In the context of the OT communication is defined as ‘skills for working in a team context to ensure that the team has an acceptable shared picture of the situation and can complete the tasks effectively’, and teamwork is defined as ‘skills for working in a group context, in any role, to ensure effective joint tasks completion and team member satisfaction’ [15]. Furthermore, situation awareness is defined as ‘developing and maintaining a dynamic awareness of the situation in theatre based on assembling data from the environment, understanding what they mean and thinking ahead what might happen next’ [15].

Procedures in the OT are complex and demand intense interaction between team members. Surgical teams should be cohesive and have similar perceptions of communication and teamwork to collaborate effectively, establish common goals for improving team performance, and ensure patient safety [9, 16]. Therefore, work processes should emphasize the interdependency of team members and support a good understanding of each team member’s tasks, roles and responsibilities within the surgical process. This facilitates effective teamwork, ensures that action is linked to reflection, and creates a culture that is open to change [6, 9, 13, 17, 18].

The discrepancies we found may have a negative effect on patient safety. A first step to improve patient safety is acknowledging that errors are made and discussing these errors. Although errors are inevitable, team members are often reluctant to discuss these failures, especially human errors. Surgeons might be hesitant to discuss failures because they are educated to ‘do the right thing and do it right’ and thus find it hard to acknowledge that errors are made [24]. Other team members might be discouraged to speak up because of traditional hierarchical structures, authority, social barriers or differences in professional training and responsibility [3, 17, 19, 24]. Also poor teamwork could lead to team members’ withdrawal from discussions and could lead to decreased job satisfaction and efficiency, which in turn could result in communication failures and poor performance. Not taking time out to discuss complications as a team or to perform a thorough analysis of what went wrong and why results in poorly performing teams. Research in aviation shows that, regardless of workload, poorly performing teams spend only 5% of their time discussing possible complications compared with 33% of time spend by effective teams [25]. Research has also shown that similar perceptions of the current situation will result in effective collaboration and patient safety [7, 9, 16]. Similar perceptions of the future state; on what to improve and why, will support implementation of quality improvement initiatives and improve collective learning [1, 3, 12, 13, 16, 19, 20, 26]. All team members should understand and be well informed about the surgical procedure and about specific patient-related subjects, such as allergies or co-morbidity. A lack in this ‘shared understanding’ among team members might result in adverse events, such as wrong site surgery or wrong person surgery [7, 16, 20]. Many of our respondents experience a lack of shared perception both on the current and the future state, with the exception of the surgeons. One method to improve shared understanding is by means of pre-operative briefings. These create an opportunity, just before the start of the surgical intervention, to exchange information on the patient and on the surgical procedure with the whole team in order to prevent errors [20]. This establishes a shared mental model among team members.

The overall findings of this study are consistent with previous research, the most common pattern being that surgeons have a positive perception of communication and teamwork and that nurses have the most negative perception [3, 7, 8, 11, 16, 18, 19]. OT nurses who have a poor perception of communication sometimes have difficulty in speaking up, and are afraid of confrontation. This could also prevent other team members from correcting errors before patients are harmed and inhibit discussing and learning from errors as a team [5, 7, 17–19].

A limitation of this study was the number of centres involved; only five hospitals participated of the ~90 hospitals in the Netherlands (6%). However, these hospitals represent the whole spectrum of hospital types at a regional level and are comparable for quality of care. On the national list of quality indicators for patient care, the hospitals that volunteered ranked from average to good, but change positions annually when compared over the last 5 years [27].

Comparing response rates to similar studies is complicated because of the large differences in results/outcome measurements [3, 8, 16]. This study showed large discrepancies in response rate, both between hospitals and between disciplines. The surgeons’ response rate was 45%, which is comparable to Flin et al. [8] (48%) and higher than Mills et al. [16] (12%). The OT nurses’ response rate was higher: 40% versus 19% (Flin et al.) and 36% (Mills et al.). Makary et al. [3] showed a much higher response rate for all different disciplines (surgeons, anaesthetists, OT nurses, nurse anaesthetists). Future research should include results on differences between hospitals, and study which factors contribute to such high discrepancies in response rates.

The large amount of missing data for the surgeons (Table 4) was caused by human error. At the university hospital, the last page was not distributed, which resulted in unreliable answers for this discipline. To prevent errors like these, it is recommended that hard copies be distributed or to a web-based version (including required fields) used. The missing data concerning the statement about ‘Projecting and anticipating future state’ (S3) was directly related to a specific task: anticipating conversion. Apart from the high response from the OT nurses, being responsible for this task, most team members did not see this as part of their job, which might be the reason for the low response.

This study shows the differences in perception of surgical team members in relation to the non-technical skills communication, teamwork and situation awareness. Although these skills are considered the most important ones to work safely and effectively [1, 6, 9, 11–14, 28], skills such as leadership and decision-making are important as well. Therefore, a follow-up study was set up including these items in the questionnaire to get a more complete picture of the whole spectrum of non-technical skills.