A Common Body of Care: The Ethics and Politics of Teamwork in the Operating Theater are Inseparable

In the operating theater, the micro-politics of practice, such as interpersonal communications, are central to patient safety and are intimately tied with values as well as knowledge and skills. Team communication is a shared and distributed work activity. In an era of “professionalism,” that must now encompass “interprofessionalism,” a virtue ethics framework is often invoked to inform practice choices, with reference to phronesis or practical wisdom. However, such a framework is typically cast in individualistic terms as a character trait, rather than in terms of a distributed quality that may be constituted through intentionally collaborative practice, or is an emerging property of a complex, adaptive system. A virtue ethics approach is a necessary but not sufficient condition for a collaborative bioethics within the operating theater. There is also an ecological imperative—the patient’s entry into the household (oikos) of the operating theater invokes the need for “hospitality” as a form of ethical practice.

Keywords:

• collaborative intentionality
• ecological sensitivity
• the imperative
• shared practices
• teamwork
• virtue ethics

I. INTRODUCTION

How are ethical and value positions generated or applied in a micro-political healthcare setting such as the operating theater? Are there ethical principles at work, and/or do ethical positions arise from context or situation, especially as an improvised response to value conflicts emerging from the dynamic unfolding of work activity? This article will address these questions through a conversation between bioethics models and data derived from empirical study of the micro-politics or communication patterns of operating theater teams. The approach adopted is then based partly on casuistry—the case study as exemplar, tested and adapted through subsequent cases.

The cases here are illustrative examples of work issues arising in the operating theater and peri-operative care that come to show how a certain values position (a distributed virtue ethic) emerges in better performing teams through collaborative intentionality—open, constructive dialogue about what to do next in dynamic work practice. In contrast, teams that do not communicate well are usually characterized by a closed, monological atmosphere set by the surgeon as leader and then do not collaboratively construct shared value positions.

Paradoxically, given that values positions in operating theater practice often arise as pragmatic, situated responses to immediate uncertainties, this article will argue that a common principle can bind bioethical (values) and biopolitical (communication) issues in the operating theater team. This principle is “hospitality,” and can be equated with the “centeredness” of “patient-centered” practice. Further, hospitality is set in a wider imperative of “education of attention,” or witnessing, as sensitivity to environmental conditions. This is an ecological imperative and describes how one “in-dwells” an oikos, habitat, or work place.

Operating theater teams face bioethical dilemmas on a regular basis—the operating theater is the clinical environment where most medical accidents occur. However, 75–80% of such accidents are not due to technical mishaps or incompetence, but to systemic non-technical issues, such as miscommunication (Helmreich & Merritt, 1998). The micro-politics of the operating theater (communication within a conventional hierarchical setting) constitute a biopolitical field where such communications are centered on, and directly affect, quality of patient safety and care. Because medical errors in the operating theater and peri-operative environments are grounded in systems-based (mis)communication, the micro-biopolitics of these environments then become the loci for bioethical issues. Bioethics and biopolitics are inseparable in this clinical context, where, for example, choices about communication style directly affect patient safety. An authoritative, surgeon-led monological climate is more likely to provide a context for systems-based miscommunication than a facilitative, collaborative, dialogical climate (Allard, Bleakley, & Hobbs, 2006a).

An ongoing inquiry into the dynamics of operating theater teams in relationship to improving patient safety (Bleakley, Hobbs, Boyden, & Walsh, 2004) gathers data from naturalistic observation, videotape analysis, individual and group interviews, questionnaires, and textual analysis of close-call reports (issues that may have led to an incident or accident). This dataset reveals that the characteristic ethical or values position taken up by operating theater staff to approach value conflicts is pragmatic: best described by Aristotle’s notion of phronesis or “practical wisdom,” and consistently linked to the exercise of “professionalism.” However, such a values ethic is typically described in individualistic terms, and individualism is the very perspective that works against the potential of good communication in teams as shared practice and distributed knowing. The discourse of individualism is so deeply naturalized that teams are seen as a collection of individuals, and collectivism is not a given condition, but a condition to be achieved.

The naturalized condition of individualism can be described as ego-logical and the collaborative condition as eco-logical. An eco-logical perspective on ethical practice again highlights the importance of collaborative and intentional in-dwelling of the common habitat, the operating theater as work space into which a patient arrives as a particular kind of guest. This common household can also be configured as a common body of practice (shared communication) that is ethical as well as political. The notion of a shared virtue for an ethical, micro-political practice underpinning patent safety goes beyond simple distribution of values across a team. A shared virtue can be framed both as an act of hospitality that is an extension of friendship, and as a response to an ecological (environmental) imperative.

