Surgical Team Mapping:

Implications for Staff Allocation

and Coordination
MARK SYKES, MBus, BPsych (HONS); BRIGID M. GILLESPIE, PhD, RN;
WENDY CHABOYER, PhD, RN; EVELYN KANG, MPH, RN

ABSTRACT
Perioperative team membership consistency is not well researched despite being essential in reducing
patient harm. We describe perioperative team membership and staffing across four surgical specialties
in an Australian hospital. We analyzed staffing and case data using social network analysis, descriptive
statistics, and bivariate correlations and mapped 100 surgical procedures with 171 staff members who
were shared across four surgical teams, including 103 (60.2%) nurses. Eighteen of 171 (10.5%) staff
members were regularly shared across teams, including 12 nurses, five anesthetists, and one registrar.
We found weak but significant correlations between the number of staff (P < .001), procedure start
time (P < .001), length of procedure (P < .05), and patient acuity (P < .001). Using mapping, personnel
can be identified who may informally influence multiple team cultures, and nurses (ie, the majority
of team members in surgery) can lead the development of highly functioning surgical teams. AORN J
101 (February 2015) 238-248. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2014.03.018
Key words: operating room, social network analysis, surgery, teamwork, patient safety.

http://dx.doi.org/10.1016/j.aorn.2014.03.018
ª AORN, Inc, 2015
238 j AORN Journal www.aornjournal.org
February 2015, Volume 101, No. 2
M embers of surgical teams work interdepen-
dently to perform complex and varied tasks.1
Crucially, team performance often depends
on team members’ familiarity with each other and with
specific surgical routines.2 However, despite a growing body
of research to support the relationship between nurse staffing
and patient outcomes,3-6 few studies have examined staffing
in the OR. Several researchers have described the critical role
that membership in surgical teams has in defining team
performance.7-10 To foster highly functioning surgical teams,
consistency in team membership is considered important in
reducing the potential for error and patient harm. However,
in reality, the stability of team membership is often a luxury
as teams comprising nurses, surgeons, anesthesia personnel,
and surgical technicians are frequently ad hoc.11
Managing surgical teams that have dynamic membership can
be made easier by visualizing team membership using a
technique developed for sociometric analysis. Sociometry is a
method that can be used to map team membership to
discover existing relationships among these individuals and
for disclosing the structure of the group itself.12,13 Using
data sets from the electronic health record (EHR) for pur-
poses beyond clinical documentation, billing, and adminis-
tration is rapidly increasing.14 Best of all, these data are
routinely collected as part of the OR electronic register
that records surgical information about the surgical
procedure details, staff attendance, and skill mix. Elements of
the EHR can be used as a basis for a sociometric analysis
to map team membership. Sociometric maps are useful
management tools when implementing procedural or team
changes as they can be enhanced to reflect people, process, and
technological perspectives. We used sociometric analysis to
describe team membership and staffing characteristics across
four surgical specialties.
STATEMENT OF PURPOSE
This project was part of a larger multicenter observational
study that described the nontechnical skills (eg, communica-
tion skills, teamwork) used by surgical teams in two metro-
politan Australian hospitals. Based on the results of the
structured observations, this larger study sought to develop a
team training intervention to improve team members’
nontechnical skills to enhance team cohesiveness and perfor-
mance. We present the results of using a sociometric analysis
of team structures at one of the participating hospitals. The
aim of this correlational substudy was to map team member-
ship using social network analysis and describe relationships
between case-related variables across four surgical specialties.
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Surgical Team Mapping
RESEARCH QUESTIONS
We asked the following questions to guide this study:

What proportion of individual staff members involved in
surgery are RNs, anesthesia professionals, surgeons, and
registrars/residents across four surgical teams?

How many team members are shared across four surgical
teams?

