Using the Operating Room Black Box to Assess Surgical Team Member Adaptation Under Uncertainty

Abstract

Objective:

Identify how surgical team members uniquely contribute to teamwork and adapt their teamwork skills during instances of uncertainty.

Background

The importance of surgical teamwork in preventing patient harm is well documented. Yet, little is known about how key roles (nurse, anesthesiologist, surgeon, and medical trainee) uniquely contribute to teamwork during instances of uncertainty, particularly when adapting to and rectifying an intraoperative adverse event (IAE).

Methods:

Audiovisual data of 23 laparoscopic cases from a large community teaching hospital were prospectively captured using OR Black Box. Human factors researchers retrospectively coded videos for teamwork skills (backup behavior, coordination, psychological safety, situation assessment, team decision-making, and leadership) by team role under 2 conditions of uncertainty: associated with an IAE versus no IAE. Surgeons identified IAEs.

Results:

In all, 1015 instances of teamwork skills were observed. Nurses adapted to IAEs by expressing more backup behavior skills (5.3× increase; 13.9 instances/hour during an IAE vs 2.2 instances/hour when no IAE) while surgeons and medical trainees expressed more psychological safety skills (surgeons: 3.6× increase; 30.0 instances/hour vs 6.6 instances/hour and trainees: 6.6× increase; 31.2 instances/hour vs 4.1 instances/hour). All roles expressed fewer situation assessment skills during an IAE versus no IAE.

Conclusions:

OR Black Box enabled the assessment of critically important details about how team members uniquely contribute during instances of uncertainty. Some teamwork skills were amplified, while others dampened when dealing with IAEs. The knowledge of how each role contributes to teamwork and adapts to IAEs should be used to inform the design of tailored interventions to strengthen interprofessional teamwork.

Numerous studies link teamwork deficiencies (eg, communication failures and lack of situation awareness) to technical errors and poor surgical outcomes, with the odds of surgical complications being nearly 5 times higher when fewer positive teamwork skills are observed.^1–3 Improving surgical teamwork has proven deceptively difficult to achieve, partly because research often fails to capture the unique contributions of each interdisciplinary team member’s role and the adaptive skills required under uncertainty, particularly when responding to disruptions such as intraoperative adverse events (IAEs).^4,5

Past research has emphasized the summative assessment of teamwork using surveys and observational scoring tools, which has helped identify core skills for effective teamwork (eg, coordination, leadership, backup behavior, and situational awareness).^6,7 However, studying the team as a whole conceals each profession’s unique contributions.^8,9 Therefore, we lack an understanding of teamwork skills expressed at a role-based level, which is crucial given the multidisciplinary nature of surgical teams (eg, professions differ in their training, expertise, and approaches to problem-solving).⁵ Even team members themselves report having a limited understanding of how they personally contribute to operating room (OR) teams.¹⁰ This is concerning as role clarity is an essential element of high-performing teams and successful surgery.¹¹ Understanding team role contributions is critical when teams are navigating uncertainty (eg, the discovery of abnormal anatomy, unfamiliar procedure, and unexpected bleeding), since it is during these instances that teams must respond, jointly solve problems, and rectify IAEs.^11–15 During IAEs, role awareness may be particularly important as teamwork can deteriorate when there is role confusion or ambiguity.⁸

Good teamwork necessitates not only role clarity but also adaptive capacity to know how these roles need to adjust based on context.^6,16,17 That is, team members must amplify or dampen distinct teamwork skills depending on situational demands. While existing research has provided little insight into these critical temporal and contextual adaptations, there is emerging evidence that innovative methods can help fill this gap. For example, a recent study used the OR Black Box (ORBB), a multisource data and audio/video-recording platform, to reveal how surgeons’ leadership styles fluctuated by operative phase.¹⁸ There have been calls to use innovative methods to better understand the complexity of adaptative surgical teamwork by identifying and analyzing patterns of behavior by team member role and context (eg, uncertainty) to enhance teamwork skills and training resources.^6,17 We sought to use the ORBB to identify the frequency and distribution of teamwork skills exhibited by surgical roles during instances of uncertainty. We hypothesized that (1) skills expressed would vary by role and (2) some skills would be amplified, while others would be dampened during an IAE versus no IAE.

METHODS

Study Design

Prospectively collected intraoperative audio/video data recordings were retrospectively reviewed.

