Most interview respondents indicated that the WHO SSC was not used consistently for all surgical operations performed by teams working at UTH, despite the MoH endorsement of the SSC as standard practice.
Barriers to SSC utilisation
Respondents provided detailed accounts of the reasons why the checklist was not integrated as a standard procedure before each surgery performed. These barriers to SSC utilisation are presented in the following sections according to the three overarching categories: organisational factors, systemic factors and team factors.
Surgical Team- Inconsistent training and lack of supervision
Study participants reported that, after initial training, there had not been further training opportunities for new staff in order to reinforce consistent use of the SSC at UTH. This would have been beneficial in particular for newly hired staff as well as staff rotating from other departments. As a result, the checklist was not followed in the operating rooms run by new or rotating staff (mainly emergency OTs). In these OTs, medical and nursing senior staff who had undergone training rarely conducted routine checks to monitor and reinforce the use of the SSC. Lack of adequate and regular training for all members of the surgical team consequently led to a poor understanding of the purpose and benefits of the SSC, or misbeliefs about its purpose.
Lack of ownership and management structures
Interviewees stated that poor ownership of the SSC initiative, among other reasons, was because some of the senior staff did not attend the initial SSC training. Consequently, these staff members failed to fully grasp the value of the SSC and perceived it as an unnecessary imposition.
(MD6) “Yes, very senior staff, especially some medical doctors who have been operating for years without any recorded AEs/complications, may think that the tool is being imposed on them by the westerners, and feel it is not important and won’t utilize the tool. If they are trained and shown actual data from other countries they may change and they would do well to be part of the adverse events audit.”
Study participants also indicated that there was no supervision nor any formal oversight measure in place to ensure consistent use of the SSC at UTHs operating theatre department. Due to the result of a flawed introduction of the SSC, the main reported issue was the lack of a designated person in-charge of ensuring the SSC’s utilisation. This resulted in lack of accountability of members of the team in instances of non-adherence.
(AP1) “Where I work from I rarely see among other leaders, consultants to check on how the junior medical doctors are working. In short there is no leader figure ensuring that the SSC is utilized consistently at UTHs, despite the fact that there are a lot of new staff who haven’t yet been trained on the application of the SSC, and who find it difficult to fit in.”
Non-availability of resources
According to study participants, the often-occurring non-availability of essential surgical equipment and supplies at the time of an operation had an indirect, negative impact on the use of the SSC. All participants consistently indicated that in some instances, a considerable amount of time was spent on searching for and borrowing resources from other theatre rooms, or sending faulty equipment for repairs, reflecting challenges in the management of the OTs.
This delayed the operations and took away some of the actual surgery time, which could only start when all required resources were present in the operating room, with a knock on effect on the surgical list. As a result, in these instances the surgical teams tried to make up for lost time by skipping the SSC.
(MD6) “You would want to be out of theatre as soon as possible”...and therefore, you end up not utilizing the SSC. This is because the challenges with the availability of material resources are huge and come in the form of less numbers or nothing at all to use for most times, such as equipment, instruments, consumables and there are no comfortable well ventilated theatres.
Staff workload and fatigue
Additionally, there was a reported widespread shortfall of essential surgical staff such as nurses, anaesthesia providers and support staff to cover each operating room at any given time. Participants reported that non-specialized nurses (non-perioperative) were often allocated to work in the surgical departments to fill these gaps. The non- specialist nurses were usually given on the job orientation to be able to work in the operating theatres, but the use of the SSC was mostly not routinely covered during this orientation, because its use had not been mainstreamed into routine practice. Further, the use of the SSC was not adapted to the local environment at the time of the study.
(PN9) ...staffing is also a huge barrier because you have for example…. [There are] very few nurses [available] against all the operating rooms that are open, the recovery room and theatre sterile supply unit to prepare surgical sets continuously. You end up having the medical doctors conducting certain operations alone, while the nurses are scrubbed up in the other operating rooms and you find that the SSC will not be used.”
