Adaptive is defined in the Oxford Dictionary (2022) as the ability to change to deal with different situations constantly. Cao and Taylor's [
10] study shows how nurses encountered an increased cognitive load due to the uncertainty from haphazard communication between themselves and the surgeon. Tiferes et al. [
43] reported a new communicative practice using the paired system to communicate accurately between the surgeon and assistant, the surgeon and nurse, or the assistant and scrub nurse. This new approach reflects an original way of getting information seamlessly and effectively compared to other surgeries. In addition, all studies recognised that the nurses and the surgical team had to modify the communication system as an adaptive strategy, such as adjusting their thinking processes and behaviour to cope with the changes in a coordinated fashion.
Role adaptation in practice during RAS varied depending on geographic location, as Cunningham et al. [
16] reported. The coordinated way of working and interacting has been previously identified as a central mechanism for safe and effective performance in healthcare and other high-risk work environments [
8]. The observation from this review, in particular, the adoption of specific task-based communication, such as during instrument exchanges between the surgeon assistant and scrub nurse, is a significant modification to ensure that safety is observed by the team [
10,
43]. In addition, Schiff et al. [
38] and Vigo et al. (
45) recognised that greater team interdependency demonstrates the nurses’ critical position in RAS. Therefore, as Raheem et al. [
34] reported, adopting a standardised communication process would reduce the breakdown of information exchanges. Their study also suggested that verbal communication strongly correlates with efficiency in RAS. Tiferes et al. [
42,
43] found that increased reliance on non-verbal interactions, which comes with the introduction of surgical robots, requires team familiarity and a good understanding of the situation. It is, therefore, a false dichotomy only to consider interactions in RAS solely based on verbal and non-verbal acts. Tiferes et al. [
43] reported a close association between role and task-specific communication and familiarity with procedures, which impact team interactions. Cavouto et al. [
13], Randell et al. [
35,
36], Tiferes et al. [
43] separately found that this level of understanding helps to reduce the verbal exchanges between the surgeon and the scrub nurse.
Although advances in robotic surgery bring benefits at many levels, they carry unintended complications. Cao and Taylor [
10] reported that communication breakdown associated with the complexity of the robotics set-up negatively impacts team function, information flow, and decision-making. Furthermore, Lai and Taylor [
26], Nyssen and Blavier [
31], Randell et al. [
35,
36] all recognised the need for a better understanding of human factors to help integrate the surgical robot to achieve patient safety and quality care. Therefore, these findings revealed increased verbal commands to rectify errors, such as in an emergency, bringing awareness to the entire team as an adaptive operating room practice. In addition, Allers et al. [
5], and Almeras and Almeras [
4] found that the RAS team, notably the nursing team, used different communication strategies to ensure that the surgeon could hear them. Similarly, as Vigo et al.’s (
45) study showed, the surgeon may use a different feedback system to compensate for information missing in the robotic system due to room noise and separation from the team. The following two subthemes will provide a better understanding of why there was a need to navigate disruptions and the heightened interdependency of working as a team in RAS.
Navigating disruptions in RAS
Disruptions associated with intraoperative interruptions were reported consistently across this review. It was defined by Catchpole et al. (
11, p.3749) as "
deviation from the natural progression of an operation." There were two forms of disruptions reported: avoidable and unavoidable [
4,
5,
16,
17,
27,
42]. In RAS, additional robotics equipment and other patient monitoring machines have an integrated alert system which when activated requires immediate action to be taken by the team as part of the safety measures. El-Hamamsy et al. [
17] and Leitsmann et al. [
27] found that these unavoidable interruptions from alerts or even machine faults caused distractions to the workflow.
