The purpose of this study was to use a questionnaire methodology to obtain information on attitudes to a surgical checklist as administered in an Irish hospital. There would appear to be considerable variability in the implementation of the checklist and evidence that there may be a lack of rigour in its application.
Although it is positive finding that the checklist is being used, a lack of rigour in it’s application could lead to a false sense of security, and actually compromise safety and teamworking [15]. A particular area worth highlighting is the low levels of compliance with the ‘time out’ prior to surgery. The lack of adherence to the ‘time out’ has been identified as an issue in other studies. In a survey of Irish surgeons it was found that only 7.3% of surgeons stated that an adequate pre-operative team brief was frequently conducted [16].
Although this might not be expected from the reported levels of compliance, the overall attitudes towards the checklist from the respondents were overwhelmingly positive. This finding is consistent with other studies examining attitudes towards a surgical checklist [5, 7]. Nurses are the most supportive members of the theatre team for the use of the checklist. Other studies also imply that nurses are particularly positively disposed to the checklist as compared to other theatre personnel [17].
Barriers to the use of the checklist
Likely due to the fact the nurses have the responsibility for completing the checklist; they are significantly more sensitive to the barriers to completing the checklist than surgeons and anaesthetist. In particular, nurses believed that the requirement for signatures, lack of time, and assertiveness of staff were barriers to the completion of the checklist to a greater extent than surgeons or anaesthetists. Previous research in the operating theatre has found that nurses are more sensitive to issues of poor teamworking that surgeons or anaesthetists [18]. It has also been reported elsewhere that the steep hierarchy of the surgical team serves as a barrier to nurses being checklist coordinators, despite the fact that nurses have taken on the responsibility of ensuring consistent use of the checklist [17]. Commonly mentioned additional barriers provided by participants in the current study included: issues with the implementation of the checklist itself, poor teamwork, and the timing of when the checklist is carried out.
The timing of when the checklist is completed would appear to be a particular problem for anaesthetists. The checklist tends to be completed during a periods of high workload for the anaesthetist prior to surgery. Therefore, they are not able to focus on what is happening with the checklist. All of the open-ended responses on barriers concerned with the poor timing of the completion of the checklist were made by anaesthetists. Other research has also found timing to be an issue [17], and that checklists can create inter-professional tensions as a result of factors such as when the checklist is completed [19].
Recommendations for improving checklist compliance
Although the recommendation for improving checklist compliance are based upon the findings from the current study, they draw upon the broader literature discussing the implementation of surgical checklists. Therefore, these recommendations have relevance to other hospitals in which the WHO surgical checklist, or a local adaptation, have been implemented.
Need to involve all members of the theatre team in the checklist process
All members of the theatre team must be involved in the checklist procedure such that it is a true multidisciplinary intervention. Although anaesthetists have been acknowledged as the leading medical specialty in addressing issues of patient safety [20], in the current study their attitudes towards the application of the checklist were less positive than those of surgeons or nurses. It is recommended that discussions are held with anaesthetists in order to identify a time in which they are able to be involved in the checklist process. It is suggested that the checklist should be completed prior to the anaesthetising of the patient. In some cases this would have the added safety benefit of allowing the patient to be part of the checklist process.
Demonstrated support for checklist adherence from senior personnel
Giving the job of initiating the checklist to the circulating nurse reduces the likelihood of diffusion of responsibility whereby a person is less likely to take responsibility for action or inaction when others are present. However, the circulating nurse must be supported in this role by other members of the theatre team- particularly those in more senior positions. There is also a need to support the period of ‘time out’ to allow the checklist to be completed, and ensure that all members of the theatre team are engaged in the process.
In the current study, although the majority of the respondents believed that management support the use of the checklist, 10% of the open-ended comments identified a lack of senior support as a barrier to the use of the checklist. It is suggested that clinicians in a Medical Director position need to set the tone for this senior support through ‘safety leadership walkarounds’ in which they help champion the consistent use of the checklist [15]. For example, visible leadership has been found to be the most important factor in implementing teamwork training techniques and principles in a healthcare setting [21].
On-going education and training
Training has been found to raise the frequency in the implementation of surgical checklists from 8% to 97% [22]. However, there is a need for continued reinforcement of safety initiatives such as the implementation of the checklist. A one-off training programme will have limited effectiveness. In a study carried out in a French hospital the frequency in the implementation of the checklist dropped from 88% to 76% in the first year of use [10]. It is recognised that opportunities for training are limited, and not something that the respondents to the questionnaire in the current study generally felt was required. However, it is recommended that each department has a designated ‘checklist champion’ who is responsible for providing training and reinforcing the use of the checklist in theatre.
Address the barriers to the implementation of the checklist
Finally, it is suggested that there is also a need to re-examine the checklist itself. In the version of the checklist used in this study there was a requirement to obtain signatures from the surgeon, anaesthetist, and circulating nurse. In particular, the nurses recognised this as a barrier to the completion of the checklist. It could be argued that if the circulating nurse is responsible for the task, only his/her signature should be necessary, with the surgeon and anaesthetist verbally confirming it has been completed. Perhaps the requirement for signatures could be re-examined, and used as a ‘carrot’ to encourage more rigorous use of the checklist. To illustrate, pilot a version of the checklist without the requirement for all three signatures, if compliance improves with this adapted version of the checklist then it will be adopted permanently.
Study limitations
There are two main limitations to the research reported in this paper. Firstly, as the paper reports attitudes of theatre staff from one hospital to a specific locally adapted version of the WHO surgical checklist it could be argued that the findings are not generalizable. Although the checklist examined in the current study differs from the actual WHO surgical checklist, the overall goals of ensuring that it is the correct patient, for the correct surgery, on the correct site are common to both. Moreover, regardless of the exact steps in the checklist issues of timing, senior support, assertiveness, acceptance, and adherence are common issues identified with surgical checklists [9, 10, 17, 23], as well as the use of checklists in other healthcare domains [24].
The second limitation is the response rate. Although the response rate is not atypical of questionnaire studies of this type, [7, 16, 25] the findings should be regarded with some degree of caution. Nevertheless, the data were not inconsistent with other studies of attitudes towards surgical checklists [7, 9, 10, 17, 19], and the study was broadly representative of the personnel that work in theatre.