How Teamwork Affects Safety

Chapter 1: Introduction

The safety of the patients is an integral factor in all healthcare set-ups. In this context, patient safety is an essential component that determines the quality of healthcare (Allen‐Duck, Robinson, and Stewart, 2017, pp. 377-386). Regardless of the immense application of information technology in the healthcare sector, there have been concerns expressed by nurses and doctors about medical errors. In other words, medical errors have continued to be a significant challenge in healthcare facilities despite the intense application of IT approaches such as web-based incident communications, 2-D barcode identification, as well as computerized medication ordering systems (Tam, Kwai, Suen, Ho, and Tze Fan Lee, 2011). For this reason, the medical practitioners working in healthcare facilities have emphasized on assuring assertion to the public. The doctors and nurses have adopted the philosophy of ‘first, do no harm’ to enhance patient safety in the healthcare facilities (Tam et al., 2011).

There has been a reported increase in researchers reporting the reduction in medical errors linked to human errors (Ahmed, Saada, Jones, and Al-Hamid, 2019). In this context, teamwork plays a pivotal role in enhancing patient safety in healthcare facilities. Teamwork is responsible for improving efficiency in healthcare facilities. Teamwork reduces the length, frequency, and chances of delays (Tam et al., 2011). Furthermore, teamwork improves the job satisfaction and morale of workers, which contributes to improved patients’ satisfaction and reduced stress. Communication is a vital component of a productive teamwork climate. Communication improves the efficiency and safety in the healthcare set-up (Tam et al., 2011).

However, critical medical care breakdown in communication is termed as a crucial source of adverse effects. The discrepancies about effective communication and attitudes towards teamwork in the critical care nurses as well as doctors continue to affect the quality of healthcare (Tam et al., 2011). In this manner, there exist different perceptions of the teamwork climate among the nurses and doctors in intensive care units (ICU). Therefore, the nurses indicate having reduced satisfaction with the collaborations with the nurse-physicians than with the doctors. In such cases, the nurses suggest having lower teamwork climate scores than the doctors (Tam et al., 2011). In other instances, surgical care has been termed as a significant part of healthcare. In the world, approximately 234 million major surgical procedures are carried out per year. However, a considerable risk of medical complications, as well as deaths that can be avoided, are associated with surgical care (Krautz, Nimptsch, Weber, Mansky, and Grützmann, 2018). Furthermore, a systematic review indicated that the majority of the adverse events in the hospitals are linked to the providers of surgical care. In this case, surgical safety is a major concern in the improvement of the quality of health care services (Prati and Pietrantoni, 2014, pp.669-677).

Human failures have also been observed in the operation theatre. For instance, the breakdown of the teamwork, communication, leadership, as well as poor decision-making strategies, contribute to adverse events. Investigations of the attitudes of the nurses and the doctors-impacting the behaviours outlined above indicate a significant relationship between the breakdown of teamwork and the occurrence of adverse events (Kostov, Rees, Gormley, and Monrouxe, 2018). Therefore, the most effective tool for measuring the attitudes towards teamwork is the questionnaire to the surgical staffs (Prati and Pietrantoni, 2014, pp.669-677).

Some of the most effective survey tools applied in the studies include the Cockpit and Flight Management Attitudes Questionnaires (CMAQ, FMAQ); which is adopted from measuring the safety attitudes within the aviation industry. Such tools have been applied in the development of the Operating Room Management Attitudes Questionnaire (ORMAQ) (Zhao, Li, Li, Jia, Zhang, and Zhang, 2017). Therefore, ORMAQ has been intensively applied in the evaluation of the attitudes of the operation room workers towards the behaviours associated with teamwork safety. Again, ORMAQ surveys have also been used in studying the settings within the surgical environments in different countries. In this context, the surgical team members gave indicated positive attitudes towards the development of behaviours linked to effective teamwork and safety (Prati and Pietrantoni, 2014, pp.669-677).

For this reason, there has been reported differences between the surgeons and the nurses working in the operating room. For instance, the nurses indicate more positive views concerning the pre-session briefing as well as the post-session debriefing than the consultant surgeons. On the other hand, the surgeons express more positive attitudes towards the quality of communication and surgical leadership than the operating room nurses (Stone, Aveling, Frean, Shields, Wright, Gino, Sundt, and Singer, 2017). The rating of the quality of teamwork experience with the other surgeons as well as nurses among the surgeons is equally high. However, according to the nurses, the quality of teamwork experience with relation to surgeons is rated lower than with the other nurses. In a nutshell, the perception of the quality of teamwork experience, surgical leadership, and communication in the operating room differs between the nurses and the surgeons (Prati and Pietrantoni, 2014, pp.669-677).

