Optimizing Teamwork in the Operating Room: A Scoping Review of Actionable Teamwork Strategies

Suboptimal teamwork in the operating room (OR) is a contributing factor in a significant proportion of preventable complications for surgical patients. Specifying behaviour is fundamental to closing evidence-practice gaps in healthcare. Current teamwork interventions, however, have yet to be synthesized in this way. This scoping review aimed to identify actionable strategies for use during surgery by mapping the existing literature according to the Action, Actor, Context, Target, Time (AACTT) framework. The databases MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC), Cochrane, Scopus, and PsycINFO were searched from inception to April 5, 2022. Screening and data extraction were conducted in duplicate by pairs of independent reviewers. The search identified 9,289 references after the removal of duplicates. Across 249 studies deemed eligible for inclusion, eight types of teamwork interventions could be mapped according to the AACTT framework: bundle/checklists, protocols, audit and feedback, clinical practice guidelines, environmental change, cognitive aid, education, and other), yet many were ambiguous regarding the actors and actions involved. The 101 included protocol interventions appeared to be among the most actionable for the OR based on the clear specification of ACCTT elements, and their effectiveness should be evaluated and compared in future work.


Introduction And Background
Suboptimal teamwork in the operating room (OR) is a contributing factor in a significant proportion of preventable complications for surgical patients [1][2][3][4][5][6].Despite its critical implications for patient safety, best practices for effective teamwork in the OR have yet to be identified [7,8].Teamwork is defined as the collaborative effort and the dynamic interactions within a group to achieve a common goal.Whether due to poor communication or unclear roles, suboptimal teamwork causes inefficient collaboration, leading to poor performance and increased errors.When such inefficiencies are overcome, effective teamwork is achieved.This can be brought about using teamwork interventions, which focus on improving interactions to bolster performance, safety, and efficiency.Teamwork interventions in the literature include checklists (e.g., Surgical Safety Checklists (SSC)), time-outs or team huddles, tools to facilitate concise communication (e.g., Situation-Background-Assessment-Recommendation (SBAR)), teamwork tools and frameworks (e.g., Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS™)), and high-fidelity simulation training or courses.Interventions aiming to improve OR teamwork have yielded mixed results [9][10][11].While a lack of clarity regarding actionable teamwork practices is one plausible contributing factor, study design and confounding variables likely also play a role [9,[12][13][14][15][16]. Unlike other high-risk industries such as aviation, recommendations about teamwork for the OR continue to revolve around general principles such as "mutual trust" or "adaptability" [17].Without precise specification of who needs to do what differently, when, where, and how, the development of a shared mental model is challenging at best [18].
Teamwork concepts are typically covered to varying degrees in education and training sessions [10], but less attention is given to well-described and actionable behaviours that can facilitate the identification of best teamwork practices in everyday clinical practice.Previous studies have identified one of the most frequent barriers to effective teamwork within healthcare settings as being the clinicians' lack of knowledge of established best practices or strategies [19,20].It is thus crucial to empirically establish best practices and disseminate them to clinicians to enhance patient safety.This is particularly significant, given the lack of substantial annual reduction in patient safety events in recent years [21,22].Specifying expected behaviour is fundamental to closing evidence-practice gaps in healthcare [23][24][25].In implementation science, the Action, Actor, Context, Target, Time (AACTT) is an established framework that specifies the necessary elements for an intervention to be considered actionable, thus enhancing intervention effectiveness [26].Existing systematic reviews have broadly included all forms of teamwork interventions without clearly delineating which interventions contain sufficient behavioural detail for application in the OR [10,11,27].Identifying actionable teamwork strategies for the OR, rather than broad interventions that emphasize abstract concepts in a classroom setting, is an important step towards providing clinicians with a common ground from which to approach interprofessional teamwork.This scoping review aims to evaluate the extent to which the current teamwork literature describes actionable practices for use in surgery.We aim to achieve this by mapping studies according to the AACTT framework to identify actionable surgical teamwork practices.This may inform future efforts to improve interprofessional teamwork in the OR.