Sample and Data Collection

This study was conducted at a large community teaching hospital in Toronto, Ontario, Canada, that performs surgeries from a variety of specialties (eg, general, orthopedic, urology, and ophthalmology).¹⁹ Between July 15, 2019, and March 6, 2020, 23 cases were analyzed from 1 OR using the ORBB (Surgical Safety Technologies Inc). The ORBB provides a standardized platform for collecting multisource data (eg, room and laparoscope audio/video feeds), viewing and coding variables using stacked timelines, and encrypting and securely storing data.^2,20 Institutional approval was obtained (REB #16-0038), and participation was open to adult patients undergoing elective laparoscopic general surgery. Written informed consent was obtained from participants (staff and patients) preoperatively. Recording started and stopped once the patient entered and left the OR, respectively. Only surgical cases with at least 1 IAE (see Data Coding and Analysis) were included to allow comparison within a case of teamwork skills expressed during instances of uncertainty associated with and without IAEs.

Data Coding and Analysis

Human factors (HF), the scientific discipline focused on understanding the interactions of people and their work system (eg, tasks, tools/technologies, and environment), is increasingly being used to understand and improve health care safety.²¹ Audiovisual data were reviewed by HF researchers, with past teamwork and OR-related experience, to identify instances of uncertainty, defined as any moment an OR member experienced an apparent sense of doubt by carefully considering context, verbal cues, and body language (eg, smoke evacuation system intermittently alarms and the surgeon pauses and looks for alarm source).¹⁵ The reviewer transcribed instances of uncertainty from each recording (eg, at 4 minutes 15 seconds: trainee experienced uncertainty regarding aberrant patient physiology and asked the surgeon for advice to prevent bowel thermal injury) into a spreadsheet; each instance of uncertainty was considered a distinct data point.

Transcribed instances of uncertainty were then coded for teamwork skills as a function of team role. Using a framework analysis, 2 HF researchers coded the instances of uncertainty for teamwork skills at the theme and subtheme levels, which were established deductively (using previously published literature^{4,7,8,22–24}) and inductively (newly created). A “theme” was defined as a broad concept, that encompassed a similar group of expressed behaviors (eg, team leadership). The theme “psychological safety” is related to a belief among team members that they can contribute knowledge in a candid and timely manner and so was operationalized by coding the related behavioral markers (eg, speaking up about a safety issue).²⁵ “Subthemes” exist under most themes to describe skills more precisely (eg, team leadership → delegate tasks). Teamwork skills were also categorized by team role (nurse, anesthesia, surgeon, and medical trainee). For example, if the nurse noticed the trainee was having trouble operating due to the height of the table and asked “Do you need a step stool?,” the nurse [role] was coded as displaying backup behavior [theme] and offering help [subtheme]. Raters convened to review the coding scheme for the first 25 descriptions and discussed discrepancies until a consensus was reached. Inter-rater reliability at both the theme and subtheme was established after 50 descriptions (Cohen κ>0.7),²⁶ allowing 1 rater to code the remaining cases.

Board-certified surgeons, trained to review ORBB data, independently analyzed videos for IAE occurrence (Fig. 1). Although all cases contained at least 1 IAE (study inclusion criteria), not all instances of uncertainty were associated with an IAE. As such, instances of uncertainty were coded as being associated with an IAE or no IAE. An IAE was defined as “any deviation from usual medical care that caused an injury to the patient or posed a risk of harm” and the clinical impact was scored from 1 to 5 according to the SEVerity of intraoperative Events and REctification (SEVERE) Index.²⁷ Only IAEs with a SEVERE index of 3 or greater were included since they pose a risk of harm (eg, disrupted the normal flow of operation, injured a tissue). However, these IAEs frequently did not lead to patient harm due to the surgical team’s corrective actions.

FIGURE 1.

Illustrative case, showing overlap of uncertainty (U) and intraoperative adverse event (IAE) coding.

Table 1 depicts the resulting output matrix from the data coding, which concisely summarizes the case ID, procedure, description of uncertainty, teamwork theme and subtheme, team role, and IAE association.

TABLE 1.

