Towards a model of surgeons' leadership in the operating room

A Comprehensive Analysis of Leadership Attributes, Discrepancies, and Implications for Gender Equity in Vascular Surgery

OBJECTIVE

Well-developed leadership skills have been associated with a better understanding of healthcare context, increased team performance, and improved patient outcomes. Surgeons, in particular, stand to benefit from leadership development. While studies have focused on investigating knowledge gaps and needs of surgeons in leadership roles, there is a noticeable gap in the literature concerning leadership in Vascular Surgery. The goal of this study was to characterize current leadership attributes of vascular surgeons and understand demographic influences on leadership patterns.

METHODS

This retrospective cohort study was a descriptive analysis of vascular surgeons and their observers who took the leadership practice inventory (LPI) from 2020 to 2023. The LPI is a 30 question inventory that measures the frequency of specific leadership behaviors across five practices of leadership.

RESULTS

A total of 110 vascular surgeons completed the LPI. The majority of participants were white (56%) and identified as male (60%). Vascular surgeons most frequently observed the "enabling others to act" leadership practice style (8.90 ± 0.74) by all evaluators. Vascular surgeons were most frequently above the 70th percentile in the "challenge the process" leadership practice style (49%) compared to the average of other leaders world-wide. Observers rated vascular surgeons as displaying significantly more frequent leadership behaviors than vascular surgeons rated themselves in every leadership practice style (P-value < 0.01). The only demographic variable associated with a significantly increased occurrence of achieving 70th percentile across all five leadership practice styles was the male gender: a multivariable model adjusting for objective experience showed men were at least 3.5 times more likely to be rated above the 70th percentile than women.

CONCLUSIONS

Vascular surgeons under report the frequency at which they practice leadership skills across all five leadership practice styles and should recognize their strengths of enabling others to act and challenging the process. Men are recognized as exhibiting all five leadership practices more frequently than women, regardless of current position or experience level. This observation may reflect the limited leadership positions available for women, thereby restricting their opportunities to demonstrate leadership practices as frequently or recognizably as their male counterparts.

Leader airtime management and team effectiveness in emergency management command and control (EMCC) teams

We investigated the relation between leader airtime management and team effectiveness in Emergency Management Command and Control (EMCC) teams. Leader airtime management concerns leaders' interventions to structure who shares information when using opening and closing statements to respectively stimulate or reduce information sharing. We coded leaders' airtime management statements across different meeting phases (structuring, information sharing, decision making) using video-recordings of 12 EMCC exercises involving two consecutive meetings each. Experts rated two components of team effectiveness: Team Situation Awareness (TSA) and Team Decision Making (TDM). We found that closing statements were more frequently used in the decision-making phase than in any other meeting phase. Also, leaders of teams with lower TSA used more opening statements in the decision-making phase of the first team meeting than leaders of teams with higher TSA. These results confirm the importance of the timing of leader airtime management for EMCC team effectiveness. Practitioner summary: We investigated leader airtime management and team effectiveness in EMCC teams. We video-coded 12 exercises; experts rated team effectiveness. In the decision-making phase, leaders use more closing statements, and leaders of less effective teams use more opening statements. Leaders are advised to adjust their airtime management to meeting phases.

Surgeons' Leadership Style and Team Behavior in the Hybrid Operating Room: Prospective Cohort Study

OBJECTIVE

This study aimed to assess the relationship between surgeons' leadership style and team behavior in the hybrid operating room through video coding. Secondly, possible fluctuations possible fluctuations in leadership styles and team behavior during operative phases were studied.

BACKGROUND

Leadership is recognized as a key component to successful team functioning in high-risk industries. The 'full range of leadership' theory is commonly used to evaluate leadership, marking transformational, transactional, and passive. Few studies have examined the effects of these leadership styles on team behavior in surgery and/or their fluctuations during surgery.

METHODS

A single-center study included patients planned for routine endovascular procedures. A medical data capture system was used to allow post hoc video coding through Behavior Anchored Rating Scales. Multilevel statistical analysis was performed to assess possible correlations between leadership style and 3 team behavior indicators (speaking up, knowledge sharing, and collaboration) on an operative phase level.

