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.