Surgical Team Structure: How Familiarity and Team Size Influence Communication Effectiveness in Military Surgical Teams

INTRODUCTION

Preventable patient harm has persisted in health care despite recent advances to reduce errors. There is increasing recognition that non-technical skills, including communication and relationships, greatly impact interprofessional team performance and health care quality. Team familiarity and size are critical structural components that potentially influence information flow, communication, and efficiency.

METHODS

In this exploratory, prospective, cross-sectional study, we investigated the key structural components of surgical teams and identified how surgical team structure shapes communication effectiveness. Using total population sampling, we recruited surgical clinicians who provide direct patient care at a 138-bed military medical center. We used statistical modeling to characterize the relationship between communication effectiveness and five predictors: team familiarity, team size, surgical complexity, and the presence of surgical residents and student anesthesia professionals.

RESULTS

We surveyed 137 surgical teams composed of 149 multidisciplinary clinicians for an 82% response rate. The mean communication effectiveness score was 4.61 (SD = 0.30), the average team size was 4.53 (SD = 0.69) persons, and the average surgical complexity was 10.85 relative value units (SD = 6.86). The surgical teams exhibited high variability in familiarity, with teams co-performing 26% (SD = 0.16) of each other's surgeries. We found for every unit increase in team familiarity, communication effectiveness increased by 0.36 (P ≤ .05), whereas adding one additional member to the surgical team decreased communication effectiveness by 0.1 (P ≤ .05). Surgical complexity and the influence of residents and students were not associated with communication effectiveness.

CONCLUSIONS

For military surgical teams, greater familiarity and smaller team sizes were associated with small improvements in communication effectiveness. Military leaders can likely enhance team communication by engaging in a thoughtful and concerted program to foster cohesion by building familiarity and optimizing team size to meet task and cognitive demands. We suggest leaders develop bundled approaches to improve communication by integrating team familiarity and team size optimization into current evidence-based initiatives to enhance performance.

Associations of Surgical Team Communication With the Layout of Physical Space: A Network Analysis of the Operating Room in a Military Medical Center

AIM

To examine how the spatial topology of the operating room (OR) within the medical center impacts surgical team communication.

BACKGROUND

Understanding the complex association between surgical team communication and the OR's spatial network location is critical to patient safety. Effective surgical communication is associated with fewer adverse events and medical errors.

METHODS

We employed a cross-sectional, quantitative, case study, and network-centric study design. We studied the population of 204 clinicians in a large military medical center (36 perioperative nurses, 34 surgical technicians, 62 anesthesia providers, and 72 surgeons), focusing on surgical teams with cases completed within duty hours. Data were collected from December 2020 to June 2021 using an electronic survey. Spatial network analysis was done using electronic floor plans. Statistical analysis was done with descriptive statistics and linear regressions. The outcomes were general and task-specific communication, and team-level variables were aggregated from scores for all team members. Spatial effects were assessed with network centrality (degree, Laplacian, and betweenness).

RESULTS

The individual-level survey response rate was 77% (157 of 204). Data were collected on 137 surgical teams. On a 5-point scale, general and task-specific communication ranged from 3.4 to 5.0 and 3.5 to 5.0, respectively (for both, median = 4.7). Team size ranged from 4 to 6 individuals (median = 4). Surgical suites with higher network centralities were associated with significantly lower communication scores.

CONCLUSIONS

The OR's spatial network location has important impacts on surgical team communication. Our findings have design and workflow implications for ORs and even surgical care in combat zones.

The Paradox of Network Inequality: Differential Impacts of Status and Influence on Surgical Team Communication

INTRODUCTION

Introduction: Healthcare is a dynamic and complex system predisposed to adverse events caused by human and technical errors. The ability of multidisciplinary clinicians to effectively communicate clinical information influences healthcare quality. Authority gradients, culture, and organizational hierarchy frequently constrict communication and contribute to surgical adverse events. Hierarchy is especially pronounced in military medicine, where military status, rank, and professional roles potentially create barriers to communication.

METHODS

We used an exploratory, prospective, cross-sectional design to determine how the social structure of military surgical teams influences group (network) communication effectiveness. Using a social network questionnaire, we surveyed members of surgical teams concerning their close-working relationships with other team members and perceptions of their communication effectiveness. We addressed the following research question: In surgical teams, how do the status (indegree) and influence (outdegree) of its individual members impact communication within the team?

RESULTS

We surveyed 50 surgical teams comprised of 45 clinicians and found that for close-working relationship networks communication effectiveness improved with lower concentrations of status and higher concentrations of influence. Network indegree (i.e., status) (β=-0.893, p=.019) had a larger impact than outdegree (i.e., influence) (β=0.617, p=.015), indicating status had a larger effect on communication effectiveness than influence. Put simply, our results show communication improves when there is more equality of status in the surgical team. Paradoxically, communication improves when there are higher concentrations of network influence among surgical team members.