This article will argue that the practice of ethical communication in the operating theater team demands a double shift in perspective from a virtue ethics position. This may also be applicable to clinical teamwork in general. First, good communication can be described as an act of hospitality, demanding that practitioners suspend self-centeredness for other-centeredness (where “patient-centeredness” is the obvious primary value position). Second, the driver for good communication in the team need not be located in personal agency, but rather in sensitivity to an environmental imperative. Through “education of attention” of team members by the clinical field—the practice context and micro-political structure—an ethical imperative is addressed. In this dual activity of collaborative practice hospitality and sensitivity to an ecological imperative, a patient-centered atmosphere of safety and care may be established.

As an ecological imperative, this field (or common body) of care offers a bioethics constituted as a biopolitics. The imperative can be read as an unusual example of the interaction of sovereign power (the ecological imperative) and capillary power structure (the redistribution of power within a flattened hierarchy), described by Giorgio Agamben (1998).

II VALUES INFORMING COMMUNICATION IN OPERATING THEATERS

In an ongoing, open-ended, collaborative inquiry setting out to improve teamwork for better patient safety in operating theaters in a large UK hospital, we (Bleakley et al., 2004) have described in detail the knowledge and skills necessary for this practice transformation. Our focus, with over 300 theater staff, is upon team members acquiring “non-technical” capabilities. This includes expertise in both intra-group and cross-team communication; and in team situational awareness or “shared mental models,” with particular ability to anticipate events and tolerate uncertainty (Bleakley, Boyden, Hobbs, Walsh, & Allard, 2006; Allard et al., 2006a; Allard, Bleakley, & Hobbs, 2006b).

We are carrying out this collaborative research with teams, not on them, because we believe that not collaborating with teams in this context would be an appropriation of their cultural capital and therefore unethical. While we have formally mapped the fabric of communication of knowledge and skills for effective teamwork, we have not looked in depth at the ethical and value issues concerned with changing practices in surgical care. This article addresses this lack. We have set out to collaboratively change attitudes towards teamwork, where cumulative, unidirectional change creates new work climates. Central to this attitudinal shift is the achievement of porosity in traditional professional boundaries, normally crystallized through surgeon-led hierarchies focused upon technical competence rather than shared practices such as communication.

Given that the life, illness, and death of the biological body are frontline concerns in operating theaters, bioethical issues concerning how one should act in relation to the raw bodily presence of patients are ever-present. These ethical issues are inter-twined with varying levels of the governance of the bodies of both patients and their health carers. Such political governance operates at the micro-levels of the dynamic of the clinical team and relations between teams; and at the macro-levels of management of teams, including regulation by bodies such as the General Medical Council UK, in turn answerable to central Government. At the micro-political level bioethics is identified with biopolitics as far as many clinical practitioners are concerned, where the theoretical concerns of contemporary ethics are rarely discussed or formally educated at work, but the political demands that frame how bodies are regulated are keenly felt and widely discussed as they shape day-to-day practice.

III THE NATURALIZATION OF PHRONESIS

Post-Aristotelian virtue ethics is now firmly established as a “third force” in bioethics, challenging both Kantian/deontological and utilitarian/consequentialist approaches (Statman, 1997; Oakley, 2001). The virtue that seems to appeal to medical and healthcare practitioners concerned with issues of “professionalism,” is Aristotle’s notion of phronesis. This has been translated as “practical wisdom” in a clinical setting (Fish & Coles, 1998) to refer to clinical “professional judgement,” where “wisdom” is aligned with deliberative practice, including idiosyncratic and intuitive expert judgment. In other readings of phronesis, “wisdom” is read more instrumentally, as the exercise of practical judgment through rationality (Louden, 1997); as “good judgment” in business ethics (Solomon, 1997); as “prudence,” a desirable personal virtue (Simpson, 1997); and as “perspicacious judgment” and “the prudence of common sense,” desirable communal virtues (Derrida, 1997).

Depending on one’s preferred model of power, the term “practical wisdom” has achieved either sovereign status or pervasive capillary reach, as the preferred term for a dominant and permeating discourse that has come to displace the “reflective practitioner” as the “new thing” in clinical education. For canny (and perhaps somewhat cynical) contemporary medical students, “reflective practice” is part of the “pink and fluffy” stuff of “professionalism,” and has become an object of ridicule as both a vacuous description and an out-of-fashion item. Not so long ago, it was the privileged term for an ethically-sensitive but pragmatic approach to healthcare practice. In education generally, like the descriptor “adult learner,” “reflective practice” has become an empty mantra (Bleakley, 1999; Bleakley, 2006a), a naturalized term, institutionalized to insulate it from critique. Phronesis may go the way of “reflective practice” in clinical education. It certainly appears already to be naturalized and beyond critique, defended against rigorous interrogation.

