect — especially in terms of how they mutually influence the patient's journey.
Collaborative working preventatively addresses potential triggers: When collaborative working between staff and patient is neglected, key problems may be missed, thus increasing risk. An insight into human factors enables human behaviours to be more clearly understood. Defensive and reactive types of behaviour, if ignored, can undermine valuable feedback loops of data. This can lead to a negative culture of communication, where problematic organisational dynamics become enacted and are potentially played out.
Just as the physical transfer of cross-infections can occur, which can pose serious risk, so too can organisational stresses and pressures leak out and affect the staff and patient interactions, which may ultimately result in unsafe patient care. These micro or macro ruptures can cause any number issues and lead toward cycles of derailments and more serious defacto accidents.
Mature autonomy: It is imperative to look at the entire patient journey and what can be done to assess, engage, and support the patient and their family to better understand issues that will affect their emotional and physical response. In addition, the patient's active participation and proactive ownership of their own health — working collaboratively with the surgical team — is needed to ensure the best outcomes. This requires deeper, mature, and more responsible behaviour.
Developing the right tools: Surgically reducing risk and infection requires systemic understanding and solutions. What I am proposing, in addition to the robust and medical approach to manage hand-washing and surgical site infection, is an integration of a systemic human factors approach with health-related behaviour change and utilising psychoanalytic organisational approaches, so these work in conjunction. Infection prevention practical measures should not be treated as separate to the psychological prevention factors. Some of the most essential measures include the following:
Assessment: By encompassing a dynamic assessment, interventions for preventative care, and educational support for the patient and their family, the surgical team will better understand what they need to address. At its most basic, talk to your patients and find out what they are worried about and if there is anything that might be done to help them with their concern. This will help staff and patients feel much safer and re-establish a better working alliance.
Prevention: Together with the surgeon and hospital team, this would ensure a unified proactive and preventative approach to surgical care. In addition to basic preventative health hygiene for the patient and their family, this should utilise health behaviour change approaches — for example, to reduce exposure to potential colds, flus, and COVID before the operation, ensuring the patient is washing his or her hands to be healthier, and ensuring that sleep and nutrition is optimised. Prevention really is essential to best practice. Preventing miscommunication and unnecessary ruptures in trust would be the psychological equivalent.
The patient's mindset matters: The patient's psychological state of mind will have an impact on their wound healing and surgical outcome. If they are thinking negative thoughts versus positively engaging in their care, this will affect all aspects of their well-being and outcome. Fears, stresses, life events and their own self-esteem and mindset can alter the surgical results. Steps toward responsible pre-preparation can have profound impacts on how the patient presents going into the operation, as well as how they engage with self-care, aftercare instructions on wound management, and adherence to medication, which will have synergistic effects for all involved in the surgical journey.
Emotional factors — not enacting risk taking: Understanding essential factors such as the ACS Surgical Risk Calculator should be matched with the surgical psychological tools outlined in this article, which change the emotional reactivity and decision making within human relationships, and the surgical team and patient working alliance.
Psychological contamination: Paisley and Yule5 provide clear examples of how non-technical skills, human factor decision making, and human error can influence surgical safety profiles. Working to carefully integrate different disciplines of non-technical skills (the emotional understanding) of patients, with human factors, together with some of the psychoanalytic organisational insights into work-related behavioural change, provides a real opportunity to drive improvement. However, it requires looking at things differently.
Understanding the more subtle points of emotional experience has as much (if not potentially more) relevant impact on the wider profile of the system's risk, as Reason6,7 articulates in his theoretical conceptualisation of why accidents occur. This was further refined, looking at:
1. Latent failures: (including organisational influences; unsafe supervision; and preconditions for unsafe acts.
2. Active failures.
3. How these interact with failed or absent defences (adapted from Shappell and Wigemann, 2000).8
In summary, complex feelings can infect and contaminate the thinking and capacity to effectively act, for staff and patients alike.
An entire systems approach: My recent work has focused on innovating new approaches in Psychological Human Factors in Surgery Assessments. While looking at the integration of these approaches within the entire system approach, I have focused on a more comprehensive set of Pre- and Post-Surgical Psychoeducational Tools. Additionally, I am actively developing other integrated support systems such as helpful Acronyms, traffic light systems and trigger awareness for surgeons and surgical teams in collaboration with the Confederation of British Surgery* (covered in my previous article, published in CSJ).9
It is imperative to provide comprehensive support systems that deliver compassionate care frameworks designed to alleviate unnecessary risk, improve the knowledge base, expertise, and result in collaborative cooperation among all stakeholders.
