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.

[1]  T. Judge,et al.  Personality and transformational and transactional leadership: a meta-analysis. , 2004, The Journal of applied psychology.

[2]  S. Xirasagar.  Transformational, transactional among physician and laissez-faire leadership among physician executives. , 2008, Journal of health organization and management.

[3]  J. A. Lepine,et al.  Voice and cooperative behavior as contrasting forms of contextual performance: evidence of differential relationships with big five personality characteristics and cognitive ability. , 2001, The Journal of applied psychology.

[4]  N. Maran,et al.  Observation of behavioural markers of non-technical skills in the operating room and their relationship to intra-operative incidents. , 2016, The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland.

[5]  S. K. Horwitz,et al.  Transformational, transactional, and passive-avoidant leadership characteristics of a surgical resident cohort: analysis using the multifactor leadership questionnaire and implications for improving surgical education curriculums. , 2008, The Journal of surgical research.

[6]  R. Flin,et al.  Factors Influencing Surgeons’ Intraoperative Leadership: Video Analysis of Unanticipated Events in the Operating Room , 2013, World Journal of Surgery.

[7]  S. Xirasagar,et al.  Physician Leadership Styles and Effectiveness: An Empirical Study , 2005, Medical care research and review : MCRR.

[8]  S. Grondin,et al.  Introduction to concepts in leadership for the surgeon. , 2011, Thoracic surgery clinics.

[9]  Richard W. Schwartz,et al.  Physician leadership: the competencies of change. , 2008, Journal of surgical education.

[10]  Lisa M. Penney,et al.  The downside of goal-focused leadership: the role of personality in subordinate exhaustion. , 2010, The Journal of applied psychology.

[11]  Rhona Flin,et al.  The Surgeons' Leadership Inventory (SLI): a taxonomy and rating system for surgeons' intraoperative leadership skills. , 2013, American journal of surgery.

[12]  G. Healy.  Presidential address: Competence, safety, quality: the path of the 21st century. , 2007, Bulletin of the American College of Surgeons.

[13]  A. Edmondson.  Speaking Up in the Operating Room: How Team Leaders Promote Learning in Interdisciplinary Action Teams , 2003 .

[14]  Nick Sevdalis,et al.  Observational teamwork assessment for surgery: content validation and tool refinement. , 2011, Journal of the American College of Surgeons.

[15]  Stephanie Guerlain,et al.  Assessing team performance in the operating room: development and use of a "black-box" recorder and other tools for the intraoperative environment. , 2005, Journal of the American College of Surgeons.

[16]  P. McCulloch,et al.  The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre , 2009, Quality & Safety in Health Care.

[17]  W. Borman,et al.  A Theory of Individual Differences in Task and Contextual Performance , 1997 .

[18]  Fred O. Walumbwa,et al.  Leader personality traits and employee voice behavior: mediating roles of ethical leadership and work group psychological safety. , 2009, The Journal of applied psychology.

[19]  T. Wisborg,et al.  Leadership is the essential non-technical skill in the trauma team - results of a qualitative study , 2009, Scandinavian journal of trauma, resuscitation and emergency medicine.

[20]  Richard W. Schwartz,et al.  High-performance teams for current and future physician leaders: an introduction. , 2008, Journal of surgical education.

[21]  Rhona Flin,et al.  Towards a model of surgeons' leadership in the operating room , 2011, Quality and Safety in Health Care.

[22]  Robert M Mentzer,et al.  Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. , 2007, Journal of the American College of Surgeons.

[23]  P. McCulloch,et al.  Teamwork and Error in the Operating Room: Analysis of Skills and Roles , 2008, Annals of surgery.

[24]  Richard W. Schwartz,et al.  Physician leadership: essential skills in a changing environment. , 2000, American journal of surgery.

[25]  Emilie M. Roth,et al.  Protecting Patients From an Unsafe System: The Etiology and Recovery of Intraoperative Deviations in Care , 2012, Annals of surgery.

[26]  L. Neumayer,et al.  Leadership skills in the OR: Part II: Recognizing disruptive behavior. , 2012, Bulletin of the American College of Surgeons.

[27]  K. T. Fong,et al.  Surgical team behaviors and patient outcomes. , 2009, American journal of surgery.

[28]  L. Leach,et al.  Surgical teams: role perspectives and role dynamics in the operating room , 2011, Health services management research.

[29]  Rhona Flin,et al.  Surgeons' leadership in the operating room: an observational study. , 2012, American journal of surgery.

[30]  Rhona Flin,et al.  Surgeons’ Non-technical Skills in the Operating Room: Reliability Testing of the NOTSS Behavior Rating System , 2008, World Journal of Surgery.

[31]  S. Peyre,et al.  Assessing Physician Leadership Styles: Application of the Situational Leadership Model to Transitions in Patient Acuity , 2012, Teaching and learning in medicine.

[32]  B. Bass,et al.  Multifactor Leadership Questionnaire , 2011 .

[33]  Robert J. Spinelli.  The Applicability of Bass's Model of Transformational, Transactional, and Laissez-Faire Leadership in the Hospital Administrative Environment , 2006, Hospital topics.

[34]  Gerald B Healy,et al.  Error reduction through team leadership: seven principles of CRM applied to surgery. , 2006, Bulletin of the American College of Surgeons.

[35]  R. D. de Vries,et al.  Leadership = Communication? The Relations of Leaders’ Communication Styles with Leadership Styles, Knowledge Sharing and Leadership Outcomes , 2009, Journal of business and psychology.

[36]  Gerald B Healy,et al.  Error reduction through team leadership: applying aviation's CRM model in the OR. , 2006, Bulletin of the American College of Surgeons.