Framework Matrix

Case ID	Procedure	Description of uncertainty	Teamwork theme	Teamwork subtheme	Team role	Associated with IAE
X1	Colon resection right	Surgeon verbally guides medical trainee, who expressed doubt related to the amount of tension to apply during suturing.	Team leadership	Guidance	Surgeon	No
X2	Adrenalectomy	Surgeon is having trouble positioning the tool correctly. Nurse offers to make a call to get another doctor in to assist.	Backup behavior	Offer help	Nurse	Yes—level 3

To compare how roles adapted during instances of uncertainty associated with and without IAEs, the frequency of skills expressed was calculated¹⁸; teamwork skills associated with an IAE were normalized by the sum of IAE durations whereas skills with “no IAE” were normalized by the sum of no-IAE durations. The frequency of teamwork skills per hour was analyzed in a 6 level (teamwork skill: 1: backup behavior vs 2: coordination vs 3: psychological safety vs 4: situation assessment and shared mental models vs 5: team decision-making and planning vs 6: team leadership) × 4 (role: 1: nurses vs 2: anesthetists vs 3: surgeons vs 4: trainees) × 2 (associated with IAE: no vs yes) mixed factors analysis of variance with repeated measures on the first 2 factors. Analyses were conducted using IBM SPSS Version 26 (IBM Corp., 2014); α<0.05 with Bonferroni correction for pairwise comparisons.

RESULTS

Fifty-two surgical team members and 106 patients (scheduled for elective laparoscopic general surgery) consented to participate. Fifty-two of 106 cases were recorded and reviewed for IAE occurrence (36 cases not recorded, predominantly because staff forgot to start recordings; 18 cases not analyzed since recordings were destructed after 30 days, as per REB protocol, and timely staff access was restricted due to COVID-19). Twenty-three (of 52) cases had at least 1 IAE (which met the study inclusion criteria) and represented 66.5 hours of procedural time, from which 1015 instances of teamwork were identified during 578 moments of uncertainty. The cases involved 8 procedures, including colon resection (n=7), cholecystectomy (n=6), appendectomy (n=2), and other general surgery procedures (n=8). A total of 41 IAEs were identified (each case had at least 1 IAE). IAEs consisted of bleeding (n=18), mechanical injury (n=9), thermal injury (n=8), bile spillage (n=4), ischemic injury (n=1), and insufficient closure of anastomosis (n=1). All IAEs occurred during 3 procedure phases: transection (n=31), anastomosis (n=8), and removal of specimen (n=2).

Final Teamwork Skills Framework (Coding Scheme)

We identified 6 teamwork skill themes and 16 subthemes (Table 2) and inter-rater coding reliability was achieved with a Cohen κ value of 0.93 and 0.78, respectively.²⁶

TABLE 2.

