FRIDAY, May 5, 2006 (HealthDay News) -- Imagine going under the knife of a surgeon who intimidates the anesthesiologist and marginalizes his nursing team. What happens if your doctor makes a mistake, and the scrub nurse who witnessed the error is afraid to speak up?

It takes teamwork to create a culture of good communication in the operating room (OR), claims a new study from Johns Hopkins University researchers, but the OR has historically been governed by a pecking order in which members of the operating team have been discouraged from confronting the surgeon on patient-care issues.

To find out whether surgeons are team players, researchers used a survey that gauged teamwork as a proxy for patient safety. The survey revealed widely differing opinions about the quality of collaboration and communication in the OR.

"Basically, the surgeons thought there was great teamwork and the nurses thought there was terrible teamwork," said Dr. Martin A. Makary, an assistant professor in the Department of Surgery at Johns Hopkins University School of Medicine.

Fran Griffin, project director at the Institute for Healthcare Improvement, a Cambridge, Mass.-based nonprofit that aims to improve patient care practices, said the gap in perceptions speaks to the way nurses and physicians are trained to do their jobs.

"Nurses are generally trained to work in teams with each other, and with the other disciplines," she explained. The teamwork begins even before the surgeon walks into the room, "whereas the surgeons are trained to be sort of the captain of the ship."

As a result, she added, "If the personality of the surgeon is not one where he or she naturally invites people to talk, those people are going to feel intimidated about speaking up if they have a question or they're concerned about something."

Communications mishaps are the most common cause of deaths and serious injuries reported by U.S. hospitals, according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which tracks these so-called "sentinel events." In the most egregious, headline-grabbing cases, poor communication often is to blame for surgeries on the wrong patient or the wrong part of the body. But it can also be the culprit behind minor injuries and "near misses," Makary said.

To assess OR teamwork, the authors first adapted a survey originally designed to measure flight safety attitudes in the cockpit. "What the aviation industry learned was that crashes had been directly attributable to a co-pilot knowing that something was wrong but not feeling comfortable speaking up," Makary noted.

The survey involved OR personnel in a large Catholic health system, some 60 hospitals in 16 states. The results are based on 2,135 completed surveys. Overall, surgeons were given the lowest ratings of teamwork, while scrub and circulating nurses scored highest.

Surgeons, in fact, perceived that everyone on the team -- themselves included -- was doing a good job communicating and collaborating. Nurses, however, offered a more pessimistic view. Less than half of OR nurses gave surgeons high marks on teamwork. By contrast, 87 percent of surgeons believed nurses demonstrated a high level of teamwork.

"I think basically this is a wakeup call to physicians, just as the aviation industry had a wakeup call when they surveyed perceptions of management," Makary said. "There's a disconnect, and we need to do a better job as surgeons in promoting teamwork."

A number of cultural reforms are already taking shape. The JCAHO, as part of a national patient safety initiative, has proposed that U.S. hospitals conduct an annual assessment of their safety culture beginning in 2007, the study authors noted.

At Johns Hopkins, all members of the OR team, including the surgeon, anesthesiologist, medical technicians and nurses, are now required to participate in a pre-surgery briefing, during which they make introductions, review goals and expectations and discuss any issues or concerns that might crop up. The briefings are modeled after the cross-checks performed by flight teams before takeoff.

But for briefings to work effectively, Griffin explained, the surgeon must be the one that encourages team members to speak up. "It's not a briefing if the surgeon says, 'Here's what we're going to do. Everybody OK? Great. Let's go.'"

To overcome resistance to such a change, IHI advocates taking it slowly.

"Start small, and start with somebody who's willing do just that small test," Griffin suggested. "Don't start with the surgeon in your operating room who's the most difficult to deal with and has a reputation for yelling at people and throwing things across the room."

Once the tide shifts, she added, it will be difficult for recalcitrant physicians to resist. "Peer pressure can be a wonderful thing!" she said.

More information

For more information on patient safety and quality, visit the Agency for Healthcare Research and Quality.

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