IV THE CURSE OF INDIVIDUALISM

The argument presented here is not, however, primarily concerned with the naturalization of terms such as “practical wisdom,” but with the emphasis that virtue ethics approaches place upon individualism at the expense of community and ecology. For example, Dent, in defining contemporary post-Aristotelian virtue ethics, notes that the ethics of virtue “derives the desirability of the act from the desirability of…motives or traits of character” (1984, pp. 32–4). Peters is even more stark: “Each of us is ultimately lonely. In the end, it’s up to each of us and each of us alone to figure out who we are and who we are not, and to act more or less consistently on those conclusions” (1989, p. 2). In an era of teamwork as the dominant practice context in healthcare, calling also for deliberate co-configuration of a number of teams around patients in a designated care pathway, the dominant medical model’s stress on heroic individualism appears misguided. Paradoxically, individualism displaces all other virtues as the default position.

That the individual is stressed over the collaborative team or “community of practice” (Wenger, 1998) in healthcare is a legacy of a strongly hierarchical, self-regulating medical culture that values technical expertise above non-technical expertise as a basis to professionalism. That we need technically capable practitioners is self-evident. In contemporary medicine, increasing expertise in specialist technical capability is increasingly more formally examined and guaranteed. The issue for professionalism, and, perhaps surprisingly, also for patient safety, is the “non-technical” realm of communication, teamwork, and ethical practice. These capabilities are shared across healthcare teams, or are non-hierarchical.

There is a large body of evidence demonstrating that 75–80% of medical error is grounded in systemic issues concerned with miscommunication in teams (Helmreich & Merritt, 1998). Small miscommunications can accumulate and then align to form the conditions for an incident or accident. A typical example occurs regularly in operating theaters and concerns the possibility of a patient undergoing an operation on the wrong side or site of the body—a potential lateralization error (Bleakley, 2006b).

In the UK, the established communication system for indicating side or site for surgery is prone to error. A letter from the consultant surgeon to the patient’s General Practitioner indicates the side or site to be operated upon. A copy of this letter is forwarded either to the surgeon’s secretary or to an administrative pool who record the side or site on to a central computer record, from which operating lists are prepared. When the patient arrives on the surgical ward, or to day-case surgery, he or she is issued with a wrist band for identification and the side or site for operation should be clearly marked on the skin with an arrow in indelible pen. The patient is visited by the surgeon (or an assistant) and the anaesthetist, who both have sight of the patient’s medical record on which the side or site of the forthcoming surgery will also be noted. Further, the patient will sign a consent form agreeing to the surgery, on which the side or site is clearly indicated. It is not uncommon, within this web of information, for the side or site to be wrongly marked on one or more of the five intersecting records. The widespread resistance to adopting published protocols to avoid such potential error is perhaps a symptom of a wider malaise—that of operating theater teams already buckling under the weight of intense surveillance and governance that may be characteristic of “managerialism” as a biopolitics (Ball, 1990). An alternative explanation is that if the surgeon does not follow the protocol then nobody will, reflecting the strong hierarchical nature of the system. This presents an ethical dilemma, where patient safety is compromised.

A study of nearly 450 close-call (near-miss) reports from operating theater staff in one large UK Trust over two years (Bleakley, 2006b) shows that potential wrong-side surgery is sometimes avoided by chance rather than calculation or deliberation (for example, a theater practitioner such as a scrub nurse picking up that the side indicated on the operating list is different from the side marked on the body). Around 30 cases per year are reported. Many close-calls go unreported, and so the number of “accidents waiting to happen” through team miscommunication concerning potential lateralization errors will almost certainly be far more than 30 per year.

What has this got to do with the pervasive culture of individualism in medicine? Let us return to our consultant surgeon, who is supposedly “in charge” of the patient. In reality, it is a number of teams (surgical ward, auxiliaries who wheel the patient to theater and from recovery, anesthetic room, operating theater, and recovery room) who collectively manage patient care. Such patient-centered, team-based healthcare is, in principle, based on “collaborative intentionality” (Engestrom, 2005) across teams, not on hierarchical individualism. Collaborative intentionality, however, is not the normative climate in operating theaters. Again, this compromises patient safety, where horizontal, shared teamwork and communication enacted expertly addresses the greatest potential for medical error—systemic miscommunication.

Thus, it is in the surgeon’s interest to switch emphasis from a culture of heroic individualism to one of collaborative teamwork, where desirable virtues can then be framed as emergent properties of the dynamic system that is the clinical team at work. To return to the example of potential lateralization error, surgeons should, ethically, always exercise collaborative checks to make sure that the operating theater list, marking on the body, patient’s notes, wristband identification, and consent form agree, before knife is put to skin. Prior to this, the anesthetic team should check in a similar fashion, so that the wrong patient does not end up being anesthetized unnecessarily. Importantly, part of the teamwork system, the operating team should brief at the beginning of the list to raise awareness about potential miscommunication. Finally, the team should debrief at the end of the day, to collaboratively recognize good practice and to deliberate any close-calls.