What are the relationships between the procedure-related
variables of start times, the total number of staff members
per procedure, length of procedure, and patient acuity?
Length of procedure, patient acuity (ie, illness severity), and
the number of staff members involved in each procedure are
considered indicative of the complexity of the surgery11,15 and
may influence the interpersonal interactions of the team
members involved and team performance.10,15,16 Conse-
quently, inclusion of these procedure-related variables allowed
us to consider team membership in the broader context of OR
staffing, the different surgical specialties and types of surgeries
performed, and patient-related factors.
SIGNIFICANCE TO NURSING
There is limited research that focuses on mapping team mem-
bership and describing the interdisciplinary staffing characteris-
tics of surgical teams using a social network analysis framework.17
We used social network analysis to identify team structures based
on the regularity of membership to gain insight into the relations
among team members and social network structures. Previous
research has found that team membership and the quality of
intergroup and interdisciplinary communications potentially
can contribute to the quality of patient care.11,18
LITERATURE REVIEW
All surgical procedures require a high level of coordination between
various individuals from different professional disciplines.15 The
complexity of a surgical procedure affects every aspect of team
performance.15 Procedural complexity encompasses aspects such
the type of surgeries performed and their associated risks (ie,
postoperative complications), patient acuity and pre-existing
comorbidities, and the surgical technologies used.10,15 Further,
procedural complexity determines the time to complete the
procedure and who should be assigned to the surgical team.15,19
In relation to how team membership, roles, and tasks interface,
most team members view the consultant surgeon as the team
leader, while the surgical registrar or assistant surgeon, RN
circulator, and scrub person follow and support the surgeon.19
The RN circulator supports the scrub person and other team
AORN Journal j 239
Sykes et al
members as needed while the anesthesia professional
anesthetizes or sedates the patient and maintains his or her
stability during surgery. Clearly, surgical teams are required
to collaborate and coordinate their performance in a manner
that ensures that the combined experience of all members is
shared and optimized.19 For ideal performance, surgical
teams need to be more than merely groups of individuals.
Expert surgical team members characteristically have a shared
understanding of each other’s tasks, roles, and responsibilities,
obtained through developing a shared mental model of the work
they perform.19 Surgical team familiarity is cultivated over time
and gained through regularly working with other members of a
dedicated team (ie, a group of individuals who share a similar
mental model).8 Shared mental models enable individuals to
adapt quickly and coordinate their actions based on their
underlying knowledge of each other and the situation in
which they find themselves.1 Nevertheless, the majority of
“
Expert surgical team members characteristically
have a shared understanding of each other’s
tasks, roles, and responsibilities, obtained
through developing a shared mental model of
”
the work they perform.
surgical teams are formed the day of surgery or, in emergent
situations, just moments before the patient is wheeled into
the OR. This results in teams that may not work regularly
together and can leave little time for information exchange
between the surgeon, anesthesia professional, and nurses.15,20
In the absence of regularity in team membership, it is
especially important to build an effective team through
collectively fostering good communication practices before a
procedure starts and during staff turnover.9,20
Mapping Surgical Team Membership
The use of sociometry to obtain knowledge about a group has the
potential to reveal informal team leaders, socially isolated team
members, and unofficial subgroups that emerge within teams.13,21
It is a powerful tool because it illustrates social interactions among
group members based on a chosen criterion, which may facilitate
understanding of a group. Sociometry is particularly useful in
revealing the links between individuals within the group.
240 j AORN Journal
February 2015, Volume 101, No. 2
In general health care, the formal structure of a team is often
known and its hierarchy can be an approximate guide to who
is able to influence the team. However, in highly dynamic
team environments such as the OR, the formal team structure
is poorly understood or is fluid depending on the task. In this
context, a sociometric map can provide a snapshot of the team
structure and allocation for a specified duration. By comparing
a snapshot of team maps over several time periods, longitudinal
changes in team structure or attributes (eg, shifts in skill
profiles of individual members and core membership ) can be
identified by nurse managers and educators.
Team maps can also assist managers in planning both cultural
changes within a team and process changes across teams. As
potential catalysts for change, individuals bring both positive
and negative behaviors and work practices that shape team
culture. Positive work practices may be manifest in a team
member’s ability to diffuse tension during complex surgery,22,23
organize and predict the equipment needs for surgical cases,24
assist and encourage others, value input from everyone, and
provide technical savvy.9 Less desirable attributes such as
withholding information,22,25 sabotaging others, a lack of
communication, and a lack of leadership reduce the team’s
effectiveness9 and can compromise patient safety. In surgical
teams, the ability of individuals to act as influential change
agents is strengthened through collegial relationships
developed over time, active and enthusiastic participation in
the organization’s institutional initiatives, and knowledge of
the clinical setting and the patient’s unique needs.
METHODS
For our design, we used a descriptive, correlational design. We
were interested in using social network analysis to map team
membership across four surgical teams and to describe re-
lationships among length of procedure, patient acuity, and the
number of staff involved in each procedure.
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February 2015, Volume 101, No. 2
Setting and Sample
The setting for this study was a large tertiary-care Australian
hospital. During the study period, personnel at this 450-bed
metropolitan hospital performed approximately 17,000 elective
surgeries in all specialties except cardiac and transplantation
surgery. We purposively selected four surgical teams based on the
diversity of surgeries in each surgical specialty and team mem-
bers’ willingness to participate. At this hospital, surgical teams
were composed of anesthesia professionals including anesthe-
tists, surgeons and their registrars/residents, and RNs who
circulated and scrubbed and practiced as anesthetic assistants. In
this OR department, surgical technicians are not employed.
Data Collection and Measures
We derived data retrospectively using the electronic database
Operating Room Management Information System (ORMIS),
“
In surgical teams, the ability of individuals to act
as influential change agents is strengthened
through collegial relationships developed over
time, active and enthusiastic participation in the
organization’s institutional initiatives, and
knowledge of the clinical setting and the
”
patient’s unique needs.
and we collected data during 2012. We accessed the OR
attendance records based on 100 surgical procedures elec-
tronically recorded in the ORMIS database across the four
selected surgical teams. We identified teams by the attending
consultant surgeon, and we tracked each team member who
worked with the surgeon, the number of procedures for which
team members were present, and the time that each procedure
took to complete. We collected data over four months that
included the procedure, patient, and individual staff categories
(ie, nurses, registrars, consultants). Data derived about the
procedures included variables related to procedure type,
length of procedure in minutes, and the number of staff
members present.15 At the staff level, data included clinical
role, total time spent in each procedure, and the times
individuals signed in or out of procedures. Patient-level data
included the patients’ American Society of Anesthesiologists
(ASA) status,10 type of surgery, and the type of anesthetic.
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Surgical Team Mapping
Table 1 provides the conceptual and operational definitions
for the procedure variables we analyzed in this study. We
verified the data obtained through ORMIS using data
quality checks to identify any problems with missing or
incorrectly coded data. We removed personal identifiers
and reassigned anonymous identifiers to staff members
and patients.
Institutional Approval
The university and the Human Research Ethics Committee of
the participating hospital granted institutional approval.
Because we collected patient data retrospectively, there was no
requirement to seek patients’ permission to access their
ORMIS records. After ethics approval, we sought permission
to access the ORMIS database from the Director-General of
the Health Department (Queensland), as required by the
Public Health Act (2005). We did not record patients’ per-
sonal information, such as names and dates of birth.
Data Analysis
For data analysis, we obtained OR attendance records through
ORMIS and created an Excel spreadsheet, where we trans-
formed the coded data into a format that could be interpreted by
sociometric software.26 We used GephiTM software26 to generate
a map of team membership. Statistical analysis of staffing
networks was essentially descriptive. In the Gephi program, we
split data into two sets: “nodes” and “edges.” Node data
formed a discrete entity, consisting of either individuals,
collections of individuals, or an event (ie, individual surgical
procedure). In constructing our team membership map, node
data were based on individuals and procedures. We generated
nodes from a list of surgical procedures and individuals who
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Sykes et al February 2015, Volume 101, No. 2

