Effective Surgical Teams: An Integrative Literature Review
Abstract
It is imperative to understand the factors that contribute to effective surgical teams. The aim of this integrative review was to evaluate the aids and barriers for perioperative teams in functioning effectively, preventing adverse events, and fostering a culture of safety. The literature search was undertaken of 15 databases, which resulted in 70 articles being included. It was found perioperative teamwork was not widely understood. Findings indicated barriers to effective surgical teams comprised of confusion in tasks and responsibilities, existing hierarchies and prevailing misconceptions and understanding among team members. Although numerous quality initiatives exist, the introduction of protocols and checklists, team effectiveness in the perioperative setting is still insufficient and challenges in establishing effective surgical teams continue. Further research is recommended to obtain a comprehensive perception of environmental influences and barriers surgical teams encounter in the delivery of safe quality care.
Worldwide, health care organizations continuously urge interdisciplinary perioperative teams to deliver and maintain a high quality of surgical care (Health Quality and Safety Commission New Zealand [HQSC], 2013, 2014a; Huang et al., 2014; Perry & Kelley, 2014). Despite best efforts, surgical errors continue to occur due to contributing factors. These often include poor communication, information overload, stress and fatigue, emergency surgery with deviations from standard practice, interruptions, distractions, heavy workload, hierarchical structures, inadequate skill mix, and poor equipment design which can pose risks to patient safety (Arora et al., 2010; Bleakley, 2006a, 2006b; C. Garrett, 2008; Healey, Sevdalis, & Vincent, 2006; Kalra, Kalra, & Baniak, 2013; Leggat, 2007; Reason, 1995, 2000; W. Riley, Lownik, Parrotta, Miller, & Davis, 2011). Learning from errors and near misses through the establishment of high-functioning teams has long been recognized as necessary practice in most high-risk industries, such as the aviation industry (Reason, 1995). Operating theaters are recognized as high-risk environments; however, mechanisms to reduce error have not been adopted universally, leaving patients at risk of perioperative harm (Amalberti, Auroy, Berwick, & Barach, 2005; Hoff, Pohl, & Bartfield, 2006; Sevdalis, Hull, & Birnbach, 2012). A change in thinking, planning, and careful management is imperative for future health care (Gawande, 2009; Imhof, 2013; Nicolay et al., 2012; Ryall, 2013); therefore, health care organizations are expected to adapt to new strategies and make necessary changes to keep up with demand while maintaining quality care. Health administrators are expected to coordinate and manage the adoption of new strategies; nonetheless, ultimately it is frontline personnel who implement them. To achieve these multiple performance indicators and further reduce the potential for errors, it is imperative to understand the factors that contribute to establishing effective surgical teams.
Perioperative Team Model
A typical surgical team consists of a variety of health care professionals from various disciplines, all with different priorities, roles, backgrounds, clinical expertise, and experience, with nurses being the largest professional group represented. This interdisciplinary team relies on each other’s skills and performs interdependent tasks in a highly dynamic work environment, albeit they share a mutual goal: the delivery of safe surgical care (Baker, Day, & Salas, 2006; Burtscher & Manser, 2012). The specific hierarchies and organizational cultures of operating theaters, combined with the presence of continuously changing interdisciplinary teams means perioperative care differs from other high-risk industries such as the military or aviation industry (Berlin, Carlström, & Sandberg, 2012; Braaf, Manias, & Riley, 2013; Cullati et al., 2013; Styer, Ashley, Schmidt, Zive, & Eappen, 2011).
