J Bryan Sexton, Eric J Thomas and Robert L Helmreich
aviation: cross sectional surveys
Error, stress, and teamwork in medicine and
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Error, stress, and teamwork in medicine and aviation:
cross sectional surveys
J Bryan Sexton, Eric J Thomas, Robert L Helmreich
Objectives: To survey operating theatre and intensive
care unit staff about attitudes concerning error, stress,
and teamwork and to compare these attitudes with
those of airline cockpit crew.
Design: Cross sectional surveys.
Setting: Urban teaching and non-teaching hospitals
in the United States, Israel, Germany, Switzerland, and
Italy. Major airlines around the world.
Participants: 1033 doctors, nurses, fellows, and
residents working in operating theatres and intensive
care units and over 30 000 cockpit crew members
(captains, first officers, and second officers).
Main outcome measures: Perceptions of error, stress,
and teamwork.
Results: Pilots were least likely to deny the effects of
fatigue on performance (26% v 70% of consultant
surgeons and 47% of consultant anaesthetists). Most
pilots (97%) and intensive care staff (94%) rejected
steep hierarchies (in which senior team members are
not open to input from junior members), but only
55% of consultant surgeons rejected such hierarchies.
High levels of teamwork with consultant surgeons
were reported by 73% of surgical residents, 64% of
consultant surgeons, 39% of anaesthesia consultants,
28% of surgical nurses, 25% of anaesthetic nurses, and
10% of anaesthetic residents. Only a third of staff
reported that errors are handled appropriately at
their hospital. A third of intensive care staff did not
acknowledge that they make errors. Over half of
intensive care staff reported that they find it difficult to
discuss mistakes.
Conclusions: Medical staff reported that error is
important but difficult to discuss and not handled well
in their hospital. Barriers to discussing error are more
important since medical staff seem to deny the effect
of stress and fatigue on performance. Further
problems include differing perceptions of teamwork
among team members and reluctance of senior
theatre staff to accept input from junior members.
Population based research suggests that in the United
States between 44 000 and 98 000 patients die each
year from preventable errors, making medical error
the eighth most common cause of death.1–3 Research in
safety critical industries tells us that to overcome this
problem we must understand the system used to
deliver care.4 5
Adoption of a systems approach to improvement
means acknowledging the limitations of technological
solutions. Other components of healthcare delivery
systems, such as professional and organisational
cultural factors (for example, denial of vulnerability to
stress) and interpersonal aspects of performance (for
example, lack of teamwork within and between
disciplines), therefore also need to be studied to
increase the understanding of and prevent errors.6
One of the better established (yet often overlooked)
findings in stress research is that as stress or arousal
increases, an individual’s thought processes and
breadth of attention narrow.7 8
Poor teamwork and
communication have been documented during trauma
resuscitation,9 10 surgical procedures,11 12 and treatment
of patients in intensive care units.13
One systems
approach to medical error has led to the development
of simulators to study and improve teamwork for
surgical and trauma resuscitation teams.14–16
research is needed to tailor such training to the specific
needs of individual organisations.
The airline industry has used surveys to collect data
on pilot attitudes about safety and interpersonal inter-
actions to diagnose strengths and weaknesses and to
aid in the development of interventions. Individuals’
attitudes (as opposed to personalities) are relatively
malleable to training interventions17
and predict
performance.18 A successful intervention called crew
resource management training has been developed to
address specific attitudes, change related behaviour,
and improve performance of the cockpit crew.19 Corre-
spondingly, attitudes about errors, teamwork, and the
effect of stress and fatigue on performance could be
prime targets for measurement and improvement in
medicine. Surveys are an inexpensive method of data
collection that points to interventions and fit well with
the systems approach since they elicit (on a large scale)
what caregivers actually think.
For the past 20 years, the University of Texas
human factors research project has been investigating
teams at work in safety critical environments such as
aviation, space, maritime, and medicine. In this paper,
we present recent data comparing attitudes about
error, stress, and teamwork among healthcare workers
and airline cockpit crew members. We also present
error related perceptions of intensive care doctors and
nurses. Aviation data are presented to serve as a point
of reference from another safety critical domain.
The survey items presented tap into attitudes
toward stress, hierarchy, teamwork, and error. Previous
research has found that these items are relevant to
understanding error,20
predictive of performance,18
and sensitive to training interventions.17 21 22 Attitudes
regarding the recognition of stressor effects indicate
the degree to which individuals will place themselves in
error inducing conditions, and items regarding hierar-
chy and teamwork indicate the abilities of team mem-
bers to manage both threats and errors in a team
Participants and methods
We used four questionnaires to survey participants.
