Captain of the Ship: Leadership and Safety in the Operating Theatre Patient Safety Meeting, 5-7 June 2009 Sarah Henrickson Parker, MA Supervisors: S Yule, R Flin, A McKinley Supported by the Scottish Funding Council,

Leadership Theories Transformational / Transactional / Laissez-faire Leader Member Exchange (LMX) Three Factor Model Front line leadership Do these models translate to the Operating Theatre?

Surgeons = Front Line leaders –Front line leaders are those leaders that function within the team, ensuring optimal team and task performance. Leadership Research in Other Industries

Surgeons = Front Line leaders –Front line leaders are those leaders that function within the team, ensuring optimal team and task performance. –Safety Behaviours Emphasize, reward and encourage safe performance, both through their actions and through their discussions (Tomas, Melia, & Oliver, 1999, Zohar, 2000). Creating a relationship between leader and subordinates (Simard & Marchland, 1997). Cooperating and involving staff in safety issues (Simard & Marchland, 1997). Encouraging speaking up behaviour (Edmonson, 1996) –Results in Safer Performance: decreased accidents, increased safety compliance, increase in safety behaviour Leadership Research in Other Industries

Surgeons = Front Line leaders –Front line leaders are those leaders that function within the team, ensuring optimal team and task performance. –Safety Behaviours Emphasize, reward and encourage safe performance, both through their actions and through their discussions (Tomas, Melia, & Oliver, 1999, Zohar, 2000). Creating a relationship between leader and subordinates (Simard & Marchland, 1997). Cooperating and involving staff in safety issues (Simard & Marchland, 1997). Encouraging speaking up behaviour (Edmonson, 1996) –Results in Safer Performance: decreased accidents, increased safety compliance, increase in safety behaviour The style and behaviour of front-line leaders is a critical factor in determining safety outcomes in high risk, high demand industries (Simard & Marchand, 1997; Zohar, 2002; Bass, Avolio, Jung, & Berson 2003; Barling, Loughlin, & Kelloway, 2002) Leadership Research in Other Industries

Surgeon Skills Technical skill set –Excellent eye–hand coordination –Extensive medical knowledge –Expertise in Anatomy

Surgeon Skills Technical skill set –Excellent eye–hand coordination –Extensive medical knowledge –Expertise in Anatomy Non-technical skill set –Situation awareness –Decision making –Communication and teamwork –Leadership

Research Question Do certain leadership behaviours/styles impact team performance and/or patient outcomes in the operating theatre?

Literature Review Stage 1 Electronic Search Online sources PubMed Medline, OvidMedline, SCOPUS, and Science Direct Keywordsleadership in health care, leadership, error, human error, operating room, surgeon, operating theatre, safety, surgery, leadership behaviours, operating room, clinical leadership, surgeon leadership, leadership training, health care, physician leadership, surgeon, leadership training, clinical leadership, operating room, teamwork/team communication LimitationsPublished Stage 2- Screening of Results Selection of keywords Leadership behaviours, operating room, operating theatre, surgeon, leadership training, leadership, surgery, safety, leader LimitationsPublished Results13,119 Stage 3- Screening of Titles and Abstracts FilterTitle examined for relevance to surgeons, leadership, and operating theatre FilterAbstract studied to assess relevance of paper FilterHand search of appropriate references Results71 papers, duplicates removed Stage 4- Inclusion Criteria 1addressing leadership skills of the surgeon 2were based in the intra-operative environment 3were empirical in nature, reporting data from either a survey, observations or self-report 4were published peer reviewed journals 5were published in English. Results10 papers

Literature Review- Results 10 Empirical Studies One study examined surgeon leadership from a leadership theory/ IO Psychology standpoint Horwitz, I, Horwitz, S, Daram, P, et al. (2008) One study examined the impact of surgeon leadership on outcomes Catchpole, K, Mishra, A, Handa, A, et al. (2008) No studies examined impact of leadership behaviours to improve safety. Leadership is measured in many different ways –Lack of precision in definitions of leadership behaviours

Henrickson Parker et al, in preparation PaperLeadership behaviours examined Catchpole, K, et al. (2008) Involves, reflects on suggestions, coaches, inspires, motivates, maintenance of standards, planning and workload management, authority and assertiveness Edmonson, AC (2003)Coordinate action when members might not know what to do, seeing the whole picture and understanding how different sources of expertise fit together, create shared meaning about the situations they face, address barriers, coach, provide clarification and feedback, seek input, be accessible and receptive to ideas and questions Flin, R, et al. (2006)Leadership decision making examined: (a) leader makes decisions and communicates them firmly, expects loyalty and obedience; (b) leader makes decisions promptly, but explains them fully, provides reasons and answers questions; (c) leader normally consults with subordinates when important decisions are to be made, listens to advice, considers it and then makes a decision; (d) leader puts problem before the group and invites discussion before accepting majority viewpoint as decision Healey, A, et al. (2004) Provision of direction, assertiveness and support among team members Horwitz, I, et al. (2008) Style of leadership examined in self report: transformational/ transactional/ laissez-faire Makary, M, et al. (2006) Overall teamwork assessed, leadership as a subscale of the SAQ, leadership specific results not discussed Sevdalis, N, et al. (2008) and Undre, S, et al. (2007) Adherence to best practice, time management, resource utilization, authority and assertiveness Yule, S, et al. (2006) and (2008) Leading the team and providing direction, demonstrating high standards of clinical practice and care, and being considerate about the needs of individual team members. Setting and maintaining standards, supporting others, coping with pressure

Literature Review- Conclusions No empirical study on leadership styles and behaviours of the surgeon that can impact patients and teams. Limited theory driven research –Anecdotally, intraoperative surgeon leadership is imperative –Where is the evidence?

Study 1 What surgeon leadership behaviours/styles present in the operating theatre? Aim: To produce a detailed description of leadership behaviours/styles Participants: –Surgeons –Higher level surgical trainees –Nurses (circulating and scrubbing) –Anaesthetists –Various specialties: general, orthopaedic, paediatric, cardiac –Aberdeen Royal Infirmary, Edinburgh Royal Infirmary, and Raigmore Hospital.

Observations (n=20) Method: Henrickson Parker et al 2009 Grounded Theory Categorization of Results Focus Groups (n=8 across all hospitals) Analysis of Multi-voting and Focus Group results Development of theoretical framework for future studies Methods for Study 1

Next Steps Determine impact of behaviours articulated by focus groups Determine team performance outcome measures Determine patient safety outcome measures

Thank you