Anne van Dalen

198 I Chapter 7 DISCUSSION Principal findings The results of this study show that the operating nurses rated the overall perception of safety the lowest, while the anaesthesiology residents rated it the highest. Overall, teamwork and communication openness were rated the most positive (PRR >63%) by the participants. Participating in the ORBB trial and hours working per week both appeared to be correlated with the overall attitude towards patient safety, when correcting for possible confounders. Interpretation within the context of the wider literature In line with previous (HSOPSC) studies, this study indicates there is a variety in perception of the safety culture in the OR between the different OR professionals. (10, 19) This remains to be a significant challenge for safety improvement initiatives, as a strong safety culture is based on a shared mental model of peri-operative situations. A shared mental model can only be established when beliefs, opinions, needs and attitudes on surgical safety can be safely expressed and discussed amongst all the members of the OR team. 7,20 Nurses rated overall perception of safety, communication openness, supervisor expectations and action promoting safety, significantly lower compared to the rest of the team. This may indicate that their perception of their colleagues’ safety behaviour is lower. Studies have shown that nurses usually have higher levels of intended engagement in safety behaviour (such as incident reporting) than doctors. 7,21 Surgeons are often the cause of conflict communication and nurses are most often the recipient of conflict- provoking behaviour. 22 Traditionally, OR teams are hierarchical and divided by role which has often discouraged nurses to speak up to or confront a surgeon. 22,23 However, the willingness to speak up about a safety concern is a key factor of safety in the OR. 23 Surgical residents rated non-punitive response to error significantly lower compared to the rest of the team. Junior doctors are more likely to perceive blame as a result of an incident and are less likely to speak up when an error is made. 7 This may be caused by the fact that there is still a take-the-blame culture in the OR, where surgeons