The cockpit management attitudes questionnaire has
been widely used in aviation and was developed to
measure attitudes toward stress, status hierarchies,
University of Texas
Human Factors
Research Project,
1609 Shoal Creek
Boulevard, Austin,
Texas 78701, USA
J Bryan Sexton
doctoral candidate
Robert L
Department of
Medicine, Division
of General Internal
Medicine and
Section for Clinical
Houston Medical
School, University
of Texas, 6431
Fannin, Houston,
Texas 77030, USA
Eric J Thomas
assistant professor
Correspondence to:
J B Sexton
[email protected].
BMJ 2000;320:745–9
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leadership, and interpersonal interaction issues.23 The
questionnaire is reliable, sensitive to change,22 and the
elicited attitudes have been shown to predict perform-
ance.18 24 A subsequent version, the flight management
attitudes questionnaire,25
was developed to broaden
the perspective of the instrument to include the effect
of organisational climate and national culture on
Two medical surveys have also been developed as
part of an extension of human factors research into
medical environments: the operating room manage-
ment attitudes questionnaire11 and the intensive care
unit management attitudes questionnaire, which is
reported here for the first time. All the questionnaires
contained a core set of 23 items from the cockpit man-
agement attitudes questionnaire with minor modifica-
tion of wording to match the work environment—for
example, “Junior cockpit crew members should not
question the decisions made by senior cockpit crew
members” was changed to “Junior operating room
team members should not question the decisions
made by senior team members.” These core items allow
comparisons to be made over time, across different
organisations, across positions within an organisation
(such as nurses and doctors), and between disciplines.
We report here results of the core items as well as a set
of error related items specific to the intensive care
All surveys were administered through hospital or
airline internal mail (with parallel covering letters).
Respondents were given the option of returning their
questionnaires in an anonymous drop box or a
stamped envelope addressed to our laboratory in Aus-
tin, Texas. In each administration, the survey content
was essentially the same.
The core items have been administered to cockpit
crew members (captains and first and second officers)
from 40 different airlines in 25 countries over 15 years
(with the flight management attitudes questionnaire
used in the past seven years). The operating room
questionnaire was completed by theatre staff (surgical
and anaesthetic consultants, nurses, and residents)
from 12 urban teaching and non-teaching hospitals in
Italy, Germany, Switzerland, Israel, and the United
States in the past three years. The intensive care data
are from staff in one large urban teaching hospital in
the United States. The respondents were intensive care
physicians (adult and child pulmonary physicians, car-
diologists, and neonatologists) and nurses (registered
nurses, licensed vocational nurses).
Statistical analysis
Data from each of the surveys were merged into a
combined database of operating theatre, intensive care,
and flight crews. Data from each of the staff positions
were collapsed across all hospitals with representative
samples. We excluded two hospitals from the analyses
because they did not provide representative samples.
We have presented descriptive data, as the sample size
is not large enough for multilevel modelling.
The flight management questionnaire and cockpit
management questionnaire were returned by over
30 000 pilots, with response rates ranging from 15% to
over 90% (average 45%). The operating room
questionnaire was returned by 851 staff (response rate
40% to 100%) and the intensive care questionnaire by
182 staff (response rate 59%). In an effort to make the
medical and aviation samples roughly equivalent, pilot
data from Latin America and Asia, which were not
sampled in medicine, were not included.
Perceptions of stress and fatigue
In response to the item, “Even when fatigued, I
perform effectively during critical times,” 60% of all
medical respondents agreed, ranging from 70%
among consultant surgeons to 47% among consultant
anaesthetists (table). The rate of agreement was much
higher in medicine than in aviation (26% of pilots
agreed). As there were no differences between captains,
first officers, and second officers the data are not
presented separately.
