Teamwork Communication Makary Et Al Operating Room Teamwork Among Physicians and Nurses

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<ul><li><p>Operating Room Teamworka esT BM ie ACh Lisa</p><p>of pnd wing tsurgtals wd reging a5 ofthe), anratinegive</p><p>type of caregiver: surgeons rated other surgeons high or very high 85% of the time, and nurses</p><p>Ercoins</p><p>CoSupberPregres</p><p>Rec30,Froandvers(MHesityGroMeCogerof MA-5</p><p> 2Pubrated their collaboration with surgeons high or very high only 48% of the time.CONCLUSIONS: Considerable discrepancies in perceptions of teamwork exist in the operating room, with</p><p>physicians rating the teamwork of others as good, but at the same time, nurses perceive team-work as mediocre. Given the importance of communication and collaboration in patient safety,health care organizations should measure teamwork using a scientifically valid method. TheSafety Attitudes Questionnaire can be used to measure teamwork, identify disconnects betweenor within disciplines, and evaluate interventions aimed at improving patient safety. ( J Am CollSurg 2006;202:746752. 2006 by the American College of Surgeons)</p><p>rors in the operating room (OR) can have catastrophicnsequences for patients, families, caregivers and entiretitutions. Retained sponges, wrong-site operations,</p><p>mismatched organ transplants or blood transfusions canbe the result of interpersonal dynamics, where commu-nication and collaboration breakdowns occur amongOR team members.1-3 The Joint Commission on Ac-creditation of Healthcare Organizations recently identi-fied breakdowns in communication as the leading rootcause of wrong-site operations, and other sentinelevents.4 Teamwork is an integral component of a cultureof good communication in the OR5 and, accordingly, isan important surrogate of patient safety. To this end, the1999 Institute of Medicine report on medical error con-cluded that hospitals need to promote effective teamfunctioning as one of five principles for creating safehospital systems.6 The Joint Commission on Accredita-tion of Healthcare Organizations proposed that hospi-tals measure culture beginning in 2007. A reliable andwidely used measurement tool for the OR setting doesnot currently exist.</p><p>mpeting Interests Declared: None.ported by the Agency for Healthcare Research and Quality, grant num-s 1UC1HS014246 and 1PO1HS1154401.sented at the American College of Surgeons 91st Annual Clinical Con-s, San Francisco, CA, October 2005.</p><p>eived November 15, 2005; Revised January 20, 2006; Accepted January2006.m the Departments of Surgery (Makary, Freischlag, Millman, Pronovost)Anesthesiology (Sexton, Holzmueller, Pronovost), Johns Hopkins Uni-ity School of Medicine; Department of Health Policy and Managementakary, Millman, Pronovost), Johns Hopkins Bloomberg School of Publicalth; Department of Nursing (Rowen, Pronovost), John Hopkins Univer-School of Nursing, and the Johns Hopkins Quality and Safety Researchup (Makary, Sexton, Holzmueller, Millman, Pronovost), Johns Hopkinsdical Institutions, Baltimore, MD.rrespondence address: Martin AMakary, MD,MPH, Department of Sur-y and Health Policy and Management, Johns Hopkins University Schooledicine, Johns Hopkins Medical Institutions, 4940 Eastern Ave, Bldg</p><p>, Baltimore, MD 21224. email: mmakary1@jhmi.edu</p><p>746006 by the American College of Surgeons ISSN 1072-7515/06/$32.00lished by Elsevier Inc. doi:10.1016/j.jamcollsurg.2006.01.017mong Physicians and Nurseamwork in the Eye of theartin A Makary, MD, MPH, J Bryan Sexton, PhD, Julristine G Holzmueller, BLA, E Anne Millman, MS,</p><p>BACKGROUND: Teamwork is an important componentmost common cause of sentinel events aimprove patient safety through improvscientifically measure teamwork in the</p><p>STUDY DESIGN: Operating room personnel in 60 hospinaire. Surgeons, anesthesiologists, certifierated their own peers and each other us</p><p>RESULTS: Overall response rate was 77.1% (2,13by