Captain of the Ship: Leadership and Safety in

the Operating TheatrePatient Safety Meeting, 5-7 June 2009

Sarah Henrickson Parker, MASupervisors: S Yule, R Flin, A McKinleySupported 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 ReviewStage 1

Electronic Search

Online sources PubMed Medline, OvidMedline, SCOPUS, and Science Direct

Keywords leadership 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

Limitations

Published

Stage 2- Screening of Results

Selection of keywords

Leadership behaviours, operating room, operating theatre, surgeon, leadership training, leadership, surgery, safety, leader

Limitations Published

Results 13,119

Stage 3- Screening of Titles and Abstracts

Filter Title examined for relevance to surgeons, leadership, and operating theatre

Filter Abstract studied to assess relevance of paper

Filter Hand search of appropriate references

Results 71 papers, duplicates removed

Stage 4- Inclusion Criteria

1 addressing leadership skills of the surgeon

2 were based in the intra-operative environment

3 were empirical in nature, reporting data from either a survey, observations or self-report

4 were published peer reviewed journals

5 were published in English.

Results 10 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

Paper Leadership 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