Table 1. Conceptual and Operational Definitions for Case Variables

Case Variable Conceptual Definition Operational Definition

Procedure Start Time Time of the first incision (ie, scalpel to skin)1 Time, recorded using the 24-hour clock
Procedural Complexity

Length of Procedure Time from skin preparation to application Measured in minutes using the median
of final dressing2 and interquartile range

Number of Staff Present Each person assigned to a procedure throughout Count of total mumber of staff members
the duration of the procedure3 for each procedure tallied and a
median score obtained

Patients’ American Society A subjective measure of a patient’s underlying Rating scores range from 1 to 5, with
of Anesthesiologists4 Status illness severity assigned by the anesthsia 1 ¼ completely healthy patient through
Rating professional.5 An indicator of a patient’s to 5 ¼ moribund patient, not expected
fitness for surgery to live beyond 24 hours
References
1. Gillespie B, Chaboyer W, Fairweather N. Factors that influence the expected length of operation: results of a prospective study. Qual Saf Health
Care. 2012;21(1):3-12.
2. Gillespie B, Chaboyer W, Fairweather N. Interruptions and miscommunications in surgery: an observational study. AORN J. 2012;95(5):576-590.
3. Cassera M, Zheng B, Martinec D, Dunst C, Swanstr€ om L. Surgical time independently affected by surgical team size. Am J Surg. 2009;198:
216-222.
4. ASA Physical Status Classification System. American Socety of Anesthesiologists. https://www.asahq.org/clinical/physicalstatus.htm. Accessed
October 21, 2014.
5. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009;197(5):678-685.

