Discussion
This study shows that surgical team members confirmed that perioperative
briefing and debriefing have a significant influence on the
participative safety of team climate 5 years after implementation.
Surgical team members agreed that briefing and debriefing should be
maintained. Briefing clarifies agreements of the day and ensures that
team members remind each other of agreements. Furthermore, the
instrument enables them to work as a team. The long-term evaluation of
surgical safety tools has been shown to be meaningful: a number of
barriers and facilitators were mentioned and can be used to improve the
surgical safety tools.
Perioperative briefing and debriefing have less influence on efficiency.
Surgical team members reported that this intervention had less influence
on work to rectify agreements, starting on time and work pleasure. The
team members explicitly mentioned that incomplete teams at both the
start and end of the day prevented both briefing and debriefing from
being efficient. This is also in accordance with the lower scores of
(strong) agreement for the item ‘start on time’ in the evaluation
questionnaire.
The team members expressed a more negative attitude towards debriefing
compared to briefing, mainly due to suboptimal performance. This can be
attributed to the fact that team members do not see the added value of
debriefing due to the fact that the proposed improvement actions are
barely implemented and their experienced lack of safety for giving
(constructive) feedback. This result is somewhat surprising given the
fact that the TCI scores for participative safety increased
significantly in 2019 compared to baseline (p < 0.05). This
significant increase in participative safety means that team members
feel safe sharing information in their team. It seems that team members
only feel safe sharing technical information rather than personal
issues. Another explanation could be that there is less culture of
learning from the aspects that did not work very well that day. The lack
of a learning culture for improving patient safety in the OR could also
explain the result that overall team climate scores did not increase
significantly 5 years after implementation. Alternatively, the surgical
team members do not sufficiently recognise what perioperative briefing
and debriefing have delivered and this has now become the new reality.
A number of the barriers of briefing and debriefing identified in this
study were in accordance with Fruhen et al. ,17for example, incomplete staffing, negative attitudes towards debriefing
and having different surgeons throughout the day. However, the same
study also mentioned that a lack of knowledge about briefings hindered
performance.17 We did not find such a barrier, which
shows that perioperative briefing and debriefing are well-integrated in
our hospital. A prominent barrier to debriefing we identified was the
lack of safe culture for giving feedback. The interviewees mentioned
that they did not feel comfortable giving (constructive) feedback in the
group. This is also in accordance with Nathwani et
al .,31 who reported that surgical staff members
highly valued postoperative feedback but also mentioned barriers to
giving postoperative feedback such as lack of time and discomfort with
giving feedback.31 These barriers were also mentioned
by our interviewees.
A strength of this study is that we measured the effect of perioperative
briefing and debriefing 5 years after implementation, and showed that
even well-integrated patient safety intervention can be further
improved. Furthermore, we used a mixed-method approach, which included a
validated questionnaire to study team climate (the
TCI),20 21 23 a short evaluation questionnaire
survey16 and in-depth interviews to gain insight into
experiences with perioperative (de)briefing. A mixed-method approach is
particularly appropriate for evaluating patient safety
interventions.32 Combining the evaluation
questionnaire and individual interviews enhanced the reliability of the
findings. The in-depth interviews contributed to the knowledge on
resistance towards perioperative (de)briefing and how this can be
improved.28 29 33 34 The TCI is able to identify the
effects of interventions over time and has discrimination
capacity.20 Another strength of our study is the
purposive sampling of interviewees in terms of job function and years of
experience for maximising diversity.
Several limitations have to be taken into account. First, we included
eight teams in 2019 versus five in both 2014 and 2016. The differences
in the number of teams could have influenced the TCI scores. However, we
included the additional teams reflecting all surgical specialties
because perioperative briefing and debriefing were integrated in all
surgical teams. Furthermore, we believe that the experiences of the
added teams are valuable for the understanding the performance of
perioperative briefing and debriefing. Another limitation is that we did
not measure patient safety outcomes, e.g. adverse events. The relation
between perioperative briefing and debriefing and patients safety
remains uncertain, and was beyond the scope of the present study. We
also did not include an outcome measure for efficiency, e.g. difference
between planned and realised operative time. The response rate of the
TCI in 2019 was just 25%. This appears to be a low response rate;
however, low response rates among healthcare professionals are not
uncommon.16 35 36 It remains unclear whether
non-responders have a highly different attitude towards team climate.
Another point of uncertainty is the fact that the interviewees were
mostly positive towards perioperative briefing and debriefing. This
might have resulted in selection bias, as surgical staff members with
negative attitudes towards this patient safety intervention might have
been unwilling to cooperate in the interview evaluation. A
methodological point of concern is the fact that we did not take into
account possible unknown confounders, e.g. different roles within the
team and intermediate factors that could also have had an influence on
the association between perioperative briefing and debriefing and
perceived participative safety of surgical teams. For example, it might
be assumed that a well-integrated briefing and debriefing structure
increases expectation management, which in turn influences team climate
positively. After all, expectation management enables team members to
anticipate crucial moments during surgery. This could have influenced
the TCI scores but was beyond the scope of this study. Not all team
members work in dedicated teams only, which renders the TCI a less
applicable questionnaire. This might have influenced the
representativeness of the results. Finally, we assume that,
perioperative briefing and debriefing has more benefits on working as a
team in a tertiary care university hospital compared to a non-university
hospital or an ambulatory surgery centre. In a tertiary care university
hospital more high-complex and low-frequent procedures are delivered
which requires more team coordination and cooperation. Besides, in a
tertiary care university hospital, the team composition continuously
changes, whereas in a non-university hospital or an ambulatory surgery
centre surgical teams work together in more fixed teams.