Why gender matters in the operating room: recommendations for a research agenda

A recent study on non-surgical Medicare hospitalisations in the USA has estimated that approximately 32 000 deaths could be prevented every year if men physicians achieved the same outcomes as women physicians.¹ Emerging evidence also shows that surgeon gender is relevant to postoperative complications and 30 day mortality, and surgeons' skill acquisition, training, and evaluation of practice, particularly after an adverse patient outcome.2, 3, 4, 5, 6 As healthcare professionals, women and men perform differently depending on the context. Both female and male healthcare professionals frequently practice as part of teams, and patient safety in the high-stakes, hierarchical operating room (OR) relies on their effective teamwork.⁷ It is therefore time to address whether gender influences intra-team dynamics and communication in the OR. Our aim is to address the possible relevance of gender for OR teamwork and patient safety, with suggestions to bridge the existing knowledge gap.

Defining sex and gender

Unlike sex, which refers to biological or physiological factors, gender is a multidimensional construct that includes social, environmental, cultural, and behavioural factors.⁸ Gender can refer to gender identity (i.e. how individuals see themselves and are seen by others), gender roles (i.e. behavioural norms applied to women and men in society, which influence actions, expectations, and experiences), and gender relations (i.e. how individuals interact with or are treated by people based on their ascribed or experienced gender).⁹

Gender, teamwork, and patient outcomes in the operating room

Ineffective teamwork is a primary contributing factor in two-thirds of surgical complications⁷; thus, we believe the study of gender in the OR should extend to the team level. The effects of gender may be especially relevant in crisis situations, where effective teamwork is vital.¹⁰ A recent simulation study found that women-only cardiopulmonary rescue teams had significantly less ‘hands-on’ time and more delays in beginning chest compressions compared with men-only teams.¹¹ Within teams of both men and women, women rescuers issued fewer leadership statements and engaged in fewer unsolicited cardiopulmonary rescue measures. However, new research suggests that gender diversity may actually increase cooperation among OR teams.¹² Specifically, cooperation and communication in the OR were observed to decrease when more than half of the healthcare professionals in the room were men, and was strongest when the attending surgeon was also a man.¹² Still, in another recent study, the authors report that women respiratory therapists were challenged more often than men respiratory therapists in a cannot intubate, cannot oxygenate simulation scenario when an incorrect clinical decision was made.¹³ There are many psychosocial reasons which may underlie each of these reported observations.¹⁴ More research is needed to determine the generalisability of these results for surgical patient safety, especially when OR situations demand defined leadership and quick, coordinated action.

Additional challenges can arise among OR teams given that interprofessional hierarchies within the healthcare system are further complicated by gendered hierarchies in both healthcare and society at large.¹⁴ For example, women who pursue ‘masculinised’ surgical specialties (e.g. thoracic surgery, neurosurgery) are often directed towards more ‘family-friendly’ specialties (e.g. gynaecology).¹⁴ This occurs through experiences of social processes of exclusion, sexual harassment, and gaps in pay. Women in thoracic surgery residency are also granted less autonomy in the OR by faculty surgeons than men.³ Meanwhile, men in ‘feminised’ professions, such as nursing, are routinely stereotyped as feminine, and often have their intelligence or ambition questioned (e.g. viewed as not ‘smart enough’ for medical school).¹⁵ Each of these experiences and judgements is shaped by broader patterns of gender inequality in society as well as gender roles and norms, or sociocultural beliefs about the respective value and acceptable qualities of men and women.

Gender roles and norms also affect behaviours relevant to teamwork such as leadership and followership, communication, and how individuals are perceived by other team members. In healthcare, most nurses are women and most physicians are men, albeit numbers have become more equal in recent years.¹⁴ Nevertheless, gender can become particularly salient in situations involving a challenge by an individual from one profession to another or when the situation requires one to take the lead. Evidence suggests that women and men use different conversational strategies in the workplace, and even when they use the same speech styles they are reacted to differently by others.⁹ Nurses rate quality of communication with surgeons and anaesthesiologists markedly lower than these two professional groups rate quality of communication with nurses, with gender likely playing a role.¹⁶ Variation in communication expectations, techniques, and perceptions creates tremendous potential for miscommunication—a significant threat to effective teamwork and ultimately patient safety and outcomes.¹⁶