Surgical Teamwork Versus High-Functioning Teams
The conventional model of a high-functioning team implies a consistent group of people who continuously tend to work closely together and experience permanent leadership (Baker et al., 2006). Such models do not compare with perioperative teams, which are characterized by frequent changes due to rostering, surgical demands, and surgical specialty, particularly for the nursing profession (Cima & Deschamps, 2013; W. Riley et al., 2011). Surgical teams are considerably larger in size compared with the well-used comparator of aviation cockpit teams (Baker et al., 2006; Coe & Gould, 2008; Cullati et al., 2013; Huang et al., 2014). As a result, surgical team composition increases the opportunity for miscommunication and potential error can negatively impact team efficiency (Ricci, Panos, Lincoln, Salerno, & Warshauer, 2012). Irregular and continuous change of team consistency, like the arrival of new medical registrars and nurses, can cause delays and communication issues (Styer et al., 2011). This lack of team stability may increase error rates, decrease efficiency, and can lead to additional stress among the team as the learning curve restarts far too often (Blum, Shea, Czeisler, Landrigan, & Leape, 2011; Coe & Gould, 2008; Sevdalis et al., 2012). In addition, interdisciplinary teams often experience conflict related to a difference in personal and professional priorities when it comes to patient care can create barriers to effective teamwork (Burtscher & Manser, 2012).
Leadership is an important factor in team performance, yet certain challenges are inherent in the perioperative setting (Sevdalis et al., 2012; Styer et al., 2011). Clinical seniority in itself is not a sufficient principle for leadership; understanding management structures and acquired knowledge of organizational targets is essential; however, training is often not available (Sevdalis et al., 2012). In contrast, aviation pilots and their copilots are trained to perform similar tasks and procedures leading to corresponding competencies, whereas members of surgical teams may have overlapping skills and expertise, although they also bring different and specific disciplinary competencies (Amalberti et al., 2005; Hoff et al., 2006; Sevdalis et al., 2012).
A hierarchical structure on a flight deck is often unquestioned and the perception of leadership is likely to be more straightforward, while establishment and perception of leadership roles in a surgical team proves to be more complicated and misperceptions with respect to leadership are common, which in turn can influence conditions that lead to human errors (Ricci et al., 2012).
Organizational Culture
Cultural issues such as workplace discrimination, bullying behavior, fear of disciplinary action, lack of feedback, and strong hierarchical models are known barriers for effective teamwork and communication (Evans et al., 2006; Kalra et al., 2013). Within the hierarchical structure of a perioperative environment, it is recognized that team members can be reluctant to communicate across disciplines (Walker, Reshamwalla, & Wilson, 2012).
Braaf and colleagues (2013) note that professional self-sufficiency, displayed by surgeons and anesthetists, leads to information ownership and the predisposition to work independently, which can lead to conflicting perceptions about leadership and responsibility (World Health Organization [WHO], 2008b). Surgeons are trained to work independently and often possess control over decision making, which can hinder the introduction of change. Added to this, the rest of the team typically depends on surgeons’ decisions as part of existing hierarchical structures in the perioperative environment, and communication is key (Hoff et al., 2006; Manser & Staender, 2005). Surgical teams are traditionally shaped according to a strong hierarchical and task-oriented team model with a focus on technical knowledge and performance, with little emphasis on interpersonal behaviors such as good communication and team coordination and rotating leadership (Rogers, Lingard, Boehler, Espin, Mellinger, et al., 2013). Bleakley (2006a) found that the surgeon, identified as the leader, usually enhances an environment characterized by closed monologs. An authoritative climate, where some maybe silenced, is more likely to provide a context for patient harm and systems-based miscommunication.
Perioperative Harm
With increased use of complex surgical technology, the susceptibility and opportunity for failure through human error is expanding and, as a result, improvement of surgical safety cannot be obtained through a solitary resolution. According to Polk (2006) and Braaf and colleagues (2013), surgical mortality and morbidity rates are a multidisciplinary challenge for the surgical team. The Joint Commission on Accreditation of Health Care Organization reported that between 1995 and 2003, a total of 70% of errors involving serious injury or death could be related back to ineffective communication (Imhof, 2013).
The WHO’s (2009b) performance indicators necessitate surgical team communication improvements, such as briefing and debriefing, team training, and the use of the Surgical Safety Checklist (SSC), a quality tool that is implemented for every surgical procedure, enabling teams to review their processes and engage in discussion. Ten years later, international figures show little improvement has been made and numbers of perioperative harm incidents are still unacceptably high (Braaf et al., 2013; Haugen et al., 2013; HQSC, 2014a, 2014b; Polk, Tyson, & Galandiuk, 2010; Ricci et al., 2012; WHO, 2008a, 2008b, 2009a, 2011, 2012). The hope invested in complete prevention of perioperative harm through implementation of a checklist is somewhat elusive. If barriers like poor attitudes and lack of a safety culture exist and are not addressed, it is doubtful that any checklist would make a difference (Perry & Kelley, 2014; Sevdalis et al., 2012).
