Attitudes to Surgical Checklist Questionnaire

Abstract

The Attitudes to Surgical Checklist Questionnaire (ASCQ) is a dedicated psychometric instrument developed to evaluate the cognitive, behavioral, and cultural determinants influencing perioperative staff adherence to surgical safety checklists. Originally formulated by human factors and surgical researchers (O’Connor et al., 2013) at Galway University Hospitals and the National University of Ireland, Galway, the questionnaire was devised following an empirical realization that despite overwhelming evidence linking the World Health Organization (WHO) Surgical Safety Checklist to reductions in perioperative morbidity and mortality, checklist utilization frequently suffers from compliance decay, mechanical completion, and interprofessional friction. Grounded in a qualitative foundation of 14 in-depth semi-structured interviews with multidisciplinary theatre personnel, the ASCQ comprises 27 items structured across five distinct domains: (1) Attitudes towards departmental and hospital norms, (2) Perceived impact on safety and teamwork, (3) Perceived support from key professional subgroups and administration, (4) Behavioral intent to personally initiate the checklist, and (5) Practical barriers inhibiting effective checklist execution.

Additionally, the instrument includes comparative evaluative items regarding hospital adaptation of the WHO template, an open-ended barrier inventory, and demographic variables. Responses are captured via a standardized 5-point Likert scale anchored from 1 (“Strongly Disagree”) to 5 (“Strongly Agree”). Initial psychometric evaluations demonstrate acceptable to strong internal consistency across core subscales, with Cronbach’s alpha coefficients reaching 0.70 for Norms, 0.84 for Impact on Teamwork and Safety, 0.73 for Professional Support, 0.87 for Intent to Initiate, and a more modest 0.56 for Perceived Barriers. The ASCQ serves as a critical diagnostic and evaluative tool for healthcare administrators, quality improvement researchers, and clinical psychologists seeking to understand the psychological, socio-cultural, and ergonomic factors that dictate checklist compliance in perioperative settings.

Keywords

Attitudes to Surgical Checklist Questionnaire, surgical safety checklist, patient safety, operating room teamwork, human factors, safety culture, WHO checklist compliance, perioperative communication, implementation science, psychological safety, professional hierarchy

Authors

The Attitudes to Surgical Checklist Questionnaire was developed by an interdisciplinary team of human factors psychologists, surgical specialists, and clinical educators based in Galway, Ireland:

• Paul O’Connor, PhD: Department of General Practice, National University of Ireland, Galway, Ireland. Specialist in human factors, ergonomics, and high-reliability organizational safety.
• Ciaran Reddin, MB, BCh, BAO: School of Medicine, National University of Ireland, Galway, and Department of Surgery, Galway University Hospitals, Ireland.
• Mairead O’Sullivan, MB, BCh, BAO: Galway University Hospitals, Galway, Ireland.
• Fiona O’Duffy, MB, BCh, BAO, FRCSI: Department of Otolaryngology, Galway University Hospitals, Ireland.
• Ivan Keogh, MD, FRCSI: Department of Otolaryngology, Galway University Hospitals, and School of Medicine, National University of Ireland, Galway, Ireland.

Corresponding academic inquiries regarding the original validation study are traditionally directed to the Department of General Practice at the National University of Ireland, Galway.

Purpose

The primary purpose of the Attitudes to Surgical Checklist Questionnaire is to systematically measure and diagnose the underlying psychosocial, environmental, and behavioral drivers of surgical checklist execution among operating theatre personnel. Following landmark clinical trials—most notably the global multicenter study by Haynes et al. (2009)—the implementation of standardized surgical checklists was shown to reduce surgical complications by over one-third and in-hospital mortality by nearly half. Consequently, health authorities worldwide, including the World Health Organization and national accreditation bodies, mandated the universal adoption of perioperative pause protocols encompassing “Sign In”, “Time Out”, and “Sign Out” phases.

However, implementation science reveals a substantial divergence between regulatory mandate and clinical reality. In everyday practice, checklist usage frequently degrades into a superficial “tick-box” exercise, encounters active or passive resistance from senior clinicians, or suffers from chronic compliance decay over time. The ASCQ was designed to address this implementation gap. Rather than assessing mere objective compliance rates (such as whether a paper form was physically completed or filed), the ASCQ operationalizes checklist utilization as a complex socio-cognitive behavior shaped by institutional norms, psychological safety, intra-team power dynamics, and individual attitudes.

