In 2008, the World Health Organization introduced a surgical safety checklist (SSC) designed to foster a culture of safety and encourage communication and teamwork in the operating room (OR). The World Health Organization SSC was associated with a 46% reduction in postoperative mortality and a 36% reduction in postoperative complications in the original pre/post-trial that took place in 8 hospitals located in diverse settings throughout the world.1 More than 10 years later, a meta-analysis by Sotto et al2 that included favorable and nonfavorable studies evaluating the SSC showed a pooled estimate showing a significant reduction in mortality and postoperative complications. Despite the data supporting the use of the SSC, there exist multiple barriers to effective implementation, adherence, and sustained use of the SSC. A longitudinal study in the UK found that the 3 checklist components (brief, time out, and debrief) were only completed 62.1% of the time.3 Furthermore, a government mandate in Ontario, Canada, did not demonstrate any improvements in postoperative outcomes following the introduction of an SSC.4 The reason for this is most likely multifactorial, likely due to less than optimal compliance and a lack of institutional support and resources.5 The aim of this perspective is to introduce key theories from social psychology into the discussion of how to implement the SSC and support its use. These social psychology theories focus on conformity, pluralistic ignorance, trending norms, ambiguity, in-group bias, and social referents as helpful concepts that can be applied to our understanding of checklist performance to cultivate an environment that is more conducive to using the SSC.

The concepts outlined below are terms used to describe specific phenomena that may occur when the SSC is used and can be best explained by social norms theory, which is the idea that individuals’ perceptions of how others around them behave and what they believe can influence their own behaviors and beliefs. These concepts can be targeted to improve the use of the SSC by using a socioecological framework, which has been previously used in understanding the effects of prevention strategies. The socioecological model we propose is adapted from Scarneo’s model6 and our model includes the following factors: intrapersonal, interpersonal, organizational, and environmental (Fig. 1). In addition, it is important to underscore that addressing these concepts may be necessary but not sufficient to improve the implementation of the SSC.

FIGURE1: Socioecological framework for incorporating principles of social psychology to improve the use of the surgical safety checklist (SSC) in the operating room (OR). The rectangles contain different domains of the model in the context of a hospital, and the circles include recommendations for implementing improvements in SSC use. Adapted from Scarneo et al6 5-level socioecological framework. Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.CHALLENGES WITH COMPLIANCE AND BUY-IN OF THE SSC: CONFORMITY, PLURALISTIC IGNORANCE, and TRENDING NORMS

True compliance with the SSC may not be as high as what is reported by institutional administrative audits. A recent study in Toronto, Ontario, found that, although near 100% compliance was reported by one hospital to the provincial Ministry of Health, the actual compliance at that site, when measured through direct observation, was significantly lower. In fact, the debrief portion of the SSC was completed in only 22% of operations.7

Buy-in, especially from surgeons, is a known barrier to checklist use. Russ et al8 reported that the most prominent barrier to proper checklist use was resistance or noncompliance by senior surgeons and anesthesiologists, which made it difficult for nurses to complete the SSC. To address this issue of physician noncompliance, it is helpful to consider the social psychological principle of conformity—the idea that humans like to follow social norms. The lack of buy-in from surgeons and anesthesiologists may cultivate a potentially harmful social norm in the OR: that the SSC is perceived as not being useful in promoting patient safety. Consequently, other OR staff may also conform to that norm and choose not to comply with using the SSC. This phenomenon can be further exacerbated by pluralistic ignorance, or the idea that one’s feelings and ideas are unique from those of the majority. Pluralistic ignorance may make a member of the OR team who does support the SSC feel that they are alone in that belief. Subsequently, they may strive to conform to the perceived prevailing norm that the SSC is not useful. Thus, a cycle of low compliance with the SSC is sustained. One method of addressing this cycle of conformity exacerbated by pluralistic ignorance is by using trending norms. Trending norms are statements about the changes in popularity of an opinion or an action. They have been found to be more effective than descriptive norms (ie, statements that simply state the current popularity of an opinion or an action) in changing people’s behavior.9 One way to utilize trending norms for positive change is by displaying posters throughout the OR and surgical departments that publicize the growing use and perceived effectiveness of SSCs elsewhere, as has been published in the literature. By employing this strategy, the human tendency to conform may be used to increase buy-in for the SSC and subsequently its use. This approach can also challenge pluralistic ignorance by making visible the perspectives of individuals who felt alone in their views on the value of the checklist.