Teamwork Themes and Subthemes Identified Using Framework Analysis

Theme	Subtheme	Description of behavior marker	Example
Backup behavior	Offer and/or ask for help	Recognized when assistance was needed and asked other team members for support.	A Medical Trainee needs saline, but the Scrub Nurses are busy counting, so the Circulating Nurse says: “Here, here, I’ve got it.”
Coordination	Check-back	Closed-loop communication used (ie, when a message was sent, the receiver acknowledged it was heard and repeated it back; the sender confirmed it was heard correctly and clarified if it was not).	Surgeon asks: “Cautery up to 80 spray.” Circulating Nurse confirms: “80?” Surgeon responds: “Yeah.”
	Precise communication	Message was communicated with all relevant details.	Surgeon asks: “Can I get a stapler—60 Purple?” as opposed to simply stating: “Can I get a stapler.”
Psychological safety (PS)	Admit mistakes	Openly described errors committed.	Surgeon has made an error and is tracing steps back “Ok, let’s see what I did here. Lots of bleeding, great. Where did we say I put a hole into… there, right?”
	Speak up	Verbalized a personal or team safety concern.	The patient has a latex allergy. A Nurse stops the Medical Trainee from scrubbing in wearing normal gloves and says: “The patient has a latex allergy.”
	Be solution-oriented	Provided a message focused on problem-solving and avoided assigning blame to the operator.	A Medical Trainee is putting the drape on the patient incorrectly. The Circulating Nurses steps in and says “OK, so let’s throw this out. You can’t put this drape on [correctly] by yourself” and gets another drape to start again together.
Situation assessment and shared mental models (SASMMs)	Give updates	Communicated the status of activities or responsibilities to team.	Surgeon has successfully retrieved the gastric band and notifies the OR team that: “It’ll be coming out in two pieces.”
	Conduct briefs	Instructed or informed team about the operative plan.	Surgeon says: “So we’re gonna continue this side and immobilize as much as you can. And then we’ll start stapling….just immobilize the whole line down all the way to the sigmoid.”
	Huddle to problem solve	Brought team together to problem solve.	There’s a lot more bleeding than the Surgeon expected so they ask the OR team for the status on the patient’s blood consent and for input. The Nurse confirms blood consent, Anesthesia asks: “Are you encountering some bleeding? Do you want 1-2 units ready?” The Surgeon confirms this would be good and the Nurse dials the phone and confirms 2 units are available.
Team decision-making and planning (TDMP)	Open to feedback	Asked for suggestions and constructive feedback.	Medical Trainee is stapling the bowel and asks the Surgeon: “are you happy with my position?” The Surgeon is not, so Surgeon guides the Trainee to the right spot.
	Encourage participation	Encouraged team members to acknowledge other team members’ opinions.	Surgeon and Medical Trainee discuss how they want to complete the transection. After the Trainee provides a suggestion by “thinking out loud,” the Surgeon says, “that’s a good idea.”
	Ask others for input	Prompted team members to contribute by asking for their insights or ideas on the plan.	Surgeon asks the OR team’s opinion on whether they need to do a cross stitch to prevent anastomotic leaking: “I don’t know. Do you think we need it?”
Team leadership (TL)	Guidance	Supported others by providing direction and coaching.	Surgeon tells Medical Trainee “This is a good place to use a sponge. You don’t have to, but it’ll stop the bleeding.”
	Delegate tasks	Assigned tasks based on role and workload.	OR team is moving patient from surgical table to postop bed. Anesthesiologist asks the Circulating Nurse to move the bed down so they can focus on patient’s head positioning.
	Give feedback	Provided information about reactions to a situation or team member performance of a task.	While the Surgeon directs the Medical Trainee on how to use the harmonic they say “Your left hand goes in there now. Perfect. No no, with your right hand, push some of these things down. Correct, like that. And this hand you want it to be… nope. Right there to the bottom.”
	Informal leadership	Took initiative or provided direction if the task required action.	The Medical Trainee asks for an instrument, but there are none in the OR, so the Nurse goes to retrieve one from inventory.

Teamwork Skills by Role

The frequencies of teamwork skills expressed by role when managing uncertainty (with an IAE vs no IAE) are shown in Table 3. The most frequently expressed skill in all roles was coordination. Surgeons also frequently demonstrated team leadership. The 3-way interaction between teamwork skill, team member role, and association with IAE was significant [F (15, 330)=3.84, P<0.001].

TABLE 3.

Mean Frequencies of Teamwork Skills Per Hour, Sorted by Provider Role and IAE Association

	Nurses			Anesthesiologists			Surgeons			Trainees
	No IAE	IAE	P	No IAE	IAE	P	No IAE	IAE	P	No IAE	IAE	P
Backup behavior	2.2 (0.6)	13.9 (4.1)	0.008	0.5 (0.3)	1.4 (1.4)	NS	1.5 (0.5)	2.9 (1.2)	NS	1.0 (0.4)	1.4 (1.0)	NS
Coordination	31.1 (9.2)	43.4 (4.4)	NS	10.4 (3.2)	—	0.004	46.0 (6.8)	39.5 (10.4)	NS	31.0 (8.3)	28.7 (5.2)	NS
Check-backs	23.6	36.6		6.1	—		41.0	39.1		28.5	28.7
Precise communication	7.5	6.8		4.3	—		5.0	0.40		2.5	0.0
Psychological safety	2.8 (1.1)	—	0.023	1.3 (0.6)	—	0.035	6.6 (1.7)	30.0 (5.5)	<0.001	4.1 (1.4)	31.2 (8.2)	0.004
Admit mistakes	1.2	—		0.9	—		5.4	6.7		2.8	0.8
Speak up	1.4	—		0.4	—		0.9	12.2		1.3	30.4
Be solution-oriented	0.2	—		0.0	—		0.3	11.0		0.0	0.0
Situation assessment and Shared Mental Models (SASMMs)	4.3 (1.3)	—	0.004	1.3 (0.5)	—	0.017	7.1 (2.1)	1.3 (0.9)	0.019	4.8 (1.6)	0.2 (0.2)	0.010
Give updates	0.0	—		0.1	—		1.2	0.6		0.3	0.0
Conduct briefs	0.0	—		0.0	—		0.5	0.0		0.0	0.0
Huddle to problem solve	4.3	—		1.2	—		5.4	0.7		4.5	0.2
Team decision-making/planning	0.2 (0.1)	—	NS	—	—	NA	1.1 (0.5)	0.3 (0.3)	NS	0.8 (0.4)	1.7 (1.2)	NS
Open to feedback	0.0	—		—	—		0.6	0.0		0.8	1.7
Encourage participation	0.1	—		—	—		0.0	0.0		0.0	0.0.
Ask others for input	0.1	—		—	—		0.5	0.3		0.0	0.0
Team leadership	3.2 (1.3)	—	0.023	0.7 (0.3)	—	0.045	42.2 (7.0)	35.6 (4.4)	NS	0.6 (0.3)	—	0.035
Guidance	2.3	—		0.6	—		19.4	32.3		0.2	—
Delegate tasks	0.4	—		0.1	—		5.5	1.8		0.4	—
Give feedback	0.3	—		0.0	—		15.2	1.4		0.0	—
Informal leadership	0.2	—		0.0			2.1	0.1		0.0	—