Since the determination of the workplace attitudes can be done culturally, there has been a continuous determination of the generalization of the observations stated earlier in different countries. Therefore, each country has different results as far as the analysis of the attitudes towards the teamwork climate of the nurses and surgeons in the operating rooms are concerned. The investigations of the attitudes towards safety and teamwork vary from one country to another and are influenced by gender and experience (Prati and Pietrantoni, 2014, pp.669-677).

The safe and reliable care of the patients depends significantly on the complexity of the hospital climates that influence the performance of the healthcare professionals. In this manner, the complexity in the healthcare climates is not linked to the number of professionals but rather the interdependence of the professionals (Gillespie, Gwinner, Chaboyer, and Fairweather, 2013). The healthcare professionals are tasked with the mandate to ‘do no harm’; thus, the quality of public healthcare depends on the safety of the patients. In this manner, the errors in healthcare due to human errors are major contributors to the death tolls in the medical set-ups. Therefore, the collective acknowledgement of individuals about the critical role of teamwork in promoting safety is significant in health care settings. The safety of the patients is regarded as a significant factor without which medical errors contribute to adverse events. The research on the medical errors; their sources and ways of mitigating such errors have been linked to the functions of teamwork. Furthermore, organizational culture and safety culture result from the aggregate behaviour of the individuals as well as groups. In this context, the beliefs, norms, values, attitudes of the individuals and groups impact the commitment of the leadership/management towards the provision of critical safety (Gillespie et al., 2013).

The most significant factor in healthcare is linking teamwork with the provision of safety. In this context, teamwork influences the attitude of the healthcare personnel towards each other as well as the working environment. The teamwork influences the performance of individual members by promoting or decreasing the motivational, collaboration, and coexisting factors. Other influences of teamwork on the working environment include job satisfaction, morale, as well as communication. Furthermore, leadership and staff-staff relationships are affected by teamwork. In this manner, the factors mentioned herein affect the frequency and occurrence of medical errors, such as human errors. Since medical errors are linked to increased occurrence of adverse events in healthcare, the existence of safety issues is influenced by a teamwork environment. As noted earlier, health care professionals are bound by the principle of ‘doing no harm’. For this reason, patient safety becomes a major factor in the provision of quality health care. Furthermore, the quality of public health depends mainly on the provision of efficient patient care. The creation of an enabling teamwork environment in the healthcare entails the provision of patient safety, whereby adherence to efficient communication and teamwork.

Relevance of the Topic area to Nursing Profession

The working environment of the nurses involve caring of the patients and taking the orders from the surgeons and doctors. Since the working environment of the nurses involve the collaboration of the nurses, doctors, and surgeons, teamwork is a vital part of safety and quality in healthcare. The communication and coordination of activities of the nurses in the surgical department influences the safety and relationship between the staffs. In this context, the nursing profession requires a good cooperation between the team members to minimize human errors. Since the human errors results to adverse events in the healthcare, minimizing them translates to improve net of patient safety (Labrague, Hammad, Gloe, McEnroe‐Petitte, Fronda, Obeidat, Leocadio, Cayaban, Mirafuentes, 2018).

Relevance of the Topic to the NMC Code (2018)

The NMC Code (2018) emphasizes on the roles of the registered nurses in promoting the best code of behavior and practice of the midwives as well as the nursing associates. The NMC Code 2018 also emphasizes on ensuring that the registered nurses play a key role in controlling the safety of the mothers and the infants in the maternity set-ups. The maternity set-ups are characterized by team members involving the midwives and registered nurses. Therefore, the cooperation (teamwork) of the nurses, midwives, and nurses influence the safety of the patients by provision of conducive environments that have reduced human errors.

Chapter 2: Literature Review

Influence of attitude teamwork and safety among surgeons and nurses in operating rooms

In the previous research, there has been a piece of evidence that the attitude of surgical group members influences safety as well as teamwork in the operating theatre. Additionally, teamwork attitudes influence personal protection in surgical theatres. In a study aiming at assessing the attitudes concerning the teamwork and safety among the surgeon nurses and operating room nurses in Italy, Operating Room Management Attitudes Questionnaire (ORMAQ) was used. The results indicated significant discrepancies in the attitudes about the teamwork as well as a safety between the surgeons and the nurses working in the operating room. The study results indicated that the surgeons exhibited more positive views on the quality of communication, surgeon leadership, teamwork as well as the organisational climate in than the nurses working in the operating rooms. The nurses in the operating room indicated having more disregard to safety rules and procedures than the surgeons. The study concluded that the results were partially aligned with the previous studies conducted using the Operating Room Management Attitudes Questionnaire (ORMAQ) in other countries. The differences between the study results and previous surveys were influenced by the national culture and the culture of the particular healthcare system. Therefore, the study suggested that the solution to the discrepancies would be found by the application of team interventions as well as human factor training. The study recommended that the attitude surveys offer the method for assessing the safety culture in the surgical environment in order to evaluate the effectiveness of training efficiency, as well as a collection of the data used in quality assurance programs in hospitals (Prati and Pietrantoni, 2014, pp.669-677).

