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Göras, C. (2019). Open the door to complexity: Safety climate and work processes in the operating room. (Doctoral dissertation). Örebro: Örebro University
Open this publication in new window or tab >>Open the door to complexity: Safety climate and work processes in the operating room
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

A complex adaptive system such as the operating room (OR), consists of different safety cultures, sub-cultures and ways of working. When measuring, a strong safety climate has been associated with lower rates of surgical complications. Teamwork is an important factor of safety climate. Discrepancies among professionals’ perceptions of teamwork climate exists. Hence it seems crucial to explore if diversity exists in the perception of factors related to safety climate and between managers and front-line staff in the OR. Complex work processes including multitasking and interruptions are other challenges with potential effect on patient safety. However, multitasking and interruptions may have positive impact on patient safety, but are not well understood in clinical work. Despite challenges a lot of things go well in the OR. Thus, the overall aim of this thesis was to evaluate an instrument for assessing safety climate, to describe and compare perceptions of safety climate, and to explore the complexity of work processes in the OR.

To evaluate the Safety Attitudes Questionnaire-operating room (SAQ-OR) version and elicit estimations of the surgical team a cross-sectional study design was used. How work was done was studied by observations using the Work Observation Method by Activity Timing and by group interviews with OR professionals.

The results show that the SAQ-OR is a relatively acceptable instrument to assess perceptions of safety climate within Swedish ORs. OR professionals´ perceptions of safety climate showed variations and some weak areas which cohered fairly well with managers' estimations. Work in the OR was found to be complex and consisting of multiple tasks where communication was most frequent. Multitasking and interruptions, mostly followed by communication, were common. This reflects interactions and adaptations common for a complex adaptive system. Managing complexity and creating safe care in the OR was described as a process of planning and preparing for the expected and preparedness to be able to adapt to the unexpected.

Place, publisher, year, edition, pages
Örebro: Örebro University, 2019. p. 100
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 193
Keywords
Patient safety, operating room, complexity, safety climate, psychometrics, cross-sectional, observations and qualitative
National Category
Other Health Sciences
Identifiers
urn:nbn:se:oru:diva-73093 (URN)978-91-7529-285-4 (ISBN)
Public defence
2019-05-24, Föreläsningssalen Falu Lasarett, Lasarettsvägen 10, Falun, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2019-03-11 Created: 2019-03-11 Last updated: 2019-05-06Bibliographically approved
Göras, C., Olin, K., Unbeck, M., Pukk-Härenstam, K., Ehrenberg, A., Tessma, M. K., . . . Ekstedt, M. (2019). Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study. BMJ Open, 9(5), Article ID e026410.
Open this publication in new window or tab >>Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study
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2019 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, no 5, article id e026410Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: The work context of the operating room (OR) is considered complex and dynamic with high cognitive demands. A multidimensional view of the complete preoperative and intraoperative work process of the surgical team in the OR has been sparsely described. The aim of this study was to describe the type and frequency of tasks, multitasking, interruptions and their causes during surgical procedures from a multidimensional perspective on the surgical team in the OR.

DESIGN: Prospective observational study using the Work Observation Method By Activity Timing tool.

SETTING: An OR department at a county hospital in Sweden.

PARTICIPANTS: OR nurses (ORNs) (n=10), registered nurse anaesthetists (RNAs) (n=8) and surgeons (n=9).

RESULTS: The type, frequency and time spent on specific tasks, multitasking and interruptions were measured. From a multidimensional view, the surgical team performed 64 tasks per hour. Communication represented almost half (45.7%) of all observed tasks. Concerning task time, direct care dominated the surgeons' and ORNs' intraoperative time, while in RNAs' work, it was intra-indirect care. In total, 48.2% of time was spent in multitasking and was most often observed in ORNs' and surgeons' work during communication. Interruptions occurred 3.0 per hour, and the largest proportion, 26.7%, was related to equipment. Interruptions were most commonly followed by professional communication.

CONCLUSIONS: The surgical team constantly dealt with multitasking and interruptions, both with potential impact on workflow and patient safety. Interruptions were commonly followed by professional communication, which may reflect the interactions and constant adaptations in a complex adaptive system. Future research should focus on understanding the complexity within the system, on the design of different work processes and on how teams meet the challenges of a complex adaptive system.