In addition, studies by Cao and Taylor [
10], Aller et al. [
5], Cavuoto et al. [
13], Sexton et al. [
40], Almeras and Almeras [
4], Tiferes et al
. [
43], and Steffan et al. [
41] reported that the new member in the RAS team, whether learning the equipment or the surgery, was considered as an interruption. There are procedural interruptions commonly found in RAS which have increased the workload demand from nurses, such as the need for frequent instrument exchange and attending to surgeons’ requests, including cleaning robotic camera lenses [
5,
13,
26,
41,
43,
47]. This observation could be associated with the high quality of the surgeon’s 3D console monitor, which amplifies minute dirt on the lens. An earlier study by Nyssen and Blavier [
31] found that reduced interruptions and better coordination resulted from increased team experience in RAS. Therefore, interruptions in RAS significantly disrupt the normal communication flow.
The non-procedure interruptions or risks associated with RAS that were classified as avoidable included noises in the environment from conversations, telephone calls, or physical movements from the OR personnel [
4,
5,
16,
17,
27,
42]. The study by Schiff et al. [
38] reported an increase in the nurses’ mental load and mental demand due to the high noise level. The complexity of communication with interruptions from multiple perspectives could disrupt the flow of thoughts and information exchanges. Attempts to review the systematic reduction of the noise level in RAS to improve the quality of communication and team interaction, as reported in the study by Leitsmann et al. [
27], found no change to the noises related to procedure or others. However, their finding presented a reduction in the noise level from quieter verbal exchanges in the team with special devices worn by the team members. Despite efforts to reduce distractions and improve communication quality in RAS, how they impact the quality of nursing practice in this environment remains unclear.
This review highlighted the concern that preventable disruptions cause unnecessary stress to the surgeon and team, affecting surgical efficiency and potentially jeopardise patient safety. Studies by Almeras and Almeras [
4], Cao and Taylor [
10], Cunningham et al. [
16], Schiff et al. [
38], Sexton et al
. [
40], Randell et al. [
35], and El-Hamamsy et al. [
17] considered the effect of decision-making on safety and the implications of distraction of the surgeon, posed substantial risks to patient safety in RAS. Moreover, Weigi et al. (
47) reported that communication demands to overcome surgical flow disruptions in RAS are essential to promote situational awareness to all personnel involved in the surgery. In addition, Jing and Honey [
23], Kang et al. [
25], Uslu et al. [
44], and Schussler et al. [
39] recognised the added responsibilities of nurses, including guiding new robotic team members while managing seamless workflow coordination, which adds to their mental burden. Therefore, a fundamental suggestion of how a coordinated robotics team could reduce their mental stress is by adopting a new system of work such as using feedback verbal communication loop on specific task interaction between the nurse, the surgeon assistant, and the surgeon [
31,
34,
43]. The specific communication feedback is a form of unique communicative practice from realising surgical robots’ challenges on the surgical team's communication flow.
The surgeon’s immersion in the robotic console, away from the nurses at the bedside, could be a source of reduced interaction with the team. Interestingly, Randell et al. [
35] and Almeras and Almeras [
4] reported that the surgeon’s isolation has a protective effect of increasing the surgeon’s concentration. However, in the study by El-Hamamsy et al. [
17], the concern with surgeon’s isolation in RAS poses communication challenges that impact situational awareness and team emotions. The studies from Aller et al. [
5], Randell et al. [
35], Weber et al. [
46], and Weigi et al. [
47] reported no significant associations between disruption and the surgeon’s situational awareness and their perception of stressful demands in RAS. Therefore, the experience of the surgeon’s isolation from the nurses assisting and how it impacts their communication remains unclear in the literature.
El-Hamamsy et al. [
17] reported that a dedicated robotic team with a good understanding of their role may need careful consideration to help reduce surgical flow interruptions, thus decreasing perceived stress. In addition, Uslu et al. [
44] and Schussler et al. [
39] highlighted how nurses' involvement from the start of robotic surgery consistently recognised this factor in contributing to the overall efficiency of RAS. Randell et al. [
35,
36] suggested active engagement of the perioperative practitioner, including nurses, to improve the efficiency and implementation of the robotics programme. Moreover, Nyssen and Blavier [
31], Kang et al. [
25], Aller et al. [
5], Sexton et al. [
40], and Stefan et al. [
41] indicated that having a knowledgeable and skilled workforce is an essential requirement for safe practice in RAS.