Standard errors are in parentheses. Means and standard errors reflect frequency of skills expressed per hour.

P values are for pairwise comparisons with Bonferroni correction.

NA indicates not applicable; NS, not significant.

Skills Amplified During Times Associated With an IAE

Nurses expressed significantly more backup behavior (5.3× increase) during times associated with an IAE (mean=13.9/hour, SE=4.1/hour) versus no IAE (M=2.2/hour, SE=0.6/hour). Surgeons and trainees expressed significantly more psychological safety (3.6× and 6.6× increase, respectively) during times associated with an IAE (surgeons: M=30.0/hour, SE=5.5/hour; trainees: M=31.2/hour, SE=8.2/hour) versus no IAE (surgeons: M=6.6/hour, SE=1.7/hour; trainees: M=4.1/hour, SE=1.4/hour). The following example highlights the expression of these skills in these roles during an IAE:

A patient’s unusually narrow pelvic cavity caused difficulty for the Trainee when orienting the stapler to reconstruct the anastomosis. The Surgeon stepped out to answer a phone call. The Trainee continued having difficulty and cursed as he caused a thermal injury [coding: IAE Level 3] by using the monopolar electrical surgical device in the wrong orientation. The Nurse asked: “You ok?” [coding: Nurse; backup behavior; offer and ask for help] The Surgeon returned and asked: “What’s wrong?” The Trainee responded: “It’s harder on this side. I don’t know why.” The Surgeon and Trainee discussed and Surgeon said: “You just gotta get good bites here. It’s not gonna be an easy sewing job.” Trainee said: “Oh no, I messed up.” [coding: Trainee; psychological safety; admit mistakes and shortcomings] The Surgeon reassured the Trainee: “No, no, get good bites and put in a second layer.” [coding: Surgeon; psychological safety; be solutions oriented]

Skills Dampened During Times Associated With an IAE

All roles expressed significantly less situation assessment and shared mental models (SASMM) during times associated with an IAE (nurses: M=0/hour, SE=0/hour; anesthesia: M=0/hour, SE=0/hour; surgeons: M=1.3/hour, SE=0.9/hour; trainees: M=0.2/hour, SE=0.2/hour) versus no IAE (nurses: M=4.3/hour, SE=1.3/hour; anesthesia: M=1.3/hour, SE=0.5/hour; surgeons: M=7.1/hour, SE=2.1/hour; trainees: M= 4.8/hour, SE=1.6/hour). Since it is inherently difficult to describe the absence/dampening of a skill, comparing similar scenarios with and without the skill may provide insight. For example, contrasting the IAE example described above where the surgeon left the OR with no brief (ie, SASMM skill dampening), the following is a similar scenario in which a brief was conducted (ie, the presence of SASMM skill) and not associated with an IAE:

The Surgeon needed to leave the OR so he quickly outlined the plan for the team: “So, the plane’s here, ok? The plane is NOT there. So you’re gonna continue this side and immobilize as much as you can. And then we’ll start stapling. I’ll be back—just immobilize the whole line down all the way to the sigmoid. That’s a lot of work.” [coding: Surgeon; situation assessment and shared mental model; conduct brief]

While surgeons’ expression of team leadership did not differ significantly during an IAE versus no IAE, all other roles showed significantly less team leadership during times associated with an IAE (nurses: M=0/hour, SE=0/hour; anesthesiologists: M=0/hour, SE=0/hour; trainees: M=0/hour, SE=0/hour) versus no IAE (nurses: M=3.2/hour, SE=1.3/hour; anesthesiologists: M=0.7/hour, SE=0.3/hour; trainees: M=0.6/hour, SE=0.3/hour). Team leadership during no IAE for nurses, trainees, and anesthesiologists included providing guidance, delegating tasks, and informal leadership (eg, the scrub nurse directed the circulating nurse to proactively replace subpar equipment, trainee directed a nurse to help improve equipment setup, and anesthesiologist instructed trainee to lower the bed).