That these kinds of collective practices meet with resistance can be explained by socialization, of surgeons in particular, into heroic individualism. This should not come as a surprise where the wider cultural context privileges individualism over community, and encourages narcissism. Max Weber famously described the rise of capitalism as inextricably linked with the Protestant work ethic of self-sufficiency (1946). It is good to save and inwardly invest (but one must not spend, as this is indulgent). In education, knowledge is a form of capital that is explicitly framed as privately “owned.” We encourage self-direction or autonomy, and self-assessment, through fashions of “andragogy” (“adult” learning, wrongly opposed to “pedagogy” or child education), offering untested notions that are not even intellectually sophisticated enough to deserve the status of “model” or “theory” of education (Bleakley, 2006a).

It is easy to explain why individualism remains the dominant force in clinical education—it is an ideological issue. Thanks to the Cold War, it was only in the 1970s that educationalists in Western Europe and North America began to hear of the educational praxis developed in the post-revolution Soviet bloc. This work was inspired by the work of Vygotsky in particular, and based ideologically on the premise of collaboration and the collective rather than the individual (Bleakley, 2006a). Briefly, where clinical education continues to privilege individualistic models of learning, there will be resistance to collaborative practices such as teamwork and co-configuration of teams, because there is no fundamental understanding of their dynamic, purpose, and value. The individualistic model of learning is also ideological.

An ethical dilemma is raised by the skills and knowledge blind spot created by individualism. Healthcare practitioners in general find it difficult to adequately frame ethical issues in collaborative intentionality or team terms. This is exacerbated by the fact that in turning to virtue ethics to inform practice, the versions of virtue ethics that are privileged, as noted above, tend to be individualistic. Ethical dilemmas tend to be framed as taxing the individual mind and heart rather than as an effect of distributed cognition and affect. Virtues tend to be described as personally held or personally realised. There are important exceptions to this, such as thinkers who ground virtues not in the idea of a good individual, but rather in consideration of what virtues are good for humans in general. In particular, Alasdair MacIntyre (1984) and Philippa Foot’s (1978) later work move out from individual concerns to what is good for a community. MacIntyre argues, for example, that the important virtues are those that sustain the communities that invest in them. However, these are minority views in a literature that largely assumes an individualistic perspective, and has come to naturalize this perspective.

Socialization of healthcare practitioners within a medical model valorizing heroic individualism, and within an educational model valuing autonomy, leads to valuing idios (the individual citizen) over polis (the State) and demos (the body of the people). To pursue the heroic individualistic project in an era of patient-centered teamwork is literally idiotic. We need an ethic of practice that is true to the polis or community of practice—a distributed bioethic that is biopolitical.

As Aristotle uses the term in Rhetoric (11. xii–xiv), ethos at root means “the prevalent tone of sentiment of a people or community.” This describes collective and collaborative character, not individualism. Further it describes an atmosphere, not a character trait. A “tone of sentiment” in a clinical team is an emerging climate, a process, constituted not constitutive. Team process can be thought of as “teeming”, a dynamic process of whole teams getting into the rhythm and flow of the day’s unfolding activity. Here, the team must be collectively attuned through distributed cognition, affect, and situational awareness.

We need to get our ethical house (oikos) in order for this new era of clinical teamwork, because the shift of emphasis from the vertical hierarchy (the tree) to the horizontal and shared realm (the rhizome) is so dramatic. We need to better research and understand distributed effects of cognition such as situational awareness (Allard et al., 2006a), and distributed affect such as team “climates” and “atmospheres” (Lewis, Rees, Hudson, & Bleakley, 2005). Our ethos needs to widen to understand not just the character of persons within a virtue ethics frame, but the ecological character of clinical work. It is here, paradoxically, in re-inscribing the habitat of work with an ecological “imperative” (Lingis, 1998), that we recover a link between Kantian ethics and contemporary virtue ethics, a point elaborated later.

Throughout Nicomachean Ethics, Aristotle describes virtue as “a state of character” (Book II:6), where virtue is individualized and interiorized. However, there is a transition in the last chapter (Book X) that prepares the way for Aristotle’s Politics and argues that the most important virtue is political–civic participation. Here, Aristotle sketches out a meeting of bioethics and biopolitics, where “medical men”, in “distinguishing the various habits of the body”, do so by “particular classes of people” or through a “political art”. This is population health, and, for Aristotle, as for us, it demands expertise. It is done by “experienced people” while “to the inexperienced it is valueless” (Aristotle, Book X:9).

What, then, is the process by which political or community virtues are consolidated? The answer to this is in Book VIII of the Nicomachean Ethics—the key factor for transition from an ethics of the idios or individual to an ethics of the polis or community, is friendship. Aristotle argues that friendships based on pleasure or utility are mock friendships, for they disguise selfish motives of gratification or gain. The friendship which is virtuous is that of “those who wish well to their friends for their sake” (VII:3, emphasis mine).