The study herein is vital to the development of the study area by comparing the results of the outcome with the previous studies. The research also provided a tool for assessing the safety culture in the surgical operation rooms with regards to the teamwork environment. The study used the ORMAQ assessment tool; hence, provide the alternatives for gathering the data applicable for the training of the surgical team members. The study was also relevant in the development of literature for future studies in assessing the impact of the organisational culture and national culture in the development of safety rules and procedures in the surgical operating rooms. The research gives an impression that the teamwork environment exhibited by the operating room nurses and the surgeons is differentiated and has a role in the safety situations within the operation theatres (Prati and Pietrantoni, 2014, pp.669-677).

In a critique of the study, one can see that the study aimed mainly at assessing the attitudes about teamwork and safety among the surgeons and the operating room nurses from Italy. In this sense, the author admits that the operating room nurses and the surgeons have significant perceptions about safety and teamwork. Again, the researcher outlines that the perception of the operating room nurses towards safety and teamwork differ from those of the surgeon nurses. In this context, the author tries to link the issue of the teamwork perception among the theatre personnel and the safety concerns in the surgical theatre environment. The significance of this research lies in the study results whereby, discrepancies between the surgeon nurses and the nurses in the operating rooms regarding the teamwork and safety. In this case, safety and teamwork are influenced by the type of staffs and personnel in the surgical theatres. The author uses a simple approach in which the standard research method following the scientific method was used. The language used in the research is easy to understand (Prati and Pietrantoni, 2014, pp.669-677).

The study was conducted in a hospital located at the middle of Italy. In the study, the surgical team was served with the oral as well as written questionnaire distributed by the concerned contact persons. The study used an Italian version of the ORMAQ, which entailed 56 Likert scale statements of attitude attached to eight themes. The eight themes in the ORMAQ format included (Prati and Pietrantoni, 2014, pp.669-677);

• Structure of leadership
• Assertion of confidence
• Sharing of information
• Stress and fatigue
• Teamwork
• Work values
• Error/ compliance with procedures
• Organisational climate

The instrument was translated as well as re-translated and finally presented with the help of a committee that included two surgeons. However, the study disregarded the following items because they were termed as irrelevant to the prevailing study; they were hard to be understood by the two surgeons at hand (Prati and Pietrantoni, 2014, pp.669-677).

• The doctors who supported the perceptions of operating theatre team members are weak in leadership.
• Truly committed professionalism in the theatre means forgetting personal issues.
• Team members are supposed to feel free to share their personal psychological stress or even physical problems with the other operating theatre personnel prior to or during the assignments or shifts (Maile, Harrison, Chikura, Russ, and Conroy, 2016).
• Personal problems can have adverse effects on the performance of theatre personnel.
• The operating theatre personnel love their job.

Furthermore, the study adjusted some of the items in the questionnaire, such as the performance of the operating theatre personnel is not adversely affected by having an inexperienced or less capable team member. The study adopted the notion that the performance of the operating theatre personnel is adversely affected by having an inexperienced or less capable team member. The study approach has an advantage in its simplicity in the format of adjustments of the questionnaire tool. Nevertheless, the simplicity of the study is outlined in the method of response in which the participants were supposed to answer the questionnaire. The study used a five-point scale in which the participants were expected to state their level of agreement to the statements in the questionnaire. The questionnaire allowed the application of anonymity of the respondents; the study required only the biographical information of position, experience, and gender (Prati and Pietrantoni, 2014, pp.669-677).

The data analysis used the SPSS 20.0 software. The generalised linear model was used to compare between surgical team members per each grouping/categorisation using the generalised linear model. During the statistical analysis of the data, the ORMAQ items were used as the dependent variables while the independent and covariate variables were experience, gender, and position (Prati and Pietrantoni, 2014, pp.669-677).

The statistical analysis was appropriate because it took care of the false discovery rate characterised by multiple comparisons by employing the sequential approach. The method herein contributed to greater power as opposed to the application of the usual Bonferroni Technique. Furthermore, the study applied the application of the kurtosis less <5 and the skewness <2; whereby an indication of an insignificant violation of the normal distribution was evidenced (Prati and Pietrantoni, 2014, pp.669-677).

The results of the study indicated that three respondents did not illustrate their positions; such questionnaire results were excluded from the research. Exactly 103 questionnaires were inapplicable; 55 questionnaires from the surgeons that translated to the response rate of 89% were uncollected. Likewise, 48 questionnaires from the operating room nurses translating to 67% were uncollected. In overall, 34% if the respondent surgeons were female while 66% of operating room nurses were women. The mean of the years of experience for the operating room nurses was 10.56 years, while the standard deviation (SD) was 8.68. On the same note, the mean of the years of experience of the surgeons was lower at 15.48 years, and the SD was 11.46. The study illustrated that the differences between the surgeons and the nurses were similar prior, and after controlling the gender and experience (Prati and Pietrantoni, 2014, pp.669-677).

