Study Design and Participants
This cross-sectional and descriptive study was designed and carried out with the primary purpose of adapting new PSF taxonomy for surgical setting application following the SPAR-H technique (January and February, 2020). Operating rooms of four teaching hospitals of Yazd City were the sites where the present study was executed.
Based on the opinion of operating rooms management and personnel, surgeons, anesthesiologists, surgical technologists and anesthesiology technologists are four specialist groups who participate the most in operating processes. Because of this, we have conducted our study based on the judgments of these four specialist groups.
Data collection procedure
Convenience sampling technique was employed to recruit experts from operating rooms of the participating hospitals. Age, work experience (year), gender and specialty groups represented the considered demographic characteristics of the participated experts in this study.
To capture experts' perception about the weight and the negative influence rate of the PSFs on their technical performance, a three-section questionnaire along with face-to-face interviews and interactive discussions, was employed. First section of the questionnaire was dedicated to the description of the purpose and the generalities of the whole study. Second and third sections were dedicated to the quantification of weight and negative influence rate of the PSFs, respectively.
Suggested PSF Taxonomy Design
Available Time, Stress/Stressors, Complexity, Experience/Training, Procedures, Ergonomics/ HMI, Fitness for duty and Work Processes form the PSF taxonomy of SPAR-H technique . In the literature, deficiencies like unclear definitions and semantic overlap between PSFs that may lead to double calculation of the effect of a particular PSF are mentioned [12, 13]. In the current study to overcome these deficiencies, more explicit definitions and new PSF taxonomy which are more consistent with surgical setting were suggested based on the PSF taxonomy of the SPAR-H technique.
Available time, threat stress, task complexity, experience/training, procedures, working conditions, human-machine interface (HMI), fatigue and teamwork are the nine PSFs of the suggested taxonomy for the surgical setting. Our suggested definitions for the PSFs are as follows:
Available Time: The purpose of the suggested definition for this PSF is to express the ratio between the time it takes to complete a specific task and the whole time available for completing it before any deleterious consequences emerge. Our suggested definition for the available time PSF follows Laumann and Rasmussen : Available time represents the ratio between the time it takes to complete a specific task (required time) and the time available before the consequences of failing to complete the task are realized.
Threat Stress: In the definition of stress/stressors in the original SPAR-H guideline, there is some semantic overlap with other PSFs like Available time and Ergonomics/HMI . It is stated that “one aspect of the stress/stressors PSF in SPAR-H that is not covered by other PSFs, the concept of threat stress” . Our suggested definition for threat stress is: Threatening situation is when unstable conditions or novel environmental events may cause pain, discomfort or endanger patient's life. In this situation, operating room personnel are aware that their error may seriously endanger patient's life and have negative impact on their professional status.
Task Complexity: Complexity is defined as the amount of difficulty in task performance . The SPAR-H guideline suggests 14 contributing factors to complexity. These factors considerably overlap with other PSFs, for example, “Transition between multiple procedures” overlaps with procedures PSF . In the current study, the title task complexity is suggested for this PSF to present more objective definition that does not overlap with other PSFs and represents an expression of the complexity of the task in surgical context explicitly. Six categories of task complexity were suggested for the task complexity in one review study : Goal complexity, Size complexity, Step complexity, Connection complexity, Dynamic complexity and Structure complexity. Our suggested definition follows these categories of task complexity : Task complexity refers to the degree of complexity demanding for task performance according to the complexity categories. Which means the more complexity categories there are, the more complex the task is.
Experience/Training: In the SPAR-H guideline , this PSF specially refers to the experience and training of the operators involved in task performance. In the definition presented for this PSF, only the time of experience or training is considered. While other factors like the level, frequency and type of training that are more important in the success or failure of the task performance are overlooked . Our suggested definition for Experience/training is: Experience/Training is related to possession or lack of task-related training, the frequency of task experiences in the field, the number of task-related retraining courses and the spent time between them.
Procedures: The concept of this PSF refers to the existence and use of work procedures to perform specific tasks . In nuclear power industry, a procedure has been generally defined as “a written document (including both text and graphics) that presents a series of decision and action steps to be performed by plant personnel (e.g., operators, technicians) to accomplish a goal safely and efficiently” . In the current study we have considered availability, quality and use of formal procedures in the suggested definition. Our suggested definition for the procedures PSF is: The procedure is a written document that provides a set of decision and action steps that must be followed by operating room personnel to safely and efficiently achieve task's goals. The purpose of procedures is to guide human actions when performing a task to reduce the likelihood of HEP and increase the chance for reaching task's goal efficiently.