This last quote prefigures Emmanuel Levinas’ writing on hospitality (Levinas, 1969; Bleakley, 2002), considered below. Aristotle points out that “the friendship of host and guest” can usually be considered to be in the same category as “utility” friendships, only because, conventionally, hosts have sovereign power over guests (“you are a visitor in my house/my country”) (VIII:3). However, Aristotle has already provided an internal contradiction in his discussion of host and guest that provides us with a convenient entry point into a different view of hospitality. This point of entry serves to frame an ethic of care for clinical teams. An act of hospitality for Aristotle in virtuous friendship is suspension of one’s own desire in the face of the Other. In the household of the operating theater, ethical practice is characterized by suspension of personal desire for the safety and care of the patient as special Other or Guest—an act of hospitality and a gesture of friendship.

V FRIENDSHIP AND HOSPITALITY

Giorgio Agamben (1998) wonders why Foucault, in his (albeit unfinished) project anatomizing biopower as capillary and productive, never wrote on the Holocaust, the power structure displayed in concentration camps, or the general structure of authoritarian regimes, whether fascist or Stalinist. Agamben suggests that Foucault’s argument for the displacement of sovereign power by forms of biopower in modernity (where direct control of the birth, life, illness, and death of the biological body—as “bare life”—now becomes a concern for government) is premature. Agamben recognizes that sovereign power continues into modern times through totalitarianism and the authoritarian personality. Sovereign power and biopower must then coexist. An example (not used by Agamben but illustrating his argument), is that while biopower enters the bedroom subtly through sex manuals and popular magazine articles, a family planning dictate from Central Government that says you will populate the world with many blonde-haired, blue-eyed children (Nazi Germany) or that you must have only one child per couple (post-Maoist China) is an entry into the bedroom by force.

Slavoj Zizek (1999) offers another reason why we cannot dismiss sovereign power. Foucault’s analysis of liberalism is that power is present but is not naked—it achieves purposes subtly. Seating people in a circle in a classroom setting may break down hierarchy for democratic discussion, but it forces eye contact and allows no place for the shy or vulnerable, privileging the extrovert. Foucauldians say power still operates but now in a permeating, capillary manner. Zizek is far more direct in his analysis. “Enjoy!” or “Have a nice day!” are not liberal invitations but imperatives, injunctions, up front. People are prescribed antidepressants for not having a nice day.

We should then reconsider the place of sovereign power in high modernity. Later, sovereign power is described as an ecological imperative, reading Kantian ethics in an unusual manner, where virtue ethics is recognized as a necessary but not sufficient condition for effective clinical teamwork. But first, let us consider Agamben’s argument that we cannot simply displace sovereign power with Foucaldian biopower.

Agamben’s penetrating analysis of the Holocaust reminds us that Foucault’s (1987a; 1987b) description of “technologies of the self” misses an obvious point. Where Foucault privileges the micro-political apparatus that makes power productive, for example in identity construction through a variety of “self-help” techniques since antiquity, he misses the historically recent authoritarian (sovereign) identity construction of the mass “race” experiments conducted by the Nazis, based on “scientific” eugenic theory. Subjectivization, for Agamben, again works through two faces of power: capillary and sovereign.

For Agamben, bioethics and biopolitics are similarly co-dependent. Just as “bare” or natural life (zoe) can be reduced to inclusion (life) or exclusion (death), so politics must follow the same logic. Natural life that is included becomes political as life is lived in the cultural sphere (bios). Natural life that is excluded (death) is, however, also political in the sense that politics can decide what a life is worth—shall we send them to war, or to the concentration camp or detention center, or to an early death thanks to inadvertently supporting poverty through poor use of health resources? Agamben concludes that “the fundamental categorical pair of Western politics is not that of friend/enemy but that of bare life/political existence … exclusion/inclusion” (1998, p. 8).

Surely hospitality, as a basis to friendship, is subject to the same exclusion/inclusion dynamic that is inevitably a political appropriation of the body? The borders between Israel and the Palestinian settlements, India and Pakistan, northern and southern Ireland, and so forth, are arenas that demand the collapse of distinctions between the pairs of bare life/political existence and friend/enemy. The suicide bomber translates political existence back to bare life because he or she cannot accommodate or entertain the translation of enemy into possible friend through the freely given gift of hospitality. Such a translation is necessary if we are to entertain Levinas’ ethic of hospitality. And it is this ethic that provides the basis for crossing the borders from the safety of one’s own professional group and identity (uniprofessionalism) to accommodate the views and practices of another professional group within a mixed clinical team (interprofessionalism—learning with, but also about and from, another professional group).