The results on the leadership structure as well as confidence assertion illustrated a slight agreement that the senior staff should encourage queries from the junior staffs during the operations if they deem appropriate. The results indicated slight agreements that the senior people if present, should take over and make all the decisions within the life-threatening emergencies. Therefore, the study indicated that the junior staffs rely on the orders of the superior staffs. Furthermore, the study found out that the operating room personnel agreed with speaking up about problems with the management of patients irrespective of whoever is affected. The results also supported the asking of questions and clarifications among the operating room officers in case of misunderstandings in the procedures. The study results found that there was a slight disagreement of the operating room personnel on the perception that there are no situations when the junior team members should take control of the management of a patient. The results of the study indicated mean values close to the mid-point for the other responses (Prati and Pietrantoni, 2014, pp.669-677).

According to the results, the surgeons were more likely to agree to the following themes unlike the operating room nurses;

-the success of the operating theatre management is mainly influenced by the medical and technical efficiency of the doctor.

-the medical staff is responsible for the leadership in the operating room team.

-in cases of life-threatening emergencies, the senior person if present should take over as well as make all decisions (van der Kluit, Dijkstra, and de Rooij, 2018).

The study indicated that information sharing, stress and fatigue are essential factors in the operating theatre environments. In this context, results suggested that the participants supported the sharing of information/communication concerning the actions and procedures in the theatres are essential. The participants agreed that personal problems need to be left behind while working in the operating theatre environment. There was a slight appreciation of regular briefing and debriefing, as well as information sharing by the team members. The nurses favoured the regular debriefing as well as teamwork behaviours like verbalisation of actions and plans more than the surgeons. The difference between the nurses and surgeons about positive attitudes towards verbalising the actions and plans became statistically significant only after controlling the gender and experience. Again, the attitudes towards briefing the team before the session was differentiated between the nurses and the surgeons. In this manner, the study discovered that the surgeons were less likely to report that they were unaffected by fatigue than the nurses (Prati and Pietrantoni, 2014, pp.669-677).

According to the results of the study, the respondents had an only slight disagreement that the only people with qualifications to give feedback are the people from the same profession with the operating theatre staff. The study also indicated that the participants showed slight disagreement with the perception that it is better to agree with the other members of the operating theatre team rather than voice a different opinion. Despite the existence of a slight agreement that the operating theatre personnel enjoy working in a team, and solving conflicts open discussion of the difference among team members is vital, there results for the perception that all the operating room personnel working as a team didn’t work in the study area obtained closes to mid-point values. More surgeons were likely to buy the above idea than the nurses (Gillespie et al., 2013).

The study results indicated that the surgeons were more likely than the nurses to feel that they were respected by fellow team members or professionals (Prati and Pietrantoni, 2014, pp.669-677). However, after controlling the gender variables, the statistical significance of the observation herein became irrelevant. The controlling the experience parameter, the statistical significance of the view that surgeons perceived being respected by their fellow professionals was evident (Chesney and Devon, 2018). In other words, the more they experienced the operating room nurses and the surgeons were, the more respected they felt as opposed to those with less experience (Prati and Pietrantoni, 2014, pp.669-677).

On the issues of response towards the attitudes to compliance with procedures, errors, as well as organisational climate, the results were close to the midpoint. Therefore, the results for the response towards the statements of the inevitability of human errors and perception of shame after making mistakes in front of the team members were close to the midpoint. There was merely a slight agreement that the surgical room staffs were provided with adequate training to accomplish their tasks successfully.

In the case of the surgeons, they were less likely than the nurse to accept the perception that their team members frequently disregarded the guidelines/rules in the operation theatre. On the other hand, the surgeons, unlike the operating room nurses, were more likely to accept the perception that (Prati and Pietrantoni, 2014, pp.669-677);

-There exists strict adherence to procedures and policies within their operating theatre.

-There was appropriate handling of mistakes in the hospital.

-The department provides timely and adequate information about adverse effects; this affects the work of the operating theatre personnel.

-Working in the study area (hospital) was like belonging to a large family.

-The department leadership listens and cares about the concerns of the staffs.

-The operating theatre personnel were proud of working in the hospital.

After comparing the nurses and the surgeons, the study did not find any statistical significance for the statements such as (Prati and Pietrantoni, 2014, pp.669-677);

-Errors/mistakes in the surgical rooms are signs of incompetence.

-The operating room staffs were ashamed when they commit a mistake in front of the team members.

-There is an inevitability in human error (Helmreich and Sexton, 2017, pp. 117-132).

