Journal of Interprofessional Care, October 2006; 20(5): 485 – 495
The complexity of measuring interprofessional teamwork in the operating theatre
ANDREW N. HEALEY, SHABNAM UNDRE, NICK SEVDALIS, MARIA KOUTANTJI, & CHARLES A. VINCENT Clinical Safety Research Unit, Imperial College, University of London, London, UK
Abstract Surgery depends on interprofessional teamwork, which is becoming increasingly specialized. If surgery is to become a highly reliable system, it must adapt and professionals must learn from, and share, tested models of interprofessional teamwork. Trainers also need valid measures of teamwork to assess individual and team performance. However, measurement and assessment of interprofessional teamwork is lacking and interprofessional team training is scarce in the surgical domain. This paper addresses the complexity of measuring interprofessional teamwork in the operating theatre. It focuses mainly on the design and properties of observational assessment tools. The report and analysis serves to inform the researcher or clinician of the issues to consider when designing or choosing from alternative measures of team performance for training or assessment.
Keywords: Interprofessional, surgery, teamwork, observation, measures, OTAS
Introduction Interprofessional collaboration underpins much of modern healthcare (Baker et al., 2005; Borrill et al., 2001; D’Amour et al., 2005). It is especially critical in the operating theatre, where anaesthetists, nurses and surgeons work interdependently in complex arrangements, where patient care is distributed among these professionals (West, 2000). The level of teamwork in the operating theatre is therefore critical to patient care; inter-group relations and processes may enhance or hinder the care provided (Hall, 2005). Research shows that there are frequent communication failures in healthcare, particularly among different professional groups (Leonard et al., 2004; Lingard et al., 2004; Sexton et al., 2000). These and other human factors (Calland et al., 2002; Vincent et al., 2004; Weinger & Englund, 1990) may contribute to the adverse events that occur in surgery (Brennan et al., 1991; de Leval et al., 2000; Etchells et al., 2003). In order to implement effective systems across healthcare, and improve safety and reliability, clinicians need various measures of teamwork. Without standardized measures, it is difficult to assess the effectiveness of training programmes and other aspects of the work system. Measures of teamwork are defined internally by their structure and content, in terms
Correspondence: Dr Andrew Healey, Research Associate, The Clinical Safety Research Unit, Imperial College, University of London, Department of Bio-Surgery & Surgical Technology, 10th Floor, QEQM, St Mary’s Hospital, Praed Street, Paddington, London W2 1NY, UK. Tel: þ44 (0)207 8866328. Fax: þ44 (0)207 8861810. E-mail:
[email protected] Website: www.csru.org.uk ISSN 1356-1820 print/ISSN 1469-9567 online Ó 2006 Informa UK Ltd. DOI: 10.1080/13561820600937473
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of a particular process and function. Teamwork might be specified in broad behavioural terms or in highly technical terms, stating who should be doing what, when, where and perhaps how. Teamwork measures will therefore vary in structure and content, depending on the object and purpose of their measurement. Importantly, measures of teamwork should refer externally to a model of team performance, which permits predictions about the factors that cause or affect team performance. This provides a framework to indicate which measures might be needed to improve the system of surgery and to test the validity of teamwork measures. This paper refers to the design and properties of various observational teamwork assessments for operating theatre teams, in the light of a model of team performance and in the foreground of issues introduced concerning the theory and practice of measuring teamwork. A team performance model We may define team performance simply as how effectively the team fulfils the function/s it serves. A model of team performance accounts for and describes the determinants of team performance. The basic model of team performance often adopted for work systems follows the principles of an input-process-output system (Annett, 2000; Gladstein, 1984). For instance, the model applied to surgery (see Figure 1) states that surgery demands interprofessional teamwork. Surgical teams demand certain infrastructure, resources and competencies, collectively termed as team input factors (Healey et al., 2004). Team process amounts to all the interactions between these input factors including, of course, a team’s physical and social interaction. Performance parameters, such as reliability and safety is likely to demand interactions over and above the behaviours which task
Figure 1. A schematic model of team performance in surgery (Healey et al., 2004).
