Attitudes to Surgical Checklist Questionnaire

Abstract

The Attitudes to Surgical Checklist Questionnaire (ASCQ) is a specialized 27-item instrument developed to assess the perceptions and behaviors of operating theatre personnel concerning the use and implementation of surgical checklists. Developed following 14 comprehensive semi-structured interviews with staff, the scale addresses the known issue of checklist implementation decay despite their proven efficacy in reducing mortality rates and improving teamwork. The ASCQ is structured around five core subscales measuring attitudes towards hospital norms, the perceived impact of the checklist on safety and teamwork, perceived support from colleagues and management, intent to initiate use, and perceived organizational and human barriers to implementation. The primary goal of the ASCQ is to provide a quantitative measure of the human factors influencing the consistent and complete application of these critical patient safety tools in the surgical setting.

Keywords

Surgical checklist, patient safety, operating theatre, teamworking, attitudes, implementation barriers, psychometric scale, WHO Surgical Checklist.

Authors

O’Connor, Reddin, O’Sullivan, O’Duffy, Keogh.

Purpose

The primary purpose of the Attitudes to Surgical Checklist Questionnaire is to systematically evaluate the attitudes, beliefs, and behavioral intentions of personnel working within the operating theatre environment regarding the adoption and sustained use of surgical checklists. The scale is designed to identify specific human and organizational factors that either facilitate or impede the successful implementation of safety protocols, thereby providing data necessary for developing targeted interventions and training programs.

Construct

The ASCQ measures attitudes toward the practical implementation and perceived efficacy of surgical checklists, focusing on factors known to influence adherence in high-stakes environments. The scale comprises five distinct psychological constructs, each represented by a subscale:

• Attitudes Towards Hospital Norms: This measures the perceived cultural expectations and actual behavioral standards within the hospital regarding checklist usage (e.g., whether the complete checklist is used for every procedure).
• Impact on Safety and Teamwork: This assesses the belief that the checklist effectively reduces the likelihood of human error, improves patient safety, and enhances professional teamwork within the operating environment.
• Support: This quantifies the perceived level of support for the checklist from various professional and hierarchical groups (e.g., surgical personnel, nursing staff, and management).
• Intent to Initiate: This measures the respondent’s personal willingness and behavioral intention to proactively start or enforce the use of the checklist.
• Barriers to Use: This identifies specific practical and organizational obstacles perceived by the staff that prevent the consistent and complete application of the checklist (e.g., lack of time, lack of training, or requirement for signatures).

Validity

The initial development of the ASCQ provides evidence of strong content validity. The questionnaire’s 27 items were not arbitrarily created but were derived directly from a foundational qualitative study involving 14 semi-structured interviews with surgical staff. This rigorous preliminary process ensured that the items generated were ecologically relevant and directly addressed the lived experiences, concerns, and implementation challenges encountered by end-users in the operating theatre.

The defined structure, which isolates five key subscales (Norms, Impact, Support, Intent, and Barriers), confirms a theoretically robust approach to measuring the multidimensional nature of attitudes toward safety compliance, which is essential for assessing the instrument’s overall validity in organizational behavior research.

Reliability

The internal consistency reliability of the Attitudes to Surgical Checklist Questionnaire was assessed using Cronbach’s alpha coefficients for each of the five subscales. The results demonstrate generally acceptable to strong levels of reliability across most measured constructs:

• The subscales measuring Intent to Initiate (0.87) and Impact on Teamwork and Safety (0.84) both demonstrated excellent internal consistency.
• The Support (0.73) and Norms (0.70) subscales exhibited acceptable reliability, aligning with common standards for psychometric research.
• The Barriers to Use subscale showed lower internal consistency (0.56). This result suggests that the items comprising the barriers scale may be measuring a more diverse or heterogeneous collection of practical obstacles, or that further refinement of these items may be necessary to achieve higher internal consistency in future research applications.

Factor Analysis

The ASCQ is fundamentally structured around a five-factor model corresponding to the five defined subscales: Norms, Impact on Teamwork and Safety, Support, Intent to Initiate, and Barriers. This structure was derived from a thematic synthesis of the initial qualitative data, implying that these five dimensions represent the primary orthogonal components of attitudes toward checklist usage. Although the source content does not explicitly detail the statistical results of an Exploratory Factor Analysis (EFA) or Confirmatory Factor Analysis (CFA), the clear delineation of subscales confirms that the instrument is designed to measure distinct, yet related, latent constructs influencing successful checklist implementation.

Instrument

Test Type: Psychometric Attitude Questionnaire / Self-report scale.

Format: The questionnaire consists of 27 mandatory items covering the five subscales, plus an additional item comparing the local checklist to the WHO surgical checklist, an open-ended question for identifying additional barriers, and two demographic questions. Responses use a 5-point Likert scale ranging from 1 ‘strongly disagree’ to 5 ‘strongly agree’.

Language Available: English (Original development language).

Population Group: Healthcare professionals and multidisciplinary staff involved in surgical procedures.

Age Group: Adult (working professionals actively involved in the surgical environment).

Population Details: Specifically designed for operating theatre personnel, including surgical staff, anaesthetic staff, and nursing staff.

Test Methodology: Typically administered as a self-report survey, suitable for paper-based or electronic deployment in clinical research settings focusing on human factors and psychometrics in healthcare.

Keywords

Attitude measurement, healthcare, human factors, surgical safety, checklist adherence, implementation science, organizational culture, psychometrics.

Authors

Author ORCID Identifier: Not provided in source.

Affiliation Email addresses: Not provided in source.

Correspondence Address: Not provided in source.

Permissions & Fee and Test Year

The Attitudes to Surgical Checklist Questionnaire was developed and published in 2013. The key reference article describing the scale’s development is open access, suggesting that the instrument is generally available for non-commercial research and quality improvement initiatives. Researchers and practitioners are advised to consult the publisher, Patient Safety in Surgery, or the lead author regarding specific permissions for widespread clinical or commercial use.

Test Year: 2013.

Reference’s

O’ Connor, P., Reddin, C., O’Sullivan, M., O’Duffy, F. & Keogh, I. (2013). Surgical checklists: the human factor. Patient Safety in Surgery, 7, 14. This is an open-access article available for download from: www.pssjournal.com/content/7/1/14/abstract

Items of the Attitudes to Surgical Checklist Questionnaire

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

(Responses range from 1 ‘strongly disagree’ to 5 (strongly agree’)