What a few months! You may have heard of the #theatrecapchallenge. There are advocates and detractors aplenty (and of varying degrees) on this matter. I started wearing a named theatre cap a couple of months ago and this is my take on what is a somewhat controversial topic…
Let’s start with why I wear them. Many assume it’s for patient safety reasons, indeed, this seems to be the most commonly cited rationale. It goes something along the lines of knowing someone’s name leads to clearer communication, accountability and therefore speed in managing a critical incident. Or a flattening of the hierarchy to facilitate ‘speaking up’ when an error happens (for a complete list of reasons and references see here). Fair enough, but no, I don’t wear a named cap for these reasons. I wear one because I want the rest of the theatre team to wear one. So that when new-comers join the team they feel comfortable wearing a cap with a name on. Again, why? Because… I can’t remember the name of everyone in theatre, and I’m not alone. And there comes a point where asking is awkward. There comes a point where getting someone’s attention whilst hiding this fact is shameful. Even 10 years from now when I, in fact, do know everyone’s name there will be others that don’t, feeling awkward and slightly guilty. That’s not an environment I want to work in if I can help it.
We don’t all know each other. 50/60/70% of the team might do but there are visitors/rotating staff/students who don’t and aren’t known back. To ask these individuals to wear a named cap because they are the only person in the room that everyone doesn’t know is hypocritical. Making that person, who is more vulnerable than the regular members of the team, mark themselves out is a big ask, and possibly cruel?
So what were the reactions of those around me? Mixed. Some were all for it with one or two purchasing named hats of their own. Others put forward reasons why they weren’t supportive. Some are simple to counter but others deserve further exploration because I haven’t seen them discussed widely.
The simple ones:
“But everyone wears name badges”. There’s some truth in that… the badge which is under the scrub gown, tucked into a pocket or worn 180 hanging down their back on a lanyard? The one flipped the wrong way round or obstructed by keys/USB sticks/name stamp? Or the badge placed next to the computer whilst its owner is scrubbed? The partly rubbed out 10pt print that doesn’t detail their job? Not to mention the location of badges and the challenge this creates reading them – on chests or around the groin area! My experience is that name badges in theatre are persistently thwarted in their primary function, to identify.
“What about infection risk?” – this has been covered in much more detail by others. The religion-like status infection prevention has acquired in the last decade stifles debate and villanises discourse. Discourse such as: ‘is single use equipment really the gold standard of infection prevention?’ Suffice to say I am yet to be convinced that cloth caps pose a higher risk of surgical site infections compared to disposable caps. Furthermore, the environmental impact of single use equipment has to be recognised, including theatre caps.
“What’s the right thing to write on your hat? – patients and staff use different terms” – first name, title, nickname, job title (with grade)? All the above? For me I put it all up there so others can choose which they feel more comfortable using. ‘Dr’ – so patients know that anaesthetists are, in fact, doctors. ‘Andy’ – first name option if staff want to. ‘Hughes’ – so people can enter my name on any necessary paperwork. ‘Anaesthetist’ – so it’s clear what my role in theatre is. Why not my grade? As a new consultant frankly I’d feel embarrassed. I don’t think it’s ‘imposter syndrome’ but I believe I am still settling into this new identity. What’s printed depends why you’re wearing it – is it for patients, for staff, for… dare I say it… ego?! It’s ultimately a personal choice but in my opinion name and role are a minimum.
It’s possible the above problems are put forward instead of deeper held reservations. Ones which are likely to be the true motivators:
“I don’t want people to know my name” – said in jest, or is it? Does this refer to people other than those they work frequently with? Come to think of it, why would you want people you don’t work with to know your name? Is there an anxiety associated with being widely identifiable and a comfort that comes with anonymity? Could this be a personality preference (e.g. introversion) or maybe the effect of a ‘blame & shame’ culture?
“It’s easy for you, you’re a ‘white middle class male’.” Come again? “If I wore a named hat I’d get a different reaction” [thank you to the colleague who provided this insight]. Here we might stumbled upon a wider problem. Is this demographic shielded from certain reactions? What are those different reactions? We know that the same behaviours exhibited by male and female surgeons are perceived differently due to ingrained societal expectations (witness the #ILookLikeASurgeon and #ChangeTheNorm campaigns). So is it surprising that some groups who may decide to wear a named cap may be perceived [more] negatively by others? This, of course, doesn’t have to be limited to women, it could be the case for other groups (e.g. race, socioeconomic background, sexual orientation, even different job roles).
“I don’t want to look like a ****”. Here’s what I think: it’s relative. The ‘look’ is as compared to specific group characteristics: “You look like a **** [compared to x]”. If everyone looked the same the point of reference is changed. So what this boils down to is standing out for being different. Daniel Coyle states that the need for belonging is a strong motivator. It’s probably down to an evolutionary trait which confers a survival advantage when being part of a tribe. Disapproving looks, annoyance and even overt mocking are symptoms of not belonging. If I’m honest, there is a vulnerability that goes with wearing a named hat (even though logically it’s a ‘no-brainer’). So why would anyone voluntarily put themselves in that position? A different viewpoint maybe that named caps infantilise healthcare professionals? Perhaps some feel it damages credibility/authority?
Changing behaviours is a complex business. Many factors influence the decision to wear a named theatre cap. Pointing to scientific evidence of benefits or financial/ environmental gains is not enough. Consideration must be given to the feelings change gives rise to. Feelings which cannot always be parried with logic. In fact, persist with this strategy and the situation is likely to become hostile, shutting down discussion. Resistance becomes a point of principle. I suggest that this has been one of the problems with the #theatrecapchallenge movement – the focus on logical argument at the cost of examining the feelings engendered. To some now, opposition is a principle.
Mandating named hats for all staff would overcome some challenges but not others. Growing it organically can work but, in the face of some of the psychology described above, this could be a tall order. If you are going to grow it, the “first follower” has been described as the most important person in this process and can be illustrated amusingly in this video [thank you to the colleague who signposted this].
I will continue to wear my named cap because: ‘it’s a no-brainer’. But I won’t be evangelising because I better understand the perspectives around this issue. We all have differing levels of confidence, belonging, security and the decision to gamble with these is very personal one.
Single Malt 