Levinas (1969) reads friendship through the category of hospitality, and this becomes a fundamental category for re-thinking clinical practices. This reading collapses Aristotle’s distinction between three kinds of friendship: ethical, nomic (or legal), and loving or sexual. Friendship for Levinas is of one kind, and arises from a unique reading of the host/guest relationship. Where the host is usually read to have sovereign power over the guest, and the judicious use of this power controls and shapes the friendship, Levinas casts the guest in terms of the Other to whom the host must offer the freely given “gift” of hospitality (Bleakley, 2002). This is friendship without strings, requiring a sacrifice of self to Other, in recognition that “otherness” or difference is only realized through such a sacrifice.

This is not the gift of the potlatch, which must be returned and doubled. There are no conditions attached. Indeed, the giver must walk away without expectation of reciprocity. The model here is a woman giving birth. This returns us to Agamben, who suggests that it is only in recognizing what “bare” or natural body is excluded and sacrificed by a political order (such as the Nazis’ sacrifice of the Jews) that the oppressors come to understand the shape of their political order (Agamben, 1998). Fascism is then a direct reversal of the gift of birth and is constituted by what it excludes; and the shapes or forms of biopolitical acts are known by their exclusions, not their inclusions (although it can be argued that, paradoxically, every inclusion necessarily creates exclusion; and, by definition, surplus cannot be encompassed by an inclusion/exclusion dimension). If one does not work through this understanding of what is excluded, then one is always in identity (selfsame) struggling to recognize the difference of the Other.

Generating ethical stance through inclusion rather than exclusion describes a shift from an egology to an ecology. The oikos or household is typically known not by who lives there, but who is refused entry or excluded. Again, this notion can be readily applied to the relationships between professional groups (surgeons, anesthetists, anesthetic assistants, operating department practitioners [scrub], circulating nurses, recovery nurses) in the operating theater and peri-operative care. An egology follows Descartes’ “I think, therefore I am.” An ecological view transforms this to “I think of the Other, therefore I am.” This leads us to a different interpretation of phronesis, as practical judgment (common sense). The wisdom of the team, the common senses, is shared, collaborative, and, most importantly, grounded in dialogue. This does not mean that teams are not often internally tense, or that members do not disagree. What it does mean is that dialogue is held as collaborative intentionality, with a focus on the best teamwork process for the patient in theater at that time, care then being shaped by inclusion not exclusion.

This shift of emphasis for phronesis from individual to collaborative decisions, necessary for setting up the conditions of possibility for the emergence of hospitality, does not compromise individual technical clinical decisions. Rather, it signals the emergence of a shared cognition and affect that forms a safety net(work) for patient care based on both expert technical practice and good communication. At the heart of shared communication is situational awareness, the initiation and maintenance of a shared mental model of the day’s activities with a particular emphasis upon anticipation and future event and upon tolerance of uncertainty (Allard et al., 2006a). At the heart of situational awareness is witnessing and close noticing, keeping one’s “antennae” up, using the senses, maintaining both focused and peripheral attention. These capabilities are enhanced by friendship as hospitality or suspending self on behalf of the Other (welcoming the unknown to table with grace), because, in suspending personal judgments, a collective or collaborative professional judgment must emerge from communal opening to Otherness. “Friendship” in this sense is the collaborative production of tolerant dialogue to maintain expert practice in team communication. Now we see that patient-centeredness, as hospitality, is prefigured by the interprofessionalism of the clinical team, modeling friendship as interprofessional empathy.

Properly, Levinas (1969) notes that hospitality of this kind is an impossible project. “Welcoming” is at the core of hospitality (Derrida, 1997; 1999) and heralds in itself two “impossibilities.” The first impossibility is the recognition of the “face” of the Other (that the Other has a voice, an opinion, a reasoned argument, is upset, shows tact, and so forth). This is not to give a face to the Other, but to see the face that the Other offers. Second, this “total” recognition is necessarily infinite. Finitely, there is no way that the Other can be fully comprehended. Rather, there is usually a disconcerting present in which I struggle with tolerating difference. But infinitely such recognition offers a horizon that is an imperative.

Derrida (1997) describes this horizon scenario of friendship as a condition “to come.” In describing democracy, Derrida says, “democracy remains to come … indefinitely perfectible, hence always insufficient and future” (1997, p. 306). So may we describe a democracy of operating theater team politics, as in permanent revolution, always “to come.” This trajectory of becoming offers an ethical framework for team practice. In this climate of mutuality, we can perhaps best describe the role of friendship in teamwork in Deleuzean terms, as “becoming-friends.”

For Derrida, there is both “an ethics … and a law or a politics of hospitality” (1999, p. 19). While we may see hospitality as a primary ethical gesture, the politics of hospitality are still rooted in sovereign models (again, “you are a guest in my house,” “a patient in my theater”). What is “to come” for Derrida is the transformation of the politics of hospitality by its ethics as described by Levinas, so that the law of hospitality becomes in the presence of the Other I recognize and tolerate difference. At the same time, I recognize that the Other is more than I can contain. This is infinity in the global political landscape, a wide horizon, even a vanishing point, but in the local culture of the clinical team, why not “infinity now!”?

