Surgical safety checklist compliance process as a moral hazard: An institutional ethnography.

BACKGROUND: Charting is an essential component of professional nursing practice and is arguably a key element of patient safety in surgery: without proper, objective, and timely documentation, both benign and tragical errors can occur. From surgery on wrong patients to wrong limbs, to the omission of antibiotics administration, many harms can happen in the operating room. Documentation has thus served as a safeguard for patient safety, professional responsibility, and professional accountability. In this context, we were puzzled by the practices we observed with respect to charting compliance with the surgical safety checklist (SSC) during a study of surgical teams in a large, urban teaching hospital in Canada (pseudonym 'C&C'). METHODS: This article leverages institutional ethnography and a subset of data from a larger study to describe and explain the social organisation of the system that monitored surgical safety compliance at C&C from the standpoint of operating room nurses. This data included fieldnotes from observations of 51 surgical cases, on-the-spot interviews with nurses, formal interviews with individuals who were involved in the design and implementation of the SSC, and open-ended questions from two rounds of survey of OR teams. FINDINGS: We found that the compliance form and not the SSC itself formed the basis for reporting. To meet hospital accuracy in charting goals and legislated compliance documentation reporting requirements nurses 'pre-charted' compliance with the surgical checklist. The adoption of this workaround technically violated nursing charting principles and put them in ethically untenable positions. CONCLUSIONS: Documenting compliance of the SSC constituted a moral hazard, constrained nurses' autonomy and moral agency, and obscured poor checklist adherence. The findings highlight how local and extra local texts, technologies and relations create ethical issues, raise questions about the effectiveness of resulting data for decision-making and contribute to ongoing conversations about nursing workarounds.

The ritualisation of the surgical safety checklist and its decoupling from patient safety goals.

Patient harm, patient safety and their governance have been ongoing concerns for policymakers, care providers and the public. In response to high rates of adverse events/medical errors, the World Health Organisation (WHO) advocated the use of surgical safety checklists (SSC) to improve safety in surgical care. Canadian health authorities subsequently made SSC use a mandatory organisational practice, with public reporting of safety indicators for compliance tied to pre-existing legislation and to reimbursements for surgical procedures. Perceived as the antidote for socio-technical issues in operating rooms (ORs), much of the SSC-related research has focused on assessing clinical and economic effectiveness, worker perceptions, attitudes and barriers to implementation. Suboptimal outcomes are attributed to implementations that ignored contexts. Using ethnographic data from a study of SSC at an urban teaching hospital (C&C), a critical lens and the concepts of ritual and ceremony, we examine how it is used, and theorise the nature and implications of that use. Two rituals, one improvised and one scripted, comprised C&C's SSC ceremony. Improvised performances produced dislocations that were ameliorated by scripted verification practices. This ceremony produced causally opaque links to patient safety goals and reproduced OR/medical culture. We discuss the theoretical contributions of the study and the implications for patient safety.

It's not the arrow, it's the archer: the role of the surgeon leader in a safety driven-era.

BACKGROUND: In an era where team communication and patient safety are paramount, standardized tools have been deemed critical to safe, efficient practice. In some cases-perhaps most notably in the surgical safety checklist (SSC)-these tools have been elevated as the key to safe patient care. However, effects of the SSC on patient safety in practice remain mixed. We explore the role and impact of the surgeon leader in the use of structured communication tools to understand how surgeon engagement impacts intraoperative teamwork. METHODS: Using a constructivist grounded theory approach, OR staff members (surgeons, anesthetists, nurses and perfusionists) were recruited to participate in a one-on-one semi-structured interview. The interview explored participant experiences working in the OR, focusing on the role and impact of the surgeon as leader. RESULTS: Engaged use of the surgical safety checklist by the attending surgeon had the potential to improve teamwork in the operating room. Surgeons who used the checklist to engage with their team and facilitate group discussion were able to avoid tensions later in the operation typically arising from lack of situation awareness and familiarity with team member experience levels. Surgeons who engaged with the SSC as more than a memory aid were able to foster a better team environment. CONCLUSIONS: Surgeons can harness their role as leader in the operating room by engaging with structured communication tools such as the SSC to foster improved teamwork.

Contextualizing the tone of the operating room in practice: drawing on the literature to connect the dots.

The study of teamwork in the operating room has made significant strides in uncovering key constructs which shape safe and effective intraoperative care. However, in recent years, there have been calls to understand teamwork in the operating room more fully by embracing the complexity of the intraoperative environment. We propose the construct of tone as a useful lens through which to understand intraoperative teamwork. In this article, we review the literature on culture, shared mental models, and psychological safety, linking each to the construct of tone. By identifying tone as a theoretical orientation to demonstrate the overlap between these concepts, we aim to provide a starting point for new ways to understand intraoperative team dynamics.