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completion depends on. Such behaviours might include cooperative support in the recovery from error (Sasou & Reason, 1999) or leadership in adaptation across time (Edmondson, 2003). Team output refers to the product of the team; it can also refer to the outcome for the team, perhaps in terms of learning and innovation. A model of teamwork describes team process in detail, perhaps for a particular set of tasks or a process. In contrast, a model of team performance describes the relations between input, process and output. Specifying a formal model of team performance provides a frame of reference when conceptualising and developing measures. It shows how, in theory, certain factors might cause a certain condition or outcome, which in turn indicates which measures might be needed to assess and develop a system of work, such as surgery. To be effective, members from all groups that compose a team must share some understanding about the team’s processes and functions (Klimoski & Mohammed, 1994; Kraiger, & Wenzel, 1997; Rouse et al., 1992). Therefore, measures of shared cognition in surgical teams may indicate how effectively they will perform (Undre et al., 2006). We can also predict from the model that a set of behavioural constructs, such as communication and coordination, are necessary components of teamwork in team process. Therefore, measures of communication and coordination can reflect the levels of teamwork in the process of surgery; they may form a model of teamwork along with other specified behaviours and associated tasks. However, measurement of team performance and of teamwork is neither simple in theory or in practice (Paris et al., 2000).
Team performance measurement Methods and objects of measurement Measures of team performance are important to improve interprofessional teamwork (Dickinson & McIntyre, 1997). These are useful for feedback during training, and for evaluating attempts to improve teamwork or the system. There are several methods of measuring team performance. These include questionnaires, surveys, observation, interview and retrospective analysis of archival data, such as that gained from reporting systems (Tesluk et al., 1997). Some studies employ multiple methods, which is useful when validating one measure against another (Brannick et al., 1993). Measures vary in their design and properties according to the object they measure and their purpose (Paris et al., 2000). The object of assessment in any system might be the individual, a team or sub-team (Paris et al., 2000). In surgery, three main professional groups, namely anaesthetists (A), nurses (N) and surgeons (S) interact in various ways. Their interaction is represented by the Venn diagram in Figure 2. The purpose of measurement might be to assess how team input factors, such as new technology, affect teamwork (Stanton & Ashleigh, 2000). Whatever the object or purpose of measures, they must measure what they purport to measure and ideally account for the technical and behavioural dimensions of teamwork (Annett et al., 2000). Observational measures Observational research is particularly useful for researching complex work systems, such as surgery, particularly for gaining different objective perspectives on the system (Hazelhurst et al., 2004; Nemeth et al., 2004; Roth et al., 2004). Observational studies may be unstructured, such as those that provide a narrative of work processes or vignettes of communication failures. However, structured observations are needed to measure teamwork or any other system property systematically (Carthey, 2003). This, in turn, requires
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some specification of the structure and process of teamwork, partly derived from a formal model and partly from a detailed account of the tasks and processes the team is carrying out. This specification is important for the theoretical development of valid measures but also for their practical design; a measure’s validity, reliability and usability is determined by its structure and content. The observational process Figure 3 shows a systematic measurement process, showing four main components, namely: referral to a model of performance, which forms performance criteria (A), observation of performance (B), notation and scoring (C) and formalization of scores and their derivation (D). Measurement structure permits data to be taken and scores to be allocated (C) to the unit under analysis, according the comparison between observed (B) and expected behaviours and events, which are specified by the performance model or criteria (A). An important issue in the development of measures is to consider the balance between actual observation and performance scoring. Scoring should be as simple as possible, so that notation occurs without disrupting the process of observing the team. One can imagine a task-list so long that it demands more observation than the teamwork assessed. This is a particular issue if, during observation, the scoring itself is time-consuming or it demands complex judgements. Observational assessment of intense teamwork relies, to some extent, on an observer’s short-term memory, though the reliance on memory should be minimized to preserve accuracy. Clearly, certain trade-offs are involved in the design of instruments for
Figure 2. A diagram representing the three main professional groups in the operating theatre and their interaction (Healey et al., 2004). A ¼ anaesthetists, N ¼ nurses & S ¼ surgeons.
Figure 3. A schematic model of the observational measurement process.