This review has shown the challenges nurses face using robotics in practice when the surgical team is in the learning period. Logistical concerns, structural support, and policies were a few of the frameworks that Randell et al. [
36] suggested as tools to improve efficiency and maintain patient safety by reducing interruptions in RAS. McCarroll et al. [
30], Allers et al. [
5], Jing and Honey [
23], Kang et al. [
25], Uslu et al. [
44], and Schuessler et al. [
39] also highlighted in their study the impact of extended operating time due to those avoidable interruptions. This contributed to poorer outcomes and lengthened patient recovery. Jing and Honey [
23], Kang et al. [
25], Uslu et al. [
44], and Schuessler et al.’s [
39] studies found a significant shift in efficiency with task and information-based communication using checklists to optimise safety in a complex setting. McCarroll et al. [
30] and Jing and Honey [
23] proposed a pragmatic approach with checklists and protocols to overcome the disruption attached to innovative surgical techniques. Vigo et al. (
45) reported that the training protocol identified two important behavioural markers for successful nurse training: eye gaze/contact with the surgeon and anticipating movements to overcome their separation. They have also discussed nursing demands in managing their workloads as required in the operating room. These include technical tasks such as tending to robotic arms and addressing information from the robotic screen with immediate measures to resolve errors.
RAS heightens interdependence on team working
The surgeon's physical separation placed a higher reliance on the team during robotics surgery. The studies by Aller et al. [
5], Randell et al. [
35], Weber et al. [
46], and Almeras and Almeras [
4] found that surgeon’s immersion in the console significantly impaired their awareness of the environment, which then added to the team members’ burden of responsibility, including nurses assisting at the bedside to ensure safety for the patient while anticipating the surgeon’s needs. Tiferes et al. [
43] reported a significant increase in verbal communication (75%) when the surgeon lacked visual evidence from scrub nurses. Therefore, these assumptions may suggest that effective teamwork and cohesiveness from the team are assistive measures to overcome those limitations reported in the previous studies by Allers et al. [
5], Cavuoto et al. [
13], Weber et al. [
46], and Weigi et al. [
47].
Furthermore, Cao and Taylor [
10], Lai and Entin [
26], MaCarroll et al. (
50), and Weber et al. [
46] stressed the significance of technical coordination among the RAS team to reduce workload and improve flow. Weigi et al. (
47) reported the correlation between communication and coordination, which further supports the evidence of increased interdependencies between the workflow processes, the team, and technology. Their findings supported the findings from Uslu et al. [
44] and Schuessler et al. [
39] that the ability of nurses to actively engage with anticipation improves surgical efficiency and patient safety. These qualities are fundamental to an experienced robotics team to improve care outcomes. Nyssen and Blavier [
31] and Tiferes et al. [
42] also reported these as a practical solution to the robotics team communication pathway. Moreover, those purposive and task-specific communication pathways taken by the robotics team, including their ability to anticipate the surgeon’s needs, have been identified in studies by Tiferes et al. [
42] and Sexton et al. [
40] as key variables correlated with team efficiency. The individual's ability to respond quickly and effectively when assisting was found to be helpful in a highly stressful situation, especially to the surgeon. In addition, Almeras and Almeras, [
4] pointed out that assistants, including nurses at the bedside, experience a sense of isolation, which adds to their mental load due to increased responsibility as the surgeon is physically separated. Tiferes et al. [
42] pointed out that the lack of physical interactions between the bedside team and the surgeon could explain the need for higher verbal communication. A new way of working in RAS presents opportunities to review the team dynamics, the augmented workflow, and the impact of RAS on nursing empowerment to achieve the best outcomes and patient safety.