Moving beyond teamwork in the operating room to facilitating mutual professional respect

Abstract

Psychological safety enables the interpersonal risk-taking necessary for providing safer patient care in the operating room (OR). Limited studies look at psychological safety in the OR from the perspectives of each highly specialized team member. Therefore, we investigated each member’s perspective on the factors that influence psychological safety in the OR. Interviews were conducted with operative team members of a level 1 trauma center in central Texas. The interviews were transcribed, de-identified, and coded by two investigators independently, and thematic analysis was performed. Responses were collected from 21 participants representing all surgical team roles (attending surgeons, attending anesthesiologists, circulating nurses, nurse anesthetists, scrub techs, and residents). Circulating nurse responses were redacted for confidentiality (n = 1). Six major themes influencing psychological safety in the OR were identified. Psychological safety is essential to better, safer patient care. Establishing a climate of mutual respect and suspended judgment in an OR safe for learning will lay the foundation for achieving psychological safety in the OR. Team exercises in building rapport and mutual understanding are important starting points.

CME

Target audience: All physicians.

Learning objectives: After completing the article, the learner should be able to

1. Identify six major themes of psychological safety within the operating room.

2. Describe positive influencers of psychological safety.

3. Describe negative influencers of psychological safety.

4. List ways to encourage or build psychological safety.

Faculty credentials/disclosure: Dr. Adair White is a health professions educator at MGH Institute with expertise in organizational psychology and educational leadership. Dr. Papaconstantinou serves as chair of the Department of Surgery at Baylor Scott & White Medical Center – Temple with expertise in quality, safety, efficiency, and leadership in surgery. Dr. Lin was a general surgery resident at the time the study was conducted and will resume her studies as a radiology resident. The authors and planner for this educational activity have no relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by or on patients.

Accreditation: The A. Webb Roberts Center for Continuing Medical Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Designation: The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health designates this journal CME activity for a maximum of 1.0 AMA PRA Category 1 Credit^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM MOC: The successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health will submit participant completion information to the ACCME, which will be transferred to the ABIM for MOC credits claimed. By entering your ABIM Diplomate number into your profile and completing the credit claim process for this activity, you are giving permission for the transfer of your information to take place.

Process: To complete this CME activity, read the entire article and then go to https://ce.bswhealth.com/Proceedings2020. You will register for the course, pay any relevant fee, take the quiz, complete the evaluation, and claim your CME credit. For more information about CME credit, email ce@bswhealth.org.

Expiration date: January 1, 2025.

Psychological safety is an important construct within healthcare teams, as it encourages a culture of trust and open communication that ultimately allows teams to provide high-quality patient care and ongoing quality improvement.^1,2 Psychological safety is imperative in the high-stress and high-demand space of the operating room (OR). In the OR, the attending surgeon typically leads a large multidisciplinary team. While the overall goal of the team is to provide high-quality care to the surgical patient, each team member has specific skills, goals, experience levels, and personalities that they bring to the OR, which ultimately affect the experience of the team.³

There are limited studies examining psychological safety in the healthcare environment.⁴ Much of the literature on psychological safety within healthcare teams has focused on the roles of the leader.^5,6 However, Remtulla et al investigated the facilitators and barriers of psychological safety in primary care at the level of individuals, teams, and the organization and suggested that further research into profession-specific attitudes could increase psychological safety within general practice.⁷ Further, limited studies have examined psychological safety from the perspectives of each highly specialized OR team member. One study demonstrated significant differences in the perceptions of nurses, anesthesiologists, and surgeons on teamwork, wherein surgeons reported good teamwork, while reciprocal sentiments were not reported by the other groups.⁸ Thus, the purpose of this study was to investigate the factors that enhanced and acted as barriers to establishing psychological safety in the OR and ultimately define what psychological safety in the OR is from the perspective of the operative team.

METHODS

This qualitative phenomenological study examined the lived experiences of surgical team members. The Baylor Scott and White Research Institute institutional review board approved this study’s protocol (IRB #021-247). Twenty-one interviews or focus groups were conducted by two investigators (MWL, BAW), and recruitment continued until saturation. Four questions were developed to guide the investigation (Table 1).

Table 1.