operating room caregiver type, withsurgeons (F[4, 2058] 41.73, p 0.001The percent of operating room caregivershigh or very high was different by car:eholderFreischlag, MD, FACS,Rowen, RN, DNSc, Peter J Pronovost, MD, PhD</p><p>atient safety. In fact, communication errors are therong-site operations in the US. Although efforts toeamwork are growing, there is no validated tool toical setting.ere surveyed using the Safety Attitudes Question-istered nurse anesthetists, and operating room nurses5-point Likert scale (1 very low, 5 very high).2,769). Ratings of teamwork differed substantiallygreatest differences in ratings shown by physicians:d anesthesiologists (F[4, 1990] 53.15, p 0.001).g the quality of collaboration and communication asr role and whether they were rating a peer or another</p></li><li><p>redinORisfcreastheshoativenthetrativvowoteathibe</p><p>MOuis aAtfroanQuchforbeQuateatuantenpeanthacowhco</p><p>with: eg, surgeons, anesthesiologists, surgical techni-ciaan4 </p><p>tercoofcluCRusewiratadmemaexiretcar</p><p>StUscoteacalothprehigpe</p><p>REOf(22cia2,1ofnuha43ho(12</p><p>TeTesidpephan</p><p>747Vol. 202, No. 5, May 2006 Makary et al Teamwork in the Operating RoomAttitudes about teamwork are associated with erroruction behaviors in aviation,7 with patient outcomesintensive care units,8-10 and with nurse turnover in the.11 Good teamwork is associated with better job sat-</p><p>action,12 and less sick time taken from work.13 Dis-pant attitudes about teamwork have been suggesteda considerable source of nurses dissatisfaction withir profession14 that has led to the critical nursingrtage.15 They might be a root cause of errors in oper-ons, and surgeons are increasingly pressured to pre-t negative outcomes.5 In the name of patient safety,re has been a plethora of new programs andiningwith varying degrees of success. These initia-es represent a stride in the right direction, but they areid of reliable metrics to measure their effect on team-rk. We developed and validated a survey to measuremwork in the surgical setting. In this study, we useds tool to compare ratings of teamwork within andtween OR caregivers.</p><p>ETHODSr survey, the Safety Attitudes Questionnaire (SAQ)16</p><p>refinement of the Intensive Care Unit Managementtitudes Questionnaire.17,18 The latter was adaptedm the Flight Management Attitudes Questionnaire19</p><p>d its predecessor, the Cockpit Management Attitudesestionnaire.20 These surveys are reliable, sensitive toange,21 and the elicited attitudes shown to predict per-mance.7,22,23 There is a 25% overlap in item contenttween the SAQ and Flight Management Attitudesestionnaire. We improved content validity and cre-d an OR version of the SAQ after reviewing the liter-re on teamwork in the OR, conducting focus groups,d asking OR caregivers to review the survey for con-t relevance. Previous research suggested differences inrceptions of OR teamwork by OR caregiver type,17</p><p>d, to this end, we focused on the ratings of teamworkt OR caregivers give to one another. We used themmunication and collaboration section of the SAQ,ere the respondent is asked to describe the quality ofmmunication and collaboration you have experienced</p><p>Abbreviations and Acronyms</p><p>CRNA certified registered nurse anesthetistsOR operating roomSAQ Safety Attitudes Questionnairens, certified registered nurse anesthetists (CRNA),d OR nurses (1 very low, 2 low, 3 adequate,high, 5 very high).</p><p>The SAQ (Operating Room Version) was adminis-ed to all OR caregivers in a Catholic health systemmprised of 60 hospitals in 16 states in July and August2004. No one was excluded and OR caregivers in-ded surgeons, anesthesiologists, surgical technicians,NAs, and OR nurses. Random sampling was notd because small sample sizes in caregiver positionsthin a hospital, instead, highly representative responsees were sought from each institution. Surveys wereministered during preexisting departmental and staffetings, with a pencil and return sealable envelope tointain confidentiality. Individuals not captured in pre-stingmeetings were hand-delivered a survey, pencil, andurn envelope. All surveys were anonymous to theegivers name but not to caregiver type or hospital.