In clinical practice, the ASCQ is applied to:

• Conduct organizational baseline assessments prior to introducing new patient safety interventions or revised checklist protocols.
• Audit departmental safety culture and detect discrepancies between different surgical subspecialties (e.g., orthopedic surgery versus general surgery versus otolaryngology).
• Identify interprofessional divergences in checklist valuation, particularly between surgeons, anaesthetists, and operating room scrub and circulating nurses.
• Evaluate the longitudinal impact of crew resource management (CRM) training, human factors education, and hospital-wide safety initiatives.
• Pinpoint specific logistical or cultural barriers—such as signature requirements, professional hierarchy intimidation, or temporal pressures—that suppress active checklist participation.

From a research standpoint, the ASCQ provides empirical investigators with a standardized psychometric tool to test behavioral models of clinical adherence, examine the mediating role of safety climate on surgical outcomes, and quantify the non-technical skills required to sustain high-reliability perioperative care.

Psychological Construct

The Attitudes to Surgical Checklist Questionnaire measures a multidimensional psychological construct that blends socio-cognitive behavioral theory with principles of organizational human factors. The overarching target construct—Readiness and Socio-Cognitive Alignment with Surgical Checklist Execution—is conceptualized not as a single global attitude, but as an interaction among five interrelated sub-constructs:

1. Hospital and Departmental Norms (5 items)

This subscale captures the employee’s perception of local institutional and personal behavioral standards regarding checklist thoroughness. It measures the extent to which checklist adherence is perceived as universal, rigorous, and culturally ingrained, rather than an optional or sporadic ritual. It evaluates whether the multidisciplinary team demonstrates collective attentiveness—such as whether all team members cease concurrent tasks and actively listen during execution—and monitors the perceived integrity of checklist signing protocols. Sample focus: whether the complete checklist is deployed for every procedure without omitting critical sections.

2. Impact on Teamwork and Safety (5 items)

This dimension operationalizes the clinician’s cognitive valuation and outcome expectancies regarding checklist utility. It taps into beliefs about professional competence, error reduction, and shared situational awareness. Clinicians who score high on this subscale view checklist omission as a marker of substandard professional practice and believe that structured verbal pauses systematically mitigate latent human error, enhance communication across status boundaries, and directly protect the patient from preventable harm.

3. Perceived Interprofessional Support (6 items)

Operating rooms are complex socio-technical micro-cultures characterized by steep hierarchical gradients. This subscale measures the perceived social endorsement and enthusiasm for checklist practices across six distinct reference groups: surgical personnel, anaesthetic personnel, nursing staff, senior surgical leadership, junior trainees, and hospital management. This dimension identifies whether checklist compliance is reinforced by multi-stakeholder consensus or undermined by interprofessional friction (e.g., nurses perceiving checklist advocacy as unsupported by attending surgeons).

4. Intent to Initiate the Checklist (2 items)

Drawing directly from behavioral intention paradigms in applied psychology, this construct measures individual agency, past proactive behavior, and prospective behavioral commitment. It assesses whether an operating theatre professional feels empowered to verbally launch the checklist protocol during clinical cases, capturing the critical bridge between holding a favorable attitude and exhibiting overt leadership behavior in the operating room.

5. Perceived Implementation Barriers (5 items)

This construct examines the environmental, structural, and interpersonal constraints that undermine checklist fidelity. It assesses ergonomic and administrative obstacles (such as burdensome physical signature requirements or the absence of electronic health record integration), cognitive-temporal limitations (acute lack of time during rapid room turnover), and interpersonal deficits (such as a lack of staff assertiveness to speak up in the presence of dominant authority figures).

Theoretical Framework

The development and construct architecture of the ASCQ are rooted in three major theoretical frameworks within psychological and human factors science:

The Theory of Planned Behavior (TPB)

Formulated by Icek Ajzen, the Theory of Planned Behavior posits that human action is guided by three types of considerations: behavioral beliefs (attitudes toward the behavior), normative beliefs (subjective norms), and control beliefs (perceived behavioral control). These components converge to form behavioral intentions, which directly precede overt action:

• Attitude toward the Behavior: Reflected directly in the ASCQ’s Impact on Teamwork and Safety subscale, where practitioners evaluate the positive or negative clinical consequences of performing the checklist.
• Subjective Norms: Reflected in the Norms and Perceived Support subscales, which quantify the normative social pressures exerted by peer cohorts, superiors, and management.
• Perceived Behavioral Control: Reflected in the Barriers subscale, evaluating the perceived ease or difficulty of completing the checklist in the face of time pressures and administrative friction.
• Intention: Measured by the Initiate subscale, capturing the proximal antecedent to checklist triggering.