Recommendations and suggested research agenda

Current research on teamwork and safety in the OR has largely ignored gender despite emerging evidence demonstrating its relevance to surgeon4, 5 and team¹¹ resuscitation performance. Research from other high-stakes industries tells us this is an erroneous omission. For example, although gender does not predict the number of aviation incidents or accidents a pilot is involved in, the outcomes and reasons behind the incidents/accidents can be different for men and women. Men tend to make ‘mental mistakes’ (i.e. flawed decisions) whereas women tend to make ‘procedural mistakes’ (i.e. handling errors).¹⁷ The advanced technology of modern aircraft is better able to compensate for handling errors than bad decisions, increasing the likelihood of a fatal outcome when the pilot is a man. Consequently, recommendations have been put forward for gender-specific training related to flight duties and flying skills, with many early initiatives underway.¹⁷ Had gender not been studied here, an important contributing factor to these fatalities might never have been discovered. The unintended consequences of this gender knowledge gap in the OR can range from inadequate organisational responsiveness to the needs of OR team members, to the maintenance of gendered inequalities in research, healthcare services, and patient outcomes. This costs both money and lives.2, 4 Therefore, we should begin to build the evidence base on gender and teamwork in the OR.

Based on the existing knowledge gaps we have highlighted, we recommend several priority areas for research. Exploration of these areas would benefit from an interdisciplinary team of investigators, such as partnerships among anaesthesiologists with educational research expertise and nurses, surgeons, psychologists, and sociologists. Research teams should also aim for gender diversity to ensure representation of different perspectives.

First, observational studies could determine how OR teamwork practices vary according to dimensions of gender. Parameters such as individual clinician gender, number of men and women on the team, distribution of gender among professions, and gendered dimensions of hierarchy/power within specific specialties might have implications for teamwork and patient safety. Research questions might include: How does a surgeon's gender influence OR team performance across different specialties and clinical situations? What about the anaesthesiologist? How does the gender composition of the OR team affect intraoperative events, postoperative complications, and outcome? When a nurse challenges an anaesthesiologist's or surgeon's decision, how does the nurse's gender influence the team decision? Are these observations different for men-dominated specialities (e.g. orthopaedic surgery) compared with women-dominated specialities (e.g. gynaecology)? These questions can be investigated using a quantitative prospective observational design as well as subsequent qualitative ethnographic analysis, interviews, and focus groups. With the introduction of new audio–video recording technologies such as the OR Black Box®,¹⁸ it is certainly now possible to investigate gender dynamics in the OR to a greater extent than was previously possible. Although we have focused on clinician gender here, it is important to note that patient gender can also play a role in processes of care, including communication and cooperation, and outcomes.¹² Furthermore, clinician and patient gender can interact with other variables such as profession or hierarchical power relations,¹² and these relationships should be explored further.

Second, incorporation of gender in knowledge translation research could improve teamwork in the OR. After clearly establishing the role of gender in OR teamwork, research should next turn towards understanding its implications for teamwork training interventions. Just as the individual practice of surgical trainees appears to benefit from different training approaches,² so too may the practice of all OR team members (e.g. surgeons, nurses, anaesthesiologists). One potential direction for research might therefore be to determine the effectiveness of teamwork interventions according to gender and whether gender-specific or gender-neutral interventions are needed for each OR profession. Barriers and facilitators to effective teamwork practices might also differ according to gender, and this should be explored further using qualitative interviews.

Based on existing evidence in surgery2, 3, 4 and other healthcare fields,¹¹ it is likely that attention to gender among OR teams can result in improved quality of care, more effective interventions, and better outcomes for surgical patients. We believe the OR community should encourage gender research in order to optimise their practice and patient outcome.

Authors' contributions

Both authors contributed to all aspects of this article.

Declaration of interest

The authors have no potential conflicts of interest relevant to the subject of this manuscript.

Funding

No financial support was provided for completion of this manuscript. Dr Boet was supported by The Ottawa Hospital Anesthesia Alternate Funds Association.