CONCLUSIONS

Inequality in surgical team networks has paradoxical effects on communication effectiveness. The impact of network structure on organizational behavior is of high interest to the military and provides essential insights into clinicians' ability to communicate in a highly complex and task-based environment. Communication will likely improve in surgical teams through methods to foster equality of team member status and promote surgical leadership. Military medical policies could both amplify the positive effects and mitigate the negative effects of network inequality.

Military Surgical Team Communication: Implications for Safety

Introduction

Medical error is the third leading cause of death in the United States, contributing to suboptimal care, serious patient injury, and mortality among beneficiaries in the Military Health System. Recent media reports have scrutinized the safety and quality of military healthcare, including surgical complications, infection rates, clinician competence, and a reluctance of leaders to investigate operational processes. Military leaders have aggressively committed to a continuous cycle of process improvement and a culture of safety with the goal to transform the Military Health System into a high-reliability organization. The cornerstone of patient safety is effective clinician communication. Military surgical teams are particularly susceptible to communication error because of potential barriers created by military rank, clinical specialty, and military culture. With an operations tempo requiring the military to continually deploy small, agile surgical teams, effective interpersonal communication among these team members is vital to providing life-saving care on the battlefield.

Methods

The purpose of our exploratory, prospective, cross-sectional study was to examine the association between social distance and interpersonal communication in a military surgical setting. Using social network analysis to map the relationships and structure of interpersonal relations, we developed six networks (interaction frequency, close working relationship, socialization, advice-seeking, advice-giving, and speaking-up/voice) and two models that represented communication effectiveness ratings for each participant. We used the geodesic or network distance as a predictor of team member network position and assessed the relationship of distance to pairwise communication effectiveness with permutation-based quadratic assignment procedures. We hypothesized that the shorter the network geodesic distance between two individuals, the smaller the difference between their communication effectiveness.

Results

We administered a network survey to 50 surgical teams comprised of 45 multidisciplinary clinicians with 522 dyadic relationships. There were significant and positive correlations between differences in communication effectiveness and geodesic distances across all five networks for both general (r = 0.819–0.894, P < 0.001 for all correlations) and task-specific (r = 0.729–0.834, P < 0.001 for all correlations) communication. This suggests that a closer network ties between individuals is associated with smaller differences in communication effectiveness. In the quadratic assignment procedures regression model, geodesic distance predicted task-specific communication (β = 0.056–0.163, P < 0.001 for all networks). Interaction frequency, socialization, and advice-giving had the largest effect on task-specific communication difference. We did not uncover authority gradients that affect speaking-up patterns among surgical clinicians.

Conclusions

The findings have important implications for safety and quality. Stronger connections in the interaction frequency, close working relationship, socialization, and advice networks were associated with smaller differences in communication effectiveness. The ability of team members to communicate clinical information effectively is essential to building a culture of safety and is vital to progress towards high-reliability. The military faces distinct communication challenges because of policies to rotate personnel, the presence of a clear rank structure, and antifraternization regulations. Despite these challenges, overall communication effectiveness in military teams will likely improve by maintaining team consistency, fostering team cohesion, and allowing for frequent interaction both inside and outside of the work environment.

A Social Relations and Networks Perspective of Depressive Symptoms in Older African Americans Relative to Two Other Ethno-racial Groups

Background and Objectives

Family ties and role relationships through their effects on exchanges of resources and social support are critical health contexts for older African Americans. We studied the influence of affect-based (positive or negative) social relations and respondent-role network centrality on depressive symptoms in older African Americans compared to two ethno-racial groups, Black Caribbeans and Non-Hispanic Whites.

Research Design and Methods

We used data from the multigenerational 2004 National Survey of American Life Family Connections across Generations and Nations Study (NSAL 3-Gen). For respondents aged 50 years or older, we used tie affect (positive or negative) to code family role relations and two-mode (where an entity or thing is connected to a different type of entity, here individuals are connected to role relations) family networks. We used survey linear regressions to probe the independent association of relations and networks on depressive symptoms among older African Americans as compared to Black Caribbeans and Non-Hispanic Whites.

Results

Negative and positive relations are significantly associated with depressive symptoms, but there were some ethno-racial differences. For example, the negative Father relation is significantly associated with greater depressive symptoms among African Americans, but not in Black Caribbeans and Non-Hispanic Whites. Negative two-mode networks (connections from individuals to role relations) are significantly associated with depressive symptoms among African Americans and in the two comparison ethno-racial groups, while there is no significant association between positive networks and depressive symptoms.

Discussion and Implications

We found that negative relations had larger effects on depressive symptoms than positive ones, and conversely that negative networks had larger effects than positive networks. Simultaneously modeling social relations and networks could potentially enhance our understanding of the links between social structure, and depressive symptoms among older adults in African American and other ethno-racial minorities.