</p><p>atistical analysising ANOVA, we tested for differences in ratings ofmmunication and collaboration (previously calledmwork ratings) that surgeons, anesthesiologists, surgi-technicians, CRNAs, and OR nurses gave to eacher. In addition to the means used in ANOVA, we alsosent the percent rating teamwork highly (high or veryh) for each caregiver type. All statistical analyses wererformed using SPSS version 12.0.</p><p>SULTS2,769 questionnaires handed out in 60 hospitals2 surgeons, 1,058 OR nurses, 564 surgical techni-ns, 170 anesthesiologists, and 121 CRNAs), a total of35 surveys were returned, for an overall response rate77.1% (range across hospitals of 57% to 100%). ORrses (79%) had the highest response rate and CRNAsd the lowest (67%) (Table 1). Average respondent wasyears old with 10 years of experience at the currentspital. Surgeons (8.6% women) and anesthesiologists.7% women) were predominantly men.</p><p>amwork ratingsamwork ratings for each OR caregiver differed con-erably by caregiver type, with the largest differences inrceptions of teamwork between physicians and non-ysicians. Table 2 shows the mean ratings of teamworkd ANOVA results. Physicians had the lowest overall</p></li><li><p>rat(scteageoowestgivteathe5.0</p><p>cotalwihratCR92evteacoesttivdifSuanof</p><p>DISuistothteaofph</p><p>aptiorathadifstaspoofwihigtiotenancalphcoticare</p><p>Table 1. Characteristics of Respondents Surveyed and Response Rates by Operating Room Caregiver Position</p><p>Pos</p><p>Response rate</p><p>SurAnCRORTo</p><p>*VaCR</p><p>Ta Op</p><p>Ra</p><p>SurAnCRORSur</p><p>*1 ScCR</p><p>748 Makary et al Teamwork in the Operating Room J Am Coll Surgings of teamwork (3.68 of 5.00) and OR nursesrub and circulating) were given the highest ratings ofmwork (4.20 of 5.00). This, despite the fact that sur-ns and anesthesiologists rated teamwork within theirn discipline the highest, their group received the low-ratings overall. In addition, OR nurses, who wereen the highest overall ratings of teamwork, ratedmwork with surgeons as only 3.52 of 5.00, relative tohigher ratings surgeons gave OR nurses (4.42 of0).Each OR caregiver rated teamwork with their ownlleagues highly within their peer group at their hospi-. Surgeons rated teamwork among surgeons highly,th 85.2% describing the teamwork with surgeons asigh or very high (Fig. 1). Similarly, anesthesiologistsed teamwork among anesthesiologists very highly andNAs rated CRNAs very well (scores were 95.8 and.7, respectively). In fact, surgeons perceived thateryone in the OR is doing a good job in terms ofmwork (Fig. 2). Figures 3A, 3B, and 3C display thentrast between surgeons and nurses, surgeons and an-hesiologists, and anesthesiologists and nurses, respec-ely, and Figures 4A and 4B demonstrate interpositionferences in teamwork among all members of the OR.ch differences underscore the disconnect in teamworkd the methodological barrier in aggregating measuresteamwork in surgery.</p><p>ition Age (y)*%Returned/</p><p>administered</p><p>geon 73 222/305 48.3 9.92esthesiologist 77 170/220 45.8 9.31NA 67 121/181 44.6 10.71nurse 79 1,058/1,335 43.3 10.85</p><p>tal 77 2,135/2,769 42.6 11.3</p><p>lues are mean SD.NA, certified registered nurse anesthetist; OR, operating room.