Although the utilization of quality initiatives (QI) and performance indicators have become the norm in health care provision, the application and adherence to achieving targets is irregular and inconsistent. Questions need to be asked why minimal progress has occurred in reducing perioperative harm: what would encourage continuous quality improvements and foster a culture of safety and why does health care continues to struggle when it comes to adapting common error management techniques from other industries. The aim of this integrative review was to evaluate the aids and barriers for perioperative teams in functioning effectively, preventing adverse events, and fostering a culture of safety.
Method
This review followed the Joanna Briggs Institute (JBI; 2014) approach for undertaking reviews, drawing on Whittemore and Knafl’s (2005) methodology for conducting integrative reviews, which enabled the inclusion of diverse methodologies aimed at elucidating multiple perspectives on the topic. Integrative reviews capture qualitative and quantitative studies and expert opinions. This approach was selected to capture both the interpersonal and cultural domains within team dynamics and the outcomes of surgical procedures. Maintaining scientific integrity while conducting an integrative literature review involves careful consideration to threats to validity; therefore, specific criteria for consideration of applicable studies for this review were formulated.
Therefore, a systematic search of electronic databases was conducted; the titles and abstracts of studies identified were screened to assess suitability against the aim and the inclusion and exclusion criteria. The full report of studies that appeared to meet the review objective were retrieved, read, and assessed as above, and then assessed for methodological quality.
Search Strategy and Keys Terms
A total of 15 electronic databases were searched from June 28, 2015, to August 1, 2017, and manual searching from the reference lists occurred. The search for this review targeted studies that involved surgical teams as the primary focus of interest, by applying the search terms “surgical, teamwork, operating room, operating theatre, perioperative, behaviour, performance, error, and communication.”
Inclusion Criteria
Articles were included if they reported primary research using qualitative, quantitative, mixed methods, and expert opinion, and concerned health professionals working in perioperative surgical teams such as surgeons, anesthetists, nursing staff, scrub technicians, anesthetic technicians, and registrars/residents. English-only publications were included while field and emergency, and ad hoc surgical settings were not. The titles and abstracts retrieved by the search of the electronic databases were examined. Studies were screened by two investigators working independently. Those who identified surgical team work as their foci were selected for more detailed examination. The full-text versions of these studies were then obtained.
Study Quality Assessment
Qualitative studies were quality appraised according to the JBI-QARI (Qualitative Assessment and Review Instrument), the NOTARI (Narrative, Opinion and Text Assessment and Review Instrument) appraisal tool was used with textual and expert opinion papers and the JBI-MAStARI (Meta-Analysis of Statistics and Review Instrument) appraisal tool was used with quantitative studies (JBI, 2014). Studies scoring a minimum of 70% or higher in the JBI appraisal tools were included in the review.
Data Extraction
The JBI QARI-tool was used to extract the key data for qualitative data extraction in which findings were selected using standardized fields such as methodology, method, phenomena of interest, setting, geographical context, cultural context, participants, data analysis, author’s conclusions, and reviewer’s conclusions (JBI, 2014). Quantitative data were extracted from studies using the standardized data extraction tool from JBI-MAStARI. The data extracted included specific details about the interventions, participants, setting, data analysis, study methods, and outcomes of significance to the review question (JBI, 2014). The JBI NOTARI-tool was used to extract the key data including the authors standing, reference to extant literature, the extent of client focus, the quality of the arguments posed, and evidence of peer support (JBI, 2014).
Results
Search results generated a total of 4,249 studies. After removal of duplicates, 241 studies remained and abstracts were retrieved. Articles were removed if they were not relevant to the aim and research question, or did not meet the inclusion criteria. A total of 115 articles were included for final quality appraisal. Figure 1 provides the PRISMA flowchart of primary study selection (Moher, Liberati, Tetzlaff, Altman, & PRISMA Group, 2009).