Another significant dampening of teamwork skills (ie, the absence of) was that nurses and anesthesiologists expressed significantly less psychological safety during times associated with an IAE (nurses: M=0/hour, SE=0/hour; anesthesiologists: M=0/hour, SE=0/hour) versus no IAE (nurses: M=2.8/hour, SE=1.1/hour; anesthesiologists: M=1.3/hour, SE=0.6/hour) and anesthesiologists expressed less coordination (IAE: M=0/hour, SE=0/hour; non-IAE: M=10.4/hour, SE=3.2/hour).

DISCUSSION

The current understanding of surgical teamwork omits a detailed assessment of contributions by role and how teamwork skills dynamically change when navigating uncertainty, particularly when managing the added complexity of IAEs. In this study, ORBB provided the ability to assess critically important details about the expression of surgical teamwork skills by roles during instances of uncertainty. Our results demonstrate that interprofessional roles contribute unique teamwork skills under conditions of uncertainty, which are amplified or dampened when managing IAEs. While some teamwork skills were consistently demonstrated during all instances of uncertainty (eg, coordination by all roles, team leadership by surgeons), other skills were amplified (eg, backup behavior by nurses; psychological safety-related skills by surgeons and medical trainees) and dampened (eg, situation assessment by all roles) during an IAE (vs no IAE). This study is an important step in understanding how interdisciplinary roles uniquely contribute to teamwork and how teams adapt under different uncertainty scenarios (ie, no IAE vs IAE), which can ultimately inform the design of targeted interventions to improve surgical teamwork.

Skills Consistently Expressed

The study identified some teamwork skills that are consistently expressed during instances of uncertainty (with and without IAEs). Our results support previous findings that coordination is a central tenet of effective and safe surgery as it is inherently required to complete many tasks (ie, orchestrating the sequencing and timing of interdependent actions).^4,8–10,13 Seeing as coordination was the most frequently expressed teamwork skill across all roles, engraining standard coordination strategies, such as check-backs (ie, closed-loop communication to verify and validate information) and precise communication (ie, high-quality and accurate messages to avoid confusion) should be prioritized to build a common fundamental communication protocol across all roles.^4,28

Another skill frequently expressed was surgeons’ team leadership, whose importance is widely accepted since the leader is often their de facto role. While surgeons’ leadership remained high during all instances of uncertainty, our study unveiled specific underlying leadership skills expressed, providing insight into how surgeons adapt leadership during an IAE. When there was no IAE, surgeons focused heavily on providing both guidance (ie, direction) and feedback (ie, evaluation) to trainees, whereas during an IAE, surgeons augmented their guidance and decreased feedback, likely to focus on timely and effective IAE rectification (ie, task completion). This variation in leadership skill is consistent with recent research that a surgeon’s overall leadership style (eg, transformative vs transactional vs passive) fluctuates within an operation in response to context (eg, surgical phase).¹⁸ Although most successful leaders modify their style to meet circumstances, this adaptation may be less intuitive for some new surgeons who could benefit from explicit mentorship and formal training in adaptive leadership.²⁹

Skills Amplified During Times Associated With an IAE

Our results suggest that some skills may need amplification by particular roles to support effective teamwork when navigating an IAE. For instance, the amplification in backup behavior—expressed only by nurses—during IAEs brings into focus nurses’ unique contribution to anticipating needs and offering assistance (eg, ensuring an alternate tool is available when one type seems to be giving the surgeon trouble). Similarly, the amplification of psychological safety-related skills by surgeons and trainees during an IAE suggests they are comfortable admitting mistakes (eg, they caused a bleed), voicing concerns (eg, unsure if a certain technique will work), and blameless problem-solving (eg, focusing on solutions vs assigning fault). Our findings are particularly relevant given the numerous studies emphasizing psychological safety as a critical component of successful teamwork and underscore the importance of creating cultures in which all providers feel empowered to speak up.²⁵ Future research should explore whether the amplification of these specific skills by these specific roles can help clarify team roles/responsibilities (eg, a nurse’s key role during an IAE is to provide backup behavior) or if they are indicative of opportunities to expand skills expressed by other roles (eg, surgeons, trainees and/or anesthesiologists should also augment backup behavior during an IAE).