After controlling the variables of gender and experience, the study found no statistical significance between the surgeons and the nurses as far as the provision of adequate training was concerned. However, the study found a significant difference between the nurses and the surgeons concerning the organisational climate, unlike in the provision of adequate training.

Furthermore, with comparison to the operating room nurses, the surgeons were more likely to endorse the perception that;

-There was the provision of adequate and timely information concerning the events within the hospital, which might affect their performance.

-Working in the hospital was similar to being a part of a large family.

-The leadership of the department listens and cares about the concerns of the team members.

-They were proud to work in the hospital at hand.

Although the study was successful in utilisation of a clear and precise research method that entails the application of the Operating Room Management Attitudes Questionnaire (ORMAQ), there were some weaknesses. Firstly, the study used a small sample on the basis of the study area. The study used only one hospital as a representative of the entire country (Italy). Therefore, the generalisation of the natural culture as an influence of the organisational culture and the attitude of the operating theatre professionals was not well represented. In this manner, the study should have included more hospitals. The inclusion of more hospitals could have reduced the errors in the data that would have resulted from biased responses (Prati and Pietrantoni, 2014, pp.669-677).

The mandate of the study was to measure the attitudes of the Italian surgical team members towards organisational and human factors linked to patient safety hence analysing the differences in the responses between the surgeons and nurses, with controlling on their gender and experiences. The study indicated the existence of the differences between the nurses and the surgeons in the operating theatre environment concerning the eight themes illustrated earlier. The study found out the surgical team had a hierarchical organisational structure such that the senior staffs encouraged the junior staffs to ask them questions. The study also found out that the surgical teams were willing to speak up about a problem that was unclear. Therefore, the study found out that the performance of the surgical theatre personnel was influenced by the teamwork. In this case, the teamwork influenced the relationship between the staffs such as respect, communication, as well as adherence to rules procedures. Furthermore, teamwork influenced the perception of errors, such as the inevitability of human errors and communication of mistakes. Since all the above-mentioned factors have an impact on the performance of the staffs, it also affects the safety of the parents. The safety of the patients is impacted in the sense that teamwork affects the provision of adequate training, communication of adverse events as well as a chain of command in decision-making (Prati and Pietrantoni, 2014, pp.669-677).

Safety and Teamwork Climate of Intensive Care

In a study conducted by Tam et al., (2011), the safety teamwork climate within the intensive care units was investigated. The author selected an appropriate topic since safety is a vital factor that influences the quality of healthcare. Furthermore, the intensive care unit is a delicate working environment whose safety and teamwork plays a major role in influencing the quality of the outcomes.

The results of the study were summarized by the following points (Tam et al., 2011);

-A good teamwork environment comprises of effective communication as a vital component.

-The perception of the doctors about safety and teamwork is more positive than that of the nurses in their working areas.

-The hospitals ought to endorse the no-blame culture; staffs would act openly to discuss patient safety in cases of occurrences of errors.

-There should be strategies implemented to promote good teamwork so that the quality of the care, as well as enhancement of patient safety, is achieved in intensive care units (ICUs) (Tam et al., 2011).          The study aimed at measuring the perception of the ICU workers concerning teamwork climate and safety (Ryan, Ward, Vaughan, Murray, Zena, O’Connor, Nugent, and Patton, 2019). The purpose of the study was to develop the recommendations for improvement of the teamwork as well as foster patient safety within acute care. The study setting involved seven clusters within the Hong Kong Hospital Authority. Seven hospitals and three adult intensive care units existed within the seven clusters — the questionnaire method adopted from the Safety-Attitude Questionnaire with specifications to the ICU (SAQ-ICU version). The study sample population involved 25 doctors and 184 nurses from the three ICU facilities. The SAQ-ICU was appropriate since it was brief and applicable for administration to a large pool of respondents (over 500 globally). The author was successful in reducing the original SAQ-ICU items from 64 to 10 items that dealt with patient safety and the other ten items that involved the teamwork climate. The study applied the Likert scale for measuring the teamwork and safety factors independently from a scale of between 0 to 100 (Tam et al., 2011).

The statistical data analysis technique used in this study was simple because it determined the frequency of the responses of every item in the survey. The analysis also involved the determination of the mean scores as well as percentage-favourable scores between the doctors and the nurses. The T-test analysis was also performed to compare the scores of the items between the responses of the doctors and the nurse. The study used an appropriate tool, SPSS because it is powerful in dealing with large data. The percentage-favourite score was appropriate in determining the positivity in the responses. The T-test was significant in determining the statistical significance of the difference in the responses between the doctors and the nurses (Tam et al., 2011).

