Teams in all areas of healthcare may deploy a range of strategies when under pressure and make adaptations to the way care is delivered. The primary aim is to minimise the risks to patients and maintain a reasonable, if not ideal, quality and safety of care within the available constraints. We recently developed a generic taxonomy of strategies for responding to pressures [8]. This provided the foundation for the present study in which we explored the specific pressures in surgery and the strategies used by clinical leaders and their teams when delivering care under pressure.

The dominant source of pressure reported by the surgical teams in this study is simply that patient demand exceeds the available resources, with a shortage of skilled staff being the most frequently cited problem. When demand exceeds capacity, then working conditions become more difficult which in turn disrupts patient flow which, in a vicious negative feedback loop, makes it more difficult to cope with rising demand. Plans are in place to increase the medical and nursing workforce in the longer term [10] but, in the meantime, clinical teams have to constantly meet the challenge of being unable to deliver either the volume or standard of care that they would ideally like to. The challenge for surgical teams then is how best to adapt care to give the best possible outcomes for patients within the constraints while not placing impossible burdens on staff.

In surgery, many strategies and adaptations are made in advance to anticipate pressures, with a focus on scheduling to improve efficiency coupled with strategies for controlling and prioritising demand. When waiting lists are long, teams constantly have to make difficult decisions about whether or not to cancel surgery. Immediate risks of operating are often easier to assess than the potential risks of delaying the surgery on the patient’s physical and mental wellbeing. Cancelling elective surgery also has to be weighed against the wider impact on the health system and on patients and their families (e.g. deterioration or developing a comorbidity) [11]. For instance, patient liaison teams need to inform and support disappointed patients, theatre managers need to reallocate space, consultant surgeons and anaesthetists would have to reorganise their time and surgical lists, and trainees would have to make up the surgical hours and cases for their training. Leaders under pressure constantly need to make these trade-offs in order to balance competing priorities, such as between patient safety, staff wellbeing and service efficiency. Sometimes responding to pressures in one place inevitably has consequences for another [13].

Teams in surgery also employ a range of other adaptations and adjustments to care alongside cancellations and delays to surgery. The strategy of flexing and adapting the use of equipment and resources is commonly used. Care is often moved to other areas of the hospital. For instance, patients who might normally be in intensive care may be cared for on the wards; patients stay in the recovery suite overnight rather than returning to the ward after an operation; male patients may be allocated to female day surgery wards. Surgical teams also make many adaptations to their usual ways of working. Task shifting for instance is very common, with junior doctors taking on additional responsibilities, or student nurses being trained to take on full clinical roles much earlier than would be usual. Task shifting also extends to patients and families, as early discharge home effectively means shifting clinical tasks and responsibilities, such as monitoring patients and caring for wounds, from nurses on the ward to families in the home [14, 15]. Clinical leaders also employ an additional range of on-the-day adaptive strategies in both wards and theatre, such as a greater emphasis on multi-modal communication to monitor care and detect safety issues and the practice of pausing an operation or care to enable the clinical team to refocus and prioritise. Effective teamwork is vital in surgery and to be effective, all these adaptive strategies need to be co-ordinated between the different professions within the operating team (i.e. surgeons, anaesthetists, scrub nurses), and between the operating team, theatre managers (to allocate theatre space) and ward managers (to allocate bed space) [16, 17].

Adaptations are made by staff in the face of substantial pressures which demonstrates the complexity of decision-making in a stretched system, but at times adaptations lead to major departures in standards outlined in policies. The care provided may then be a long way from the standards of care staff aspire to provide. For instance, some interviewees reported that some practices that formerly would have been considered unthinkable and a patient safety incident, such as caring for a patient overnight in recovery or discharging a patient home from intensive care, are becoming normalised. This is obviously stressful for staff, with the violation of professional norms increasing the risk of ‘moral injury’ and burnout (Wilkinson, 2020). Individual patients may benefit in the sense of having an operation that might otherwise have been cancelled, but at the cost of a very different standard of care, potentially distressing experiences and an increased burden on those caring for the patient at home. There is a critical role for leaders, both executive and clinical, in discussing such compromises openly and supporting teams faced with unenviable decisions [19]. The risk of moral injury will be less if such decisions are seen as a necessary collective decision rather than an individual personal failing [20].

We purposely selected four different and diverse hospitals to obtain a broad perspective of views. Given multidisciplinary working is a strong feature in surgery, a key strength of this study was that the sample represented a cross-section of different professions involved (albeit not all) and provides a rich understanding of the pressures and strategies used from the different perspectives. We should also note that most participants were relatively senior, as they seemed most able to explicitly acknowledge, describe and initiate adaptations to usual care. Of course, more junior staff also adapt, but they generally have less autonomy to make system level adaptations. There may also be some selection bias in that those who volunteered to be interviewed are potentially more committed to patient safety initiatives and so more aware of risk management strategies. Another limitation is that it is not always possible for people to articulate exactly how they adapt when under pressure and interviewees varied in how well they could describe the strategies they use. It is possible that by using ethnography/observations, additional strategies might be revealed. Strategies will also vary to some degree between different types of surgery which can be explored in future research. A strength of the paper is that the analysis was sense-checked by two clinicians (a surgeon and an anaesthetist), and that the interviews were conducted with two members of the research team present.

When pressures are high, a coordinated strategy of balancing resources and demand and managing the workload is likely to be much safer than a fragmented and individualised set of improvisations [7]. The multidisciplinary nature of surgery means it is important to coordinate adaptations across disciplines, aligning objectives and coming to joint decisions. The strategies described here could help clinicians and managers respond to similar pressures, providing a portfolio of strategies that clinical teams could use or develop for their own contexts. The implications of using certain strategies should be considered from multiple perspectives, including service performance, patient risk and impact on staff. Strategies may have very different effects on these various parameters; a strategy may for instance reduce risk for patients but increase burden on staff.

These strategies could be incorporated into training programmes to prepare staff moving into leadership roles or those newly in charge, who are responsible for the functioning of a service and have the authority to guide and support team and system-level adaptations. For example, simulation or scenario-based exercises on prioritisation and managing competing demands could help to reduce stress and uphold safe practices when individuals have to make strategic decisions quickly in pressurised situations [21, 22]. In surgery in particular, training in interprofessional groups or teams may be especially beneficial for sharing expertise and generating discussion of collaborative strategies [23]. Clinical teams can explore their own current approaches, which will vary between individuals, with the aim of achieving a more coordinated approach. Wider, more formal training programmes will require organisations, and indeed regulators, to explicitly acknowledge the difficulties of maintaining standards of care when under pressure and see such training as a necessary form of proactive risk management. Future work will explore what this type of training might look like and how it could be organised, with attention given to efficacy, trade-offs and implications of a menu of strategies.

All strategies have benefits and risks, and our study design does not allow us to systematically assess the effectiveness or adverse effects of any of the strategies described. For example, staff staying late to complete a list may improve patient safety but will clearly have a negative impact on staff wellbeing. Systems that rely on individuals adapting at maximum capacity every day leave no margin to respond to unusual demands, and there is a limit to the benefit of some strategies especially when used frequently [24]. There may be certain strategies or combinations of strategies that are better than others or have differential trade-offs and impact on safety, staff well-being, patient flow and patient experience [7]. Further research is needed to explore the effectiveness of different strategies and combinations of strategies in surgery. The development of our taxonomy of pressures and strategies and the exploration of such strategies in surgery provides the foundation for describing the portfolio of strategies used in different surgical units and an assessment of their impact and effectiveness.