TRIAL REGISTRATION NUMBER: 2016/264.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2019
Keywords
Complexity, interruptions, multitasking, operating room, patient safety
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:oru:diva-74314 (URN)10.1136/bmjopen-2018-026410 (DOI)000471192800188 ()31097486 (PubMedID)2-s2.0-85065927356 (Scopus ID)
Note

Funding Agencies:

Center for Clinical Research Dalarna  

Finnish state funding for university-level health research 

Available from: 2019-05-20 Created: 2019-05-20 Last updated: 2019-11-14Bibliographically approved
Nilsson, U., Göras, C., Yang Wallentin, F., Ehrenberg, A. & Unbeck, M. (2018). The Swedish Safety Attitudes Questionnaire - Operating Room Version: Psychometric Properties in the Surgical Team. Journal of Perianesthesia Nursing, 33(6), 935-945
Open this publication in new window or tab >>The Swedish Safety Attitudes Questionnaire - Operating Room Version: Psychometric Properties in the Surgical Team
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2018 (English)In: Journal of Perianesthesia Nursing, ISSN 1089-9472, E-ISSN 1532-8473, Vol. 33, no 6, p. 935-945Article in journal (Refereed) Published
Abstract [en]

Purpose: To validate the Swedish Safety Attitudes Questionnaire–operating room (SAQ-OR) version by re-evaluating its psychometric properties for the surgical team.

Design: Cross-sectional questionnaire study.

Methods: 541 surgical team members including perioperative nurses, physicians, and licensed practical nurses at three Swedish hospitals were included.

Findings: For the total sample, the Cronbach’s a for the six factors ranged from 0.51 to 0.76. Goodness-of-fit analyses indicated that the six-factor model was acceptable and the factor loadings were statistically significant. The test of the hypothesized relationships among the factors showed a correlation from 0.936 to 0.042.

Conclusions: The refined Swedish version of the SAQ-OR is a reasonably reliable and acceptably valid instrument for the measurement of patient safety climate in the surgical team. However, the results related to the different analyses varied among the different professionals and further research, using larger samples, is needed to explore these differences, especially among the physicians.

Place, publisher, year, edition, pages
Maryland Heights, MO, United States: Elsevier, 2018
Keywords
Safety Attitudes Questionnaire, safety climate, operating room, patient safety, psychometrics, surgical team
National Category
Nursing
Research subject
Caring Sciences w. Medical Focus
Identifiers
urn:nbn:se:oru:diva-64024 (URN)10.1016/j.jopan.2017.09.009 (DOI)000450368000017 ()30449442 (PubMedID)2-s2.0-85040001880 (Scopus ID)
Available from: 2018-01-10 Created: 2018-01-10 Last updated: 2019-04-30Bibliographically approved
Göras, C., Maria, U., Nilsson, U. & Ehrenberg, A. (2017). Interprofessional team assessments of the patient safety climate in Swedish operating rooms: a cross-sectional survey. BMJ Open, 7(9), Article ID e015607.
Open this publication in new window or tab >>Interprofessional team assessments of the patient safety climate in Swedish operating rooms: a cross-sectional survey
2017 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 9, article id e015607Article, review/survey (Refereed) Published
Abstract [en]

Background: A positive patient safety climate within teams has been associated with higher safety performance. The aim of this study was to describe and compare attitudes to patient safety among the various professionals in surgical teams in Swedish operating room (OR) departments. A further aim was to study nurse managers in the OR and medical directors’ estimations of their staffs’ attitudes to patient safety.

Methods: A cross-sectional survey with the Safety Attitudes Questionnaire (SAQ) was used to elicit estimations from surgical teams. To evoke estimations from nurse managers and medical directors about staff attitudes to patient safety, a short questionnaire, based on SAQ, was used. Three OR departments at three different hospitals in Sweden participated. All licensed practical nurses (n=124), perioperative nurses (n=233), physicians (n=184) and their respective manager (n=22) were invited to participate.

Results: Mean percentage positive scores for the six SAQ factors and the three professional groups varied, and most factors (safety climate, teamwork climate, stress recognition, working conditions and perceptions of management), except job satisfaction, were below 60%. Significantly lower mean values were found for perioperative nurses compared with physicians for perceptions of management (56.4 vs 61.4, p=0.013) and working conditions (63.7 vs 69.8, p=0.007). Nurse managers and medical directors’ estimations of their staffs’ ratings of the safety climate cohered fairly well.