worked with a particular attending surgeon during a specific and measured length of procedure in minutes. We calculated the
period. The relationships between the nodes give a network its median and interquartile range (IQR) for length of procedure.
structure. In this study, we allocated a unique staff identity We used Kendall’s tau-b (s) rank correlation to assess bivariate
number to each individual. relationships between procedure start times, total number of
staff involved, length of procedure, and patient illness severity
We connected node data by edges, which represented either rating (ASA). Our decision to use this nonparametric statistic
“undirected” or “directed” contact with other team members was based on the level and distribution of the data and the sample
during the procedure. Edge data described the paired re- size. We considered P < .05 significant.
lationships between all team members in a single surgical
procedure. For instance, in a fictitious scenario, if there were
five staff members involved in performing a surgical procedure, RESULTS
the surgeon, assistant surgeon, scrub nurse, anesthesia profes- We analyzed case- and patient-related data for 25 procedures
sional, and circulating RN, the following undirected edges in general, thoracic, orthopedic, and pediatric surgical spe-
exist; surgeon/assistant surgeon, surgeon/anesthesia profes- cialties (n ¼ 100). The total number of individuals in the
sional, assistant surgeon/anesthesia professional, scrub nurse/
surgeon, and RN circulator/scrub nurse. The relationship Table 2. Participants in Surgical Procedures Across
Four Specialties
edges are described as undirected (ie, the relationship can flow
either way and is not necessarily initiated by one person) All Participants
because saying the surgeon/assistant surgeon worked together
Number (%) Type
is identical to saying the assistant surgeon/surgeon worked
together. When tracking the team interactions, the team map 103 RN
shows lines that are thicker when individuals spend more time 53 Anesthesia personnel
together, talk to each other more often, engage in more team- 15 Surgical registrar/resident
related communication, or instruct, discipline, or praise
each other.13 Participants Shared Regularly Between Teams
12 (66.6) RN
We analyzed case- and patient-level data using the program IBM
5 (27.8) Anesthesia personnel
SPSS Statistics 20 for Windows to tally categorical data (ie,
1 (5.6) Surgical registrar
total number of staff involved in each case, staff role, ASA status)

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February 2015, Volume 101, No. 2 Surgical Team Mapping

Figure 1. A visual depiction of the combined individual team maps that provides a complete picture of team
relationships both within and across the four surgical specialties studied.

combined networks was 171. Of the 171 staff working within
these four specialties, 103 (60.2%) RNs, 53 (31.0%) anes-
thesia professionals, and 15 (8.8%) surgical registrars or resi-
dents (Table 2) were shared across all networks. Figure 1
depicts the combined individual team maps to provide a
complete picture of team relationships both within and
across the four surgical specialties. Across these teams, core
membership was characterized by members who regularly
worked together and also included members who were
shared across a number of the teams.
The team map indicates that 12 RNs, one surgical registrar, and
five anesthesia professionals were regularly shared across the four
surgical specialities (18/171; 10.5%), over the 100 procedures
(Table 2). The thicker edges (ie, lines) between members of the
pediatric and thoracic teams suggest that those members spent
more time working together. Data for the number of core
team members across each specialty indicated that the team
with the greatest number of core members was the thoracic
team (average four members), while the general surgery team
had the least number of core members for any given

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Sykes et al February 2015, Volume 101, No. 2