After quality appraisal and assessment of methodological validity, 70 articles originating from 12 countries were deemed eligible for inclusion in the review. Articles were appraised but not included if they did not fit the aim sufficiently, the sample size was too small, the design was weak, or they did not meet the criteria for robustness. The 70 articles selected for final review and synthesis were separated according to the applied approach, resulting in 38 quantitative, 23 qualitative, three mixed-methods studies, and six expert opinion texts or reports.
A total of five themes representing key factors integral to high-performing and effective surgical teams emerged from the thematic syntheses (Figure 2): Team Talk hierarchical versus collaborative team dynamics; professional practice environment and shared clinical governance; strategic urgency, system perspectives, and clinical partnership for success; limitations and barriers of a specialized microculture; and possibilities and opportunities for quality improvements.
The key factors contributing to each of the five themes are presented in Figure 3.
Team Talk: Hierarchical Versus Collaborative Team Dynamics
Studies reported on surgical teams, the interdisciplinary nature and dynamics of these teams, and the importance of teamwork. Results revealed that constraints on interprofessional teamwork and ways shared practices can be established are directly related to team members’ understanding of each other’s roles, aims and responsibilities, and nontechnical skills (Bogdanovic, Perry, Guggenheim, & Manser, 2015; Collin, Paloniemi, & Mecklin, 2010; Sexton et al., 2006).
Conflicting professional demands, differences in hierarchical level, deeply ingrained professional identities, and escalating independence between surgical disciplines disconnect teams even further (Finn, Learmonth, & Reedy, 2010; Sandelin & Gustafsson, 2015; Undre, Healey, Darzi, & Vincent, 2006).
Consequently, opportunities to learn from and through errors were threatened by highly individual cultures where shared responsibility is disregarded. Strong traditional hierarchical structures were identified and were considered major barriers to interprofessional work in the operating theater environment (Collin et al., 2010; Finn et al., 2010; Finn & Waring, 2006; Paloniemi & Collin, 2012).
Professional Practice Environment and Shared Clinical Governance
Nontechnical skills were a focus in the literature with “communication” being the most frequently described nontechnical skill. Team effectiveness and positive outcomes of surgery can be directly related to the degree of communication, the process of sharing information, and situational awareness (SA; Alfredsdottir & Bjornsdottir, 2008; Boquet, Cohen, Reeves, & Shappell, 2017; Cumin, Skilton, & Weller, 2017; J. H. Garrett, 2016; Halverson et al., 2011; Lingard, Regehr, Espin, & Whyte, 2006; Michalak, Rolston, & Lawton, 2016; Mitchell & Flin, 2009; Parush et al., 2011; Phitayakorn, Minehart, Hemingway, Pian-Smith, & Petrusa, 2015).
Bleakley, Allard, and Hobbs (2013) suggest that a high level of team SA will characterize a high-functioning team. In addition, the authors concluded that successful reduction of communication breakdowns and application of sound surgical SA can substantially improve patient safety and reduce errors. Brown et al. (2017), on the contrary, concluded significant variations in perceived importance among team members in “time-outs” led to an imperfect team-based mental model. (The surgical team pauses in their workflow to confirm that the surgery team has completed listed safety tasks before it proceeds with the operation; WHO, 2009a.)
Interestingly, R. Riley and Manias (2006) discuss the knowledge and SA of theater nurses as a source of power, and nurses often apply this knowledge of individual surgeons to inform and discipline practice. They expanded on the principle of governance in nursing and researched the way gatekeeping is applied by nurses through technical knowledge of surgeons’ preferences, equipment, and procedures. Nestel and Kidd (2006) concluded that theater nurses are often perceived to be responsible for “running a theatre” and assume “invisible” leadership.
Strategic Urgency, System Perspectives, and Clinical Partnership for Success
Studies described factors relating to system failures, strategies to improve succession planning within organizations, and how surgical team composition can both support and hinder efficient practice (Christian et al., 2006; Zheng, Panton, & Al-Tayeb, 2012). Organizational structures in health care were often characterized through management-driven hierarchies where either incentives (often economic) or punishment were common practices (Benn, Healey, & Hollnagel, 2008; Braxton, 2012; Costello, Clarke, Gravely, D’Agostino-Rose, & Puopolo, 2011; Silén-Lipponen, Tossavainen, Turunen, & Smith, 2005).