The study results involved a total of 209 questionnaires sent to all the respondents. The number of the returned questionnaires was 135, but one was inapplicable due to missing data. Therefore, the response rate of the study was 64.1%. The average years of experience of all the respondents were 8.02 years. The mean safety scores were 69.08, and team scores were 63.88. The per cent-favourable safety scores were 36.07, and the per cent-favourable scores for teamwork was 15.57. Therefore, both of the scores mentioned herein were below 50%.

Despite the observation that all the ICU staffs believed that the unit was putting efforts to ensure the safety of patients (mean score of 77.43), it also illustrated that respondents faced difficulties in the discussion of errors in the ICUs (mean score of 57.65). The perception of doctors towards the factors was more positive than those of the nurses. Again, the nurses gave higher ratings for patient safety than those of teamwork climate (Tam et al., 2011).

The study was successful in measuring the perception of the doctors and nurses towards the teamwork climate and safety in the intensive care unit. In this manner, the study outlined that the doctors indicated higher rates of safety and teamwork factors than the nurses. The study was consistent with other research conducted in the overseas. Therefore, the repeatability of the study was confirmed by the application of a precise methodology. The nurses had lower perceptions of safety and teamwork than the doctors in the ICU set-ups. In this manner, the study has a clear indication of the differences between the doctors and the nurses in the ICUs concerning the safety and the teamwork. The author suggested that the perception of the doctors and nurses in the ICU concerning patient safety and teamwork climate influences the quality of healthcare (Tam et al., 2011).

Despite having a clear research methodology, the sampling criteria of the study was not clearly explained. Again, another weakness of the study was the application of a small sample of healthcare facilities (only 3 ICUs). Therefore, the accuracy and reliability of the study results as a representation of the entire country or ICU staff’s fraternity could be jeopardized by biasedness.

Team Communication and creation of safety culture in surgery

In a study conducted by Gillespie et al. (2013), team communication in the surgery was studied with emphasis on the creation of a safety culture. The selection of the study topic was relevant since the department of surgery a crucial working environment characterized by risky conditions. The outcomes of blunders are high, regardless of the generally low paces of events in the surgery rooms. The performance of team surgery is progressively being viewed as essential for a culture of safety. The point of this investigation was to depict the group correspondence and the manners in which it encouraged or compromised safety culture in surgery. Ethnography was utilized and included a 6-month hands-on work time of perception and 19 meetings with 24 participants from nursing, anaesthesia and surgery. Data were gathered during 2009 in the working rooms of a tertiary consideration office in Queensland, Australia. Through investigation of the textual data, three subjects that exemplified teamwork culture in surgery were produced: “constructing shared understandings through open correspondence”; “overseeing contextual stressors in a various levelled condition” and “irregular enrollment impacts group execution”. In making a safety culture in a human services association, a group’s ideal execution depends on the open dialogue of teamwork and group desire and fundamentally relies upon how the hierarchical culture advances such exchanges (Gillespie et al., 2013).

The relevance of the study area was based on the background information involving the complexity of the hospital environments on the healthcare providers. In this manner, the changes in the hospital environments bring about challenges in the safety and reliability of care to the patient. However, the complexity in the healthcare set-ups is insignificantly linked to the number of caregivers. In this context, the responsibility of the caregivers is to ‘do no harm’. Nevertheless, the previous two decades have indicated substantial harm to public due to inadequate care to the patients. Therefore, the author selected the topic diligently to acknowledge the notion of ‘To Err is Human’ proposed by the Institute of Medicine (IOM); thus, healthcare is not foolproof to errors. In this context, the authors base their argument on the basic principle that surgical environments are susceptible to errors that contribute to safety impacts on the patients. Furthermore, the authors also implied that communication within the medical surgery personnel has an impact on the development of organizational safety culture (Gillespie et al., 2013).

The study used a sample of 250 health professionals who worked under ten different categories within the surgical medicine specializations. The participants involved the specialized personnel in the surgical, anaesthetic, consultation, registration, registered nurses and resident nurses in the fields. The interview tool was used in the collection of the data. The Interview used the open-ended questions in which the participants were expected to describe their perceptions regarding specific items of the questions. For instance, the respondents were required to describe their understanding of effective team surgery. Each participant was interviewed independently, and ethical considerations involved compliance with the requirement of ethical committees for approval of human research. The data analysis involved the employment of the investigator triangulation, whereby all members of the interdisciplinary research contributed to the development of a reasonable interpretation. The descriptive statistics were used rather than statistical description/ analysis. The thematic for the conceptual data analysis involved the creation of major and sub-themes (Gillespie et al., 2013).

The study found out that the texts obtained from the interviews, journal entries, and field notes resulted in three major themes of (Gillespie et al., 2013);

• Building shared understanding via the open conversation/communication
• There was a hierarchical culture in the management of contextual stressors.
• The performance of the team was influenced by intermittent membership.

