Evaluation of the Perceptions of Safety of Surgical Practice at a Tertiary Academic Trauma Hospital in Havana, Cuba

INTRODUCTION

As the availability of surgical care expands throughout the world, the gap in mortality and morbidity between high-income and low- and middle-income countries (LMICs) becomes an important issue to address. Between 2004 and 2012, the total annual global surgical volume increased from 226.4 million to 312.9 million operations, an estimated 38.2% increase.¹ Despite these findings showing higher surgical volume globally, postoperative morbidity and mortality have been shown to be significantly higher in LMICs compared to high-income countries.^2–4 Ongoing work to improve access to surgical care throughout the world should also incorporate the need to improve the safety of surgical care in limited-resource settings.

Understanding the perceptions of safety of surgical practice in the operating room is an essential component of making surgery safer. The culture of safety can be evaluated by measuring the perception of safety of professionals who work in a particular environment.⁵ Singer et al. have previously developed and validated a survey to measure the perceptions of safety of surgical practice specifically in an operating room.⁶ This survey has been used to measure the perceptions of surgical safety in operating rooms located in the state of South Carolina and in operating rooms in ambulatory surgery centers in the United States.^7,8 Use of this validated survey has demonstrated that hospitals with an unfavorable perception of surgical safety had worse postoperative mortality compared to hospitals that had a favorable perception of surgical safety.⁹ Furthermore, measuring the perceptions of safety of surgical practice can serve as a needs-based assessment that can inform subsequent quality improvement initiatives that aim to improve the safety of surgical care.

Measuring, interpreting, and learning from the perceptions of safety of surgical practice occurs infrequently, if at all, in hospitals located in LMICs. We sought to measure the perceptions of safety of surgical practice at the General Calixto García University, Hospital of Havana, Cuba, in order to advance this line of research and to improve the quality of surgical care.

MATERIALS AND METHODS

RESULTS

The survey response rate was 46.5% (200 completed surveys out of 430 eligible healthcare providers). The majority of participants were trainees (58.0%, n = 116), followed by surgeons (27.5%, n = 55), surgical nurses (9.5%, n = 19), and anesthesiologists (5%, n = 10). The highest proportion of participants reported being in their respective role for 1–5 years (39.5%, n = 79) (Table 1). Among trainees, 49.1% (n = 57) reported having %3C;1 year of experience in their respective role, and 50.9% (n = 59) reported having 1–5 years of experience in their respective role. Conversely, 69.1% (n = 38) of the surgeons reported having ≥6 years of experience in their respective role.

Using the Chi-square test to evaluate the differences in perception of surgical safety between surgeons and trainees, there were statistically significant differences between surgeons and trainees in 3 out of the 16 statements (Table 2). Compared to surgeons, trainees were more likely to agree with the following statement: “For complex cases, briefings include planning for potential problems” (statement 9; 69.8% of agreement among trainees compared to 50.9% among surgeons, p value = 0.016). Trainees were less likely to agree with the statement (statement 13) that they were “treated as a highly valued member of the team” in comparison to surgeons (57.8% vs 76.4%, p value 0.018). Trainees were also less likely to agree that they “would feel safe being treated here as a patient” (statement 16; 47.4% vs 63.6%, p value = 0.047).

Table 3 demonstrates the differences in the perception of surgical safety between operating room personnel according to their reported years of experience. Out of the 16 statements, 6 demonstrated statistically significant differences between operating room personnel with ≤5 years of experience and ≥6 years of experience. For all of the six statements that showed a statistically significant difference, operating room staff with ≥6 years of experience reported a more favorable perception of safety of surgical practice when compared to participants who reported ≤5 years of experience. For example, participants with ≥6 years of experience were more likely to disagree that “Pressure to move quickly from case to case gets in the way of patient safety” (statement 3, disagreement among participants with ≥6 years of experience was 54.4% compared to 37.3% among participants with ≤5 years of experience, p value = 0.028). Similarly, participants with greater years of experience were more likely to disagree that it was “difficult to speak up when I perceive problems with patient care” (statement 6, 61.4% vs 45.8%, p value = 0.046). Differences in the four affirmative statements that showed statistically significant differences according to years of experience showed that participants with greater years of experience were more likely to agree that “physicians maintain a positive tone throughout operations” (statement 7, 84.2% vs. 67.6%, p value = 0.018); “all team members work together as a well-coordinated team” (statement 8, 71.9% vs. 54.2%, p value = 0.022); “I am treated as a highly valued member of the team” (statement 13, 75.4% vs. 57.8%, p value = 0.020); and “I would feel safe being treated here as a patient” (statement 16, 73.7% vs. 45.8%, p value < 0.001).