</p><p>ble 2. ANOVA Results for Teamwork Ratings by and of Each</p><p>tings of df F p Value Surgeo</p><p>geons 4, 2058 41.73 0.001 4.38esthesiologists 4, 1990 53.15 0.001 4.39NAs 4, 1571 37.36 0.001 4.37nurses 4, 2061 12.93 0.001 4.42gical technicians 4, 2044 6.17 0.001 4.36</p><p>very low; 5 very high.rub and circulating.NAs, certified registered nurse anesthetists; df, degrees of freedom; OR, opeSCUSSIONbstantial discrepancies in perceptions of teamwork ex-in the OR, with physicians rating the teamwork ofers as good, and at the same time, nurses perceivemwork as poor. These findings mirror similar resultsdiscrepant attitudes about collaboration betweenysicians and nurses in intensive care units.18</p><p>Based on our findings, surgeons and anesthesiologistspear more satisfied with physiciannurse collabora-n than nurses. Nurses did not reciprocate the highings of teamwork given by physicians. This mightve been a result of fundamental and long-standingferences between nurses and physicians, includingtus, authority, gender, training, and patient-care re-nsibilities. It might also be a result of different ideaswhat constitutes effective teamwork. Discussionsth respondents during survey feedback presentationshlighted that nurses often describe good collabora-n as having their input respected, and physicians of-describe good collaboration as having nurses who</p><p>ticipate their needs and follow instructions. Histori-ly, there are differences between the expectations thatysicians and nurses bring to a communication en-unter. Nurses are trained to communicate more holis-ally, using the story of the patient, and physicianstrained to communicate succinctly using the head-</p><p>Women Experience inposition (y)*</p><p>Working atcurrent</p><p>hospital (y)*n %</p><p>8.6 19 17.4 9.41 12.3 9.2012.7 21 15.8 8.18 10.6 8.6050.0 63 14.7 12.32 9.5 9.3589.0 942 13.9 10.04 10.7 8.6968.5 1,462 13.7 10.47 10.0 9.08</p><p>erating Room Provider TypeMean ratings* of teamwork by</p><p>OverallAnesthesiologists CRNAs OR nurses</p><p>4.03 3.72 3.52 3.684.80 4.25 3.85 3.964.58 4.67 3.94 4.044.31 4.10 4.25 4.204.17 3.95 4.07 4.10</p><p>room.ns</p><p>rating</p></li><li><p>lintecuc</p><p>ApGotiethicobetwcraluccauthedeassint</p><p>NuThpathehanupaexp</p><p>IngenoftalpobytonotriThcomiarywh</p><p>AThOrbecuproa spsycoonhooftiosafthafroap</p><p>% R</p><p>atin</p><p>g q</p><p>ua</p><p>lity </p><p>of </p><p>colla</p><p>bo</p><p>rati</p><p>on</p><p> an</p><p>d c</p><p>om</p><p>mu</p><p>nic</p><p>atio</p><p>n h</p><p>igh</p><p> or </p><p>very</p><p> hig</p><p>h</p><p>Figcarnur</p><p>85.2% 87% 87.6%100</p><p>% R</p><p>atin</p><p>g q</p><p>ual</p><p>ity </p><p>of c</p><p>olla</p><p>bo</p><p>ratio</p><p>n &amp;</p><p>FigORiste</p><p>749Vol. 202, No. 5, May 2006 Makary et al Teamwork in the Operating Roomes.24 Differences in communication expectations andhniques might have roots in medical and nursing ed-ational cultures.</p><p>proachabilityod teamwork-related behaviors can lead to better pa-nt outcomes.25 One of the best-studied laboratories ofs science has been the aviation industry. Research inmmercial aviation has demonstrated important tiestween teamwork and performance.26 The link be-een teamwork and safety was most obvious after planesh investigations exposed cockpit crew members re-tance to question a captains performance as a rootse of aviation accidents. Surveys to assess culture incockpit and predict performance were subsequently</p><p>veloped.27We applied the aviation model to a culturalessment of teamwork in medicine and found similarimidation or lack of approachability barriers.17</p><p>rse hesitancy to express concernse willingness of personnel to speak up about atient-safety concern is an important part of safety inoperating room.The traditional hierarchy of surgerys often discouraged speaking up to a surgeon, andrses can be hesitant to confront a surgeon on issues oftient care because they might have less training orerience in dealing with a patients medical condition.</p><p>85.2%95.8% 92.7%</p><p>81%</p><p>0</p><p>20</p><p>40</p><p>60</p><p>80</p><p>100</p><p>Surgeons rateSurgeons</p><p>Anesthes. rateAnesthes.</p><p>CRNAs rateCRNAs</p><p>OR Nurses rateOR Nurses</p><p>ure 1. Teamwork as viewed within peer groups by operating roomegiver role. Anesthes., anesthesiologist; CRNA, certified registeredse anesthetists; OR, operating room.addition, theremight be social barriers involving race,der, and socioeconomic status. A nurses per...</p></li></ul>