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assessing teamwork by observation; limitations in observation and the demands of reliability and validity constrain design. Measurement specificity and system scope Observational teamwork measures vary in their measurement specificity, depending on the object and purpose of assessment. In theory, there is a possible landscape of teamwork measurement for any given work system, which ranges from low technical specificity and broad system scope to high technical specificity and narrow system scope. For example, we might observe an entire surgical team (see Figure 2 where all groups A, N and S overlap ¼ I) over the course of a long operation and make a broad assessment of coordination and communication over several hours. Measures of this kind may be quite broad and low in technical specificity, yet account for a wide system of interprofessional teamwork. At the other end of the spectrum, we might observe a particular individual (A, or N or S) carrying out a defined set of tasks, important for the work of the whole team, but quite circumscribed in nature. Measures of this kind may be highly technical in specification, but fail to account for other members of the team in which the individual plays a part. Neither type of measure is necessarily better than the other measure; each measure demands a different design according to its purpose. The following is a description of an observational teamwork assessment in surgery (OTAS) designed to assess the performance of the entire interprofessional team in the operating theatre at the level of task and of behaviour (Healey et al., 2004).
An example of an observational teamwork assessment in surgery (OTAS)1 Design summary OTAS has two main components: tasks and behaviours. From the clinical perspective, tasks are critical in that checks of anaesthetic equipment and essential communications are essential for safe care; they reflect the elements of the team’s work. However, the elements of performance do not necessarily amount to the sum of team performance, or its synergy. It is quite feasible that some operating theatre teams complete a similar number of routine tasks, but their leadership and communication for maintaining reliability and enhancing safety varies. Structured and highly prescribed measures may be too narrow in their scope to capture some attributes of a team’s performance. Semistructured measures provide a looser structure and a freedom to record ad hoc events and performances. Put simply, measuring tasks alone may not capture all aspects of a team’s performance. OTAS therefore comprises two parallel measures: a task checklist and a set of behavioural dimensions, both of which apply to phases and stages of normal routine surgical process. Structure. We divided the surgical process into meaningful phases (Table I), namely: preoperation (pre-op) intra-operation (intra-op) and post-operation (post-op). Pre-op includes everything up to the point of the actual operation, intra-op from the point of incision to the point of closure, post-op from the point of closure to recovery. Each phase divided into three conceptually distinct stages, separated by critical events, such as ‘‘the patient enters the operating theatre under anaesthesia for transfer to the operating table’’. The critical events also signify the transition from one team state to another. For example, pre-operative preparation is a different state to that of the stage associated with the surgical operation
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(intra-op) proper. There is clear benefit from attempting to integrate such frameworks for potential data integration in future research and training. With a staged process, it is possible to record the length of time from one stage to another, simple yet potentially valuable information. Task-list. There is no explicit model of interprofessional teamwork in surgery. However, there are guidelines for best practice and work protocol, and numerous documents on safety, quality and efficiency regarding surgical care. OTAS, for example, was constructed from a collation of relevant performance criteria identified (Healey et al., 2004). Criteria were allocated as tasks within and between stages to reflect the normal sequence of events in surgery. The criteria for including a task (A) at any given stage is that other tasks (B, C, D, etc.) or objectives in the immediately proceeding stage depend on task-A completion. For instance, the communication between members of the team to acknowledge a readiness to proceed to incision is a crucial point in the surgical process (see Table II). This occurs before the surgeon makes an incision and commits to operate; this work sequence determines its position in the task-list. Eighteen experts, six each from the three disciplinary groups in the operating theatre examined the task-list. They judged whether each individual task should be included or excluded, which guided task-list revision. Refinement of the task-list involved the following rules: Inclusion criteria. Tasks must contribute to the quality of patient care, surgical outcome and/ or enhance the team’s work. Table I. The structure of OTAS stages (Healey et al., 2004). Phase
Stage 1
Stage 2
Stage 3
1 PRE-OP
Pre-op planning and preparation Opening to contact of target organ Anaesthetic reversal to exit
Patient sent for to anaesthesia Op-specific procedure
Patient set-up to op-readiness
2 INTRA-OP 3 POST-OP
Recovery & transfer
From prepare to close to closure complete Feedback; self-assessment
Table II. OTAS communication tasks. Pre-op
Surgeon informs of any co-morbidity Anaesthetist informs team of special patient needs Surgeon briefs team on the surgical procedure Scrub-nurse & circulating nurse confirm instruments check Correct patient is confirmed verbally by team
Intra-op
Surgeon asks team whether they are ready to start Ok to start acknowledged by team members Surgeon provides clear instrument requests to scrub nurse Nurses confirm final counts on swabs and instruments Anaesthetist instructs ODP on reversal of anaesthesia
Post-op
Anaesthetist instructs team to move patient Anaesthetist informs recovery of operation Anaesthetist informs recovery of patient condition Anaesthetist informs recovery of drugs used Recovery staff acknowledge information about patient
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Exclusion criteria. Tasks were excluded if they duplicated another task, if they were irrelevant to the task categories and if they were inherent to a certain procedure. Behavioural measures To measure teamwork by observation it is useful to begin by reducing teamwork behaviour to a set of distinct dimensions, or ‘‘behavioural constructs’’. OTAS includes five behaviours adapted from a general model of teamwork (Dickinson & McIntyre, 1997; there are other models, see, e.g., Militello et al., 1999); these behavioural constructs include: . . . . .
