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Pre-surgery briefings and safety climate in the operating theatre
  1. Jon Allard1,
  2. Alan Bleakley1,
  3. Adrian Hobbs2,
  4. Lee Coombes3
  1. 1Institute of Clinical Education, Peninsula College of Medicine & Dentistry, Universities of Exeter and Plymouth, Truro, Cornwall, UK
  2. 2Royal Cornwall Hospital, Truro, Cornwall, UK
  3. 3Institute of Clinical Education, Peninsula College of Medicine & Dentistry, Universities of Exeter and Plymouth, Plymouth, Devon, UK
  1. Correspondence to Jon Allard, Institute of Clinical Education, Peninsula College of Medicine & Dentistry, Universities of Exeter and Plymouth, The Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall TR1 3HD, UK; jon.allard{at}


Background In 2008, the WHO produced a surgical safety checklist against a background of a poor patient safety record in operating theatres. Formal team briefings are now standard practice in high-risk settings such as the aviation industry and improve safety, but are resisted in surgery. Research evidence is needed to persuade the surgical workforce to adopt safety procedures such as briefings.

Objective To investigate whether exposure to pre-surgery briefings is related to perception of safety climate.

Methods Three Safety Attitude Questionnaires, completed by operating theatre staff in 2003, 2004 and 2006, were used to evaluate the effects of an educational intervention introducing pre-surgery briefings.

Results Individual practitioners who agree with the statement ‘briefings are common in the operating theatre’ also report a better ‘safety climate’ in operating theatres.

Conclusions The study reports a powerful link between briefing practices and attitudes towards safety. Findings build on previous work by reporting on the relationship between briefings and safety climate within a 4-year period. Briefings, however, remain difficult to establish in local contexts without appropriate team-based patient safety education. Success in establishing a safety culture, with associated practices, may depend on first establishing unidirectional, positive change in attitudes to create a safety climate.

  • operating room
  • surgical error
  • safety
  • teamwork
  • patient safety
  • safety culture
  • surgery

Statistics from

Background and objectives

While technical medicine has achieved a high standard,1 the non-technical aspects of medicine (communication, teamwork) are not practised so well by doctors,2 who continue to act as leads for clinical teams, and in surgery in particular, shape the activities of teams. In the UK, National Health Service hospital trusts report almost 100 000 patient safety incidents annually, resulting in the death of over 2000 patients.3 The operating theatre (OT) remains the most common site for incidents,4 with errors occurring in up to 14.6% of surgical patients.5 With 50% of incidents potentially avoidable,6 health services have not responded quickly enough to lessons learnt from error avoidance in other safety-critical industries,7 which are far safer now than 20 years ago.8

Despite significant cultural differences, the aviation industry has been used to provide a model for establishing safety practices in temporary, or ad hoc, teams, commonly found in the OT.9 Both are high-risk, stressful environments,10 in which multi-professional teams interact around technologies, while threats emerge from a variety of environmental sources.11 Team members must monitor and act on multi-sourced information and work collaboratively to ensure safety.12 Early air accident investigations found that non-technical skills, including communication and situation awareness, were essential if teams were to respond appropriately to emerging threats and ensure safety. These skills are now seen as imperative during all high-risk team activity, including surgery.13

Safety-critical industries have introduced evidence-based practice changes, including education in human factors, as part of wide-reaching organisational reform to improve standards.14–16 In the OT, such practice changes have not occurred despite the acceleration of surgical technology and complexity17 18 and evidence that team-based initiatives improve patient outcomes.19

In aviation, crew resource management (CRM) has standardised team working and communication.20 Barriers between professional workgroups can be eroded21 and collaborative team working improved.22 There is no direct, definitive, data-driven link between CRM and decreased aviation error, but its pivotal role in improving passenger safety is widely accepted.17 23

With the absence of team training in the OT, non-technical skills are simply learnt ‘on the job’.9 Teams may subsequently display the behavioural characteristics of pre-CRM flight crews.24 Poor communication contributes to almost half of incidents,25 with professional boundaries,26 hierarchy,27 poor team working,28 and a lack of openness to discuss error29 acting as barriers to improving patient safety. The potential for CRM-derived practices to improve non-technical skills,30 and to reduce risk during surgery, are regularly cited,11 23 but financial, practical and cultural barriers are complex and substantial.31 32 In particular, there is a lack of structure to enable differing professions and specialities to learn together.