Two levels within an organization that can prevent system failures were described: the perioperative team (micro level) and the wider organization (macro level). System failures on macro level were caused by planning failures, attrition rates, organizational learning, workflow and workload management, the unavailability of equipment, financial constraints, or avoidable cancelations of elective surgery. Whereas findings indicated the perioperative team should focus on SA, briefing and debriefing, simulation-based training, including practice in checklists, improving nontechnical skills and regular performance feedback with team members (Benn et al., 2008; Korkiakangas, 2017).
Of the studies which described system transformation, a range of approaches to improve the quality of surgical care were proposed such as evidence-based medicine and clinical practice guidelines (Braxton, 2012; HQSC, 2015), professional education, development and organizational learning (Braxton, 2012; Costello et al., 2011), assessment and accountability (Braxton, 2012; Silén-Lipponen et al., 2005), patient-centered care (Arakelian, Gunningberg, & Larsson, 2011; Braxton, 2012), and quality management and continuous quality improvement (Costello et al., 2011; Silén-Lipponen et al., 2005). Addressing the surgical team composition and effectiveness is also necessary. Although several studies allude to the threat of financial constraints in a meta-analysis, only one study researched the relation between surgical team composition and the financial implications such as surgical delays and extended operation times (Özdemir-van Brunschot et al., 2015).
Limitations and Barriers of a Specialized Microculture
Numerous studies defined the current challenges teams experienced, namely, fluctuating team dynamics, culture and political nuances (Bleakley, 2006a; Carvalho, Donato Göttems, Gomes Maia Pires, & Cunha de Oliveira, 2015; Cheriyan et al., 2016; Clark & Kenski, 2017; Fan et al., 2016; Fleming, Smith, Slaunwhite, & Sullivan, 2006; Gillespie, Chaboyer, Longbottom, & Wallis, 2010; Keller et al., 2016; Pimentel, Choi, Fiumara, Kachalia, & Urman, 2017; R. Riley & Manias, 2009; Rogers et al., 2011; Rogers, Lingard, Boehler, Espin, Mellinger, et al., 2013; Rogers, Lingard, Boehler, Espin, Schindler, et al., 2013; Weldon, Korkiakangas, Bezemer, & Kneebone, 2015; Wheelock et al., 2015). Interpersonal conflict was reported as a significant barrier for safe practice (Chipps, Stelmaschuk, Albert, Bernhard, & Holloman, 2013; Rogers et al., 2011; Rogers, Lingard, Boehler, Espin, Schindler, et al., 2013) resulting in considerable numbers of errors. High stress levels in the perioperative environment due to an excessive workload were noted (Bleakley, 2006a; Fleming et al., 2006; Hull, Arora, Kassab, Kneebone, & Sevdalis, 2011; Rogers et al., 2011).
Barriers related to effective surgical teams were noted as being intra-operative interruptions, deviations, and distractions (Cheriyan et al., 2016; Gillespie, Chaboyer, & Fairweather, 2012; Keller et al., 2016; Morgan et al., 2013; Persoon, Broos, Witjes, Hendrikx, & Scherpbier, 2011; Schraagen et al., 2011; Tsiou, Efthymiatos, & Katostaras, 2008; Weldon et al., 2015; Wheelock et al., 2015). Issues of concern regarding surgical team effectiveness were limited funding, demands for increased productivity, the lack of adequate training and leadership, and bureaucratic approaches to introducing protocols or patient safety initiatives (Bleakley, 2006a; Carney, Mills, Bagian, & Weeks, 2010; Gillespie, Chaboyer, & Lizzio, 2008; Gillespie et al., 2010; Rogers, Lingard, Boehler, Espin, Mellinger, et al., 2013).