Improved frameworks and transparent (shared) goals and agreements: The psychological covenant and contract alone need to be addressed. Just like the patient's legal agreement and identification of possible side effects and risks, these issues must be visualised, and actual agreed consent needs to be evolved. I would add that (like invisible pathogens or microbes that can cause infection) we need better visualisation of the behavioural and unconscious factors that can hijack and corrupt working alliances, in order to control for these variables — thus significantly affecting the optimum outcome.
Improving patient (as well as surgical team) care: Surgeons look at surveillance data and trends, but some essential personalised patient factors may be overlooked. Some key examples could include whether the surgical patient has a needle phobia, whether they feel listened to (and respected), how they feel their pain management is handled, and especially if they feel that they can trust their surgeon and their surgical team. All of these factors will fundamentally change whether or not they feel safe.
Any, and all, of these factors can profoundly change the patient's experience of navigating through the task of the surgical procedure and, in turn, can deeply affect their innate stress response, and dynamically decrease the patient's wound healing. Intense physiological responses can derail surgical process and outcomes — from the patient not adhering to discharge protocols, to engaging in unhelpful behaviours, which can affect their recovery.
It is important to know that stress factors go both ways. Surgical team members can feel impacted by anxiety, as well as patients or their families. There are also individualised, deeply held triggers (for both), which can influence the functional milieu affecting the socio-technical system.10 Here, the working environment for the successful completion of the task needs to integrate with the technology and people involved, and we need to understand how conflict and anxiety may operate within the work environment to affect this functioning.
The balance between the elements in this dynamic symmetry is crucial, as any compromise will have synergistic and a very real impact throughout the entire system — contributing to changes in the decision making, situational awareness, and communications (with all concerned).
Factors of anxiety, conflict, and defences also affect the leadership of the surgical team and can alter the communication for everyone involved. Stress can compound these reactions. Factors such as feeling safe and understood can profoundly alter interactions and can reduce the stress reactions. Unseen influences, such as neurodiversity, are critical in that stress can profoundly make clarity and shared goals and collaborative communication so much harder if undermined. Better understanding of stress and how these factors negatively affects clear and optimised communication is critical. Neurodiversity can negatively activate wider social defence factors (and even group dynamics such as bullying) that can also significantly change the human side of the socio-technical system.
It is important to conceptualise that neurodiversity is not a problem but has stress sensitive vulnerability components and cognitive processing styles that need to be supported and understood. If this factor is met with compassion and understanding, this can provide for a much safer and smoother system for all concerned. Neurodiversity needs to be understood as being a human factor for patients, as well as surgeons and surgical teams. Attention deficit hyperactivity disorder (ADHD), Asperger's Spectrum Condition (ASC), Dyslexia, Dyspraxia and many other kinds of neurodiversity all contribute to the necessity to attend to different learning styles and felt experiences.
Feeling heard and respected
Seeing the physical body and viscera is only one aspect of understanding the patient. We need to also understand their psyche and the broader social and environmental context, to ensure the provision of holistic surgical care. Ultimately, this can enfranchise and transform multiple key areas of health and well-being. When patients, as well as staff, feel heard and respected, this will lower more (immature) defensive and stress related responses replacing these with more optimal (and mature) flow responses.
Neglecting to consider this more integrated human factors psycho-social approach may eventually be viewed as a negligence of high-quality patient and medical care. What I am proposing in this paper is for the 'invisible' psychological factors to be recognised as important as Semmelweis' medical necessity of hand washing and prevention of cross contamination for good patient surgical care.
I appeal to you to see and comprehend both patients and the whole surgical team as complete human beings who must navigate immense stress, and that the decision making of both have considerable and profound impacts on each other and the overall team environments. Changing the technologies, ethical legal values, and approaches to guarantee increased control and consistent quality of safety critical environments will be a significant influence. This crucial behavioural adaptation also needs to contribute to creating an environment where patients feel truly heard and understood, allowing us to seamlessly address the fears and anxieties around the surgical process in a compassionate manner, so triggers and defences are not predominating their engagement with their surgical pathway.
Understanding the deeper psychological factors — and even being able to effectively map and identify what might lead to a significant emotional trigger or derailment (for both the patient and staff) — can drastically increase the feeling of psychological containment for all concerned. This will ultimately lead to improvements in the physiological management of stress reactivity, wound healing and transition toward complete recovery.
Valuing each person and the greater ecosystems of care
As identified, there are unseen factors that could greatly influence neglecting preventative measures such as hand washing, or further consequences of developing surgical site infections. All of these play a critical part in determining patient mortality (which is currently around 3%). In his fascinating book, Deep Survival,10 Gonzalez looks at who lives and who dies — where the core experience of fighting through adversity, versus simply giving up, has roots within the person's belief system. However, the environment and support available, versus stress triggers, can completely change what belief system is activated and expressed. We need to look at building new, more mature ways to ensure professional psychological approaches are harnessed within surgical systems of healthcare, which could potentially change the expression and outcomes.