Research questions and guiding questions for focus groups and one-on-one interviews

Guiding questions	Interview questions
1. What is psychological safety in the operating room (OR)?	1. Describe an OR where you feel completely at home.
2. What are the factors that influence psychological safety in the OR?	2. Aside from clinical aspects, what are the biggest challenges facing the operating team?
3. How can we promote these factors? How can we prevent barriers?	3. Has there been an event in the OR where you felt that you wanted to say or do something but didn’t? Why?
4. How do surgeons influence psychological safety in the OR?	4. What does psychological safety in the OR look like to you?
	5. What do you think are things that would support psychological safety in the OR for you?
	6. What do you think are things that would act as barriers to achieving psychological safety in the OR for you?
	7. How do lead operating surgeons contribute to or detract from psychological safety in the OR?

Participants were recruited from November 2021 to January 2022 at Baylor Scott and White Medical Center in Temple, Texas, a level 1 trauma center and academic medical institution. Individuals were eligible if they were members of the surgical team, including attending anesthesiologists, attending surgeons, nurse anesthetists (CRNA), circulating nurses (ORN), surgical technologists (scrub tech), anesthesia residents, and general surgery residents. Participants were recruited through email lists and in person using a fact sheet that was approved by the institutional review board. Participants were invited to join a single 1-hour focus group with their peers or an individual interview with the study investigators. Participants did not receive incentives for participation.

Interviews and focus groups were conducted through WebEx over a 2-month period. Seven interview questions (Table 1) were developed to capture perceptions and experiences on what strengthens or weakens psychological safety within the OR. Meetings were recorded and transcribed using WebEx, manually reviewed for accuracy, and de-identified to protect confidentiality. Transcripts were reviewed repeatedly throughout data collection, and when no new topics emerged recruitment stopped.

Thematic analysis was utilized to identify factors that influenced psychological safety. The data from the transcripts were independently reviewed and manually coded by two investigators (MWL, BAW). Their process included initial review of the data with inductive coding, pattern identification, category creation (e.g., familiarity, team stability), and theme identification. The investigators met regularly to re-analyze the transcripts, discuss discrepancies in coding, and come to agreements on the themes identified.

RESULTS

Thirty-seven individuals responded with interest in participating. Sixteen were unable to participate due to scheduling conflicts or time constraints. Twenty-one participants were interviewed or participated in a focus group (Table 2). The responses from the circulating nurse were redacted to protect confidentiality. Six themes were identified (Table 3). Perhaps unsurprisingly, each theme identified was linked to or exerted an influence on the other themes. For example, a lack of mutual professional respect due to distrust in a colleague’s expertise could erode communication.

Table 2.

Study demographics

Role	N (%)
Attending anesthesiologist	2 (10%)
Attending surgeon	7 (35%)
Nurse anesthetist	4 (20%)
Circulating nurse	1 response redacted (0)
Surgical technologist (scrub tech)	3 (15%)
General surgery resident	4 (20%)
Anesthesiology resident	0 (0%)

Table 3.

Themes that influence psychological safety in the operating room with select quotes from each role