Although the major themes and the sub-themes were separated, they were interconnected. In this context, the theme of the significance of team members was attributed to the building of a culture that appreciates the activities of each other team members. Furthermore, the existence of team members assisted in the development of common views/perceptions as well as behaviours that could be identified in the communication behaviours. The relationship between team members before the procedures were characterized by communication behaviour and was also witnessed during the tasks. The development of communication cultures such as greetings to the patient or among the surgical personnel contributed to the dialogue that assisted in confirmation of actions and creation of a rapport between individuals who have never worked together before (Gillespie et al., 2013).

The continuation of the mutual relationship between the surgical team members contributes to the motivation as well as agreement in the procedures (Aveling, Zegeye, and Silverman, 2016). In other words, communication between the surgical team members assists in building harmony in decision-making strategies and thus improve the quality of healthcare (Gillespie et al., 2013).

Although the study was effective in the application of the descriptive statistics by application of the interview method, the study missed a great deal of statistical data. In this manner, the study relied significantly on the personal imaginations/perceptions of the interviewees that might have been jeopardized by biasedness. The application of the open-ended questionnaire gave room for the misinterpretation of the actual meaning of the respondents’ perception due to errors in transcription and comprehension (Gillespie et al., 2013).

Nevertheless, the study was successful in determining the high interdependence of the surgical team members. The authors also assisted in illustrating the necessity of building a safety culture in the medical surgery such that medical errors, stressors, and miscommunications are minimized (Levett, Mellott, Smith, Fasone, Labovitz, Labovitz, and Dotan, 2017). Consequently, the study proposed the significance of optical performance of surgical teams as the integration of efficient communication and the development of teamwork. The study concludes that the organizational culture is relevant in the promotion of communication and discussions between the senior and medical staffs. For this reason, the sharing of information, as well as picking orders and instructions, are characterized by reinforcement of relationships and behaviour between the various categories of medical surgery staffs. In a nutshell, communication in the medical surgery environment is a vital tool that promotes the development of appropriate cultures and behaviours that enhance patient safety. Finally, the existence of a safety culture fosters the quality of care in the medical surgery by bringing about ethical behaviours, coordination, respect, as well as reduction of medical errors.

Improving Preoperative Patient Safety

In a study conducted by Laflamme, (2017, pg. pp.13-57), the author concluded that the core factors of professional preoperative nursing include teamwork, patient advocacy as well as high safe care. The study was based on the background that there exist high prevalence preventable adverse events regardless of the increased efforts to offer high quality and safety in the preoperative nursing profession. For this reason, there is a necessity to improve patient safety in the preoperative nursing environment (Hsu, Kosinski, Wallace, Saha-Chaudhuri, Chang, Speck, Rosen, Gurses, Xie, Huang, and Cameron, 2018).

The author used a systematic literature review that used medical databases like MEDLINE/PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). The researcher used search terms such as ‘Team Training, Operating Room, Preoperative, Preoperative Surgery, as well as Preoperative Safety’. The process was conducted repeatedly on each of the databases such that additional terms were included such as ‘interprofessional, collaboration, human factors, evidence, and team skills’ were included (Laflamme, 2017, pg. pp.13-57).

The inclusion criteria of the articles included those that were peer-reviewed and published in English between 2006 and 2016. The study selected journals concerning multidisciplinary preoperative team training. The repeated articles were omitted, and a final total of 510 articles was obtained with an addition of 6 articles from the reference list (Laflamme, 2017, pg. pp.13-57).

The study results outlined that 37 articles fulfilled the established criteria and were investigated to determine the topic area with the measurement of the correlation between preoperative team training and the safety of the patients. The 37 articles included six literature reviews as well as seven explanatory papers, and all supported the teamwork within the preoperative nursing environment. Three studies also measured the compliance with the safe surgery checklist (SSCL) and associated with the patient outcomes, one of them was linked to the behaviour of the team but didn’t specify the intervention (Laflamme, 2017, pg. pp.13-57).

Although the study provided statistically significant data, it relied significantly on the secondary data of the peer-reviewed journals from medical science databases (McComb, Lemaster, Henneman, and Hinchey, 2017). In this manner, the study was susceptible to inaccuracy in the data due to biases in the selection of the articles. Alternatively, the study would apply the primary data by conducting interviews or administering questionnaires to the healthcare professionals involved in preoperative nursing environments (Chan and Esmailian, 2018).

All in all, the study was successful in indicating the link between the application of team preoperative training interventions and patient safety. In this manner, the study concluded that a substantial number/ majority of the articles indicated that the existence of an appropriate preoperative nursing team training initiatives contributes to high standards of patients’ care. Therefore, perioperative team training initiatives were significantly linked to patient mortality and morbidity (Boet, Etherington, Nicola, Beck, Bragg, Carrigan, Larrigan, Mendonca, Miao, Postonogova, and Walker, 2018).