One key point in updating Human Factors in Surgical Care is the importance and value of genuine empathy and care, as a significant preventative system to reduce complications and infection. Emotional insights are part of a connected relationship and getting these parts right reduces conflict and negative emotions - including anger and rage - which can be played out within the patient care journey. These negative emotions can break down trust, which forms the baseline of most medico-legal lawsuits.
Systems of decision making
My objective is to put forward a case to understand and incorporate how the psychological perspective of the surgical patient and their family context can have a powerful bio-psycho-social impact, which has previously been a rather invisible field and largely overlooked. Furthermore, we need to understand that, as long as human beings are involved (this includes the surgeons and surgical teams), everyone needs to be understood and supported. When experiences are not understood and supported, a negative cycle of distress, lack of trust, and a greater likelihood of conflict can materialise, which will affect both the patient journey and safety.
The present model of team work significantly neglects that the patient and their family are a critical part of the surgical team and their active participation is part of responsible team working practice. Ignoring this engagement is to everyone's detriment. Addressing negative patterns of communication and harnessing a deeper psychological human factors approach can result in a truly meaningful adjustment — supporting positive engagement. This enhances satisfaction for patients, surgeons, and surgical teams, leading to improved outcomes, as well as risk reduction. Overall, understanding emotions, each person's experience and how positive engagement can be supported is an important part of leadership and patient safety.
Flow states: One aspect of immense value is the passion that surgeons usually have for operating. By enabling them to get into a deep flow state, outcomes can be significantly improved, leading to noticeably enhanced satisfaction and health benefits for all involved. This is a critical and viable way of reducing medical burnout and stress-related reactions and illness, helping to improve the quality of care delivered. Patients also have their own version of this and, if we can get both staff and patient flow states to work together, to optimise this engagement, this would be the gold standard of optimised, collaborative team performance.
Infection control
From my analysis, there is an essential missing piece in infection prevention. In a nutshell, this is the human factors or psychological component. Reducing infections is about changing the understanding, the experience, and the cooperation and care that goes into the surgical and patient teamwork. It requires an understanding of human behaviour and emotions9 and where this can be in peak performance versus just preventing patient error. To use an analogy, Thomas Eddison's innovation of the lightbulb was part of a deeply planned and carefully integrated system of generators, civic and domestic electrical wiring, and other related first-tier development engineering firsts that were able to bring a more mature and technologically workable system to bring light and functionality to what had not been previously available. The psychological engagement was the crucial factor that allowed the uptake and utilisation to begin. The invention of the lightbulb would have been useless unless the other inventions had been put in place to support these new ways of working. In addition, a psychological understanding of how people would feel safe enough to make use of the technology was required for its dissemination.
In much the same way, ensuring critical behaviour and system change to reduce infections, human behaviour and improved care are a fundamental point of innovation for proper change to occur. Therefore, there needs to be a shift away from viewing emotions as distractions or problems — to these being understood as part of feedback, in a dynamic system of directional culture and ecosystem, which ultimately improves communication and ensures connected, meaningful care.
Summary
Historical paradigm shifts — with Semmelweis' understanding of the invisible pathogens, hand washing with carbolic acid and close attention to cross infection — changed the entire profile for medical and surgical risk and mortality, thereby increasing patient safety. What I have proposed in this paper is the need to better understand the invisible world of emotional psychological processes — to be better equipped to assess, account for, and understand how these might be more effectively addressed and controlled. There is an opportunity for better patient and surgical team engagement, which understands the need for containment of emotional contagion, and the tools and processes to proactively remedy these human factors. This approach leads to a holistic improvement in the collaborative surgical health journey of patients, families, and surgical teams alike.
* For further information, visit: https:// www.cbsgb.co.uk/
About the author
Dr. Richard Sherry is a Consultant Chartered Clinical Psychologist, HCPC Reg., and Fellow of the BPS CPsychol, CSci, FBPsS. He is a BPC and UKCP Reg. Psychoanalytic Psychotherapist. He is a Specialist Aerospace and Aviation Clinical Psychologist. Dr Sherry is on the BPS Board for Aviation and Aerospace Psychology where he has been working to innovate the new field of aerospace psychology. He is a Clinical Neuropsychologist (SRCN Register) and Full DoN BPS Member). Is a Full Member of the BPS Division of Occupational Psychology (DOP).
Dr. Sherry has a specialist training and interest in military psychology, the psychology of surgery, plastic, and aesthetic surgery. He is currently the Clinical Psychologist in Residence and Fellow with the Confederation for British Surgery (CBS) where he is looking in innovating human factor and psychological interventions to improve safety and positive surgical outcomes. He is a lecturer at Regent’s University in the Psychotherapy and Psychoanalysis Department. He is deeply interested in complex safety critical and stressful environments.
References
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