Themes	CST (scrub tech)	CRNA (nurse anesthetist)	Attending anesthesiologist	Surgical resident	Attending surgeon
Mutual professional respect and understanding	CSTs felt the ORs that they were most comfortable in were those where their concerns were acknowledged: “All the surgeons that I work with are respectful. I’ve never been in a situation where if I felt I needed to speak up that I’m not going to be listened to.”	CRNAs identified teams that valued their expertise and acknowledged their concerns: “Feeling at home is having a [team] who values [me], where they’re not trying to dictate what I do but values the approach that [I] take.”	Attending anesthesiologists valued working in a respectful environment: “There is an atmosphere of camaraderie and gratitude … conducive to that collegial, efficient, orderly, purposeful work environment.”	Surgical residents felt acknowledgment of their roles and responsibilities by other team members was important: “It just helps to kind of touch base with everybody, … what we’re doing and acknowledgment of my role and what I’m responsible for.”	Attending surgeons felt they played an active role in supporting an environment of mutual respect: “I try to seriously hear what suggestions people are making…. It’s worthwhile listening to people.”
Approaches to communication	CSTs identified the importance of keeping an open line of communication between team members: “Everybody needs to feel like their voice matters. If they are concerned, it needs to be listened to no matter the agreement on the concern.”	CRNAs felt encouraging open communication was crucial to patient safety: “The ability of the entire team to feel free to voice concerns, especially if it is related to patient safety … is the bottom line.”	Attending anesthesiologists felt communication challenges affected the team’s ability to provide good patient care: “Communication is probably the biggest obstacle to good care.”	Surgical residents identified communication breakdown as a vicious cycle leading to further challenges for the team: “Communication can be a struggle in the OR that can lead to other frustrations that further worsen communication [between] people.”	Attending surgeons noted the importance of open, nonjudgmental communication: “An important part of a safe OR is when we can give feedback to each other … and it’s not taken in a personal way.”
Seniority, hierarchy, and power imbalances	CSTs felt the social hierarchy of the OR impeded their ability to attain certain career opportunities: “You may be overlooked, because you may not be good friends with whoever is going to be ultimately making those decisions or the ones that have influence.”	CRNAs felt their training was not as valued as that of physicians, despite having more experience: “If a patient has a [high medical comorbidity score], CRNAs can’t sign them out [but a new resident] can.… It’s just built into the system…. The disrespect is there.”	Attending anesthesiologists recognized the need to correct power imbalances: “It’s a tough balance to allow humor and casual interaction and to remain focused on professional complex endeavors. But when you see it happen, it feels magical.”	Surgical residents noted the impact of the OR hierarchy on the surgical team’s performance: “It’s confidence and competence from the top. When you know that the chief or the attending knows what they’re doing, I think it really pushes everyone in their role to be better.”	Attending surgeons acknowledged their position in the OR hierarchy and their influence on the rest of the team: “It’s really hard sometimes for everyone to feel empowered to say anything … the more asymmetric the knowledge or power gap is.”
Healthy and unhealthy team dynamics	CSTs noted the importance of team members’ personalities cooperating and motivations aligning: “As long as I know that we’re a team that meshes well, that people are going to do their job, and I don’t have to worry about them, then it’s a good day.”	CRNAs felt it was easier to not voice concerns when facing difficult personalities on the team: “It’s taking the path of least resistance. Sometimes it’s easier to get through the day by not getting confrontational with certain personalities.”	Attending anesthesiologists identified the importance of team familiarity and preparation: “[The ideal OR is] a place where everybody knows your name. Everyone knows the task at hand, there is robust evidence of preparation for the task.”	Surgical residents felt self-conscious about their words and actions in the OR due to fear of retaliation: “There’s a lot of concern about preserving relationships. It’s more difficult when people don’t like you or don’t want you to be there.”	Attending surgeons valued working with teams with aligned goals, motivations, and expectations: “If the team knows exactly what we are doing, how, and what might be the variations, and everybody knows what is expected, … it sets up a good procedure.”
Internal and external pressures	CSTs identified equipment availability as well as personality types as factors affecting psychological safety: “I feel comfortable when I don’t have to worry about going out of my way to make sure I have every little thing in the room … and have a surgeon getting mad at me because I don’t have it.”	CRNAs felt that as rotating members of surgical teams, they lacked the familiarity and mutual understanding shared by stable members of the team: “Anesthesia is not on [any specific] team, … so nobody seems to know what we do or understands what we do.”	Attending anesthesiologists noted the effects of imposter syndrome on self-confidence and performance in the OR: “I think there are individual developmental, maturational deficits that we all have, being confident in who we are and our skill.”	Surgical residents recognized the effects of emotional contagion and the need to balance this with internal pressures such as a lack of self-confidence: “What we put out gets bounced back toward us.… When I can really introduce myself and [engage with the team] then things go smoother and the scrub tech [is suddenly] wanting to help me more.”	Attending surgeons identified external pressures to increase productivity and expedite patient turnover: “There’s a huge pressure to be productive, the idea of, ‘Hey, you’ve gotta do this case fast. You need to have the turnover [time] minimized.’”
Systems process improvements and issues	CSTs felt the solutions they suggest for problems they identify are frequently dismissed by leadership: “Workers will identify a problem that management [tries to] correct, but not using the feedback they were given. Ultimately, they find out ‘Oh, this isn’t the solution. Let’s try what was suggested.’”	CRNAs felt systems processes have helped team members speak up, especially on patient safety issues: “I hear the phrases, ‘hold the line!’, ‘time out!’… People are more vocal and I have seen it help catch a lot of potential errors that could happen in the ORs…. People just seem more free to voice concerns.”	Attending anesthesiologists felt systems processes could be improved to better support team engagement: “It is part of our corporate culture to dehumanize, depersonalize…. I think it takes a toll on those of us who work there.”	Surgical residents felt certain systems processes contributed to poorer efficiency in the OR: “I think other challenges are policies and stuff that just kind of slow things down, … things like having to wait at the end … for films or … [equipment] counts are incorrect because people aren’t communicating.”	Attending surgeons felt consideration for personal experiences would benefit system process application: “There was a recent [systemwide] change in [surgical] sponges that fall apart within wounds. So psychological safety would include some degree of local control over your own practice.”