RESULTS

Twenty-two cases were analyzed (47 hours recording). Transformational leadership is positively related to the extent to which team members work together (γ=0.20, P <0.001), share knowledge (γ=0.45, P <0.001), and speak up (γ=0.64, P <0.001). Passive leadership is significantly positively correlated with speaking up (γ=0.29, P =0.004). Leadership style and team behavior clearly fluctuate during a procedure, with similar patterns across different types of endovascular procedures.

CONCLUSIONS

Consistent with other professional fields, surgeons' transformational leadership enhances team behavior, especially during the most complex operative phases. This suggests that encouraging surgeons to learn and actively implement a transformational leadership style is meaningful to enhance patient safety and team performance.

Effects of structured intraoperative briefings on patient outcomes: multicentre before-and-after study

BACKGROUND

Operations require collaboration between surgeons, anaesthetia professionals, and nurses. The aim of this study was to determine whether intraoperative briefings influence patient outcomes.

METHODS

In a before-and-after controlled trial (9 months baseline; 9 months intervention), intraoperative briefings were introduced in four general surgery centres between 2015 and 2018. During the operation, the responsible surgeon (most senior surgeon present) briefed the surgical team using the StOP? protocol about: progress of the operation (Status), next steps (Objectives), possible problems (Problems), and encouraged asking questions (?). Differences between baseline and intervention were analysed regarding surgical-site infections (primary outcome), mortality, unplanned reoperations, and duration of hospital stay (secondary outcomes), using inverse probability of treatment (IPT) weighting based on propensity scores.

RESULTS

In total, 8256 patients underwent surgery in the study. Endpoint data were available for 7745 patients (93.8 per cent). IPT-weighted and adjusted intention-to-treat analyses showed no differences in surgical-site infections between baseline and intervention (9.8 versus 9.6 per cent respectively; adjusted difference (AD) -0.15 (95 per cent c.i. -1.45 to 1.14) per cent; odds ratio (OR) 0.92, 95 per cent c.i. 0.83 to 1.15; P = 0.797), but there were reductions in mortality (1.6 versus 1.1 per cent; AD -0.54 (-1.04 to -0.03) per cent; OR 0.60, 0.39 to 0.92; P = 0.018), unplanned reoperations (6.4 versus 4.8 per cent; AD -1.66 (-2.69 to -0.62) per cent; OR 0.72, 0.59 to 0.89; P = 0.002), and fewer prolonged hospital stays (21.6 versus 19.8 per cent; AD -1.82 (-3.48 to -0.15) per cent; OR 0.87, 0.77 to 0.98; P = 0.024).

CONCLUSION

Short intraoperative briefings improve patient outcomes and should be performed routinely.

Dissecting leadership education and assessment in surgery

The importance of leadership is well recognised within surgery owing to the heavily teamwork dependent nature and uniquely dynamic working environment of the operating room. Teaching and assessment methods of leadership within UK surgical training has arguably lacked credence in comparison to the more tangible technical clinical competencies due to the fact that the daily tasks of surgeons are multifaceted and cannot be simplified into a tick-box exercise. As such, some surgical trainees perceive themselves to be minimally competent in their leadership ability. The new surgical curricula planned to be implemented by the Intercollegiate Surgical Curriculum Programme in August 2021 aims to address this by shifting leadership training and assessment towards an outcome-based approach, rather than a competency-based approach, with an emphasis on the role of the professional judgement of trainers as well as trainee self-reflection. This article explores these proposed changes by framing them within the context of the wider literature pertaining to surgical leadership education.

Value of Nontechnical Skills in Minimally Invasive Surgery

Nontechnical skills are of increasing importance in surgery and surgical training. The main studies on its impact on the safety and effectiveness of surgical interventions were mainly published in the first decade of the 2000s. Due to the significant technical complexity and great diversity of instruments for nontechnical skills evaluation, the interest in training and in measuring the impact on surgical safety has relatively decreased. However, the advent of minimally invasive surgery and its peculiar technical characteristics of sophisticated technique and constant innovation through the adoption of new materials and drugs has rekindled interest in this expertise area. In the present review, we have revisited the main instruments available to measure nontechnical skill of surgical teams and analyzed the role of the main competencies on which they are based, such as situational awareness, leadership and communication skills, and the consistency of the intraoperative decision-making process. We conclude that despite the great consensus that exists among all members of the health team on the importance of nontechnical skills for the surgical team in minimally invasive surgery, the reproducible evidence on the subject is scarce and laborious to obtain. To the extent that protecting and expanding nontechnical skills is fundamental to the path toward the high reliability of health institutions, it is possible to anticipate here the role of these institutions as promoters of continuity and new research models in this area of knowledge, especially in minimally invasive surgery, an access route to which more and more patients undergoing surgical treatment in these same institutions are submitted.