Methods
We carried out the scoping review following the updated Preferred Reported Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines [28].These guidelines help ensure that scoping reviews possess greater transparency and reliability [28].Unlike systematic reviews, scoping reviews aim to provide an overview of the available evidence rather than "a summary answer to a discrete research question" [29].Scoping reviews are useful for answering complex questions in broad areas of literature that have yet to be comprehensively summarized [29,30].As such, scoping reviews are often preliminary steps to conducting one or several systematic reviews, as the identification of key knowledge gaps informs specific research questions.Since scoping reviews usually contain an expansive purview of information, meta-analytic methods are most often impossible, and risk of bias assessments are not considered essential [29,30].

Information Sources and Search Strategy
Literature searches were conducted using MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC), Cochrane, Scopus, and PsycINFO databases from inception to April 5, 2022 (See Appendices).The electronic search strategy was developed by an information specialist (AD) in collaboration with the research team and then peer-reviewed in accordance with the Peer Review of Electronic Search Strategies (PRESS) guidelines [31].A manual screening of the reference lists of included studies was conducted by senior investigators to identify additional potentially relevant articles.All identified articles were imported into DistillerSR (Evidence Partners, Ottawa, Canada), a web-based review software.Duplicate records were removed.

Eligibility Criteria
We defined teamwork interventions as interventions that focus on improving interactions to bolster performance, safety, and efficiency.All empirical study designs were eligible for inclusion provided they explored a teamwork intervention that is actionable, as per the AACTT framework, and could be implemented during the intraoperative period.This meant that an intervention was eligible if it did not require resources/equipment that were not accessible in the OR, did not significantly disrupt OR flow, and did not put at risk patient or staff safety.Studies had to include two or more healthcare professions and could be conducted in any healthcare environment to broaden the possibilities of interventions.Clinical and simulation studies were also eligible for inclusion.Measures of intervention efficacy were not a requirement for inclusion in this scoping review, as our goal was to identify actionable intraoperative teamwork practices or strategies.The elements of the AACTT framework include (I) Action (i.e., behaviour that can be observed and measured), (ii) Actor (i.e., the individual that is doing or could do the behaviour), (iii) Context (i.e., the setting in which the action is performed), (iv) Time (i.e., when the behaviour is performed), and (v) Target (i.e., the person/people with/for whom the action is performed) [26].Initial eligible study settings included healthcare and other high-risk industries (aviation, military).The protocol was later amended to include only studies conducted in a healthcare setting to provide a more focused review.Only peer-reviewed studies published in English and French were included, while studies in other languages were excluded due to limited resources.Commentaries, editorials, and letters to the editor were not eligible for inclusion.

Screening
Screening was conducted by investigators in two stages using the inclusion and exclusion criteria: (I) title and abstract and (ii) full-length screening.All screeners had a background in research and/or medicine.To ensure standardization, the screening protocol was discussed during an introductory meeting, and a pilot screen was conducted until standardization was achieved.
Two independent investigators screened articles at the title and abstract stage, as well as the full-text stage in duplicate.Excluded studies were flagged with a reason for exclusion and reviewed by two additional healthcare and teamwork experts to confirm the reason for exclusion.Both stages followed the same process, whereby all articles were reviewed in duplicate by two independent reviewers.If consensus could not be achieved, a third reviewer was involved in resolving conflicts.

Data Extraction
A data extraction form was created prior to the literature search and piloted by the research team.There was a training period to trial the form and ensure all reviewers understood the items and documented pilot articles in a unified manner.Data items were extracted using the data extraction form by pairs of independent reviewers.The second reviewer of each pair verified the data extraction of the first reviewer for accuracy, and any disagreements between the two reviewers were flagged for discussion.If consensus could not be reached, a third reviewer was involved.When data items were inadequately reported in the full text, attempts at contacting the original authors were made to clarify and confirm relevant details.