Possibilities and Opportunities for Quality Improvements
This theme comprised studies where quality tools, training, and simulation were researched to generate work standardization and improved teamwork. Recent quality improvements such as intra-operative pathways based on a “relational coordination” teamwork model (Lee et al., 2008) include Standard Operating Procedures, such as checklists, forms, posters, protocols, or manuals (Criscitelli, 2015; Morgan, Pickering, et al., 2015; Prabhakar et al., 2012; Rhee et al., 2017; Weld et al., 2016; Wright, 2016). Other innovations have involved training programs based on aviation crew resource management to increase knowledge, change attitudes, and improve behavior related to perioperative technical and nontechnical skills of surgical team members (France, Leming-Lee, Jackson, Feistritzer, & Higgins, 2008; Griswold et al., 2012; McCulloch et al., 2009; Morgan, Hadi, et al., 2015; Stephens, Hunningher, Mills, & Freeth, 2016; Wetzel et al., 2011). Despite these initiatives, lack of SA was compellingly associated with surgical technical error. With training, nontechnical skills were found to improve; nevertheless, overall technical performance declined and surgical complications increased slightly (McCulloch et al., 2009; Morgan, Hadi, et al., 2015; Morgan, Pickering, et al., 2015; Prabhakar et al., 2012).
Discussion
A significant gap in the literature relating to interventions to improve surgical team effectiveness was noted at the onset of this review. The majority of study findings in this review are consistent in assuming existing hierarchies, prevailing misconceptions, and understanding among team members related to tasks and responsibilities are barriers to the effectiveness of surgical teams. Although numerous QI toward team training, introduction of protocols, and checklists have occurred, team effectiveness in the perioperative setting is still insufficient and challenges in establishing effective surgical teams continue.
The appraised studies concur on the need to overcome professional boundaries by sharing knowledge and gaining an understanding of each other’s role, to establish an open environment between and within the various professionals (Collin et al., 2010; Paige, 2010; The Royal College of Surgeons of England [RCSENG], 2007; Weller, Boyd, & Cumin, 2014). These results contribute to the growing body of evidence about teamwork practices and confirm that practices certainly have consequences for interprofessional work and evidently patient safety (Finn, 2008; HQSC, 2014b; RCSENG, 2007). Deficiencies in the understanding and interpretation of the perioperative teamwork concept remain. For example, the ability to accurately evaluate and validate the competencies of each team member and the methods in which surgical teamwork is measured are notable (Hull & Sevdalis, 2015b; RCSENG, 2007; Weller et al., 2014).
Financial influences, health targets, and expenditure priorities often take precedence over other developments in service organization and delivery which result in increased workloads and hence stressors (Blumenthal, Song, Jena, & Ferris, 2013; Paige, 2010; Warshawsky, Havens, & Knafl, 2012). Therefore, it is widely agreed that effective teamwork starts at the top, with executive leaders in health care needing to lead their organizations in the implementation and accomplishment of their fundamental strategic goals (Finn, 2008; Paige, 2010; Santa, Ferrer, Bretherton, & Hyland, 2010). Studies have documented a need for moving beyond the financial agenda and to consider the implications and impact on surgical teams. There is urgent need for managerial support, investment in professional and team development, performance evaluations, and effective incentive systems (Blumenthal et al., 2013; Flin, Yule, McKenzie, Paterson-Brown, & Maran, 2006; Frankel, Leonard, & Denham, 2006; LePine, 2005; Masiello, 2012; Santa et al., 2010; Sarkar & Fletcher, 2014; Taplin, Foster, & Shortell, 2013; Veitch, 2008; Weller et al., 2014).
Before any commitment toward implementation of new practices and technologies can occur, managers ought to identify performance gaps in their own organization. Moreover, governance boards, senior administrative leaders, and clinical leaders must reinforce the organizational values supported by robust structures, realistic organizational objectives, and recognized and established systems before they can even start considering developing into a high reliability organization (Blumenthal et al., 2013; Frankel et al., 2006; Institute of Medicine [IOM], 1999, 2001, 2011; Koh, Park, Wickens, Ong, & Chia, 2011; Paige, 2010; RCSENG, 2007; Salas, DiazGranados, Weaver, & King, 2008; Salas, Wilson, Burke, & Wightman, 2006; Warshawsky et al., 2012). Conversely, all too often, managerialistic approaches are standard practice, with rigid hierarchies, accountability, and measurement, resulting in tightly managed organizations (Finn, 2008). Health care organizations should have a great interest in professional, effective communication and sharing of information, as failures can generate escalation in costs and cause inefficiencies such as treatment delays, prolonged hospitals stays, and wastage of valuable resources (Weller et al., 2014).