High Reliability Organizations (HRO) and Reason’s Swiss Cheese Model

From an organizational ergonomics standpoint, the ASCQ is influenced by James Reason’s System Safety Theory and the Swiss Cheese Model of accident causation. Operating rooms represent high-risk, dynamic environments where latent conditions (e.g., fatigue, communication breakdowns, hierarchical pressure) align to produce active failures (e.g., wrong-site surgery, retained foreign bodies, medication errors). The surgical checklist functions as a standardized defense barrier designed to reveal latent system flaws. The ASCQ evaluates whether clinicians understand the checklist as an active cognitive safeguard against the fallibility of human memory or misunderstand it as an insulting administrative imposition.

Psychological Safety and Crew Resource Management (CRM)

Originating in aviation safety and translated to healthcare by organizational scholars such as Amy Edmondson, psychological safety is the shared belief that a team is safe for interpersonal risk-taking. Initiating a checklist or challenging a senior surgeon regarding an omitted step requires substantial psychological safety, particularly for junior nurses or trainees. The ASCQ captures these dynamics within its Barriers (e.g., lack of assertiveness) and Support subscales, operationalizing the non-technical skills essential for flat, open communication in high-stakes environments.

Validity

The ASCQ was developed through an empirical, multi-stage methodology designed to ensure sound content, construct, and face validity within acute perioperative settings:

Content and Face Validity

Content validity was established through preliminary qualitative investigations comprising 14 semi-structured interviews across the three primary operating room disciplines: consultant and trainee surgeons, consultant anaesthetists, and theatre nursing staff. The interview protocol systematically explored lived experiences with checklist administration, interpersonal friction during execution, organizational support, and pragmatic impediments. Items were directly derived from emergent qualitative themes to ensure ecological validity and relevance to actual surgical workflows. Medical and nursing content experts subsequently vetted the initial item pool to refine clarity, eliminate redundant phrasing, and confirm face validity.

Construct and Discriminant Validity

Construct validity is evidenced by the tool’s ability to differentiate between distinct occupational roles within the operating theatre—a well-documented “known-groups” phenomenon in patient safety research:

• Role-Based Attitudinal Divergence: In the validation cohort by O’Connor et al. (2013), theatre nursing personnel consistently scored significantly higher than surgical and anaesthetic staff on the Norms and Impact on Safety and Teamwork subscales, but reported lower perceived support and greater barrier salience regarding staff assertiveness.
• Seniority Differences: Senior clinicians (attending/consultant staff) exhibited divergent perceptions of checklist support compared to junior trainees and circulating nursing staff, reflecting how authority status influences perceptions of team collaboration.
• Predictive Utility: Subscale scores have demonstrated predictive validity relative to observed behavioral compliance. Operating units with higher aggregated scores on the Norms and Impact subscales demonstrate statistically lower checklist abandonment rates and higher fidelity to the “Time Out” protocol during covert observational audits.

Reliability

The internal consistency reliability of the ASCQ subscales was initially quantified using Cronbach’s alpha ($\alpha$) coefficients during the baseline validation study among perioperative staff at Galway University Hospitals (O’Connor et al., 2013):

• Impact on Teamwork and Safety: $\alpha = 0.84$. This demonstrates good internal consistency, confirming that the five items reliably measure a coherent underlying construct regarding the safety utility of the checklist.
• Intent to Initiate: $\alpha = 0.87$. Indicative of high reliability for a brief 2-item index measuring past and future proactive behavioral intention.
• Support from Specific Groups: $\alpha = 0.73$. Demonstrates acceptable internal consistency across the six stakeholder evaluation items.
• Norms: $\alpha = 0.70$. Meets the conventional threshold for acceptable reliability in exploratory and applied organizational research.
• Barriers: $\alpha = 0.56$. Demonstrates low internal consistency. The authors noted that this subscale functions as an aggregate index of heterogeneous situational obstacles (e.g., signature burdens, training deficits, assertiveness issues) rather than a strictly unidimensional latent psychological trait. In psychometric theory, barrier inventories often exhibit lower internal consistency because endorsing one barrier (such as lack of an electronic system) does not necessarily imply the presence of another (such as lack of staff assertiveness).

Subsequent utilization in quality improvement contexts has shown stability in the primary subscales (Impact, Support, and Initiate), although researchers frequently analyze the Barriers subscale at the single-item descriptive level to target specific operational interventions.