Data Items and Synthesis of Results
The data collected included publication details (e.g., first author, journal, year of publication, country of origin), study design, sample and participants, setting, title, type, description of the teamwork intervention, and which of the AACTT elements the intervention specified.Data collection and synthesis were conducted by one reviewer, with a second reviewer verifying the accuracy and consistency of the extracted data and classifications.Data extracted from the included studies were organized into distinct domains based on established categories of practice-changing interventions.These domains encompassed various types of intraoperative teamwork interventions, including bundle/checklists, protocols, audit and feedback, clinical practice guidelines, environmental changes, cognitive aids, education, and others [32].Each intervention type was systematically identified and categorized to facilitate comprehensive analysis and synthesis of the literature.Data were organized according to the AACTT framework, which served as a guiding framework for mapping out the specific elements of each intervention, including the actions undertaken, the actors involved, the contextual factors influencing implementation, the intended targets or recipients of the intervention, and the temporal aspects of intervention delivery.This categorization facilitated a nuanced understanding of the teamwork interventions' characteristics and actionability in the intraoperative period.
Quantitative and qualitative data extracted from included studies were subject to comprehensive analysis to 2024 Ghanmi et al.Cureus 16(5): e60522.DOI 10.7759/cureus.60522 elucidate key findings and insights.Quantitative data, such as the frequency of intervention types across studies, were analyzed using appropriate summary statistics, including counts and percentages.This quantitative analysis provided a quantitative overview of the prevalence and distribution of different intervention types within the literature.Qualitative data, including descriptions of intervention components and their associated AACTT elements, were subjected to thematic analysis.The thematic analysis involved the identification of recurrent themes, patterns, and trends within the extracted data.By systematically examining the qualitative data, commonalities, variations, and nuances in intervention characteristics and implementation strategies were identified.These thematic insights provided a qualitative understanding of the diverse approaches to intraoperative teamwork interventions and illuminated the contextual factors shaping their implementation and effectiveness.

Study Selection
There were 9,289 relevant studies identified from our literature search.Of these, 7,785 were excluded at the title and abstract screening, and 1,255 were excluded at full-text screening.This resulted in a total of 249 articles included in this review (Figure 1).

FIGURE 1: PRISMA Flowchart
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

AACTT Specifications Across Included Studies
A summary of the AACTT specifications across the included studies is provided in Table 1.The action (i.e., behaviour) specified by most studies (n=133; 53.4%) was to follow a series of steps or tasks listed in the intervention bundle or checklist; however, only 76 (30.5%) of studies specified the actor (i.e., the person who performs the action).For example, the Surgical Patient Safety System (SURPASS) checklist described by de Vries et al. [33] specifies which individual team member (e.g., anesthesiologist) is responsible for completing each item (e.g., checking patient allergies and equipment) across each phase in the surgical pathway (e.g., at the OR time-out).The SSC was described by 24 studies (9.6%) and specifies many individual actions occurring throughout the procedure but did not always precisely specify the actor or target.For example, the checklist states "with at least nurse and anesthetist" regarding the actions that are to take place before induction of anesthesia but does not explicitly state who does which item.Similarly, actions before skin incision and before the patient leaves the OR are stated to take place "with the nurse, anesthetist, and surgeon," but the specific actor and target of several checklist items are not systematically indicated.

Framework Component Number of studies (%) Action
Follow a series of steps or tasks listed in a checklist or protocol 133 (53.4%)Interventions involving specific individual actions rather than a multi-step, multi-actor bundle or checklist were described by 101 studies (40.5%).A representative example of 10 studies is shown in Table 2.One example is closed-loop communication [34], which involves the components of a callout (i.e., verbal order), check back (i.e., confirmation that information was received), and closing the loop (i.e., the acknowledgement that the receiver correctly understood the information).Other examples involved protocols to minimize distractions.The noise reduction intervention described by Wright et al., for example, requires OR team members to eliminate non-essential conversation, turn the volume down or off on electronics, silence mobile devices, and avoid the use of unnecessary instruments or devices that increase noise levels (Table 2) [35].Similarly, the "sterile cockpit" protocol introduced by West et al. aiming to improve the efficacy and safety of nursing assistants (NAs) specifies the actions for registered nurses to take, such as "engage the NAs only in professional conversations" and "take phone calls and messages for the NAs" (Table 2) [36].