VI EVERYDAY PRACTICE RHETORIC WORKS AGAINST HOSPITALITY

The close-call reports gathered from theater staff, referred to earlier, are analyzed in two ways. The first way is through a gross frequency count of examples, descriptively and thematically. For example, 70% of close-calls are explicitly about team miscommunications, most often between ward and theater teams. A deeper level of analysis is to scrutinize the narrative reports as a medium for the exercise of rhetorical strategy, a main function of which is construction and management of professional identity. Close textual reading of close-calls reveals a number of rhetorical strategies at work, demonstrating that reports are neither transparent nor objective. “Factual” recollection can be seen as construction of fact shaped by particular strategies. For example, practitioners maintain traditional boundaries between professions by stereotyping the “other” professional in the team. This divergent tactic serves to construct a uniprofessional identity that frustrates the establishment of interprofessional activity.

However, a quite different, convergent, permeating rhetorical strand is to foreground the stress and fatigue commonly felt in operating theater team work so that work is stereotypically presented as always on the edge, close to collapse. This serves to shape an identity of “heroic survivors” for team members that offers a bonding. Stereotypically, identity as a team member is achieved by identifying a common enemy who is the cause for this stress. This is usually an uncaring, faceless “management,” who in turn are the puppets of politicians.

In contemporary poststructuralist thinking, identity is described not as a “given” (subject and constitutive) but as socially constructed (subject to and constituted). Identities are then multiple and fluid (Bleakley, 2000a; Bleakley, 2000b). The operating theater practitioner manages both a professional identity (“surgeon,” “nurse,” “anaesthetist”) and an interprofessional identity (“team member”). Indeed, the professional identity is further defined as “kind of surgeon” and “kind of nurse.” Scrub nurses and recovery nurses inhabit differing cultures, as do general surgeons and orthopaedic surgeons. In poststructuralist thinking, identity is not a given essence but is formulated through the mirror of the “other.” In Hegel’s description of the master-slave dialectic, the “slave” only gains this identity in the face of the other who is “master,” and vice-versa. Paradoxically, without the slave there is no master. Hence, despite the apparent power of the master over the slave, the slave actually exerts power over the master as the necessary “other” for an identity construction through the rhetorical device of antithesis.

As Lingard (Lingard, Reznick, Espin, Regehr, & DeVito, 2002) suggests, identity construction and management in the operating theater team depends upon a stereotyping and simplifying of the other, to bring a more acute sense of separateness and boundary to the “professional” self. Comparison and contrast are common and powerful rhetorical moves enacted in clinical practice, offering a simplified form of antithesis, where the juxtaposition of contrasting ideas about the same topic forces the audience (other team members) to choose one option. Thus, a typical sentiment is “I am a scrub nurse because I do not act like a surgeon and I know how a surgeon acts” (where the account reduces the other to stereotype). In a close-call report a nurse prefaces her account with “this is to be expected of” with regard to the surgeon, thus stereotyping the other. In another report, a nurse prefaces her account with “I didn’t expect to be taken notice of” (by the surgeon), thus reinforcing a conventional identity by placing herself in an inferior position in an oppressive and poorly communicating hierarchy.

To return to the argument above concerning the naturalizing of individualism (so that collectivism is seen as something to achieve rather than a given condition), construction of identity does not necessarily rely upon positioning oneself in relation to another professional group. A nurse records that “I collected a vacuum pump (for vacuum dressing) from the ward. When I opened the case to take the pump out I noticed it was very dirty. I rang the ward and complained and checked it had not been used on a patient with MRSA etc. I then took the pump out to clean it myself and found that the cassette from the previous patient was still in situ (blood and all). I disposed of this, cleaned the pump thoroughly and it was used.” Here, the reader is led to admire the diligence and autonomy of the nurse. However, without suggesting that this person is not diligent, the rhetorical device of anaphora used in the account gives the report an extra force in which the audience is distracted from the sloppy practice of whoever should have cleaned the pump in the first place to now focus on the admirable energy of the nurse.

Anaphora involves repetition at the beginning of successive sentences to drive home a point, usually resulting in a climax, insight or conclusion. Thus: “I collected …,” “I opened …,” “I noticed …,” “I rang …,” “I found (the old cassette) …,” “I cleaned …,” and “I disposed of… .” Evidence is “stacked up” in such a way that the reader is left under no illusions about the heroic role of the writer. However, not only does this detract from the issue reported—the negligence of the previous user of the pump—but the strong advert for autonomy goes against the grain of collaborative teamwork. In this egological account, we are not sure that an ecological climate (attention to the habitat, including the concurrent activities of others, as a running situational awareness) has been established.