HOW AMBIGUITY LEADS TO INACTION

The SSC was designed to be flexible and adaptable to different scenarios. This intentional design element provides many benefits to checklist implementation but also creates the unintended consequence of variable, conflicting interpretations of how the checklist ought to be used. Ambiguity often exists in the names assigned to checklist sections and in what constitutes the proper performance of each section. This lack of clarity can lead to sections being done only partially or skipped entirely but marked as being completed to avoid completion errors.7 Classic social psychology posits that the ambiguity of a situation, as well as the behaviors of others, have a significant influence on behavior in an emergency setting. In Darley and Latane’s 1968 study, harmless smoke was pumped into a room where a participant was completing a survey while the behavior of research subjects was observed. The investigator team found that when research subjects were alone in this situation, 75% of participants left the room to report the smoke by the end of the experimental period. However, when participants were with 2 other passive “participants” who were members of the study team and who did not react to the smoke, only 10% of participants got up to report the smoke. These results demonstrate how the actions of others can drastically influence our own actions in an ambiguous situation. In an OR, ambiguous situations happen commonly. For example, a surgeon might enter the room and ask if the briefing has taken place. If there is ambiguity about which section of the checklist that is and what constitutes completion, and others around are not sure either, members of the surgical team may simply respond “yes” instead of indicating that this was not completed. To combat ambiguity, it is important that all team members understand SSC components and their accepted names. An important way to do this is to ensure that implementation of the SSC always includes thorough education on the components of the SSC for all OR staff.

THE POWER OF SOCIAL CONNECTEDNESS IN IMPROVING THE CULTURE OF SAFETY IN THE OR BY IMPROVING NONTECHNICAL SKILLS: IN-GROUP BIAS

Another barrier to checklist use is failure of situational awareness, communication, leadership, and teamwork, that is, nontechnical skills, among OR staff. Nontechnical skills among OR staff, and principally among surgeons, who are often viewed as team leaders, are essential to fostering psychological safety and a culture of safety in the OR.10 OR staff perceptions of the culture of surgical safety in the OR are associated with postoperative outcomes.11 Furthermore, low ratings of nontechnical skills were found to precede minor and major safety incidents in the OR.12 These nontechnical skills also directly impact the wellbeing of other members of the surgical team. In one study, hostility from surgeons toward nurses was expressed by 94% of nurses.13 A team member’s lack of nontechnical skills may negatively impact both team member wellbeing and patient outcomes and may be addressed with social psychology theories. The fostering of a common identity as members of a surgical team can lead to greater social cohesion and improved attention to the nontechnical skills required for optimal team performance. A social psychology study evaluating the influence of “in-group” identity among soccer fans found that Manchester United Football Club fans (ie, study participants) helped actors in need if they were identified as being fans of the soccer club (eg, by having actors wear Manchester United soccer shirts). Similar results were demonstrated if the in-group was expanded to include all soccer fans in general compared with people not perceived to be soccer fans (eg, actors wearing soccer shirts were helped more often compared with actors wearing plain shirts). These results provide an example of the influence of in-group biases and suggest that the boundaries of the in-group are flexible. In the OR, social connectedness could be improved by widening the in-group and referring to all OR staff as being part of the OR team instead of being members of different teams such as the nursing team, surgical team, and anesthesia team. This may in turn lead to improved nontechnical skills and, subsequently, an improved culture of safety in the OR.

STRENGTHENING THE EDUCATION ON USING THE SSC BY RELYING ON SOCIAL REFERENTS

Education and training are important facilitators of proper checklist use.8 Adequate education can reduce some of the ambiguity in checklist use that has been cited as a barrier. To enhance education on using the SSC, we recommend employing social referents, that is, people who others view as important sources of information and role models for behavior. These people are well connected to the social network of their environment.14 In the OR, social referents are usually senior surgeons that other surgeons seek out for intraoperative consultation, or senior nurses and anesthesiologists that peers look up to and respect. These social referents, or local champions, are trusted sources who can effectively promote and publicize checklist use, thus increasing its buy-in and compliance.

CONCLUSIONS

The use of social psychology principles can be informative in addressing barriers to effective use of the SSC and thus promoting an OR culture of safety. These interconnected concepts highlight how individual behaviors and attitudes can be influenced by the social environment and, conversely, how individual behaviors and attitudes can influence the social environment. The novel lens of social psychology highlights the importance of the environment in which a surgical team works and provides multiple strategies for fortifying this environment for the benefit of both clinicians and patients.

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