Beyond the Surgical Safety Checklist: Using Intraoperative Handoff to Facilitate Team Situation Awareness in the OR.

BACKGROUND: The surgical safety checklist (SSC) has been credited with improving team situation awareness (SA) in the operating room. Although the SSC may support team SA at the outset of the operative case, intraoperative handoff provides an opportunity for either SA breakdown or, more preferably, SA reinforcement. High-functioning surgical teams demonstrate a high level of continued SA, whereas teams deficient in SA are more likely to be affected by surgical errors and adverse events. To date, no interprofessional intraoperative tools exist to support team SA beyond the SSC. METHODS: This study was divided into 2 phases. The first used qualitative methods to (1) characterize intraoperative handoff processes across surgery, nursing, anesthesia, and perfusion, and (2) identify cultural factors that shaped handoff practices. Data for phase one were collected over 38 observation days and 41 brief interviews. Phase 2, informed by phase 1, used a modified Delphi process to create a tool for use during intraoperative handoff. Data were analyzed iteratively. RESULTS: Handoff practices were not standardized and rarely involved the entire team. In addition we uncovered cultural factors-specifically assumptions held by participants-that hindered team communication during handoff. Assumptions included: (1) team members are interchangeable, (2) trained individuals are able to determine when it is appropriate to handoff without consulting the OR team. Despite claims of improved teamwork resulting from the SSC, many participants held a fragmented view of the OR team, resulting in communication challenges during handoff. Findings from both phases of our study informed the development of multidisciplinary intraoperative handoff tools to facilitate shared team situation awareness and a shared mental model. CONCLUSIONS: Intraoperative handoff occurs frequently, and offers the opportunity for either renewed or fractured team SA beyond the SSC.

Pulling our lens backwards to move forward: an integrated approach to physician distress.

The medical community has recently acknowledged physician stress as a leading issue for individual wellness and healthcare system functioning. Unprecedented levels of stress contribute to physician burnout, leaves of absence and early retirement. Although recommendations have been made, we continue to struggle with addressing stress. One challenge is a lack of a shared definition for what we mean by 'stress', which is a complex and idiosyncratic phenomenon that may be examined from a myriad of angles. As such, research on stress has traditionally taken a reductionist approach, parsing out one aspect to investigate, such as stress physiology. In the medical domain, we have traditionally underappreciated other dimensions of stress, including emotion and the role of the environmental and sociocultural context in which providers are embedded. Taking a complementary, holistic approach to stress and focusing on the composite, subjective individual experience may provide a deeper understanding of the phenomenon and help to illuminate paths towards wellness. In this review article, we first examine contributions from unidimensional approaches to stress, and then outline a complementary, integrated approach. We describe how complex phenomena have been tackled in other domains and discuss how holistic theory and the humanities may help in studying and addressing physician stress, with the ultimate goal of improving physician well-being and consequently patient care.

"Some version, most of the time": The surgical safety checklist, patient safety, and the everyday experience of practice variation.

BACKGROUND: This study investigated checklist compliance to highlight where assumptions about the Surgical Safety Checklist might not be met in practice. METHODS: We used ethnographic methods to investigate the practice of the Surgical Safety Checklist in one hospital. Fifty-one observation days, eight semi-structured interviews, and two surveys of operating room staff over two years were conducted. Data were collected and analyzed iteratively. RESULTS: Despite the near 100% compliance rates reported to the Ministry of Health, practice of the Surgical Safety Checklist varied widely: 82% of Briefings, 76% of Time-Outs, and 22% of Debriefings included some sort of team huddle. Gaps between policy and practice were identified at four different levels: compliance with the stages and items; responsibility for the checklist; documentation of adherence; and interprofessional teamwork. CONCLUSIONS: Checklist compliance data are insufficient to understand how complex interventions impact care delivery. Greater and continued attention to practice in healthcare is needed.

Mental Skills in Surgery: Lessons Learned From Virtuosos, Olympians, and Navy Seals.

OBJECTIVE: The present study investigated the role of mental skills in surgery through the unique lens of current surgeons who had previously served as Olympic athletes, elite musicians, or expert military personnel. BACKGROUND: Recent work has demonstrated great potential for mental skills training in surgery. However, as a field, we lag far behind other high-performance domains that explicitly train and practice mental skills to promote optimal performance. Surgery stands to benefit from this work. First, there is a need to identify which mental skills might be most useful in surgery and how they might be best employed. METHODS: Using a constructivist grounded theory approach, semi-structured interviews were conducted with 17 surgeons across the United States and Canada who had previously performed at an elite level in sport, music, or the military. RESULTS: Mental skills were used both to optimize performance in the moment and longitudinally. In the moment, skills were used proactively to enter an ideal performance state, and responsively to address unwanted thoughts or emotions to re-enter an acceptable performance zone. Longitudinally, participants used skills to build expertise and maintain wellness. CONCLUSIONS: Establishing a taxonomy for mental skills in surgery may help in the development of robust mental skills training programs to promote optimal surgeon wellness and performance.