Working conditions: In SPAR-H guideline, Ergonomics/HMI PSF is broadly defined and includes both aspects of HMI and Ergonomics . In the current study we suggested the splitting of this PSF into two separate PSFs (working conditions and HMI), to provide more clear definitions for these PSFs and to provide a chance of more accurate assessment of them in surgical context. Our suggested definition for working conditions PSF is: Working conditions PSF refers to the Physical elements of the working environment of operating room like noise, distraction, quality and quantity of lighting and temperature conditions.
Human-Machine Interaction (HMI): Laumann and Rasmussen recommended that HMI should encompass only the interactions between operators and computerized systems for reflecting the limited scope of this PSF . Our suggested definition for HMI PSF is: The human machine interaction PSF encompasses the quality of equipment, displayers, annunciators, labeling, physical layout of the operating room, location of the operating room personnel during surgical processes and the adequacy or inadequacy of the information received from computerized systems for task performance.
Fatigue: In SPAR-H guideline , the definition of Fitness for duty PSF refers to the suitability of the individuals for task performance. One study has pointed out that Fatigue is much more cited in incidents reports than other indicators of fitness for duty PSF such as impairment due to drugs and alcohol usage, distraction and physical or mental capacity required for task performance . In the current study we considered two types of Fatigue contributing factors, sleep homeostatic factors (overtime and sleep deprivation) and circadian factors (day or night shifts) . Our suggested definition for fatigue PSF follows these contributing factors: Fatigue is related to the physical or mental exhaustion or sleepiness that is related to indicators such as sleep deprivation and day or night shifts.
Teamwork: Work processes defined poorly in the SPAR-H guideline , and indicators related to organization, safety culture, work planning, communication and teamwork are included in this PSF. Laumann and Rasmussen , suggested the splitting of this PSF. In the present study we focused on teamwork and defined it as a separate PSF. Our suggested definitions of team and teamwork are based on Salas et al. study : A team is defined as “two or more individuals with specified roles interacting adaptively, interdependently, and dynamically toward a common and valued goal.” Moreover, Teamwork is defined as “a set of interrelated thoughts, actions, and feelings of each team member that are needed to function as a team. And which are combined to facilitate coordinated, adaptive performance and task objectives resulting in value-added outcomes.”
Quantification of the PSFs Weight
Step-wise weight assessment ratio analysis (SWARA) technique, as one of the multiple-criteria decision-making (MCDM) techniques, was used to determine the weight of each PSF (negative impact on technical performance of operating room personnel) during surgical processes in operating room .
Experts should first arrange the criterions in order of importance. The most important criterion in human error occurrences is placed first and gets a score of one. Ultimately, the criterions are ranked based on the average values of their relative importance. The steps of this technique are as follows:
Initially, the criterions should be arranged in order of importance. The most important criterions are arranged in the higher levels and the less important criterions arranged in the lower levels.
- Comparative Importance of Average Value ()
In this step, the relative importance of each criterion compared to the previous one is determined.
- Calculation of the Coefficient
Calculation of this coefficient is based on the relative importance of each criterion through Equation 1.
- Calculation of the Primary Weight of Each Criterion ()
The primary weight of the criterion is calculated through Equation 2. In this regard, it should be noted that the weight of the first criterion, which is the most important criterion is considered 1.
- Calculation of the Final Weight of Each Criterion ()
The final weight of each criterion, which also considered the normalized weight, is calculated through Equation 3.
Quantification of the PSFs Influence Rate
A numerical scale with eleven-digit (0-10) was used to evaluate the influence rate of each PSF (0 and 10 are the thresholds of the scale). Experts were asked to provide their subjective perception of how often each PSF has adversely influences their technical performance during surgical operations they have participated .
0: the considered PSF has had no negative effect on the technical performance of operating room personnel at any surgical operation.
10: the considered PSF has had negative effect on the technical performance of operating room personnel at all of the surgical operations.
Descriptive statistics, maximum (Max), minimum (Min), mean and median were used to investigate the quantitative and qualitative variables of demographic characteristics, respectively.
Statistical indicators, mean (Median), standard deviation (SD), Max and minimum Min were used to investigate the weights and the influence rates of each PSF. The order of weight and negative influence rate of the PSFs were expressed, as well in Table 1, 2.
Additionally, triangular distribution was used to investigate the probability density function of the PSFs. Triangular distribution frequently is used for the evaluation of epistemic uncertainties in risk analysis [22, 23]. “The triangular distribution contains three parameters: the lower limit a, the upper limit b, and the mode m. The probability density at x=m is determined by imposing the area of the triangle to 1” . SPSS software version 23 was used for analyzing the gathered data.