Skills Dampened During Times Associated With an IAE

The propensity to dampen skills during an IAE may have downside effects. Research is required to confirm whether the dampening of skills observed during an IAE is an appropriate adaptation to the emergent and varying demands during a case (eg, allow focused concentration on IAE rectification) or maladaptive. For example, a key principle of high-reliability organizations is deference to expertise (ie, decision-making by those with the right expertise depending on the situation).³⁰ In our study, the dampening of skills by nonsurgeons during an IAE (eg, all roles, except surgeons, showed less team leadership; nurses and anesthesiologists showed less psychological safety; and anesthesiologists showed less coordination) may be an appropriate deference to expertise. However, the dampening of a skill across all team members during an IAE may be indicative of maladaptation. For example, SASMM skills (which are critical to ensure the team is aware of what happened, what is occurring now, and future plans) were dampened across all team roles during an IAE, suggesting that individuals’ situation awareness may have been compromised while the surgeons focused on IAE rectification. This is consistent with past research, showing that surgeons often mistakenly assume IAEs are irrelevant to others or that team members could hear their conversations with trainees, so no explicit update was needed.³¹ While most SASMM research has focused on creating formal pause points/huddles to share information (eg, surgical checklist timeout), SASMM is constantly changing as a case progresses. Therefore, additional research is needed to elucidate how team roles and skills can be best used to stay abreast of evolving situations (eg, cross-monitoring, call-out) while not overburdening those with the highest workload (eg, surgeon trying to simultaneously rectify an IAE and give updates).³²

Framework

The novel framework created from this study can help support future research to understand how different roles uniquely contribute to teamwork in different contexts. Our framework builds off a systematic literature review by Gregory et al,(4) who summarized key teamwork attitudes, behaviors, and cognitions into the ABC framework, which includes fostering psychological safety and providing backup behavior—2 skills that are not consistently assessed using traditional teamwork measures (eg, Oxford NOTECHs). Our study results underscore the importance of including these 2 skills, particularly when examining IAE-related performance (see skills amplified), and support other research that advocates for expanding current teamwork frameworks to include a broader range of teamwork competencies.^4,8 Our framework also expands the ABC framework to include subthemes to provide more granularity when coding behavior, which may be particularly useful when using novel methods, such as ORBB, to study micro-interactions. In turn, this granularity deepens understanding of staff roles and adaptations in different contexts and supports more specific and actionable strategies to improve teamwork.

Limitations

This study has several limitations. First, this was an observational study so the Hawthorne effect cannot be excluded (eg, surgical team members may have improved their teamwork skills). This impact was minimized by the unobtrusive nature of video-recording equipment, lengthy acclimation period, not informing participants of study metrics, and the within-participant study design (ie, influence in both IAE and no IAE conditions).³³ Second, since the focus of this study was on pattern exploration, neither patient outcomes nor the quality/absence of skills (eg, rating of skill from poor to excellent) was measured, thereby precluding evaluative analysis of observed behaviors. Third, this study was performed at a single center with limited surgical team members, allowing for the possibility of repeated measures bias and limiting generalizability. While the exact team was unlikely to repeat (surgical staffing rotates in the recorded OR), some staff (eg, surgeons) may have had overrepresentation. This study also focused on the roles of nurses, anesthesiologists, surgeons, and trainees in elective laparoscopic general surgery cases. The incorporation of more hospitals, surgical teams, and procedures would improve the robustness of this study.

CONCLUSIONS

This study is a novel application of the ORBB that provides needed details about the expression of surgical teamwork skills by roles during instances of uncertainty and how some skills are amplified and dampened during IAEs. The results establish a foundation to acknowledge and consider how each role is uniquely contributing to team performance and adapting to changing contexts (ie, IAE vs no IAE). Continuing to study teamwork skills by role using the framework developed in this study could greatly enhance our understanding of whether the skills expressed are appropriate for the context (ie, adaptative or maladaptive). In turn, this knowledge can help promote role clarity and specific interventions that take these differences into account (eg, by role and situation), thereby truly strengthening and celebrating interprofessional surgical teamwork.