Surgical teams work in a rapidly evolving high-risk industry. Their need for continuous modification and adjustment of new best-practice standards, and acquisition of technical skills to reliably deal with the demands of existing and new procedures in the operating theater ensuring quality of surgical care appears to be often neglected by organizations (Healey, Undre, & Vincent, 2006; RCSENG, 2007). Despite growing acknowledgment of the significance of teamwork for surgical safety, professionals are still expected to adapt and convert effortlessly into an effective surgical team without appropriate team training in place (Collin et al., 2010; Hull & Sevdalis, 2015a, 2015b; Paige, 2010). The creation and sustainability of high-functioning teams requires considerable financial and organizational investment involving the release of time to attend training, recurring sessions entailing the utilization of consumables to generate realistic scenarios (Hull & Sevdalis, 2015a; Kellicut, Kuncir, Williamson, Masella, & Nielsen, 2014).
Most of the available data on teamwork and team dynamics pertain to personalities and characteristics of individuals, collaboration skills, and conflict. However, studies pertaining to conflict in the perioperative environment present contradictory outcomes. Some researchers regard conflict as a practice that prohibits cooperation, creates detrimental competition, disrupts workflow and atmosphere, allows hidden power structures, and undermines trust and respect (Finn, 2008; Gillespie, Chaboyer, & Wallis, 2009; Janss, Rispens, Segers, & Jehn, 2012; Kalleberg, Nesheim, & Olsen, 2009; Lindwall & von Post, 2008). Whereas others argue that conflict is a necessity to generate growth, establish improved QI, stimulate healthy relationships, encourage collaboration, and create an environment for tensions to be released (Grossman & Valiga, 2009; LePine, 2005; Okoli, 2010). It is our view that organizational structures characterized by an open, respectful, and supportive climate is essential to create effective teamwork.
Other barriers described are the allocation of transient teams, caused by high staff turnover rates and increasing employment of agency staff, which are customary in the perioperative environment. This directly affects team performance especially when depending heavily on team member familiarity (Dineen, Noe, Shaw, Duffy, & Wiethoff, 2007; Graves & Simmons, 2009; Healey, Undre, & Vincent, 2006; Korb, Geißler, & Strauß, 2015; Meeusen, Brown-Mahoney, Van Dam, Van Zundert, & Knape, 2010).
Studies have documented a need for compelling leadership to establish effective teams; nevertheless, opinions are divided as to who should take on that role, whether it is a competency that can be divided dependent on the situation, or if all members of the surgical team should assume leadership skills. Marques-Quinteiro, Curral, Passos, and Lewis (2013) researched SWAT action teams and noted team members cultivate an understanding of each other’s expertise and skill which enables them to easily adapt to new situations through reallocation of specific tasks to the team members with the most proficiency related to the task at hand. This allows team members to directly approach the “expert” or encourage this person to act up in a more pertinent role during that time (Marques-Quinteiro et al., 2013). This finding is consistent with other research across different fields such as firefighting, sport psychology, human factors, and military psychology in which a team can only function properly if the model of effectiveness is understood and shared by all members (Emich, 2014; Healey, Undre, & Vincent, 2006; Marques-Quinteiro et al., 2013; Ward et al., 2008; Yammarino, Mumford, Connelly, & Dionne, 2010).
Translating flexibility in leadership to the perioperative environment, one can argue that members of a surgical team have to monitor each other’s activity in real time to coordinate the workflow effectively (Healey, Undre, & Vincent, 2006). Effectively, the surgeon controls the majority of the workflow during an operation; nonetheless, in case an issue occurs which leads to compromised patient safety or performance, the scrub nurse or another member of the team may need to transfer the control briefly. Overall, the evidence suggests that leadership can be a changeable multilevel dynamic construct influencing practices and processes at the individual, interprofessional, and group levels (Yammarino et al., 2010).