here has enabled us to depict team membership over a four-

Table 3. Median Length of Procedure Time Across month period relative to core staff and peripheral team
Four Specialties
members across four surgical specialties. These results build on
Range in Minutes previous research that has focused on interdisciplinary staffing
Surgical Median Interquartile characteristics17 and augments our understanding of team
Team (Minutes) Range Minimum Maximum
structures among interacting health professionals and the
General 90 123 23 621
relationships between staffing variables. As such, this study
Surgery
contributes to the current paucity of research in this
Orthopedics 109 63 27 163
emerging area.
Pediatric 38 54 7 185
Thoracic 56 45 12 166 In the absence of a formal team structure, a team map can
confirm status and role allocation. Ibarra and Andrews27
identified that formal organizational hierarchy and informal
social networks contribute to team attitudes. In this study, the
procedure with only one regular member (eg, usually an RN)
team map shows four teams with a central connecting bridge
present. During longer cases (ie, longer than four hours),
and a small outer ring. The outer ring is composed of
there were as many as six team member changeovers, most of
individuals who are shared between two teams. The RNs at
which involved nurses in circulatory and/or scrub roles.
the center of the map float among all the teams, and their
The average length of surgery per procedure varied across each team membership function may range from a disconnected
specialty (Table 3). Orthopedics procedures tended to take outlier (ie, a team member that may be infrequently allocated
longer than procedures in the other specialties, with the to the team) to an integrating bridge (ie, thicker lines directed
median length of surgery being 109 minutes (IQR ¼ 63). toward the center of the diagram) between teams. Most of the
Table 4 shows results of the bivariate correlations. The team members involved in surgery were RNs (60.2%)
length of procedure was inversely correlated with start time, (research question 1), which is not surprising given that nurses
suggesting that longer procedures tended to be scheduled comprise the largest staff profile in many OR departments.
earlier in the day (s ¼ .13; P < .05). Not surprisingly, the
Only 10.5% of surgical staff members were shared across the
longer the procedure, the more staff members were involved
four teams (research question 2). However, in a previous
(s ¼ .13; P < .001). Patient illness severity measured using
study, the authors reported that up to 55% of staff members
the ASA rating was weakly but significantly correlated with
crossed over between two networks (ie, general surgery,
the length of procedure (s ¼ .18; P < .001).
neurosurgery teams).17 In our study, RNs comprised 66.5%
(12/18) of the core staff members who were shared across all
DISCUSSION four teams (research question 2). This proportion was lower
This is one of the first studies to describe team membership in in a 2011 study that examined OR staffing characteristics
surgery using sociometric methods. The team map generated and team membership, in which 56% of core staff members

Table 4. Correlations of Case Variables Across Four Surgical Specialties

Patients’
Length of American Society
Start Procedure Number of of Anesthesiologists
Case Variable Time in Minutes Staff Members (ASA)1 Rating Scores
Procedure Start Time 1
Length of Procedure 0.03 1
a
Number of S Members 0.16 0.13b 1
b b
Patients’ ASA Ratings 0.19 0.18 0.07 1
a
Kendall’s tau-b (s) rank correlation is significant at P < . 05 level.
b
Correlation is significant at P < .001 level.
Reference
1. ASA Physical Status Classification System. American Society of Anesthesiologists. https://www.asahq.org/clinical/physicalstatus.htm. Accessed
October 21, 2014.

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February 2015, Volume 101, No. 2 Surgical Team Mapping

KEY TAKEAWAYS FOR CLINICAL PRACTICE

Using Sociometric Analysis to Map Team Membership
WHY DID WE DO THIS RESEARCH?

We wanted to gain a better understanding of surgical team membership and how it affects OR staffing over time.
We used sociometric analysis to develop a simple visual map to plot staff team composition and attendance.

WHAT DID WE FIND?

Electronic health record data are suitable for mapping team membership over time.

Studying four diverse surgical teams (general, thoracic, orthopedic, pediatric), 25 surgical procedures, and 171
participating staff members, we found that 10% of team members were shared between teams and 67% of team
members were RNs.

Team function was affected in relation to the number of staff members who participated in a procedure, procedure
start time, length of case, and patient acuity.

HOW CAN CLINICIANS USE THESE RESULTS?

Clinicians: Core nursing personnel shared across teams may be better able to monitor team climate within the
team and are well positioned to take on formal and informal leadership roles in surgical teams.

Managers: Analyzing surgical team patterns over time leads to better understanding of team stability, team-focused
absences, and skill deficiencies. Team maps may identify established senior personnel who are members in more
than one team and who can facilitate consistent improvement practices across teams. Ensuring the continuity and
regularity of team membership improves team function and patient care.

Educators: Team maps could identify team members requiring further education and core team members or
specialists who could mentor new or inexperienced personnel to specific skills required in a surgical speciality.