Discussion
This scoping review provides an overview of actionable teamwork practices that could be implemented intraoperatively.We identified eight different types of teamwork interventions across 249 studies that included practices or strategies that were actionable, and thus mapped according to the AACTT framework.[9][10][11]37,38].Although these interventions may initially appear straightforward, the ambiguity of the AACTT elements may undermine their effectiveness.Other studies have confirmed that ambiguity remains one of the key implementation and compliance challenges affecting the SSC [39].These findings, along with the results of this scoping review, speak to the common implementation challenge of balancing fidelity (i.e., the intervention is delivered, received, and enacted as intended) and adaptation (i.e., adjustments to the original intervention made by implementers or users as they go about delivering an intervention) [40,41].Fidelity may be easier to accomplish with the identified communication and distraction protocols, in comparison to the bundle/checklist interventions, and adaptation may be less variable.Accordingly, the reproducibility and sustained effectiveness of the interventions may be enhanced.
Implementing specific teamwork practices or strategies also has the potential to establish effective teamwork as a routine practice across intraoperative settings.Indeed, in real-world healthcare settings, interventions that explicitly designate specific roles for actors and/or targets are more likely to be actionable for several reasons.Firstly, such interventions provide clarity and accountability by clearly delineating the responsibilities of each team member, ensuring that everyone understands their role in implementing the intervention.This clarity enhances accountability within the healthcare team and minimizes confusion regarding task ownership.Secondly, interventions with clearly defined roles are more effectively implemented, as they reduce ambiguity and enable healthcare professionals to carry out their tasks accurately and consistently [20].Thirdly, specifying roles allows for customization and adaptation of interventions to fit the unique needs and dynamics of different healthcare settings, fostering flexibility and scalability.Additionally, clear role assignments facilitate communication and collaboration among team members, promoting seamless coordination of actions and effective achievement of common goals.Finally, interventions with specific roles are easier to evaluate and provide feedback on, enabling continuous quality improvement and optimization of outcomes [42].Overall, interventions that name specific roles for actors and/or targets enhance clarity, accountability, implementation effectiveness, customization, communication, collaboration, and evaluation, making them more actionable and conducive to successful adoption in real-world healthcare contexts [43].In addition, clinicians' limited knowledge of specific practices or strategies for engaging in effective teamwork [19,20] is further indicative of the value of interventions that specify the AACTT elements.Studies demonstrate a shared mental model is an essential characteristic of high-performing teams [44][45][46].Therefore, at minimum, the teamwork practices or strategies elicited from these types of interventions could promote a common understanding of effective teamwork among interprofessional team members.
Given the proliferation of checklists over the last decade as a strategy for reducing medical errors [47] and the widespread use of the SSC in particular [48,49], it is not surprising that these were among the most identified interventions.While several reviews have demonstrated at least moderate effectiveness of the SSC in improving patient outcomes, there is less evidence that the checklist consistently enhances teamwork [50,51].In fact, when used sub-optimally, checklists can even negatively impact team functioning [52].For example, the checklist can reinforce professional divisions by failing to include all individuals or professional groups during the "checking" process.Many studies also suggest the implementation of and compliance with the SSC remains challenging [53][54][55], and that the checklist "may encourage box-ticking without true fidelity to (its) communications and process assurance aspects" [56].
Future studies utilizing checklists can be improved by ensuring all checklist items can be mapped to all components of the AACTT framework.Analyzing teamwork interventions through the lens of the ACCTT framework is valuable as it specifies how an intervention should be applied and may therefore facilitate implementation.In cases where checklists have previously failed or were deemed to be ineffective, specific communication interventions, such as those identified in this review, may provide a more direct way of improving teamwork rather than expecting it to be a by-product of various task-related checkboxes.
The implementation of any teamwork intervention should take local barriers and enablers into consideration [18].It could be expected that specific behavioural interventions are more amenable to local tailoring than those which are more ambiguous, and future research may wish to investigate this hypothesis.Differences in compliance rates between specific versus ambiguous interventions may also be an insightful area of research to pursue.

