Taking the Pulse of Surgical Teams

Leadership almost inevitably involves having to make tough decisions but few of us must make those calls with life or death hanging in the balance. Surgeons are no exception; in a pressure-cooker operating room, tempers can fray as people struggle to respond, and surgical team members can find themselves on the receiving end of belittling comments or snippy rebukes to follow orders.

While these testy exchanges may be rationalized as inconsequential, the negative behaviour has a real impact on a surgical team’s ability to successfully overcome challenges, according to a study conducted by three Queen’s University researchers. Their study, to be published in the American Journal of Surgery, was the first to assess the simultaneous effects of surgeons' positive and negative leadership behaviours on team performance.

“If we know that leadership matters in the operating room, I don’t think we can simply leave it to chance,” says Julian Barling, the Borden Chair of Leadership at Smith School of Business and one of the study’s authors.

Psychological Safety

The impact of surgeons’ leadership on surgical team performance has not been well studied. To help fill this gap, Barling teamed up with Amy Akers, a former doctoral student at Smith School of Business, and Darren Beiko, a urology surgeon at Kingston General Hospital and an associate professor at Queen’s School of Medicine. They focused on “psychological safety” and team efficacy. Psychological safety reflects the belief among team members that it is safe to take risks, voice dissent, and make errors. As the researchers note, “one of the most consistent predictors of psychological safety is high-quality leadership.”

In their study, trained observers attended 150 randomly selected operations at a tertiary care hospital to track the leadership styles of surgeons. Surgical team members being observed also completed questionnaires that rated their team’s cohesion and ability to overcome challenges.

Barling expected surgical teams would fare best when surgeons exhibited what is known as transformational leadership. “Transformational leadership picks people up and makes them feel taller, makes them feel like they can do more,” says Barling. “It leaves people with the mindset, ‘If I try hard, there’s nothing I cannot do.’ Destructive leadership leaves you with the mindset of, ‘No matter how hard I try, I can never do anything.’”

Surprisingly, the study did not find transformational leadership yielded any measurable improvement in team performance. But abusive supervision — such as putting down someone in front of others — and highly controlling behaviour did undermine team results.

“The new generation [of surgeons] will tell you that this is the time to be creative. The fact that there’s a crisis means that all the traditional things haven’t been working”

Barling has a few ideas why transformational leadership did not boost team performance. One is that “leadership bounces around the surgery room as it’s needed” and doesn’t always reside with the surgeon. At different moments, that responsibility may shift to an anesthesiologist or nurse, and their behaviours will also influence team performance.

Another possibility is that people are more likely to remember something bad that happened rather than something good. “It appears that would hold for leadership as well,” says Barling. “So you stand the risk of having a few instances of negative leadership potentially overwhelming positive instances of leadership.”

Prior research has associated operating room leadership with less information sharing during surgery, and that in turn has been linked with a greater likelihood of post-surgery complications. Given this finding and the results of their study, the Queen’s researchers call for leadership training to receive “the same rigor typically given to clinical trials and clinical research in general.”

Too Busy for Leadership Development?

Skeptics may point out that medical school students and surgeons are busy enough without having to add leadership to their load, or that leadership is less a learned skill than an inherited trait.

But Barling maintains effective leadership training need not take a lot of time. And he notes that a recent review of 335 studies found that leadership skills can indeed be developed. “The conclusion from that review is that the effects are larger than what we thought they would be,” says Barling. “So we know we can teach leadership, and what it takes to teach leadership is not that time consuming.”

Others may argue that a more authoritarian form of leadership inside the operating room is necessary during critical times. Barling heard otherwise — from surgeons and leaders in other contexts too. “The new generation [of surgeons] will tell you that this is the time to be creative. The fact that there’s a crisis means that all the traditional things haven’t been working. Exerting greater control over a situation is the human thing to want to do but it’s not necessarily the most effective thing to do.”

Barling acknowledges that even with the best training, leaders sometimes have a bad day. What separates effective and ineffective leaders in operating rooms and organizations generally is what they do after a misstep.

“Leadership abilities are challenged more as things get tougher. The question is how you handle it afterwards. Do you just wash your hands of it or do you discuss it with the team? No one’s expecting perfection.”

— John Thompson