Global Survey of Perceptions of the Surgical Safety Checklist Among Medical Students, Trainees, and Early Career Providers

Abstract

Background

The Surgical Safety Checklist (SSC) has been shown to reduce perioperative complications across global health systems. We sought to assess perceptions of the SSC and suggestions for its improvement among medical students, trainees, and early career providers.

Methods

From July to September 2019, a survey assessing perceptions of the SSC was disseminated through InciSioN, the International Student Surgical Network comprising medical students, trainees, and early career providers pursuing surgery. Individuals with ≥2 years of independent practice after training were excluded. Respondents were categorized according to any clinical versus solely non-clinical SSC exposure. Logistic regression was used to evaluate associations between clinical/non-clinical exposure and promoting future use of the SSC, adjusting for potential confounders/mediators: training level, human development index, and first perceptions of the SSC. Thematic analysis was conducted on suggestions for SSC improvement.

Results

Respondent participation rate was 24%. Three hundred and eighteen respondents were included in final analyses; 215 (67%) reported clinical exposure and 190 (60%) were promoters of future SSC use. Clinical exposure was associated with greater odds of promoting future SSC use (aOR 1.81 95% CI [1.03–3.19], p = 0.039). A greater proportion of promoters reported “Improved Operating Room Communication” as a goal of the SSC (0.21 95% CI [0.15–0.27]-vs.-0.12 [0.06–0.17], p = 0.031), while non-promoters reported the SSC goals were “Not Well Understood” (0.08 95% CI [0.03–0.12]-vs.-0.03 [0.01–0.05], p = 0.032). Suggestions for SSC improvement emphasized context-specific adaptability and earlier formal training.

Conclusions

Clinical exposure to the SSC was associated with promoting its future use. Earlier formal clinical training may improve perceptions and future use among medical students, trainees, and early career providers.

Appendices

Appendix 1: Final survey disseminated for data collection

The version disseminated through social media platforms included an additional question asking respondents if they belonged to an InciSioN-affiliated NWG. The skip logic mapping of survey branching is censored for simplicity; only responses to items completed by medical students, trainees, and early career providers were incorporated into final analyses.

• 1. Which InciSioN National Working Group are you currently a member of?

• 2. What is your age?

  • 18–24 years

  • 25–30 years

  • 31–34 years

  • 35–40 years

  • Greater than or equal to 41 years

  • Prefer not to disclose

• 3. What is your preferred gender pronoun?

  • She/her

  • Him/he

  • They/their

  • Other (please specify):

  • Prefer not to disclose

• 4. What is your highest level of clinical experience?

  • a. Medical school (current student or recent graduate)

  • b. Trainee (i.e., intern, resident, registrar, fellow, etc.)

  • c. Independent provider (i.e., completed clinical training)

• 5. In which country are you obtaining, or did you obtain most of your medical school education?

• 5a. What language(s) were/are commonly spoken in the environment where you obtained/are obtaining most of your medical school education? (select all that apply):

  • a. English

  • b. Russian

  • c. Arabic

  • d. Chinese

  • e. French

  • f. Spanish

  • g. Other (please specify):

• 5b. (If you are a student) What is the current stage of your education as a medical student?

  • a. Pre-clinical training (i.e., classroom)

  • b. Clinical training

  • c. My education combines clinical and classroom learning from the beginning

  • d. Medical school graduate

  • e. Other (please specify):

• 6 In which country are you obtaining or did you obtain most of your post-medical school training?

• 6a. What language(s) were/are commonly spoken in the environment where you obtained/are obtaining most of your post-medical school training? (select all that apply)

  • a. English

  • b. Russian

  • c. Arabic

  • d. Chinese

  • e. French

  • f. Spanish

  • g. Other (please specify):

• 6b. (If you are a trainee) How many years of post-medical school training have you completed?

  • a. < 2 years of training post-medical school graduation

  • b. ≥ 2 years of training post-medical school graduation

• 7 In which country are you currently practicing independently?

• 7a. What language(s) are commonly spoken in your current clinical practice environment? (select all that apply)

  • a. English

  • b. Russian

  • c. Arabic

  • d. Chinese

  • e. French

  • f. Spanish

  • g. Other (please specify):

• 7b (If you are an early-career provider) how long have you practiced independently?