DISCUSSION

The perception of surgical safety can be feasibly measured using a validated, translated into Spanish survey in a tertiary hospital in Havana, Cuba. We found that surgeons were significantly more likely than trainees to report being treated as a highly valued member of the team and feeling safe being treated at their hospital as a patient. Similarly, participants with ≥6 years of experience had a significantly more favorable perception of surgical safety than participants with less experience.

This study’s findings underscore that there are differences in how operating room personnel in positions of authority, i.e., physicians, perceive the safety of surgical practice compared to operating room personnel not in positions of authority, i.e., trainees or nonphysicians. Previous studies have shown that surgeons or physicians have a more positive perception of surgical safety than nonsurgeons or nonphysicians, respectively.[6,8] Furthermore, nurses have been found to have the most pessimistic perception of safety when compared to their nonnurse peers.^10,11 However, nurses have also been identified as the group that had the strongest perception of organizational commitment to safety.¹² Addressing these differences in the perception of surgical safety is important in creating a psychologically safe environment for all operating room team members.

The findings in this study contribute to the existing literature on the culture of safety in health care that has been reported from hospitals outside the United States. A study performed in Taiwan found that about 48% of healthcare workers in hospitals held positive attitudes toward teamwork.¹³ Similarly, a study in Lima, Peru, demonstrated that only 51.1% of healthcare professionals reported a positive perception of safety.¹⁴ While studies from Greece¹⁵ and Ghana¹⁶ have reported that more than 70% of their healthcare professionals reported a more favorable perception of safety. Regardless of the level of reported safety, this current study and previous studies have demonstrated that the climate of safety and, in particular, that perceptions of surgical safety can be feasibly measured using existing validated surveys.

Initiatives to improve the safety of surgical care require an understanding of the baseline level of safety. Measuring the perception of surgical safety among healthcare providers can serve as a starting point for improvement. Cuba has historically been lauded for providing its citizens with access to universal health care. Through an existing collaboration, leadership at General Calixto García Hospital in Havana, Cuba, expressed an interest in conducting work on improving the safety of care that is provided to their surgical patients. The findings from this study will be used to create initiatives that will target improving teamwork and communication with the goal of improving the safety of surgical practice, and ultimately improving the safety of care that is provided to surgical patients.

LIMITATIONS

This was the first time that a validated survey to measure the perceptions of safety of surgical practice was used in Cuba. Certain limitations exist including the inability to include nurses and anesthesiologists in the statistical analysis due to the low number of professionals in these roles that were surveyed. The response rate is moderate but acceptable given the novelty of administering a survey for research purposes at this hospital. Additionally, although the findings are descriptive, reporting survey data on the perception of surgical safety from a LMIC like Cuba is important and expands the existing literature on the subject matter.

CONCLUSION

The perceptions of safety of surgical practice among operating room personnel were successfully measured at a tertiary hospital in Havana, Cuba, using a validated, translated survey. This study reports that the perception of surgical safety differed according to professional role and years of experience. More specifically, surgeons had more favorable perceptions about surgical safety than trainees. Additionally, participants with more experience in their respective role also had more favorable perceptions of surgical safety than participants with less experience in their respective roles.

CLINICAL SIGNIFICANCE

To address these differences, we suggest implementing educational workshops that underscore the importance of teamwork and communication in the operating room. Making surgery safer for patients includes fostering a favorable culture of surgical safety in the operating room so that all operating room personnel feel empowered to speak up and act on behalf of the patient’s safety.

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