Modern Plastic Surgical Practice: Technical Competence Alone Is Not Enough

Annually, an estimated 234 million major surgical operations occur worldwide, with concomitant seven million complications and one million deaths. It is now well established that technical competence is necessary, but not sufficient for modern surgical practice and outcomes. Breakdown in non-technical skills has been attributed as a key root cause for near misses and patient harm in the operating room. This article discusses the multi-faceted skills-set that is necessary for the modern surgeon to succeed and for optimal patient outcomes. This includes technical skills, non-technical skills, with a focus on key CanMEDS framework domains, including leadership, communication, evidence-based surgery and mentorship.

A literature review exploring common factors contributing to Never Events in surgery

This literature review explores some common factors contributing to Never Events in surgery. Despite significant patient safety efforts, serious preventable surgical events that turn into Never Events continue to exist. Various search databases were used to collect relevant contemporary data within the time parameters 2008-2019. The literature revealed numerous studies from the United States of America and worldwide, and the need for more current research from the United Kingdom on the subject. The key findings emphasise that communication failure, situational awareness, fatigue, lack of healthcare professionals and surgical caseload are common contributing factors to Never Events. The implications of these findings for practice highlight that despite multidisciplinary approaches, technologies, policies and strategies, Never Events are a common phenomenon in surgery. To minimise their occurrence, more robust and reliable safety management systems need to be in place within healthcare organisations. In depth understanding of cognitive Human Factors and non-technical skills need to be encouraged through education, training and continuous evaluation of success and failure.

WITHDRAWN: What does safety commitment mean to leaders? A multi-method investigation

The Publisher regrets that this article is an accidental duplication of an article that has already been published in Journal of Safety Research, 68 (2019) 203-214, https://doi.org/10.1016/j.jsr.2018.12.011. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

What does safety commitment mean to leaders? A multi-method investigation

INTRODUCTION

Perceived management safety commitment as an aspect of safety climate or culture is a key influence on safety outcomes in organizations. What is unclear is how perceptions of management commitment are created by leaders.

METHOD

To address this gap in the literature, we position safety commitment as a leadership construct viewed from the perspectives of the leaders who experience and demonstrate it. In this paper, an established multidimensional commitment framework is applied to leaders' safety commitment (consisting of affective, normative, and calculative commitment). Via an exploratory sequential mixed methods design combining interviews (n = 40) and surveys (n = 89), we investigate the applicability of this theoretical conceptualization to safety commitment.

RESULTS

The results indicate the multiple dimensions captured leaders' safety commitment well, safety commitment can be demonstrated via a range of behaviors, and the dimensions' association with behavioral demonstrations aligned with those of other types of commitment reported in the literature. Only affective safety commitment was consistently associated with demonstrations of safety commitment. The link between high levels of affective and normative safety commitment and demonstrations was more pronounced when participants perceived their company's safety climate more positively.

CONCLUSIONS

Adopting a focus on leaders' experience of safety commitment offers opportunities for new research into the way in which safety commitment perceptions are shaped by leaders. Practical application: The findings can support leaders' reflection about their personal mindset around safety and support them in fostering strong safety climates and cultures. It further encourages organizations in creating work environments that in particular foster affective and normative safety commitments in leaders.

A search for training of practising leadership in emergency medicine: A systematic review

Objective

This systematic review examines the medical, psychological and educational literature for training in practising leadership of a team leader in emergencies. The objectives of this paper are (1) describe how literature addresses operational training in practising leadership for the emergency medical team-leader (2) enhance understanding of leadership training in the medical environment.

Background

Worldwide, medical supervisors find it difficult to get students to rise to the occasion as leaders of emergency teams. It appears that many residents feel unprepared to adopt the role as a leader in emergencies.

Method

A systematic review was conducted (May-December 2016) in accordance with the PRISMA 2009 Checklist. A literature search was conducted against a set of inclusion criteria. Databases searched included PubMed, Psycinfo (via Ovid), and ERIC.