Inadequate human resources were also reported to contribute to high workload and fatigue of surgical teams, particularly the ones handling emergency operating rooms. Respondents stated that, these staff shortages coupled with lack of the SSC protocols to enforce utilisation before every surgical operation and meant that when clinicians were overwhelmed, they skipped the SSC use at the time of operation. This was in instances where the printed out copies were misplaced. As reported, this in turn resulted in failure to conduct adequate handovers of cases at the end of shifts, which led to recording incomplete medical details about patients undergoing surgery now and then.
(PN9) “...you have the surgical ‘firm’ of medical doctors ‘On Call’ and other firms rushing in their emergency cases and adding to the already prevailing high workload and also the nature of the urgency of doing these cases. If not reminded, due to the workload the medical doctors and support staff can actually work without using the SSC”
The absence of a standard operating procedure to guide the work of the surgical teams and an assigned champion to ensure implementation of the SSC resulted in its inconsistent application. Rather than following a team approach, participants reported excessive influence of individuals whose behaviour and attitude could either drive or hinder the use of the checklist. The decision whether to implement the checklist or not was linked to individual team members’ attitude towards it, and more broadly, with their professional attitude and work ethics. This was due to several reasons as described below:
Hierarchical surgical team structure
Participants reported that the structure of surgical teams at UTH was highly hierarchical. Within this structure, the surgeon was regarded as having a central, decision-making role, while the other team members (anaesthesia providers and nurses) were perceived to be in a subordinate position. This power dynamics within the team meant that the attitude of team members at the top of this hierarchy towards the use of the checklist usually prevailed over others and guided the manner in which decisions to use the checklist were made. Respondents in ‘lower’ positions in the team indicated that often it was they who suggested following the SSC, but in some instances, the surgeon leading the operation was not supporting its use.
(TSS13) “Sometimes you find that you need to remind the medical doctors as junior staff to utilize the SSC, like ‘let’s do this …let’s do this’. However, they would not want to apply the SSC and you then just start conducting the surgery. Eventually as a junior staff, you mostly follow what senior staff take on board (...) with regard to keenness towards utilisation of the SSC.”
The perceived seniority had also an effect on the roll out of the initial training in the use of the SSC offered to UTH surgical staff in 2015.
(MD8) ‘’Some of the senior staff did not attend the training due to various reasons. This meant that they missed knowledge empowerment. It is an issue of specific team members not wanting to attend training that brings and mixes the entire surgical team in one room.”
The above quote provided an example of how the hierarchical and surgeon-centred structure of the surgical team played a role in how the SSC training was perceived. According to the interviewee, senior staff did not want to receive training from a person who they considered junior to them (a nurse).
Negative attitudes towards the SSC were also manifested in the way the checklist was perceived by some members of the surgical team. Participants reported that their seniors often ‘rushed’ to proceed with a case, seeing the SSC as an unnecessary ‘delay’. In some instances, such behaviour made the junior staff reluctant to further suggest using the SSC for subsequent cases, because they had received no support towards the utilisation processes. This attitude of senior members also resulted in a lack of team approach to the use of the SSC.
(AP1) The only problem that I have mentioned even before, is that the other team members think anaesthesia providers delay when signing in the patient and would then force the use of the SSC.
The interviewed senior surgeons, who were supportive of the use of the SSC, also indicated the same behaviour. They acknowledged that their peers’ dismissive attitude had negative consequences for the team dynamics and ultimately led to the poor utilisation of the SSC.
(MD6) ‘I think mostly it is a misconception by seniors that surgery revolves around them and not the other members of the surgical team. It is important to respect the opinions of each member of the team and discourage intimidation of junior team members for them to feel part of the team.’
