Team effectiveness in the operating room: What makes the clock tick?

Surgical teams perform highly complex procedures while maintaining the patients’ wellbeing and safety. In this potentially stressful environment adverse events occur. Human factors, such as communication errors or leadership issues, can contribute to
the occurrence of such events. It is important to optimize operating room (OR) team functioning to ensure the best patient care.
It is considered important to train members of interprofessional teams, such as OR teams, together, as patient care is inherently interprofessional. Several theories underpin the importance of interprofessional education (IPE), but so far, not one individual theory explains the potential IPE has for improving patient care. How and when interprofessional team training leads to changed team behavior, improved team effectiveness and team performance remains to be elucidated. In this thesis we aim to add to the existing research base, with the goal of optimizing OR team effectiveness.
In the first part of this thesis, we examined hospital-based IPE initiatives. We performed a systematic review to assess the effects of these interventions on students’ learning outcomes, and to investigate which components of the learning environment contribute to positive or negative outcomes (Chapter 2). Our findings show that the included interventions mostly yielded positive effects, which indicates that IPE could have potential in improving performance. However, interventions were generally short and focused mostly on short-term student-related outcomes, such as change in attitude towards interprofessional collaboration or education. Studies varied in design, assessment tools and outcome measures used. The heterogeneity of the studies makes it difficult to determine which characteristics of the learning environment are important for effective IPE.
In the second part we zoomed in on the components of effective teams. In Chapter 3 we examined shared mental models (SMMs) held by OR team members. SMMs are cognitive representations of the team task at hand. They consist of team-related (e.g. patterns of communication, team members’ skills and knowledge) and task-related knowledge (e.g. requirements for the task). We found relevant differences in SMMs between professions. This could lead to frustration among team members, ineffective performance of tasks and erroneous allocation of tasks.
In Chapter 4, we explored the relation of team member familiarity with perceived team effectiveness. We found that higher team member familiarity predicted a higher level of perceived team effectiveness. This relationship was mediated by perceived SMMs, but surprisingly, not by mutual trust.
In the final part of this thesis, we describe an in situ simulation-based interprofessional team training for complete OR teams. In Chapter 5 we focused on the effect of such a training program on non-technical skills in daily practice. Evaluation took place over the course of four years and consisted of assessing non-technical skills via systematic observations and interviews. No significant differences were found for the entire OR team, although an increase in scores for the anesthesia and nursing sub-team was seen. Qualitative analysis of interviews with surgical team members demonstrated the importance of non-technical skills and the contribution of the interprofessional training program to the development of these skills. This affirms the usefulness of interprofessional team training, but more studies are necessary to determine the optimal duration, frequency and design of team training.
In Chapter 6, we described the costs of the team training program. In the current age of limited time and resources, it is prudent to consider the costs of educational programs. The majority of costs of our program concerned missed revenues, as the teams that participated in the training could not perform their ‘normal’ work. Interprofessional team training programs have the potential to influence team work positively, but the required investments warrant further investigation of the most effective design.