In this article the authors focus on a core, but adaptable, component of CRM—pre-flight briefings.33 Briefings are designed to prepare teams to counter threats and minimise error potential. Formal and informal protocols, checklists, scenario planning, and open team discussion are commonly used. Lines of communication are opened and clarity is provided as the team prepares for the flow of procedures and forms potential contingency plans, establishing a common cognitive model or situation awareness.33

In North America, pre-surgery briefings have been shown to reduce communication errors,34 and potential for incidents.35 36 Team communication and cohesion improve,37 38 inter-professional insight is enhanced,20 and OT staff report increased confidence when speaking out about potential problems.26 39 Improvements in perception of safety and safety climate have also been reported following briefing trials.20 35

At a large, acute, general teaching hospital in the UK, pre-surgery safety briefings have been introduced and developed by several OT teams since 2003. Some practitioners are regularly involved in briefings, whereas others have limited exposure, largely depending on the idiosyncratic choices of surgeons. A snapshot questionnaire found that staff recognise the potential of briefing to improve patient safety.40

This study investigated whether exposure to briefings is related to perception of the presence of a positive safety climate, using data from a validated Safety Attitude Questionnaire (SAQ). Attitude to ‘safety climate’ is used in the aviation industry as an integral indicator of safe team practice and a predictor of individual performance.29 Attitudes identified as playing a role in air accidents and incidents can be measured,22 and such attitudes, collectively and unidirectionally, form value climates. In turn, these value climates can shape behaviour. Without establishing a strong climate (values), culture (performance) changes are unlikely to occur.41

This study builds on previous research by focusing on OT practitioners' reports of quality of ‘safety climate’ during a 4-year period, rather than a ‘one-off’ capture, such as perception of risk before and after a briefing trial.

Briefings across the hospital trust

The Theatre Team Resource Management (TTRM) project was initiated in December 2002 with more than 300 OT personnel.41 The project involves a complex, longitudinal, prospective collaborative enquiry.42 The study has shown improvement in teamwork, with a shift from multi-professionalism to inter-professionalism in model teams,43 an indicator of potential patient benefit.44 Box 1 provides a summary of the TTRM project.

Box 1

Summary of the Theatre Team Resource Management (TTRM) project

The study was implemented using principles associated with crew resource management43

  • Introductory human factors 2-day seminar for identified ‘champions’ and ‘sceptics’

  • One day human factors symposium, with follow-up 1-day seminar, for all theatre staff and managers

  • Introduction of close call (near miss) reporting with internal feedback

  • Introduction of briefing before surgery

  • Introduction of debriefing after surgery

Publications report on the theoretical and methodological justification for the large scale study,41 as well as the impact of the TTRM intervention across the hospital trust.26 40 42

TTRM was introduced into two operating theatre complexes within a 12-month period.

Briefing was introduced in conjunction with debriefing (the subject of a separate paper). OT teams have found briefing easier to adopt than debriefing (often perceived as superfluous).40 Briefing methods include:

  • formal checklist;

  • informal ‘corridor’ and ‘coffee room’;

  • ‘horizon’ (the night before);

  • ‘cumulative’, such as ‘whiteboard’ briefs (issues noted as the list unfolds).

Contexts include ad hoc teams, teams with more or less continuity, and with different kinds of surgical foci.40


Outcome measures are drawn from the SAQ, adapted for the OT, and anglicised. The SAQ is widely used in high-risk settings for organisational benchmarking purposes.45 A number of similar measures have emerged46 but the SAQ is the only safety climate measure with favourable scores that have been associated with fewer medication errors and lower patient mortality rates.29 45

Analysis focuses on the domain score ‘safety climate’, and an independent statement: ‘Briefings are common in the OT’ (item 14). ‘Safety climate’ is one of six domains from the full SAQ, and includes six statements (items). Scores for the six statements are combined to give a ‘safety climate’ score (box 2). This score provides a ‘perception of a strong and proactive organisational commitment to safety’.47 A neutral safety climate score (with an average response to each question of 3) is 18. Scores above 19 indicate a positive or favourable safety climate.