The reported hierarchical relationships were attributed to occasional occurrence of ‘intimidating’ behaviours, where some junior staff were told that they ‘want to waste time’ after they had suggested utilisation of the SSC prior to the operation. This in turn further deteriorated the already poor team dynamics and reinforced the hierarchical structure. The effect of this reported ‘intimidation’ behaviour was illustrated in the following way:
(TSS14) “Like to me, personally, I do try to engage seniors when they do something I perceive is not in line with [good] practice such as utilisation of the SSC and their responses vary as individuals. I think that is why we have even forgotten a lot about the SSC use, because this affects our confidence levels.”
Poor work ethics
Participants also reported that the utilisation of the SSC was undermined by the poor work ethics of some of the team members. One of the issues identified by respondents was the late reporting for work, which led to failure to form surgical teams on time and delayed the start of the operation. To compensate for the time lost, the surgical teams proceeded with surgery without applying the SSC. This had a knock-on effect on other surgical teams operating later on in the day. A delay caused by one team could derail the whole operating room schedule, forcing the next team to work under unnecessary time pressure.
(MD5) “Some of the barriers regarding non-utilisation of the SSC are that we are supposed to start surgery at 08.00 hours but because of the late coming by some team members we normally start work at about 09.30 - 10.00 hours... then they would want to catch up with the lost time and as such omit SSC use.”
Enablers to SSC utilisation
Identified enablers corresponded to the barriers presented above. Firstly, training on SSC for all new surgical staff members was deemed necessary before rotation to the theatre rooms from other departments. Refresher training for all existing staff was also suggested as a way to improve adherence to the checklist.
(MD7) “It is better to keep training all new staff on SSC utilisation and I think there is a need to plan on our calendars that we need to regularly hold workshops to update our knowledge. The preoperative phase is equally very important and there is a need to also empower surgical ward nurses with skills on pre-operative preparation of patients and include them in lessons about safe surgery.”
The respondents suggested that a formal system already put in place by the Ministry of Health, termed Service Quality Assessment (SQA), could improve SSC utilisation. This involved the use of a tool to monitor compliance that needed to be reinforced with specific funds allocated to this purpose, in order to enhance SSC utilisation and accountability in the operating rooms at UTH. It was also noted that, implementation champions would be needed to ensure consistency in the use of the SSC. Such champions would put in place a mechanism for constant feedback to the theatre teams and facilitate communication with hospital management. The champions would also ensure that compliance with SSC use is measured and documented. Additionally, setting up teams to periodically evaluate the SSC utilisation in view of monitoring patient safety was also seen as an essential component of standard surgical practice.
(PN9) “Another way to enhance SSC utilisation would be for management to bring on board funded initiatives to strengthen monitoring of the SSC utilisation, because it will then make the staff know that they have to be answerable to someone.”
There was a reported need to adapt the SSC to the UTH’s local setting and systems in order to enhance application in the operating rooms. Participants suggested that a review of how the SSC was implemented would help to adapt it better to the local setting, taking into account the handling of emergencies and the deficiencies in the human and material resources, as envisaged in the WHO checklist.
Additionally, respondents reported the need to ensure more visibility of the SSC tool by displaying it in the OT room in a visible place. They stated this would act as a reminder for the entire team, especially the new staff, to follow the steps during the execution time in the operating rooms.
Participants made a number of suggestions for improving the overall management of the surgical theatre, including surgical team functionality, division of roles and responsibilities and accountability at the workplace, in order to overcome challenges related to negative attitudes and poor work ethics.
(AP2)- “What we need first and foremost is agreeing on the start time for procedures. Basically the whole team should start together instead of what is happening currently, where at times some team members just come into theatre along the way, meaning their input won’t be known and they miss the briefing and ‘sign in’ of the SSC process. Conducting the briefing sessions in every operating room to discuss among other issues the SSC use is very important.
Senior staff also need to delegate leadership roles to juniors for them to learn the skills but remain answerable for the juniors’ tasks instead of what happens where sometimes the seniors usually take up a lot and fail to do important practices like SSC utilisation. Now one person does everything alone then safety is compromised. It is equally good to conduct elaborate handovers of cases at the end of a work shift too.”