VII FROM VIRTUE ETHICS TO THE ECOLOGICAL IMPERATIVE

Virtue ethics leads us away from the universal abstractions of Kantian approaches and then promises concrete applicability to particular practice contexts. However, as argued earlier, the virtue approach is limited by its naturalized, and then unreflexive, individualism. As James Hillman suggests, “(w)e have become … very aware and very subtle interiorized individuals, and very unconscious citizens” (1994, p. 30). While we work on our psyches through introspective therapies in cramped rooms, the world suffers. Our ecological awareness is anesthetized as the inner life is estheticized through consumer culture narcissism, where the mirror is the “possible self,” not the Other. In this self-imposed dulling, exacerbated by conventional virtue ethics, we fail to feel the world’s impression. We do not sense the imperative that is the world calling us, to which our attention must be turned if we are to have a future life at all.

To return to a previous point, we come to know the world by its exclusion. Hence, in Levinas’ model, we are poor hosts and show lack of friendship. The same etho-ecological model applies to the daily work of the operating theater team. Patient safety is compromised where the team members only know other members through the category of exclusion (uniprofessional groupings). The product is that situational awareness (sharing a mental model) fails to be initiated or sustained. Hospitality is doubly compromised—first by the exclusion tactics of the differing professional groups within the clinical team, conforming to hierarchical conventions; and second, by the knock-on effect of this upon the patient as guest in a team household that is dysfunctional and fails in its basic communications. Hospitality for the patient is a difficult project where the household is already in disarray.

Situational awareness demands that two kinds of attention work simultaneously. There is a focused, vigilant attention that works from the inside out and is usually task-based; and a general, free-floating paradoxical attention that is a general awareness and recognition of what is going on in the habitat, such as the operating theater. This is an “outside-in” attention. It requires sensitivity to what the environment affords, or gives off. It is a kind of animal knowing, or abductive reasoning (knowing in the senses) that is an ecological awareness (Bleakley, 2000c).

Alphonso Lingis (1998) argues for a new reading of the Kantian categorical imperative that is not set in a transcendental rule but in the phenomenology of perception. His model follows the ecological imperative outlined above. Rather than personalizing the notion of imperative as moral conscience or superego, such models return the imperative to the “summons” of the world, the habitat calling us to appreciate its self-display. Patterns emerging from our surroundings, such as a fox running across a field, call us to them for appreciation before explanation. They “capture” our attention, but also shape our feelings and ideas, as exacting directives. The phenomena that demand (again, the imperative) in this way are often shared notions such as “tact:” “Tact is a brief and modest word, but it designates the right way to speak or to be silent before our adolescent child in his anguish and before the excitement of two people in the nursing home who have fallen in love” (Lingis, 1998, p. 2).

This outside-in perspective is best encountered in the work of the psychologist James Gibson, who coined the term “ecological perception” and described the human senses as a system working within other complex, dynamic systems (see Bleakley, 2000c). This view offers a polar opposite to Cartesian self-world dualism, which has its logical conclusion in solipsism or axiological subjectivism. Such a view is readily countered as culturally-and historically-contingent. For example, the language of Homer does not place emotions “in” the individual, but describes the passions as “visiting” or “attacking” the individual from outside; and the pre-modern “animistic” world-view of shamanism uses the vehicle of an “animalizing imagination” (Bleakley, 2000c) to describe human participation in an extended realm of consciousness.

The subject-object distinctions of idealism are formally rejected in the new philosophical movement of “externalism” (Rowlands, 2003). The debate between positivism (brute objects) and textuality (objects are constructions of discourse) is challenged in the “new materialism” (Datson, 2004) that follows the life of objects, especially matter studied by science, and objects in the laboratory, seeing them as saturated with cultural and historical meaning. Finally, current models of distributed cognition answer the question “Where is mind?” by not situating “mind” in the head, but describing an embodied cognition in which mind is distributed across persons, activities and artefacts, and is constructed through activity (Clark, 1997).

For the reader who finds this “outside in” perspective difficult to appreciate, Lingis (1998) suggests that we think of how our senses are re-educated if we walk the world at night, or under moonlight, without artificial lighting. The world now presents itself to us in a way that demands we pay attention to it, rather than to our responses to it. We must reconceptualize. Things seem to blend under moonlight, where the perceptual field is softer. If we take the etymological root meanings and cognate terms for polis, they include “throng,” “crowd,” and “many” (poly-), but also “runny,” “pour,” “flow”—terms of distribution of qualities and quantities (Hillman, 1994). Practitioners must attune collaboratively to the mobile political field of the clinical team, or communicate well, to establish the conditions for patient safety and ethical practice.

Notes

Allard, J., Bleakley, A., & Hobbs, A. (2006a, in review). ‘“Having your antennae up”: understanding situational awareness in operating theatre teams,’ Communication & Medicine.

Peters, T. (1989). ‘The ethical debate,’ Ethics Digest. December, 2.