Results

27 articles covering the period 1986-2016 were analysed. Four sources of data were identified: Intervention studies practising leadership, intervention studies on simulation and leadership assessment, observation studies assessing leadership, interview/survey studies about the need for leadership training. No workable training in practising leadership in emergencies for doctors was found. The majority of the research projects focused on various different types of taxonomies.

Conclusions

No consistent and workable leadership training for the emergency medical teamleader was identified. One study for paramedics succeeded in training empowering leadership skills. For many years multiple taxonomies and leadership assessment tools have been developed but failed to come to terms with workable leadership training. The literature describes lack of leadership as highly detrimental to performance during a critical, clinical situation.

Nontechnical skills in pediatric surgery: Factors influencing operative performance

Technical competence is an essential aspect of intraoperative performance but is in itself insufficient to ensure an optimal surgical outcome. A list of other skills complement technical ability and these relate, among others, to surgical judgment and intraoperative decision-making processes as well as the role of the operating surgeon as leader of the surgical team. This article outlines the composite set of nontechnical skills (NTS) and the factors which influence surgical performance by virtue of this skill set. A framework has been developed to allow identification, teaching, and assessment of NTS known as Nontechnical Skills for Surgeons (NOTSS), and the relevance and influence of NOTSS during the intraoperative performance of pediatric surgery is presented.

Taxonomy of Trauma Leadership Skills: A Framework for Leadership Training and Assessment

PURPOSE

Good leadership is essential for optimal trauma team performance, and targeted training of leadership skills is necessary to achieve such leadership proficiency. To address the need for a taxonomy of leadership skills that specifies the skill components to be learned and the behaviors by which they can be assessed across the five phases of trauma care, the authors developed the Taxonomy of Trauma Leadership Skills (TTLS).

METHOD

Critical incident interviews were conducted with trauma team leaders and members from different specialties-emergency physicians, trauma surgeons, anesthesiologists, and emergency ward nurses-at three teaching hospitals in the Netherlands during January-June 2013. Data were iteratively analyzed for examples of excellent leadership skills at each phase of trauma care. Using the grounded theory approach, elements of excellent leadership skills were identified and classified. Elements and behavioral markers were sorted and categorized using multiple raters. In a two-round verification process in late 2013, the taxonomy was reviewed and rated by trauma team leaders and members from the multiple specialties for its coverage of essential items.

RESULTS

Data were gathered from 28 interviews and 14 raters. The TTLS details 5 skill categories (information coordination, decision making, action coordination, communication management, and coaching and team development) and 37 skill elements. The skill elements are captured by 67 behavioral markers. The three-level taxonomy is presented according to five phases of trauma care.

CONCLUSIONS

The TTLS provides a framework for teaching, learning, and assessing team leadership skills in trauma care and other complex, acute care situations.

Advantages and disadvantages of 3-dimensional printing in surgery: A systematic review

BACKGROUND

Three-dimensional (3D) printing is becoming increasingly important in medicine and especially in surgery. The aim of the present work was to identify the advantages and disadvantages of 3D printing applied in surgery.

METHODS

We conducted a systematic review of articles on 3D printing applications in surgery published between 2005 and 2015 and identified using a PubMed and EMBASE search. Studies dealing with bioprinting, dentistry, and limb prosthesis or those not conducted in a hospital setting were excluded.

RESULTS

A total of 158 studies met the inclusion criteria. Three-dimensional printing was used to produce anatomic models (n = 113, 71.5%), surgical guides and templates (n = 40, 25.3%), implants (n = 15, 9.5%) and molds (n = 10, 6.3%), and primarily in maxillofacial (n = 79, 50.0%) and orthopedic (n = 39, 24.7%) operations. The main advantages reported were the possibilities for preoperative planning (n = 77, 48.7%), the accuracy of the process used (n = 53, 33.5%), and the time saved in the operating room (n = 52, 32.9%); 34 studies (21.5%) stressed that the accuracy was not satisfactory. The time needed to prepare the object (n = 31, 19.6%) and the additional costs (n = 30, 19.0%) were also seen as important limitations for routine use of 3D printing.

CONCLUSION

The additional cost and the time needed to produce devices by current 3D technology still limit its widespread use in hospitals. The development of guidelines to improve the reporting of experience with 3D printing in surgery is highly desirable.

Attending Surgeons' Leadership Style in the Operating Room: Comparing Junior Residents' Experiences and Preferences

PURPOSE

Recent studies have focused on surgeons' nontechnical skills in the operating room (OR), especially leadership. In an attempt to identify trainee preferences, we explored junior residents' opinions about the OR leadership style of teaching faculty.