Role multidisciplinary team and safety in cancer care

The ambulatory care involves support care as well and chemotherapy in the cancer care. The study by Comerford and Shah (2019) was relevant to the study topic because the ambulatory care involves different team members. The cancer care departments involve a collaboration of different medial care professionals whose teamwork influences the success of the ambulatory care and patient safety. The study was successful in investigation of the roles of the nurses in the ambulatory care that involved but not limited to taking care of the cancer patients (Comerford and Shah, 2019).

However, the study used the nurses within London in determination of the roles of the nurses in the ambulatory care (AC) meaning that the sample population was limited to London alone. The expansion of the study area to cover more nurses across the globe would bring about a better picture of the entire population of AC workers. Furthermore, the study found out that the AC environment is served by a multidisciplinary team that enhances the safety of the patients. Apart from the nurses, the AC working environment involves interactions between the counselors and doctors who assist in fostering the safety of the patients (Comerford and Shah, 2019).

Conclusion

As noted by Tam et al. (2011), the safety of the patients is a significant component of the quality of healthcare. In this manner, several interventions have been recommended via studies for the improvement of the safety of the patients within the healthcare set-ups. In this manner, the advancement of technology, such as the inclusion of information technology in the medical field, has been applied in the improvement of patient safety. Other interventions on the improvement of the patient safety following scientific research are teamwork, team member training, communication (team member), as well as the creation of safety culture. In all these aspects, teamwork has been quoted as a pivotal factor that promotes the interdependence between the medical professionals in the operating rooms, surgery rooms, intensive care units, as well as the entire healthcare facilities (Chan and Esmailian, 2018).

Basically, the principle of ‘do no harm’ has been embraced to enhance patient safety in healthcare facilities (Tam et al., 2011). Irrespective of the purpose and size of the healthcare facility, the doctors and nurses are obliged to ensure patient safety is provided. Therefore, interventions such as effective teamwork have yielded mixed reactions between the nurses and the doctors. Furthermore, there exist differentiated views about the teamwork and safety between the surgeons and the nurses working in the operating rooms. For instance, the nurses indicate more positive views concerning the pre-session briefing as well as the post-session debriefing than the consultant surgeons (Prati and Pietrantoni, 2014, pp.669-677). Contrary, the surgeons express more positive attitudes towards the quality of communication and surgical leadership than the operating room nurses. Therefore, nurses and surgeons in the operating rooms have contrasting perceptions about their teamwork and safety (Prati and Pietrantoni, 2014, pp.669-677). While the surgeons have more positive values for teamwork and safety, the nurses in the operation rooms value the debriefing and debriefings before and during the activities. The observation herein illustrates that communication and teamwork are key drivers of the safety of the patients in the operating rooms.

In another perspective, the development of organizational culture and safety culture occurs as a combination of the individual behaviours of the health workers forming a team. Therefore Gillespie et al., (2013) argue that the beliefs, norms, values, attitudes of the individuals and groups impact the commitment of the leadership/management towards the provision of critical safety. In other words, the establishment of an efficient safety culture in a health care unit such as a medical surgery unit depends on the set code of behaviours, values, beliefs of the individuals and hence influence the management’s commitment towards the provision of patient safety.

The assessment of the attitudes of the nurses and surgeons towards teamwork and safety has a significant dependence on the national culture. Although there is interdependence in between the nurses and the surgeons in the operating rooms, there exist discrepancies in their perception about safety and teamwork. Therefore, the gender and experience variations contribute to a different perception of the safety and teamwork between the surgeons and the nurses. In this context, the operating room nurse has higher regards for communication (briefing and debriefing) as opposed to the surgeons. On the other hand, the surgeons have more regards for surgical leadership, safety and teamwork, unlike the operating room nurses.

In conclusion, it is recommended that the healthcare facilities and the entire healthcare profession need to embark on strategies that enhance the safety of the patients. The nurses, doctors, surgeons, as well as other personnel working in the critical care environment, need to embrace the efficient teamwork. The efficient teamwork creates an environment that supports the mutual relationship between the patients, and the caregiver as well as between the health care professionals. It should be noted that good teamwork increases collaboration, friendship, openness, and motivation among healthcare givers. Consequently, the negative factors such as fatigue, stress, and demotivation are reduced by efficient teamwork environment. Furthermore, efficient teamwork climate promotes communication and adherence to procedures and rules. For this reason, the medical errors that are linked to human errors are significantly reduced when the correct procedures are followed, and effective communication exists. Effective communication enhances the dialogue in asking for more information and guidance during medical operations; this would promote patient safety. In a nutshell, all medical staffs are expected to be guided by the principle of ‘first do no harm’. In this context, the medical staffs need to work diligently to ensure that the need, safety, and priorities of the patient are kept ahead of personal problems/priorities.

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