Cooperation: response to instructions and requests and support provided. Communication: effective information exchanged. Monitoring: observation and checking of processes and performance. Coordination: the management and timing of activities and tasks. Shared leadership: direction of team activity and attention provided.
During the observational process (shown in Figure 3), a team is observed and their performance is assessed in respect to the five behaviours. The observer takes notes on effective and ineffective behaviours and assigns the team under observation a score for each of the five behaviours using standard rating scales, at the end of the case (see Table III). There are five scales, with ordinal points: each scale-point relating to a certain level of quality and perhaps quantity of a given teamwork component. Broad summary statements with descriptive elements describe each scale-point. We designed these scales with the following rules. (i) Each behavioural rating scale relates to a single function, namely interprofessional ‘‘team function’’. (ii) The scales should not be too specific to scenario, group or event; they should be equally applicable to all groups in any operative phase. (iii) Together, the five behaviours should discriminate varying levels of interprofessional team performance. (iv) The scales together with data collected should provide some objective indication of why one team is more effective than another team. Reliability between observers using these rating scales, without the systematic use of behavioural markers so far for seperate behaviours is between [r ¼ ] 0.35 (p 5 0.05) and 0.72 (p 5 0.001), with a median of 0.64 (p 5 0.001) each on 51 counts of rated teamwork.
Table III. OTAS communication rating scale. 6 Team communication was highly effective in enhancing teamwork. The team exchanged information proactively and politely. Case specific communication was clearly audible and well articulated. The team made a concerted and consistent effort to maintain open communication in order to fulfil teamwork. 5 High level of enhancement to teamwork through communication. 4 Moderate enhancement to teamwork through communication. 3 Team communication neither enhanced nor hindered teamwork. Case specific communication was acceptable, though members did sometimes seek clarification. The manner and effort of communication was reasonable. 2 Slight detriment to team work through communication. 1 Teamwork compromised through poor communication. 0 Team communication severely hindered teamwork. Case specific communication was unclear and members consistently sought clarification and repeats, or did not ask for clarification. The manner of communication was negative and unacceptable. This team had a problem communicating openly.