Cognitive flow in health care settings: A systematic review.

INTRODUCTION: The state of cognitive flow, colloquially known as being 'in the zone', has been linked with enhanced performance, happiness, career satisfaction and decreased burnout. However, the concept has not been adopted strongly in health care training, continuing professional development, or daily practice. A systematic review with a narrative synthesis was undertaken to map the evidence for flow in health care. METHODS: A search was conducted in MEDLINE, PsycInfo, and EMBASE in July 2019 and updated in October 2020 for manuscripts discussing flow in all health care disciplines. Articles published between 1806 and 13 October 2020 were included. Two authors independently reviewed titles and abstracts (and subsequently full texts where necessary) for inclusion. Disagreements were resolved by consensus. Data were extracted on location, manuscript type, population and context, measures, and key findings. RESULTS: A total of 4923 unique abstracts were initially retrieved, and 15 articles were included in the final review. We report on the experience, benefits and strategies to support flow in health care. Flow may benefit providers by enhancing career enjoyment, wellness and performance, while mitigating exhaustion, burnout, and stress. Although research from other domains has focused on supporting flow through individualised training, our results highlight the importance of system and environmental factors. CONCLUSIONS: Supporting professional and trainee flow in health care requires a holistic approach, including individual training and system-level interventions.

Struggles with autonomy: Exploring the dual identities of surgeons and learners in the operating room.

BACKGROUND: Developing autonomy is a critical component of becoming an attending surgeon. General surgery training has evolved in recent decades, however, leaving residents less time to work with attendings to establish entrustment. Limited entrustment can impact resident learning and engagement. METHODS: A constructivist grounded theory approach was used to guide interviews of 12 general surgery residents and 10 attendings. RESULTS: Engagement in the OR is perceived by both residents and attendings as fundamental to achieving autonomy. Our study uncovered three key tensions: 1. Residents and attendings both occupy dual roles in the OR; 2. System demands put those roles in tension and opposition constantly; 3. Residents and attendings do deploy strategies to seek balance in those tensions. CONCLUSIONS: In an academic OR setting, competing priorities can negatively impact resident engagement. Participants described some strategies for helping residents and attendings prioritize learning and teaching to better prepare residents for future practice.

Fake It 'Til You Make It: Pressures to Measure Up in Surgical Training.

PURPOSE: Expectations of certainty and confidence in surgical culture are a source of internal conflict for surgeons and learners, with surgeons describing a pressure to project an image that is, at times, inconsistent with how they feel internally. The authors explored surgical residents' perceptions of "impression management" and its effects on surgical judgment and decision making. METHOD: The authors used a constructivist grounded theory approach to conduct and analyze 15 semistructured interviews with general surgery trainees at an urban Canadian academic health center between 2012 and 2014. Interviews explored impression management in the context of resident learning and performance. Analysis was inductive, whereby emergent themes contributed to a developing conceptual framework, and deductive, using an existing theory of impression management. RESULTS: Residents described sensing an "expectation" to portray an image aligned with the ideal surgical stereotype of confidence and certainty, and shared strategies used to mirror this image. Impression management strategies were used to portray an image of competence, with the aim to improve access to teaching and evaluations. Unintended consequences of impression management on decision making, patient safety, and resident wellness were identified. CONCLUSIONS: These findings contribute to a deeper understanding of the potential impact of the sociocultural context on residency training, and provide a language allowing for more explicit discussions about the impact of surgical culture on trainee behaviors. Translation includes formal instruction of these concepts in the curriculum so that trainees better recognize, reflect on, and cope with the pressures to perform in front of others.

Exploring and understanding academic leadership in family medicine.

OBJECTIVE: To explore how family physicians understand the concept of academic leadership. DESIGN: Case study. SETTING: Department of Family and Community Medicine at the University of Toronto in Ontario. PARTICIPANTS: Thirty family physician academic leaders. METHODS: Focus groups and interviews were conducted with family physicians from a large multisite urban university who were identified by peers as academic leaders at various career stages. Transcripts from the focus groups and interviews were anonymized and themes were analyzed and negotiated among 3 researchers. MAIN FINDINGS: Participants identified qualities of leadership among academic leaders that align with those identified in the current literature. Despite being identified by others as academic leaders, participants were reluctant to self-identify as such. Participants believed they had taken on early leadership roles by default rather than through planned career development. CONCLUSION: This study affirms the need to define academic leadership explicitly, advance a culture that supports it, and nurture leaders at all levels with a variety of strategies.