  • a. less than 6 months

  • b. More than or equal to 6 months and less than 1 year

  • c. More than or equal to 1 year and less than 2 years

  • d. More than or equal to 2 years

• 8. (If you are a trainee or provider) what is your clinical focus (i.e., specialty)?

  • a. Anesthesia

  • b. Surgery (please list sub-specialty)

  • c. Obstetrics/gynecology

  • d. General practice (i.e., family practice)

  • e. General/internal medicine

  • f. Other (please describe):

  Definition: By “exposure,” we mean having seen, heard of, used, or discussed the Surgical Safety Checklist

• 9. Where have you been exposed to the Surgical Safety Checklist (select all that apply)?

  • a. During medical school—in classroom setting

  • b. During medical school—in clinical setting

  • c. As a trainee (i.e., intern, resident, registrar, fellow, etc.)

  • d. As an independent provider (i.e., Completed clinical training)

  • e. Through InciSioN or other global organization

  • f. At conference(s)

  • g. In the academic literature or journal articles

  • h. The Checklist Manifesto by Atul Gawande

  • i. The Checklist Effect documentary through InciSioN showing

  • j. The Checklist Effect documentary independent of InciSioN showing

  • k. Other: {please describe}

  • l. I am not familiar with the Surgical Safety Checklist

• 10. (Among the selected exposures), where were you first exposed to the Surgical Safety Checklist (one option only)

  • a. During medical school—in classroom setting

  • b. During medical school—in clinical setting

  • c. As a trainee (i.e., intern, resident, registrar, fellow, etc.)

  • d. As an independent provider (i.e., completed clinical training)

  • e. Through InciSioN or other global organization

  • f. At conference(s)

  • g. In the academic literature or journal articles

  • h. The Checklist Manifesto by Atul Gawande

  • i. The Checklist Effect documentary through InciSioN showing

  • j. The Checklist Effect documentary independent of InciSioN showing

  • k. Other: {copy what was described in Q9 k}

  • l. I do not recall

• 11. How was it incorporated into the classroom setting in your medical school?

  • a. Part of the formal curricula

  • b. Other: please specify

  • c. I don’t know or I don’t recall

• 12. When you were first exposed to the Surgical Safety Checklist, how motivated were you to try it? Likert scale 1–10 with legend (1—not motivated; 5—somewhat motivated; 10—very motivated)

  Definition: By “training” we mean instruction on using the Surgical Safety Checklist in a patient care setting.

• 13. Have you been formally or informally trained on how to use the Surgical Safety Checklist?

  • a. Yes

  • b. No

• 13a. When were you trained on how to use the Surgical Safety Checklist? (select all that apply) (only display if trainee or provider)

  • a. Medical school

  • b. Trainee (i.e., intern, resident, registrar, fellow, etc.)

  • c. Independent practicing provider (i.e., completed clinical training)

• 14.. When you were trained to use the Surgical Safety Checklist, what method(s) were utilized during the training (select all that apply)?

  • a. Didactic/lecture

  • b. Role play/simulation

  • c. Seeing proper Surgical Safety Checklist use modeled for me

  • d. Other (please describe)

• 15. What training method for the use the Surgical Safety Checklist do you think was the most successful?

  • a. Didactic/lecture

  • b. Role play/simulation

  • c. Seeing proper Surgical Safety Checklist use modeled for me

  • d. Other (please describe)

  • e. I don’t know

  Definition: We define using the Surgical Safety Checklist as being involved in a patient care episode in which the Surgical Safety Checklist was used

• 16. Have you ever personally used the Surgical Safety Checklist (or a version of it) in an operating theater during a clinical case?

  • a. Yes

  • b. No

• 17. Do you currently care for surgical patients (as a provider or trainee)?

  • a. Yes

  • b. No

• 18. Select all the characteristics that describe the facility where you spend most of your time caring for surgical patients? (select all that apply)

  • a. Rural

  • b. Urban

  • c. Private

  • d. Public

  • e. Community/district hospital

  • f. Academic

  • g. Other: (please describe)

• 19. To the best of your knowledge, how was the Surgical Safety Checklist implemented (i.e., introduced into practice) in the facility where you currently practice or are being trained? (select all that apply)

  • a. Mandated

  • b. Quality improvement initiative

  • c. Other: (please describe)

  • d. I don’t know

  • e. The Surgical Safety Checklist is not currently used at my facility

• 20. What professions are using the Surgical Safety Checklist in your facility (select all that apply)?