Box 2

Safety Attitude Questionnaire


Each statement requires a response on a five-point Likert scale: disagree strongly (1 point)/disagree slightly (2 points)/neutral (3 points)/agree slightly (4 points)/agree strongly (5 points). The lowest possible safety climate score is 6 points (with 30 the highest). Safety climate is scored against a single briefing uptake statement (item 14 in the SAQ), also answered on an identical five-point Likert scale (1 disagree strongly–5 agree strongly)

The items used from the ‘safety climate’ domain of the SAQ are:

  1. I receive appropriate feedback about my performance

  2. The culture in the operating theatres here makes it easy to learn from mistakes

  3. Medical errors are handled appropriately in this hospital

  4. I am encouraged by my colleagues to report any patient safety concerns

  5. I would feel safe being treated here as a patient

  6. I know the proper channels to direct questions regarding patient safety

A ‘safety climate’ domain statement was rejected from this analysis:

1. Personnel frequently disregard rules or guidelines

A pilot study showed that the wording created misunderstanding because it was not immediately associated with patient safety, but with management interference over staff autonomy (particularly surgeons). Removal of this question does not however affect the statistical significance of the study findings

The exposure to briefing statement (item 14) is:

14. Briefings are common in the operating theatre.

Response rates

  • Round 1 (year 1): 2003 (73%—221 respondents from 302 staff)

  • Round 2 (year 2): 2004 (68%—224 respondents from 332 staff)

  • Round 3 (year 4): 2006 (53%—152 respondents from 289 staff)

SAQ returns remained representative of personnel groups and interpretable.

OT practitioners were asked to complete the SAQ on three separate occasions—in 2003, 2004 and 2006. TTRM interventions were introduced across two operating theatre complexes between round 1 and round 3. All completed questionnaire results were amalgamated into a single SPSS database (n=597). A one-way analysis of variance was used with item 14 as the outcome variable for analysis of the relationship between item 14 and ‘safety climate’ score. Prior to this test, an investigation into the independence of repeated responses from candidates across time was carried out. This was to ensure the validity of amalgamating the dataset and that any subsequent analysis and conclusion would be reliable. Evidence supporting the amalgamation of the dataset can be seen in table 1.

Table 1

The amalgamated SPSS database


Practitioners reporting a positive ‘safety climate’ are more likely to agree with the statement ‘briefings are common in the operating theatre’ (table 2). This relationship is illustrated in figure 1.

Table 2

Safety climate score and exposure to briefing

Figure 1

Briefings are common in the operating theatre.

Increase in safety climate was found to show a significantly linear correlation to respondents' score for item 14 ‘briefings are common in the OT’ (means test for a linear component is significant at p≤0.01). Using a general linear model—‘univariate analysis’—item 14 was shown to explain a significant amount of variance in safety climate (p≤0.01) (table 3).

Table 3

Univariate analysis of variance: test of between-subjects effects

Both safety climate and reported exposure to briefing increased marginally during the three rounds of SAQs but neither trend was significant, with safety climate increasing from 20.04 to 20.41 and item 14 from 2.49 to 2.56. Uptake of briefings has been sporadic and inconsistent across OTs within the 4-year period as the TTRM interventions have been introduced to staff. It is the influence of surgeons that determines whether teams sustain or abandon briefing methods.40 Despite this sporadic uptake of briefings over the course of this study, on each occasion that staff have completed the SAQ there has been a significant relationship between respondents' agreement with the statement ‘briefings are common in the OT’ and ‘safety climate’ score (table 4). The relationship indicates that staff who report that they are engaged in regular briefings score safety climate higher.

Table 4

Univariate analysis of variance for each Safety Attitude Questionnaire (SAQ): test of between-subject effects

Discussions and conclusions

The significant relationship between ‘safety climate’ and exposure to briefing indicates that those staff engaged in regular briefings during the study's 4-year period also report perception of a positive safety climate. Respondents were not asked directly about their perception of the relationship between briefings and safety, reducing the potential for practitioners to report what they believed researchers were looking for. The study confirms a previously illustrated relationship between briefings and ‘safety climate’.20 35

The findings carry an important educational message. At the hospital trust studied, common arguments voiced by practitioners who abstain from briefings were that briefings will not improve patient safety or that optimal positive safety climates already exist. Our research contradicts these local perceptions.