Theme 1: Mutual professional respect and understanding of different goals and values

All team roles perceived a lack of understanding or respect for their profession or skills as a barrier to psychological safety. Interactions that resulted in team members feeling devalued or dismissed, especially with respect to role-specific goals and expertise, were frequently described. One participant stated, “I want to feel safe, that my patient is going to be well taken care of by everybody else. If I say ‘call a code!’ that [team member] is going to actually call a code instead of … second-guessing and doubting me…. I think just having to not justify what I’m doing would really make me feel more safe.” Conversely, team members reported that feeling acknowledged, respected, or valued by the rest of the team brought comfort and confidence.

This facet of psychological safety was also influenced by the level of trust participants had in their team members’ expertise. Participants described an inability to focus completely on their responsibilities if they felt unsure of a team member’s expertise or abilities. For example, a participant described having to repeatedly scrub out (degown and leave the surgical field) to help another team member find surgical tools.

Theme 2: Approaches to communication and communication styles

Almost all participants reported communication as a crucial part of psychological safety in the OR. After describing an incident where their concerns were verbalized and ignored, a participant added, “If you don’t listen to your people, especially the folks on the front line, then I feel like they will not want to give feedback in the future.” Further, different communication styles, such as nonverbal cues, were also described as factors affecting psychological safety. The ability to recognize different communication styles and read nonverbal cues was particularly important to team members who took irregular shifts and did not have a dedicated team that they were familiar with or worked with regularly. Another participant emphasized this sentiment, stating, “You just have to be cautious, careful, [and] clearly communicate well, because you don’t know the nuances of everybody in the room.”

Theme 3: Seniority, hierarchy, and power imbalances

Several participants expressed how their position in the hierarchy affected their experience. One participant said, “You could be a superstar intern [first-year trainee], but the moment you walk in [to the OR], I think it’s normal to have it be a bit of a[n initiation]. Our staff just kind of [tests] the interns and early second years.”

Notably, some participants recognized their authority and influence within the hierarchy. As one said, “We move away from respect [when we move] into the realm of a power dynamic. It’s detrimental [to] relationships and it’s a really fine balance that requires a lot of maturity to exercise authority without exercising power.” Most attending surgeons and anesthesiologists in the study recognized their influence and position as leaders in the OR and expressed a duty to acknowledge and correct the power imbalances created by the hierarchy.

Theme 4: Healthy vs unhealthy team dynamics

Various behaviors were reported as influencers of psychological safety and were grouped under the theme of team dynamics. Both healthy (positive) and unhealthy (negative) aspects of team dynamics were described and played important roles in affecting the day-to-day function of the surgical team. For healthy team dynamics, participants identified factors such as suspended judgment, aligned goals, support from colleagues, team familiarity, and an environment that enabled learning. One participant said, “If I have to [redo a procedure] in the evening, you often see faces all around looking glum. That can be a real pressure, so it is very important that the team shares the same goal and vision and [we] have confidence in each other…. The team has to believe in the procedure that they are doing and everybody has to just do whatever it takes.”

Conversely, unhealthy team dynamics could include a fear of judgment, different goals, interpersonal conflict, avoidant culture, blame culture, and frequent rotation of team members. For example, one participant said, “Several of my colleagues continue to rely on intimidation to affect their preferences for clinical care, and that quickly erodes trust and respect…. I think a chief goal should be eradicating intimidation in the operating room environment because it’s so destructive to teamwork.”

Theme 5: Internal and external pressures

Factors affecting psychological safety within and outside the control of participants were also identified and grouped under the umbrella of internal or external pressures. Internal pressures could be things like reactions to criticism, internal dialogue or self-imposed pressures, self-confidence (or lack of), ego, perceptions of others, reputation management, and fundamental attribution error. External pressures could be equipment failures, criticism, distractions, or gossip. One participant described both external and internal factors as strong influencers of psychological safety, stating, “I feel like when members of your team sense anger from another member of the team, it really is a barrier to communication, which in and of itself is a barrier to safety in the OR…. [Also] functional equipment in the operating room is important, and when the actual equipment that you’re using is not working properly, or you keep getting defective equipment, it really affects the whole psychological environment of the operating room.”