Strengths and Limitations
This scoping review involved a comprehensive search strategy and a rigorous screening process.Nevertheless, it is likely that some relevant studies were missed based on inconsistencies in reporting across studies and the potential subjectivity of reviewers in determining whether interventions satisfied AACTT criteria.To mitigate this risk, screeners were trained prior to conducting the review; all screening was conducted in duplicate, and exclusion decisions were reviewed and verified by two independent research team members.
Although our review focused on practices that can be conducted inside the clinical OR, we recognize that other types of interventions can still be of value.The strategies we identified may be advantageous in that they can be incorporated into daily clinical practice and provide healthcare professionals with a shared foundation for effective teamwork.This, of course, does not preclude the use of additional interventions targeting individual provider skills, professional hierarchies, or organizational culture.Another limitation of this study is the deductive methodology used to identify actionable practices for use during surgery.This specific method was chosen to ensure that our study was based on a recognized framework with pre-defined categories that provide a basis for practical application.We recognize, however, that this approach may prevent us from identifying new categories of interventions that do not fit within the established categories or fit in a non-specific "other" category.In the future, employing an inductive approach may capture a more comprehensive list of practices that go beyond these pre-defined categories.Finally, we did not assess the quality of the included studies or their effectiveness, as this is typically not required for a scoping review.The goal of this scoping review was to identify actionable teamwork practices for the OR, rather than to assess intervention effectiveness.We intend to conduct a subsequent study using the identified strategies to further explore the most promising strategies from the perspective of the AACTT framework for routine application in the OR.Given its advantages, teamwork interventions should be designed and described with the AACTT framework in mind, which may improve the actionability and duplicability of interventions described in future research.Systematic reviews assessing the effectiveness of specific types of interventions based on study-reported outcomes could be among the next steps.Further studies on the varied implementation process may also help to better understand the conflicting success achieved with various teamwork strategies..nlpx"query=MeSH descriptor: [Patient Care Team] this term only","desiredResults=10000","minHitsDivisor=7","permitHyponyms=NO","lowestVocabularySearchLevel=none","phrasesBroken=NO","speedWanted=NoHypos","comment=Including Related Terms","elimEnable=NO","constraintMinTerms=2" 2 ..nlpx "query=(team*):ti","desiredResults=10000","minHitsDivisor=7","permitHyponyms=NO","lowestVocabularySearchLevel=none","phrasesBroken=NO","speedWanted=NoHypos","comment=In Related Terms","elimEnable=NO","constraintMinTerms=2" 3 ..nlpx "query= (teamwork):ti,ab,kw","desiredResults=10000","minHitsDivisor=7","permitHyponyms=NO","lowestVocabularySearchLevel=none","phrasesBroken=NO","speedWanted=NoHypos","comment=Inclu Related Terms","elimEnable=NO","constraintMinTerms=2" 4 ..nlpx "query=(team* NEAR/2 (behaviour or behavior or situation or performance))","desiredResults=10000","minHitsDivisor=7","permitHyponyms=NO","lowestVocabularySearchLevel=none","phrasesBroken=NO","speedWanted=NoHypos","comment=Including Terms","elimEnable=NO","constraintMinTerms=2"

Review
loop communication: Callout -verbal order Check back -confirm information received Closing the loop -acknowledge correct understanding with the Traffic Lights tool: Red alert -lifethreatening emergency Amber assist -help is required within minutes Green query -advice/non-urgent assistance required eliminating non-essential conversation: Turn the volume down or off on electronics, slience mobile devices, avoid the use of instruments or devices that increase noise levels if they are unnecessary at distractions and interruptions: Intercept individuals who would otherwise have contact NAs, take phone calls and messages for the NAs, answer call lights and patient requests that normally would have been handled by the NAs, engage the NAs only in professional conversations, restrict overhead paging (use phones or nurse pagers only) communication structure: (Surgeon) Call out the colour for the next tool (Surgeon) Say "disabled" once the tool is disabled on the control panel (Nurse) Say "ready" once the new tool is SBAR tool.Situation: describe the current status of the patient and provide a concise statement of the problem; Background: provide pertinent and brief information related to the situation; Assessment: provide an overall analysis of the patient and their status; Recommendation:explain what exactly needs to be done after the original team member leaves This scoping review identifies actionable teamwork practices for intraoperative implementation, encompassing eight intervention types across 249 studies by mapping the existing literature according to the AACTT framework.While most interventions lacked specificity in actions and actors, protocol interventions offered clear roles, primarily focusing on communication improvement and distraction reduction.Specific role designation enhances clarity, accountability, and implementation effectiveness.Clear role assignments facilitate communication, collaboration, and evaluation, promoting effective teamwork and shared mental models among interprofessional team members.The implementation of any teamwork intervention should take local barriers and enablers into consideration, and tailor interventions accordingly.Future research may consider evaluating differences in compliance rates between specific versus ambiguous interventions.

8 or 9 and 24 7 or 25 .
or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 6 .nlpx"query=((aviation or aerospace or aeronautic* or cockpit or military or aviator* or flight personnel or pilots or fighter pilot* or battlefield* or power plant*))

TABLE 1 : Summary of Action, Actor, Context, Target, Time (AACTT) framework across included studies
%: Represents the number of studies over the total number of studies, N, where N=249.