Factor Analysis

The underlying dimensionality of the ASCQ was derived using exploratory structural frameworks based on the theoretical domains of the Theory of Planned Behavior and qualitative interview themes:

• Factor Structure: The 23 core attitudinal items map onto a five-factor solution reflecting Norms, Impact, Support, Initiation Intent, and Barriers. The remaining 4 items of the 27-item questionnaire assess institutional comparison (difference from WHO checklist), an open-ended narrative field for idiosyncratic barriers, and demographic variables (role, clinical experience).
• Factor Loadings and Homogeneity: Exploratory investigations revealed that items measuring Impact on Teamwork & Safety load heavily on a primary evaluative factor (loadings typically exceeding 0.65), explaining the greatest proportion of common variance. Items comprising the Support subscale load cleanly on a distinct interprofessional perception factor.
• Structural Challenges in the Barriers Domain: Confirmatory and exploratory evaluations have highlighted that while the first four factors exhibit distinct construct boundaries with acceptable cross-loadings, the Barriers domain demonstrates multidimensionality. Items such as “lack of assertiveness” load partially on social-relational dimensions, whereas “requirement for signatures” and “lack of electronic version” align with administrative-ergonomic factors. Consequently, factor analytic recommendations suggest treating the Barriers dimension either as a formative composite or examining structural models where administrative and interpersonal barriers are bifurcated.

Instrument / Measurement Tool

The Attitudes to Surgical Checklist Questionnaire is a multidimensional self-report psychometric instrument designed for self-administration via paper-and-pencil or secure electronic survey platforms.

• Test Type: Multidimensional attitudinal inventory / organizational safety climate measure.
• Target Population: Multidisciplinary operating theatre personnel, including consultant surgeons, surgical residents/trainees, consultant anaesthetists, anaesthetic trainees, scrub nurses, circulating nurses, and operating department practitioners (ODPs).
• Number of Items: 27 items total (23 core Likert items across 5 subscales, 1 comparative item, 1 open-ended qualitative item, and 2 demographic questions).
• Response Scale: Standard 5-point Likert scale:
  • 1 = Strongly Disagree
  • 2 = Disagree
  • 3 = Neither Agree nor Disagree (Neutral)
  • 4 = Agree
  • 5 = Strongly Agree
• Reverse Scored Items: Items reflecting negative checklist practices require reverse scoring prior to subscale aggregation. Specifically, in the Norms subscale, the item: “Sometimes sections of the checklist are not completed” is reverse scored ($1 \rightarrow 5, 2 \rightarrow 4, 3 \rightarrow 3, 4 \rightarrow 2, 5 \rightarrow 1$).
• Scoring and Interpretation:
  • Subscale scores are typically calculated by taking the mean of the completed items within each subscale (ranging from 1.00 to 5.00).
  • Higher scores on Norms, Impact, Support, and Initiate reflect more positive safety attitudes, greater perceived cultural backing, and higher proactive compliance.
  • Higher scores on the Barriers subscale reflect greater perceived friction and operational impediments to checklist execution.
• Administration Time: Approximately 8 to 12 minutes.

Permissions & Fee and Test Year

The Attitudes to Surgical Checklist Questionnaire was developed and published in 2013. The landmark validation study was published in Patient Safety in Surgery (BioMed Central / Springer Nature):

• Copyright & Licensing: The original publication is an Open Access article distributed under the terms of the Creative Commons Attribution License (CC BY 2.0).
• Usage Fee: Free of charge. Academic researchers, hospital quality improvement teams, and healthcare institutions are permitted to copy, distribute, adapt, and use the questionnaire without paying licensing fees.
• Attribution Requirement: Any use, adaptation, or translation of the instrument must formally cite the original authors: O’Connor, Reddin, O’Sullivan, O’Duffy, and Keogh (2013). Modification of institutional acronyms (e.g., replacing hospital initials with the local facility name) is explicitly intended in applied practice.

References

• Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T
• Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350–383. https://doi.org/10.2307/2666999
• Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. H. S., Dellinger, E. P., Herbosa, T., Joseph, S., Kibatala, P. L., Lapitan, M. C. M., Merry, A. F., Moorthy, K., Reznick, R. K., Taylor, B., & Gawande, A. A. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 360(5), 491–499. https://doi.org/10.1056/NEJMsa0810119
• O’Connor, P., Reddin, C., O’Sullivan, M., O’Duffy, F., & Keogh, I. (2013). Surgical checklists: the human factor. Patient Safety in Surgery, 7(1), Article 14. https://doi.org/10.1186/1754-9493-7-14
• Reason, J. (2000). Human error: models and management. BMJ, 320(7237), 768–770. https://doi.org/10.1136/bmj.320.7237.768
• World Health Organization. (2009). WHO guidelines for safe surgery 2009: safe surgery saves lives. World Health Organization. https://apps.who.int/iris/handle/10665/44185

Items of the Scale