Conclusions: This study shows variations and some weak areas for patient safety climate in the studied ORs as reported by front-line staff and acknowledged by nurse managers and medical directors. This finding is a concern because a weak patient safety climate has been associated with poor patient outcomes. To raise awareness, managers need to support patient safety work in the OR.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2017
National Category
Nursing
Research subject
Caring sciences
Identifiers
urn:nbn:se:oru:diva-59446 (URN)10.1136/bmjopen-2016-015607 (DOI)000412650700060 ()28864690 (PubMedID)2-s2.0-85029118920 (Scopus ID)
Note

Funding Agency:

Centre for Clinical Research Dalarna

Available from: 2017-09-03 Created: 2017-09-03 Last updated: 2019-04-30Bibliographically approved
Göras, C., Wallentin, F. Y., Nilsson, U. & Ehrenberg, A. (2013). Swedish translation and psychometric testing of the safety attitudes questionnaire (operating room version). BMC Health Services Research, 13, Article ID 104.
Open this publication in new window or tab >>Swedish translation and psychometric testing of the safety attitudes questionnaire (operating room version)
2013 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 13, article id 104Article in journal (Refereed) Published
Abstract [en]

Background: Tens of millions of patients worldwide suffer from avoidable disabling injuries and death every year. Measuring the safety climate in health care is an important step in improving patient safety. The most commonly used instrument to measure safety climate is the Safety Attitudes Questionnaire (SAQ). The aim of the present study was to establish the validity and reliability of the translated version of the SAQ.

Methods: The SAQ was translated and adapted to the Swedish context. The survey was then carried out with 374 respondents in the operating room (OR) setting. Data was received from three hospitals, a total of 237 responses. Cronbach's alpha and confirmatory factor analysis (CFA) was used to evaluate the reliability and validity of the instrument.

Results: The Cronbach's alpha values for each of the factors of the SAQ ranged between 0.59 and 0.83. The CFA and its goodness-of-fit indices (SRMR 0.055, RMSEA 0.043, CFI 0.98) showed good model fit. Intercorrelations between the factors safety climate, teamwork climate, job satisfaction, perceptions of management, and working conditions showed moderate to high correlation with each other. The factor stress recognition had no significant correlation with teamwork climate, perception of management, or job satisfaction.

Conclusions: Therefore, the Swedish translation and psychometric testing of the SAQ (OR version) has good construct validity. However, the reliability analysis suggested that some of the items need further refinement to establish sound internal consistency. As suggested by previous research, the SAQ is potentially a useful tool for evaluating safety climate. However, further psychometric testing is required with larger samples to establish the psychometric properties of the instrument for use in Sweden.

Place, publisher, year, edition, pages
BioMed Central, 2013
Keywords
Patient safety, Operating room, Safety climate, Psychometrics, Translation, Safety attitudes questionnaire
National Category
Nursing
Research subject
Caring sciences
Identifiers
urn:nbn:se:oru:diva-28904 (URN)10.1186/1472-6963-13-104 (DOI)000317113300001 ()23506044 (PubMedID)2-s2.0-84875072612 (Scopus ID)
Available from: 2013-05-06 Created: 2013-05-03 Last updated: 2019-05-15Bibliographically approved
Göras, C., Nilsson, U., Ekstedt, M., Unbeck, M. & Ehrenberg, A.Managing complexity in the operating room: a group interview study.
Open this publication in new window or tab >>Managing complexity in the operating room: a group interview study
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(English)Manuscript (preprint) (Other academic)
National Category
Other Health Sciences
Identifiers
urn:nbn:se:oru:diva-73975 (URN)
Available from: 2019-04-30 Created: 2019-04-30 Last updated: 2019-04-30Bibliographically approved
Göras, C., Olin, K., Unbeck, M., Pukk-Härenstam, K., Ehrenberg, A., Kassaye Tessma, M., . . . Ekstedt, M.Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study.
Open this publication in new window or tab >>Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Other Health Sciences
Identifiers
urn:nbn:se:oru:diva-73974 (URN)
Available from: 2019-04-30 Created: 2019-04-30 Last updated: 2019-04-30Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-0883-4072

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