When the findings show a correlation between exposure to briefings and favourable safety climate, they do not indicate that behaviours (practices) for patient safety will change. A unidirectional change in attitudes within a culture, forming a shift in values that inform and shape practices, is necessary. But this is difficult to achieve. In aviation, briefing was introduced in conjunction with extensive ‘teamwork’ training. Now, compulsory briefing is welcomed, with flight crews viewing non-technical skills as integral to safe crew behaviour.32 33

Pressure to brief before surgery is increasing. In 2007 The Royal College of Surgeons in England recognised the moral obligation of surgeons to have briefings as part of a responsibility to patient safety.28 In 2008, front-page broadsheet exposure48 accompanied the arrival of the WHO briefing guide.49 Recently this checklist has been shown to improve safety significantly,50 amid further press exposure. In the absence of appropriate education in teamwork, top-down pressure to brief may not, however, be the best way to ensure uptake. Medical culture is traditionally conservative and notoriously difficult to change. ‘Top-down’ improvements are often seen as correcting perceived problems by episodic management interference in clinical autonomy, and may be rejected.20 Surgeons, acting as team leaders, characteristically cherish autonomy,51 and reject team-based, collaborative practices. Some surgeons readily embrace change, but many are offended by the notion that someone is ‘going to tell me how to run my operating room’.33 In aviation, shifting the captain's role from that of autocrat with earned status to that of a team player, as required in briefing, was an arduous process.24 This is mirrored in healthcare.

Paradoxically, there is no guarantee that briefings heighten patient safety. If done poorly, briefing can reinforce professional division, create tension and mask knowledge gaps, often occurring when individual team members treat the process as unimportant or burdensome,52 and this explains why briefings (and similar safety practices) are sometimes tried, abandoned and then ridiculed by surgeons in particular. This highlights the importance of first establishing a positive climate for practice change through unidirectional collective attitude change.

In the OT, an appropriate team-based safety climate for effective briefing is not always evident when doctors and nurses show different communication styles,20 and opinions about ‘communication’,53 and stereotype the roles and cultures of ‘others’.54 Introducing a prescriptive checklist into such a culture is not necessarily conducive to better safety for a variety of reasons, including doctors' and nurses' differing perceptions of, and levels of adherence to, guidelines and protocols,55 which in itself can lead to tension and mistrust.56

Encouraging team ownership of briefing models through collaborative enquiry42 has, in our study, engaged a significant number of teams, with over half of staff regularly exposed to some form of briefing.40 Teams have had the opportunity to tailor briefing methods to local or specialty contexts. Briefings are now initiated by a variety of staff. The authors are modelling the emergence of non-hierarchical team dynamics through a shift from monological to dialogical communication, and this can be established through briefing. Where this shift engages teams collectively, safety climate will improve and patients will benefit.44

Study limitations

There are two main limitations to the study. First it is confined to changes in attitude, and then climate, but not observed changes in performance. No indication of causality is claimed. Second, although there is a reduction in the response rate (from 73% to 53%), the latter is still representative of the surgical directorate population, with the same cross-staff group constitution. The reduction was probably due to habituation and failure to prompt staff to complete questionnaires. The overall response rate for the amalgamated dataset was, nevertheless, 64.7%, whereas the average response rate for SAQ returns for healthcare organisations is 67%.46 The amalgamated dataset does not identify or account for scores of practitioners who completed more than one SAQ.

In addition, the study findings do not account for any other quality and safety process interventions that may have been introduced in OTs during the study period.


The TTRM study has received funding from the Strategic Health Authority, National Patient Safety Agency, National Audit Office, and the European Social Fund, to whom we are grateful. We would also like to thank Colin Pritchard for help with statistical analysis and Bryan Sexton for collaboration in producing an anglicised version of the SAQ.



  • Competing interests None declared.

  • Ethical approval Ethical approval was sought and granted from the Ethics Committee of the hospital Trust, where the study was treated as an audit of an educational intervention.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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