Theme 6: Systems process improvements and issues

Systems processes strongly influence efficiency and productivity as well as team morale and dynamics. A participant said, “I think that systems processes that are in place need to make people feel at ease because the system can be a barrier…. If people don’t feel that they’re backed by [the processes put in place by] the system, they won’t make any effort. People just kind of back off.” This was a sentiment shared by many participants, who felt that system policies should empower and protect team members to seek quality improvement.

Many participants reported that processes sometimes became hindrances to efficiency and affected the ability of participants to perform their jobs effectively. A participant stated, “We spend a lot of time doing checklists, briefings … and sometimes I feel like [while] we’re doing all this stuff we’re missing the big stuff, like equipment failures and not being prepared for bleeding and all these other things, which are probably much more important…. We focus a lot on regulatory details and sometimes we just don’t have enough left over to do a good job.” Systems processes cover a very broad spectrum of issues; paradoxically, while focusing on administrative details, such processes may not thoroughly address more pressing issues like those affecting direct patient care, effectively decreasing the psychological safety of the team.

DISCUSSION

This study re-emphasizes the importance of achieving psychological safety in the OR by accounting for the perspectives of surgical team members and their lived experiences. Overall, results showed that psychological safety is present in the OR when there is an environment safe for learning, with mutual professional respect, open communication, and suspended judgment. Six factors were identified that influence psychological safety in the OR: mutual professional respect, communication, hierarchy, team dynamics, internal vs external factors, and systems processes. The third guiding question, “How can we promote these factors? How can we prevent barriers?” and the fourth guiding question, “How do surgeons influence psychological safety in the OR?” are discussed below.

Promoting factors that influence psychological safety and preventing barriers

Disrespect in the workplace is common and frequently left unresolved, contributing to communication problems that affect patient care.⁹ Our study highlights how mutual professional respect is crucial to increasing psychological safety within the OR. Several participants mentioned feeling ignored or disrespected after voicing concerns, and team members who feel their expertise is questioned are more likely to feel scrutinized and less likely to speak up.¹⁰ Conversely, team members who feel respected are more motivated to engage in tasks and experience greater job satisfaction.¹¹ Some ways to promote mutual respect and civility include team-building exercises, training on giving and receiving feedback, negotiation, and practicing mindfulness.¹¹ Supportive and trusting team relationships encourage members to share new ideas and receive constructive criticism without getting defensive.¹²

Communication is especially important in a psychologically safe OR team. All team members reported a professional responsibility and accountability to safe patient care, which may motivate speaking up.^13–15 However, fear of retribution, not wanting to cause trouble, or feeling ignored remain top concerns.^16,17 In our study, team familiarity was identified as a contributor to psychological safety; consistent teams also facilitated trust, camaraderie, and openness.¹⁸ In contrast, most team members who rotate on to ad hoc teams reported decreased psychological safety stemming in part from communication problems, which can be exacerbated due to a lack of team identity, familiarity, and trust.¹⁹ In all teams, communication problems may arise due to differences in perception and values.²⁰ Team communication may benefit from incorporating standardized processes that share information efficiently and predictably (i.e., the SBAR technique, situation-background-assessment-recommendation).^19,21,22 At an organizational level, maintaining a culture of safety that values team members’ concerns and validates their contributions can further motivate team members to speak up.²³

Hierarchy strongly influences psychological safety of all team members. As redemonstrated in our study, those higher in the hierarchy experience greater levels of psychological safety and ability to assert themselves, while those with lower status are less likely to challenge their superiors.^13,24 Leaders play a crucial role in countering the deflating effects that power imbalances have on team psychological safety.²⁵ Participants valued team leaders who were supportive, approachable, and change-oriented, characteristics that facilitate assertiveness and enable authority in the team to voice issues and make decisions.²⁶