METHODS

Overall, 20 interns and 20 mid-level residents completed a previously validated survey on the style of leadership they encountered, the style they preferred to receive, and the style they personally employed in the OR. In all, 4 styles were explored; authoritative: leader makes decisions and communicates them firmly; explanatory: leader makes decisions promptly, but explains them fully; consultative: leader consults with trainees when important decisions are made, and delegative: leader puts the problem before the group and makes decisions by majority opinion. Comparisons were completed using chi-square analysis.

RESULTS

Junior resident preference for leadership style of attending surgeons in the OR differed from what they encountered. Overall, 62% of residents encountered an authoritative leadership style; however, only 9% preferred this (p < 0.001). Instead, residents preferred explanatory (53%) or consultative styles (41%). Preferences differed by postgraduate year. Although 40% of interns preferred a consultative style, 50% of mid-level residents preferred explanatory leadership.

CONCLUSIONS

Junior resident preference of leadership style in the OR differs from what they actually encounter. This has the potential to create unwanted tension and may erode team performance. Awareness of this difference provides an opportunity for an educational intervention directed at both attendings and trainees.

Surgeons' Leadership Styles and Team Behavior in the Operating Room

BACKGROUND

The importance of leadership is recognized in surgery, but the specific impact of leadership style on team behavior is not well understood. In other industries, leadership is a well-characterized construct. One dominant theory proposes that transactional (task-focused) leaders achieve minimum standards and transformational (team-oriented) leaders inspire performance beyond expectations.

STUDY DESIGN

We videorecorded 5 surgeons performing complex operations. Each surgeon was scored on the Multifactor Leadership Questionnaire, a validated method for scoring transformational and transactional leadership style, by an organizational psychologist and a surgeon researcher. Independent coders assessed surgeons' leadership behaviors according to the Surgical Leadership Inventory and team behaviors (information sharing, cooperative, and voice behaviors). All coders were blinded. Leadership style (Multifactor Leadership Questionnaire) was correlated with surgeon behavior (Surgical Leadership Inventory) and team behavior using Poisson regression, controlling for time and the total number of behaviors, respectively.

RESULTS

All surgeons scored similarly on transactional leadership (range 2.38 to 2.69), but varied more widely on transformational leadership (range 1.98 to 3.60). Each 1-point increase in transformational score corresponded to 3 times more information-sharing behaviors (p < 0.0001) and 5.4 times more voice behaviors (p = 0.0005) among the team. With each 1-point increase in transformational score, leaders displayed 10 times more supportive behaviors (p < 0.0001) and displayed poor behaviors 12.5 times less frequently (p < 0.0001). Excerpts of representative dialogue are included for illustration.

CONCLUSIONS

We provide a framework for evaluating surgeons' leadership and its impact on team performance in the operating room. As in other fields, our data suggest that transformational leadership is associated with improved team behavior. Surgeon leadership development, therefore, has the potential to improve the efficiency and safety of operative care.

Leadership training in health care action teams: a systematic review

PURPOSE

To identify and describe the design, implementation, and evidence of effectiveness of leadership training interventions for health care action (HCA) teams, defined as interdisciplinary teams whose members coordinate their actions in time-pressured, unstable situations.

METHOD

The authors conducted a systematic search of the PubMed/MEDLINE, CINAHL, ERIC, EMBASE, PsycINFO, and Web of Science databases, key journals, and review articles published through March 2012. They identified peer-reviewed English-language articles describing leadership training interventions targeting HCA teams, at all levels of training and across all health care professions. Reviewers, working in duplicate, abstracted training characteristics and outcome data. Methodological quality was evaluated using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

Of the 52 included studies, 5 (10%) focused primarily on leadership training, whereas the remainder included leadership training as part of a larger teamwork curriculum. Few studies reported using a team leadership model (2; 4%) or a theoretical framework (9; 17%) to support their curricular design. Only 15 studies (29%) specified the leadership behaviors targeted by training. Forty-five studies (87%) reported an assessment component; of those, 31 (69%) provided objective outcome measures including assessment of knowledge or skills (21; 47%), behavior change (8; 18%), and patient- or system-level metrics (8; 18%). The mean MERSQI score was 11.4 (SD 2.9).