Sykes M, Gillespie BM, Chaboyer W, Kang E. Mapping team membership in surgery: implications for staff allocation and coordination.
AORN J. 2015;101(2):238-248. Copyright ª AORN, Inc, 2015.

www.aornjournal.org

were RNs.17 Sociometrically, the RNs in the center of the
team map are likely to act as “pulse-takers.” That is, they are
able to gauge the status of information and attitudes within
the network, but are less likely to be influential.28 However,
unlike the surgeons at the hub of the teams, pulse-takers
have greater opportunity to formally engage with members
of the entire network.21 The outer ring of our map is
composed of integrated team members who in this case tend
to hold higher organizational status. These individuals are
potentially “connectors” who can control the information
between groups and influence more than one team.
In terms of the relationships between procedure-related vari-
ables (research question 3), the positive correlation between
patients’ ASA status, an indicator of illness severity, and the
length of procedure is unsurprising. Conceivably, the patient’s
preoperative condition is more likely to increase the pro-
cedure’s complexity and length and influence team dynamics.
During field work, we observed purposeful and deliberate
patient- and case-related communications between consultant
surgeons and anesthesia professionals when the patient was
considered more ill (ie, ASA scores  3). While RNs were not
always privy to these discussions, those with more experience
and seniority were proactive and assertive and often asked
questions about the need for additional procedure- or
anesthetic-related equipment. During procedure preparations,
senior RNs communicated procedure-related information to
the more junior RNs in the room. In this way, senior RNs

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Sykes et al
acted as vital conduits for information transfer and enabled
others to be better prepared.
Previous researchers have demonstrated the inverse relationship
between staffing numbers, procedure-related variables, and pro-
cedure start times.17 The results of our study are similar and
demonstrate an inverse relationship between the number of staff
members and procedure start time (research question 3), and
this result is of some concern. The effect of having fewer core
team members available for procedures that start later in the day
may lead to variations in the quality of patient care provided.
However, this result may be a function of specialization and skill
mixdboth of which affect the availability of staff members for
scheduled or emergency procedures. This may also partly explain
why up to 12 of 103 (11.6%) RNs were shared across the four
specialties. Generally, these pulse-takers were experienced,
versatile, and able to move seamlessly among the four specialties.
In establishing whether a relationship exists between personnel
turnover and total number of personnel involved (research
“
Information sharing enables all team members
to develop a comprehensive, shared mental
”
model.
question 3), we found a commensurate increase in turnover
with increased staff numbers per procedure during longer
surgeries. While increasing team size brings in expertise that
may be necessary to achieve the desired goals, larger teams
increase barriers to communication, making it more difficult
for team members to develop and maintain shared mental
models.7,15 In our study, increases and/or changes in team
membership were supported by the observations recorded in
the field notes that our research team member took during the
observational phase of our larger study. For instance, particu-
larly in general surgery, we observed that as many as four
nurses (including relief staff) were commonly assigned to a
single role (ie, scrub or circulating roles) during procedures
lasting up to six hours (eg, Whipple procedures, liver re-
sections). Although it may be argued that personnel turnover is
needed to maintain a high level of vigilance, frequent nursing
personnel turnovers during complex procedures may
contribute to degradation in team communication and lead to
distraction and a loss of focus.15 Conversely, involvement in
the entirety of the procedure enables team members to
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February 2015, Volume 101, No. 2
develop comprehensive shared mental models in relation to
goals and tasks. Clearly, high staff turnover and short-term
involvement of staff members during a procedure require
better communication strategies to keep them updated with
the progress of the procedure.15
Limitations
We acknowledge that there are several limitations to using
this form of analysis to describe surgical team membership.
First, we have used sociometric analysis in a nontraditional
way. We did not “measure” typical attributes such as
interpersonal relations between individuals, the number of
times that members communicated with each other, or the
specific types of communications that occurred among
members. Although team maps provide useful insights about
team structure, they do not measure teamwork. Second, the
position of team members on the map was determined by
the total time worked together calculated in operating
minutes in each of the surgical specialties. Ultimately, it is a
graphical representation of a formal team structure that is
imposed by a work schedule and speciality needs. Third, we
relied on secondary data derived retrospectively from one
hospital’s database, which may not be as accurate as using
contemporaneous data collection methods. Nonetheless, we
also collected prospective observational data to confirm
surgical team details. Finally, we did not attempt to relate
our results to patient outcomes. For this, we would need a
much larger sample size.
Implications
Our innovative approach to using routinely collected data to
map team membership enables managers and leaders to visu-
ally see staffing patterns with the goal of improving decision
making around change management interventions, staff allo-
cation, and team balance. First, by identifying team members
who are shared between surgical teams, it is possible to identify
change champions who can effectively support change initia-
tives across multiple teams in a consistent manner. Nurses,
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February 2015, Volume 101, No. 2
who constitute the majority of team membership in the OR,
are well placed to assume leadership roles in the formation of
high-functioning surgical teams. Nurses can act informally to
convey group norms and work procedures that influence sur-
gical and anesthesia residents or other nursing personnel with
the potential to define and influence team culture across
multiple teams.
Second, team maps graphically differentiate nurses with a
strong team specialization or team neutrality. In the current
study, 12 of the 53 RNs we mapped regularly moved among
multiple teams. Team neutrality (ie, the ability to easily move
from one team to another) may highlight individuals who
possess wide skill repertoires, flexibility, and versatility to move
among various surgical subspecialties. Conversely, those nurses
identified as being team specialists or core members of
particular surgical teams (eg, thoracic team) may be good
persons to teach new and inexperienced nurses the specific
skills required in a surgical speciality.
Third, the information gleaned through mapping team
membership allows nurse managers to obtain longitudinal data
in relation to planning ongoing skills development strategies
across each specialty area. Such information may inform staff
development initiatives around skill mix and create educational
opportunities for orienting novice nurses and providing the
opportunity to rotate through each specialty to gain essential
skill sets needed to practice safely in the OR environment.
Finally, because turnover during surgical procedures may be
unavoidable, protocols to ensure the deliberate and timely
exchange of important information about the patient’s con-
dition, specific task requirements, and equipment for the
procedure are imperative. One approach is to develop strategies
that encourage individuals to pass on information to the newly
assigned team member before the procedure and during staff
turnover.15 Information sharing enables all team members to
develop a comprehensive shared mental model.16
CONCLUSION
Through mapping team membership, it is possible to enhance
our understanding of the stability of team membership over
time. Thus, team mapping may be useful in guiding decisions
around team and task allocation. Our results suggest that
staffing numbers increased with procedural complexity and
duration. Managers should identify and implement scheduling
practices to better facilitate the continuity and regularity of
team membership, especially for the nurses in the team, to help