Participants felt more comfortable in teams where participation in quality improvement, learning, and open discussion of questions and new ideas were encouraged. In other words, working in teams with healthy interprofessional dynamics increased psychological safety for all roles. Working in environments with continuous quality improvement positively affected psychological safety for healthcare teams.²⁷ Striving to learn and improve require critical reflection and risking being seen as incompetent or ignorant.²⁸ Thus, team familiarity was further emphasized as an important facet of psychologically safe ORs, by increasing camaraderie, decreasing the uncertainty and distrust inherent in novel interactions, and encouraging receptivity to concerns, ideas, and knowledge.^24,29–31 Further, encouraging a “team mentality,” including shared goals and shared responsibility for outcomes, establishes a supportive OR and reduces common interpersonal issues found in surgical teams.³²

Psychological safety is described as a group-level phenomenon, but can be affected by factors at the individual level, such as personalities or perceptions of personal control.^1,4,33 Team members with greater assertiveness and bravery are more likely to speak up.¹⁴ Gender can also influence psychological safety, as men are more likely than women to speak up about safety issues.²³ Additionally, unintentionally shared emotions, or emotional contagion, can exert effects on the likelihood of cognitive failures and workplace accidents, thereby affecting psychological safety.³⁴ Gossip also impacts emotional contagion and is endemic in high-stress environments like the OR, having detrimental effects on the team, generating hostility and disrupting productivity.³⁵ Providing training in conflict resolution and negotiation can promote workplace civility and curb negative gossip.³⁶

System processes affecting the OR are constantly evolving to maximize efficiency and cut costs.³⁷ Some team members felt dissuaded from bringing up concerns, reporting that their ongoing feedback was not reflected in policy changes and therefore not valued. The ability to report concerns is a professional duty, but organizations must ensure that feedback is well received and supported by policies.^16,38 This requires organizational support and an environment that maintains a culture of respect, demonstrates concern for team members’ well-being, and acknowledges their contributions.³⁹ Further, the process through which to report incidents can be a barrier, for example, if team members are not trained on how to use the reporting system or the system is difficult to navigate.⁴⁰

Surgeon influence on psychological safety in the operating room

All participants agreed that as team leaders, surgeons set the tone of the OR. The behavior of leaders has been demonstrated to be a major influencer of psychological safety, and specific behaviors, such as ethical leadership, trustworthiness, inclusivity, and change responsiveness, have been found to promote a psychologically safe environment.⁴¹ Further, team members are highly attuned to their leader’s actions, which can shape their own perceptions of appropriate behavior.⁴² As such, surgeons substantially influence psychological safety and influence the behavior of the team, for better or for worse.

Most surgeons acknowledge their leadership role in the surgical hierarchy, the responsibility of setting an example, and their influence on the team. As previously discussed, team members experience higher levels of psychological safety under the guidance of leaders who are supportive, accessible, and receptive to new ideas.²⁶ Leader inclusiveness, described as actions or words by leaders that demonstrate an appreciation or invitation for team member contribution, promotes psychological safety and team member engagement and can establish a climate of mutual respect across the surgical hierarchy.⁵ Further, surgeons and other leaders in the OR can reduce perceived barriers to discussion and promote team learning by making themselves approachable and available to the team.⁴³ Additionally, surgeons can normalize open team discussions of prior failures and error-reducing strategies, converting human fallibility into a positive agent for change.³² Seeking regular feedback from the team may also encourage ongoing participation and signal to team members that their opinion is valued.⁴⁴

Limitations

As with any study, our study has limitations. We omitted the responses from our OR nurse participant to protect confidentiality; thus, we cannot report on perspectives from the circulating nurse’s point of view. Participants were recruited from one academic institution, and the experiences captured may not be representative of those in other medical settings. Participants volunteered for the study and many were interested in psychological safety, which could be self-selection or social-desirability bias. Sponsor bias was present given one of the investigator’s positions as a surgical resident and having existing relationships with some of the participants. Further, one of the study’s co-investigators is the chair of surgery at the study institution, and responses may have been influenced by that role. Lastly, we identified that confirmation bias could be at play due to our beliefs and experiences. As such, we looked for explicit statements rather than implied language from our participants.

Conclusion

Changing the culture of safety can be a difficult task, but through our study, we identified a strong desire for change from all surgical team members. Focusing on the themes we identified will help lay the groundwork to improve psychological safety in the OR. Finally, psychological safety is determined on a personal level and should not be assumed. Thus, asking questions regarding psychological safety engages and empowers team members, creating a positive work environment, resulting in safer and more efficient patient care, camaraderie, and job satisfaction.