Tuesday, June 14, 2016

INTRAOPERATIVE LEADERSHIP SKILLS: follow up conversation with Sarah Henrickson Parker PhD

A few months back I was fortunate to speak with Dr. Caprice Greenberg and Dr. Steven Yule regarding their paper in JASC on leadership styles and team behavior in the operating room           (http://crisislead.blogspot.com/2016/03/leadership-styles-in-surgery-that-serve.html,  http://crisislead.blogspot.com/2016/03/leadership-styles-and-team-behavior-fu.html).

Both urged me to contact Sarah Henrickson Parker regarding the background studies which paved the way for that article. Dr Henrickson Parker was the lead author for several papers published by this group (including well-known names of Dr. Yule, Flin and McKinley).  Fortunately, Dr Henrickson Parker was kind enough to take the time to chat with me on this topic.

It had been recognized that surgeon non-technical skills including leadership, can be traced to success or failure of team mechanics, with the potential increase in risk for patients after poor leadership. In 2006 Dr. Yule, Flin et al, at the University of Aberdeen, published their Non-technical Skills for surgeons manuscript. In 2012 the same group observed teams and assessed parameters such as guiding and supporting, communicating and coordinating, and task management. They used this information to refine their assessment process. This 2012 study was one of the first studies to recognize that surgeons often spoke to the room at large rather than addressing specific people.  The net results of not addressing particular team members were delays and the need to repeat the request (both stress inducers). The study was noted to be limited by the fact that only one observer was able to be present during the procedures meaning some aspects of care could have been missed which prompted them to assess these groups using videotaping.

            In 2013, they refined their Surgeon leadership Inventory which paved the way for assessment of surgeon leadership performance intraoperatively using an objective based rating system. This was one of the initial studies assessing non-technical skills in surgeons. Their measures included:

  • Maintaining standards
  • Making decisions
  • Managing resources
  • Directing
  • Training
  • Supporting others
  • Communicating
  • Coping with pressure- flexibility and ability to change plans
                Next in 2013, their group assessed videos of surgeons to monitor their effectiveness in managing unanticipated events in the operating room. They developed two hypotheses they sought to assess.
    Hypothesis 1: Surgeons will engage in more ‘leadership behaviors’ prior to a specific stage in the operation (point of no return- PONR).  Observation: While leadership behavior did not vary significantly before or after the PONR, the surgeons shifted from ‘directed leading’ to more ‘generalized leading’ where communication was focused on the resident and anesthesia predominately (that is they typically directed the resident and ignored the remainder of the room except for generalized directions).
    Hypothesis 2: Surgeons will engage in more ‘directive commands’ after an unanticipated event. Observation: In comparing non-event with event procedures, the surgeons exhibited more ‘leadership behavior’ during the event cases. Having said that, ‘supporting others’ elements diminished after an event.
    After reviewing these papers I had some questions:
  • Question: In the 2011 study you brought up an important point and a question which I wondered if you had an answer to 5 years later: "during surgery, the nurse serves as the patient's advocate, and the anesthesiologist is responsible for control of respiration and maintenance of hemodynamics stability, but the surgeon retains ultimate accountability for the care and safety of the patient. This begs the question, what is the relationship between responsibility for the patient, and leadership in the intraoperative setting?" 
  • Her response was: “No. We have not figured this out. Authority and leadership in the operating room is NOT the same thing as having responsibility outside the operating room. In the operating room leadership and authority likely does not hinge on who is responsible outside the operating room similar to trauma bay care. The person with the leadership and authority may not necessarily be the person to whom the patient is being admitted to. So in each setting leadership may vary. If you believe in HRO principles, this definitely is not the case.”
  • Question: in my conversation with Dr Yule and Dr Greenberg, they clarified that transactional and transformational Leadership models are not mutually exclusive. Can you expand on that? Answer: "During non-critical events a transformation model may serve well at the beginning of the interaction. It assures that everyone is on the same page. But during a critical event Transactional leadership typically is an initial response and then a transformational response tends to work when the task at hand is less critical- trauma is a good example. It may be impossible to engage in a transformational model immediately.

  • So can transformational leadership be valuable for leadership success under duress?
  • Yes, while in the moment transactional leadership is necessary a transformational leader will pull in the team and explain their roles

  • You say you are shifting your focus of research towards assessing response patterns of providers under stress. What is the biggest challenge you face in moving I that direction?
  • "We don’t have a handle on how one handles duress well because we don’t have the right outcome measure. Death or complications may not be the result of failure to lead under duress so we need better Behavioral and physiological measures we need to determine what impacts heads up display about your distress and how does that correlate with performance. "


Hu YY, Henrickson Parker S, Lipsitz SR, Arriga AF, Peyre SE, Corso KA, Roth EM, Yule SJ, Greenberg CC. surgeon's leadership styles and team behavior in the Operating room. JACS 2016;22(1):41-51.
Henrickson Parker S, Flin R, McKinley A, Yule S. Factors influencing Surgeons' intraoperative leadership: video analysis of unanticipated events in the Operating Room. World J Surg 2014;38:4-10. 

Henrickson Parker S, Flin R, McKinley A, Yule S.the Surgeons' leadership inventory (SLI): a taxonomy and rating system for surgeons' intraoperative leadership skills. The American journal of surgery. 2013;205:745-751.

Henrickson Parker S, Flin R, McKinley A, Yule S. Surgeons' leadership in the operating room: an observational study. Am J Surg 2012;204:347-354.

Flin R, Yule S, Rowley D, Maran N, Paterson-Brown. The Non-Technical Skills for Surgeons (NOTSS) System Handbook v1.2; University of Aberdeen. Aberdeen UK. 2006. www.abdn.ac.uk/iprc/notss

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