ensure better outcomes for the patient by providing a more
cohesive better-functioning team.
www.aornjournal.org
Surgical Team Mapping
Acknowledgment: Dr Gillespie acknowledges the financial
assistance of the Australian Research Council, Early Career
Discovery Fellowship Scheme.
Editor’s notes: Operating Room Management Information
System (ORMIS) is a registered trademark of Computer Sciences
Corporation, Middleton, MA; GephiTM software is a trademark
of the Gephi Consortium, Paris, France; IBM SPSS Statistics 20
for Windows is a registered trademark of the IBM Corp, Armonk,
Town of North Castle, New York. Windows and Excel are
registered trademarks of Microsoft, Redmond, WA.
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248 j AORN Journal
February 2015, Volume 101, No. 2
Mark Sykes, MBus, BPsych (Hons)
is a research fellow at the NHMRC Research Centre for
Excellence in Nursing, Research Centre for Health Prac-
tice Innovation, at Griffith Health Institute, Griffith Uni-
versity, Gold Coast Campus, Queensland, Australia. Mr
Sykes has no declared affiliations that could be perceived
as posing a potential conflict of interest in the publication
of this article.
Brigid M. Gillespie, PhD, RN
is an associate professor at the NHMRC Research Centre
for Excellence in Nursing, Research Centre for Health
Practice Innovation, at Griffith Health Institute, Griffith
University, Gold Coast Campus, Queensland, Australia.
As a member of the Editorial Board of the AORN Journal
and as a recipient of the Australian Research Council,
Early Career Discovery Fellowship Scheme, Dr Gillespie
has declared an affiliation that could be perceived as
posing a potential conflict of interest in the publication of
this article.
Wendy Chaboyer, PhD, RN
is a professor and director at the NHMRC Research
Centre for Excellence in Nursing, Research Centre for
Health Practice Innovation, at Griffith Health Institute,
Griffith University, Gold Coast Campus, Queensland,
Australia. Dr Chaboyer has no declared affiliations that
could be perceived as posing a potential conflict of in-
terest in the publication of this article.
Evelyn Kang, MPH, RN
is a senior research assistant at the NHMRC Research
Centre for Excellence in Nursing, Research Centre for
Health Practice Innovation, at Griffith Health Institute,
Griffith University, Gold Coast Campus, Queensland,
Australia. Ms Kang has no declared affiliations that could
be perceived as posing a potential conflict of interest in
the publication of this article.
www.aornjournal.org
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