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Discussion On defining the object of measurement As Figure 1 suggests, team performance in the operating theatre may be dictated by many input factors, not least, whether or not there are sufficient numbers of staff. Team composition variation and changes mid-operation challenge the validity of the measures described. Indeed, teamwork in the operating theatre is sometimes fragmentary or difficult to define, owing to changes of personnel between cases. To resolve this, the view was taken when assigning scores to separate groups, that the object to be assessed should be the input or provision of teamwork provided by each professional group. This way, performances are not necessarily attributable solely to those individuals observed. This seems a fairer and more accurate reflection of this system of work. A team’s performance might also be affected by factors that are extrinsic to the team, such as distraction or interruption from external staff that assessment should also take into account (Healey et al., 2006). However, if the purpose of assessment is to measure observed performance, ratings will simply derive from what is observed of that performance, irrespective of latent or extraneous performance-shaping factors. The final rationale for scores and their derivation may account for any latent or extraneous factors that may have impeded performance, if their identification is needed for a particular study. The fact remains, however, that without any measures of team performance, it is difficult to begin formally assessing the effects of different team input factors, such as staffing levels and extraneous factors, such as distraction in the operating theatre. On validating measures of teamwork Measures developed to discriminate levels of team performance must be validated against measures of team output, in referral to the model of team performance (see Figure 1). This might include post-operative team self-assessment or convergence with other measures of teamwork. However, the improvement of care is the main aim, so patient outcome measures should be used to assess validity. The absence or presence of adverse events acts as a crude measure of outcome, and offers a basic categorical analysis. For instance, categorical analysis has shown some basic relationship between post-OTAS measures and operative patient outcome, but more substantial evidence of validity is needed. Ideally, measures of team output should also account for the detail of care during surgery as well as surgical outcome per se. A greater specification of the levels of care is needed to validate the various levels of a teamwork measure. The need for multiple measures of teamwork in surgery Because OTAS was designed to have a large scope, its level of technical specificity is limited, in terms of specifying who should be doing what and when in routine operations. There are, of course, instances of non-routine work in surgical teams and uncertainty about less frequent events, particularly those of a critical nature. Changes often occur to daily caselists, problems arise with equipment and procedure and crisis events may occur. Those instances introduce different task-types and different teamwork behaviours. The five behaviours described in OTAS would likely apply in any event, but their specification would be different to routine surgery. There is a variety of tools designed to assess some element of teamwork in surgery. These tools vary in the level of scope on the system to which teamwork applies. They also vary in
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their object/s of assessment and purpose of assessment or study. For instance, OSATS (Objective Structured Assessment of Technical Skills; Martin et al., 1997) is primarily designed to formally assess the technical skills of the surgeon. This assessment is not designed to assess teamwork, but it nonetheless contains teamwork elements, such as ‘‘controlling operation flow’’ and ‘‘effective use of assistants’’. Other measures, such as the Anaesthetist’s Non-technical Skills Assessment (ANTS; Fletcher et al., 2003), explicitly focus on the teamwork and other non-technical skills of an individual. Other observational tools measure certain elements of teamwork between professionals within or between groups. Researchers have, for example, evaluated communication among surgeons (Xiao et al., 2003), and among anaesthetists (Gaba et al., 1998), nurses and surgeons in the operating theatre (Lingard et al., 2004). A number of observational research studies have been carried out in the operating theatre with purposes other than deriving measures from models of teamwork (de Leval et al., 2000; Grote et al., 2004; Lingard et al., 2004). The point again is that researchers and clinicians need different types of teamwork measures for different purposes. Essentially, the criteria to determine the levels of a teamwork measure explicitly designed for assessment is that it must be fully documented and transparent; individuals and teams need to see clearly what they are measured against. Interprofessional teamwork measures should also derive from sound research and testing that involves all relevant professional groups’ perspectives. Conclusions Interprofessional teamwork is increasingly important to the evolving teams in healthcare. Models and measures of interprofessional teamwork are therefore needed to educate trainees from different professions about their own and each others’ roles. Various measures can be developed from a landscape of possible teamwork measurement, with the following issues in mind: (1) (2) (3) (4) (5)
What is the object of analysis? What is the purpose of measurement? What is the expected function of that object? What tasks, behaviours and processes fulfil that function effectively? Does the measure fulfil its purpose reliably; is it valid?
The technical specificity and scope of any measure, represented by its structure and content, will vary according to its purpose and the object of analysis. OTAS was designed to measure levels of interprofessional team performance in the operating theatre. In design terms, its broad scope on the system and reasonable level of technical specificity serves its intended purpose. Its reliability and validity need more rigorous testing. Other measures of teamwork in surgery are also needed with lower levels of scope and higher technical specificity. Indeed, various measures of teamwork are likely needed to enhance safety and reliability in surgery. A team performance model acts as a frame of reference, from which various purposes and objects might be identified for analysis, in order to improve teamwork in a complex work-system.
Note 1. A full description of OTAS use in practice is available in Healey et al. (2004) and a short user manual is freely available at http://www.csru.org.uk.
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