Moreover, the health care workforce has fluctuated considerably over the past decades, and for the first time in centuries, we are faced with five different generations in one workplace (Centre for Generational Kinetics, 2015). Surprisingly, this aspect has not been given much attention in the literature, especially considering the majority of perioperative nurses are of the Baby Boomer generation. Notably, the emerging workforce has a learning style and anticipated outcomes that are considerably different from previous generations (Andrews, 2013; Hewitt, Lackey, & Letvak, 2013; Mauleon & Ekman, 2002; Reinsvold, 2008; Sherman, 2015; Thompson, 2007). Existing strategies and approaches that were seemingly efficient and profitable 5 years ago are unlikely to succeed with younger generations; therefore, effective training and learning strategies through technology-based education, informed decisions, and specific actionable solutions are vital for surgical teams to flourish and be sustainable (Centre for Generational Kinetics, 2015; Jamieson, Kirk, Wright, & Andrew, 2015; Schlitzkus, Schenarts, & Schenarts, 2010).
Results of the current synthesis are limited to the specific selected studies, and given the set inclusion and exclusion criteria, generalization and interpretation of the results should be taken with consideration. The search strategy only searched studies published in English. It also yielded a variety of primary studies with different methodologies (qualitative, quantitative, and mixed methods), which creates challenges to combine, appraise, and synthesize texts accordingly. This, however, was overcome through a narrative presentation of the findings and all data were appraised and discussed according to a set framework. Validated appraisal tools were applied and all three reviewers appraised the data individually to prevent bias (Creswell, 2014; Dixon-Woods, Agarwal, Jones, Young, & Sutton, 2005; Dixon-Woods, Fitzpatrick, & Roberts, 2001).
This integrative literature review investigated the concept of effective surgical teams and has identified aids and barriers for perioperative teams in functioning effectively, preventing adverse events and fostering a culture of safety. Despite growing evidence and acknowledgment of the importance of surgical teamwork to ensure safe patient care, and substantial international attempts at improving teamwork through checklists, briefing/debriefing, simulation and training modules, members of the surgical team often continue to be randomly allocated and are expected to function as an effective team. These findings are consistent with previous research. Data on QI implemented over a decade ago show that little or no changes have occurred in current clinical practice and surgical teams are expected to deliver quality surgical care without adequate support or resources. Unfortunately, there are still limitations in the understanding and interpretation of the perioperative teamwork concept, the ability to accurately evaluate and validate the competencies of each team member, and the methods by which surgical teamwork is measured.
Most of the literature on perioperative teams has concentrated principally on preventing errors by comparing with aviation crews and the way these teams are trained; however, the distinct differences between the two areas and team dynamics have received little attention in the literature. The question whether perioperative care can benefit from research on fixed established and permanent teams like the aviation industry is unrealistic considering the significant differences in team composition, attrition rates, and organizational culture.
Most researchers agree that certain skills and behaviors facilitating a surgical team’s capability to adjust to unpredictability, distractions, and interruptions do increase performance. In addition, synthesized studies identified a relationship between inefficient nontechnical skills and teamwork and failures such as technical errors, delays in start times or prolonged operating time, communication failures, and other adverse events.
Effective information sharing through robust organizational protocols, consistent coordination with other external departments, and accurate theater scheduling to enable team stability are all imperative to generate effective surgical teams and overcome existing barriers. A manager’s overall knowledge of team composition, including staff strengths and weaknesses, plays an important role in influencing team adaptation to effective and efficient performance. A considerable change in organizational investment related to funding, resources, and time investment is crucial to implement ongoing training and simulation for perioperative teams to establish high quality of surgical care.
Unfortunately, the issue of blame is still widespread in the perioperative workplace. Additional research is required to gain a more comprehensive understanding of environmental influences and ensure viable succession planning is considered. Without changes in the organizational culture such as support and involvement from senior champions, nurse leaders, departmental leaders and individual clinicians, interprofessional collaboration and teamwork will not prosper.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs
Claudia Teunissen https://orcid.org/0000-0003-3711-3714
Virginia Maskill https://orcid.org/0000-0001-8596-7103
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Article first published online: March 10, 2019
Issue published: January 2020
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PubMed: 30854942
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