CONCLUSIONS

Leadership training targeting HCA teams has become more prevalent. Determining best practices in leadership training is confounded by variability in leadership definitions, absence of supporting frameworks, and a paucity of robust assessments.

Teamwork and Collaboration

Safety and quality of health care depend on collaborative efforts of multiprofessional and multidisciplinary teams of care providers. Team research in aviation and the military has produced a wealth of knowledge in terms of concepts and intervention strategies to improve team performance. Research on collaborative work in health care in the past 20 years has uncovered unique characteristics and requirements of teams in hospitals and other health care settings and has provided early assessment of the utility of the theoretical concepts, methodologies, and interventions developed outside health care. In this chapter, we review a set of concepts that have been used in characterizing teams in health care and in improving teamwork. These concepts include the organizational shell to capture the sociotechnical environment in which teams reside as well as nontechnical skills, team leadership, team mental models, and so on. We will review a number of leading interventions to enhance team performance, such as teamwork training (e.g., TeamSTEPPS) and structured communication (e.g., SBAR). Future directions are suggested on better understanding of the interdependencies between teams and their organizational shell, such as standardization of operating procedures and training, and to focus on the patient in terms of teamwork improvement.

Co-ACT--a framework for observing coordination behaviour in acute care teams

BACKGROUND

Acute care teams (ACTs) represent action teams, that is, teams in which members with specialised roles must coordinate their actions during intense situations, often under high time pressure and with unstable team membership. Using behaviour observation, patient safety research has been focusing on defining teamwork behaviours-particularly coordination-that are critical for patient safety during these intense situations. As one result of this divergent research landscape, the number, scope and variety of applied behaviour observation taxonomies are growing, making comparison and convergent integration of research findings difficult.

AIM

To facilitate future ACT research by presenting a framework that provides a shared language of teamwork behaviours, allows for comparing previous and future ACT research and offers a measurement tool for ACT observation.

METHOD

Based on teamwork theory and empirical evidence, we developed Co-ACT-the Framework for Observing Coordination Behaviour in ACT. Integrating two previous, extensive taxonomies into Co-ACT, we also suggested 12 behavioural codes for which we determined inter-rater reliability by analysing the teamwork of videotaped anaesthesia teams in the clinical setting.

RESULTS

The Co-ACT framework consists of four quadrants organised along two dimensions (explicit vs implicit coordination; action vs information coordination). Each quadrant provides three categories for which Cohen's κ overall value was substantial; but values for single categories varied considerably.

CONCLUSIONS

Co-ACT provides a framework for organising behaviour codes and offers respective categories for succinctly measuring teamwork in ACTs. Furthermore, it has the potential to allow for guiding and comparing ACTs study results. Future work using Co-ACT in different research and training settings will show how well it can generally be applied across ACTs.

Surgeons' non-technical skills

The importance of non-technical skills to surgical performance is gaining wide acceptance. This article discusses the core cognitive and social skills categories thought to underpin medical knowledge and surgical expertise, and describes the rise of non-technical skill models of assessment in surgery. Behavior rating systems such as NOTSS (Non-Technical Skills for Surgeons) have been developed to support education and assessment in this regard. We now understand more about these critical skills and how they impact surgery. The challenge in the future is to incorporate them into undergraduate teaching, postgraduate training, workplace assessment, and perhaps even selection.

Surgeons' leadership in the operating room: an observational study

BACKGROUND

There is widespread recognition in high-risk organizations that leadership is essential for efficient and safe team performance. However, there is limited empiric evidence identifying specific leadership skills and associated behaviors enacted by surgeons during surgery.

METHODS

Observational data on surgeons' intraoperative leadership behaviors were gathered during surgeries (n = 29) in 3 hospitals. Observations were coded using 7 leadership elements identified from the literature on surgeons' leadership. Surgeries were categorized by complexity using British United Provident Association ratings.

RESULTS

A total of 258 leadership behaviors were observed during more than 63 hours of observation. Surgeons most frequently showed guiding and supporting (33%), communicating and coordinating (20%), and task management behaviors (15%). In many instances the surgeons' leadership was directed to the room rather than to a specific team member. Surgeons engaged in leadership behaviors significantly more frequently during cases of high complexity compared with cases of lower complexity.

CONCLUSIONS

This study is the first step in developing an empirically derived taxonomy to identify and classify surgeons' intraoperative leadership behaviors.