  • a. Perioperative staff (i.e., nurse, scrub tech, etc.)

  • b. Surgeon (specify specialty:)

  • c. Anesthesiologist

  • d. Resident/trainee (specify specialty:)

  • e. Other: (please describe)

  • f. I don’t know

• 21. In your facility, in what proportion of patients undergoing surgery is the Surgical Safety Checklist used?

  • a. Rarely (0–25% of patients)

  • b. Occasionally (25–50% of patients)

  • c. Most of the time (51–75% of patients)

  • d. Majority of the time (76–100% of patients)

  • e. I don’t know

• 22. Why is the Surgical Safety Checklist used with this frequency in your facility? (select all that apply)

  • a. Not mandated

  • b. Only some specialties use it

  • c. Not always available

  • d. Time consuming

  • e. Low or little/no perceived value

  • f. Patients don’t like it

  • g. Implementation challenges

  • h. Other: (please describe)

  • i. The Surgical Safety Checklist is used for 100% of cases, every day

• 23. How do you think the Surgical Safety Checklist positively impacts patient care? (select all that apply)

  • a. I think it reduces errors in the operating room

  • b. It makes me feel more confident to speak up when I see something going wrong

  • c. I feel the team works better together

  • d. Other: (please describe)

  • e. I don’t think it positively impacts patient care

• 24. In contrast, why do you think the Surgical Safety Checklist does not improve patient care? (select all that apply)

  • a. We already do everything on it

  • b. We don’t have the resources to do everything on it

  • c. It was never properly introduced into my facility

  • d. There is limited buy-in

  • e. Other: (please describe)

• 25. Overall, how do you think the Surgical Safety Checklist affects patient care?

  • a. Positively

  • b. No effect

  • c. Negatively

  • d. I don’t know

• 26. Which of the following best describes the goal of the Surgical Safety Checklist?

  • a. To protect healthcare professionals from malpractice

  • b. A tool to remind you to complete key perioperative patient safety processes

  • c. A tool to improve communication among the operating room team

  • d. I don’t really understand the goal of the Surgical Safety Checklist

• 27. Why would you use the Surgical Safety Checklist in the future? (select all that apply)

  • a. It is mandated

  • b. Improves patient safety

  • c. Improves team communication

  • d. Standard of care

  • e. Easy to use

  • f. Quick to use

  • g. Patients like it

  • h. Other: (please describe)

  • i. I don’t know

• 28. Overall, how likely are you to use the Surgical Safety Checklist in your future practice? Likert scale 1–10: 1 being “not likely at all” and 10 being “very likely.”

  • a. Please describe why:

• 29. How could the Surgical Safety Checklist be improved (select all that apply)?

  • a. Changes to what is included on the Checklist (content) (please describe);

  • b. Changes to how the Checklist is structured (design and organization) (please describe);

  • c. Changes related to how it is implemented/introduced (please describe);

  • d. Other (please describe);

  • e. I wouldn’t change anything.

Appendix 2: Report of survey respondents

Among 1985 InciSioN members eligible to receive the survey, the following responses were determined using the American Association for Public Opinion Research Standard Definitions.

• Complete response = 451

• Partial response = 27

• Refusal and break-off = 5 (refusal) + 132 (break-off)

• Non-contact = 1375

• Other = 0

• Unknown household = not applicable

• Unknown other = not applicable

Please note above, break-off was considered to be <85%, partial response 85–99%, and complete response 100%. These thresholds were used given what was felt to be proportional of applicable/crucial questions. In addition, similar thresholds have been offered in the Standard Definitions report of the AAPOR [12].

The survey developed for this study was most consistent with the AAPOR definition of a non-probability Web-based survey because that the exact number of people who were exposed to the survey was not known (e.g., estimates of InciSioN’s National Working Group (NWG) size was determined based on size of e-mail listserv, not through direct contact). In such studies, the AAPOR recommends reporting participation and/or completion rates, rather than response rates. The definition used in the Standard Definition report for these rates is the “number of respondents who have provided a usable response divided by the number of personal invitations requesting participation.” Overall NWG participation rate was 45% (19/42). Respondent participation rate was determined by considering usable responses (451 complete and 27 partial responses) divided by a total of 1985 potential respondents. This respondent participation rate is 24%. Because we do not know the receipt of the survey when disseminated through social media platforms, we do not estimate a response or participation rate, consistent with AAPOR recommendations.