Surgeons exhibit the lowest level of teamwork and nurses the highest in the operating room

May 3 2006

A study based on a survey measuring attitudes toward the work environment in the operating room (OR) reveals that surgeons exhibit the lowest level of teamwork and nurses the highest.

The survey, called the Safety Attitudes Questionnaire (SAQ), was adapted from an airline industry questionnaire and applied to the health care environment. The SAQ, developed by a Johns Hopkins-led team, contains 65 questions in six areas relating to safety, including teamwork climate, safety climate, job satisfaction, perceptions of management, stress recognition and working conditions. Results appear in the May issues of the Annals of Surgery and the Journal of the American College of Surgeons.

Only 65 percent of OR personnel thought surgeons exhibited a high or very high level of teamwork. In contrast, 83.5 percent of those surveyed believed general surgical nurses exhibit a high or very high level of teamwork and 85 percent rated certified registered nurse anesthetists (CRNAs) as showing a high or very high level of teamwork. Anesthesiologist rated third at 79 percent.

"The SAQ provides hospitals with an accurate method for rating safety in the OR because it asks frontline caregivers about the OR work environment," says lead researcher Martin Makary, M.D., M.P.H., an assistant professor in the Department of Surgery at The Johns Hopkins University School of Medicine. "Results, like those telling us that surgeons rate poorly in teamwork, help target areas for improved communication and provide a benchmark for rating strategies aimed at improving patient safety."

Makary says other questions, like ones that directly ask OR teams members if they would feel comfortable being operated on in their own hospitals, send a clear message regarding patient safety concerns in the OR.

"The bottom line is, you wouldn't want to fly with a pilot or copilot who wasn't happy with his working environment and the same applies to the OR," he says.

The SAQ was adapted from the Flight Management Attitudes Questionnaire (FMAQ) and its predecessor, the Cockpit Management Attitudes Questionnaire (CMAQ), both of which were developed to address accidents in the airline industry. The theory behind all these surveys is that improving work-area issues improves safety, according to co-researcher J. Bryan Sexton, Ph.D., an assistant professor of anesthesia and critical care medicine at Hopkins. The survey is not limited to the OR. Variations of the SAQ have been used to analyze work environments throughout the hospital, he says.

"We found that using frontline caregiver assessments of patient safety can give you a valid and reliable consensus on how things are going in a particular patient care area, and that this is related to important outcomes like hospital acquired infections, length of stay and nurse turnover," says Sexton.

Reports by the Institute of Medicine regarding safety in the OR, rising malpractice costs and the demonstrated vulnerability and devastation hospitals face after public exposure of deaths due to OR errors have all drawn attention to the importance of developing sound hospital systems to reduce OR errors. As a result, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will require all hospitals to measure their culture beginning in 2007.

Wrong-site/wrong-procedure surgeries, retained sponges, unchecked blood transfusions, mismatched organ transplants and overlooked allergies are examples of potentially catastrophic events that, in certain circumstances, can be prevented by improved communication and safer hospital systems.

The team fine-tuned the SAQ by reviewing the literature on patient safety, by asking OR health care providers to review the survey, and by conducting focus groups.

These SAQ questions were presented to all OR caregivers in a Catholic health system comprising 60 hospitals in 16 states during July and August 2004. Results were gathered from 222 surgeons, 1,058 OR nurses, 564 surgical technicians, 170 anesthesiologists and 121 CRNAs. On each question on teamwork, participants were asked to rate themselves and their peer groups on a scale of 1 (very low) to 5 (very high). The overall response rate was 77.1 percent.

"The results have already led to improvements in the OR," says Makary. "Before every operation, we now require a presurgery checklist similar to what pilots do before take-off. This not only minimizes errors but also improves teamwork."

Makary says 700 hospitals are already using the survey, and he expects to see more adapting it in the near future.