Sixty seven per cent of respondents believed that
true professionals can leave personal problems behind
when working. Pilots and anaesthesia consultants, resi-
dents, and nurses were less likely to deny the effects of
Responses to questions on dealing with stress and teamwork according to discipline and position. Values are numbers (percentages)
Item description
Intensive care
or fellow
Even when fatigued, I perform effectively during critical phases of operations/patient care
89 (55)
34 (57)
49 (47)
105 (60)
29 (56)
117 (70)
70 (64)
20 (64)
1965 (26)
36 (22)
6 (10)
16 (15)
30 (17)
6 (11)
20 (12)
6 (6)
4 (13)
756 (10)
37 (23)
20 (33)
39 (38)
40 (23)
17 (33)
30 (18)
33 (30)
7 (23)
4837 (64)
A truly professional team member can leave personal problems behind when working in the operating room/intensive care unit
96 (59)
33 (55)
55 (53)
122 (70)
33 (63)
137 (82)
76 (70)
21 (68)
4005 (53)
24 (15)
8 (13)
10 (10)
16 (9)
5 (10)
17 (10)
11 (10)
7 (22)
680 (9)
42 (26)
19 (32)
38 (37)
37 (21)
14 (27)
13 (8)
22 (20)
3 (10)
2872 (38)
My decision making ability is as good in medical emergencies as in routine situations
91 (56)
37 (61)
70 (67)
126 (72)
30 (58)
127 (76)
91 (84)
28 (90)
4837 (64)
49 (30)
10 (17)
10 (10)
33 (19)
12 (23)
22 (13)
6 (5)
907 (12)
23 (14)
13 (22)
24 (23)
16 (9)
10 (19)
18 (11)
12 (11)
3 (10)
1814 (24)
Junior team members should not question the decisions made by senior team members
21 (13)
9 (15)
17 (16)
24 (14)
11 (21)
40 (24)
2 (2)
1 (3)
151 (2)
27 (17)
8 (13)
10 (10)
30 (17)
11 (21)
35 (21)
4 (4)
1 (3)
76 (1)
113 (70)
43 (72)
87 (84)
121 (69)
30 (58)
92 (55)
102 (94)
29 (94)
7331 (97)
BMJ VOLUME 320 18 MARCH 2000
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personal problems (53%-59%) than surgical consult-
ants (82%). In response to the item, “My decision mak-
ing ability is as good in medical emergencies as in
routine situations,” 70% of all medical respondents
agreed. Among theatre staff, consultant surgeons were
the most likely to agree with this statement, and inten-
sive care staff were more likely to agree than surgeons
(table). In general, only a minority of respondents
openly recognised the effects of stress on performance.
Attitudes to teamwork and hierarchy
Seventy per cent of respondents did not agree that
junior team members should not question the
decisions made by senior team members, but there
were differences with position and discipline (table).
Consultant surgeons were least likely to advocate flat
hierarchies (55%). By contrast, 94% of cockpit and
intensive care staff advocated flat hierarchies.
Over 80% of all medical staff reported that preop-
erative and postoperative discussions (for intensive
care staff before and after ward rounds) are an impor-
tant part of safety and teamwork. A quarter indicated
that they are not encouraged to report safety concerns,
and only a third said that errors are handled appropri-
ately in their hospital.
Differing perspectives of teamwork in medicine
The different perspectives on teamwork among medi-
cal staff were shown by the responses to the item “Rate
the quality of teamwork and communication or coop-
eration with consultant surgeons” (fig 1). In particular,
surgical consultants and residents rated the teamwork
they experienced with other consultant surgeons the
highest (64% (29/45) and 73% (40-55) reported high
levels of teamwork; 7% (3/45) and 9% (5/55) reported
low levels), while anaesthesia residents, anaesthesia
nurses, and surgical nurses rated interactions with con-
sultant surgeons lowest (10% (8/77), 26% (36/141),
and 28% (35/124) reported high levels of teamwork;
39% (48/124), 43% (33/77), and 48% (67/141)
reported low levels). At the aggregate level, 62% (146/
135) of surgical staff rated teamwork with anaesthesia
staff highly, and 41% (106/250) of anaesthesia staff
rated teamwork with surgical staff highly. In other
words, surgery generally reports good teamwork with
anaesthesia, but anaesthesia staff do not necessarily
hold a reciprocal perception.
Differences between doctors and nurses were
found regarding the quality of teamwork in intensive
care. Although 77% of intensive care doctors reported
high levels of teamwork with nurses, only 40% of
nurses reported high levels of teamwork with doctors.
Attitudes about error and safety
Over 94% of intensive care staff disagreed with the
statement “Errors committed during patient manage-
ment are not important, as long as the patient
improves.” A further 90% believed that “a confidential
reporting system that documents medical errors is
important for patient safety.” Over 80% of intensive
care staff reported that the culture in their unit makes
it easy to ask questions when there is something they
don’t understand (this is undoubtedly related to the
high endorsement of flat hierarchies in the unit). One
out of three intensive care respondents did not
acknowledge that they make errors. Over half report
that decision making should include more team mem-
ber input.
More than half of the respondents reported that
they find it difficult to discuss mistakes, and several bar-
riers to discussing error were acknowledged. The 182
staff in intensive care reported that many errors are
neither acknowledged nor discussed because of
personal reputation (76%), the threat of malpractice
suits (71%), high expectations of the patients’ family or
society (68%), possible disciplinary actions by licensing
boards (64%), threat to job security (63%), and expecta-
tions or egos of other team members (61% and 60%).
The most common recommendation for improving
patient safety in the intensive care unit was to acquire
more staff to handle the present workload, whereas the
most common recommendation in the operating thea-
tre was to improve communication.
Historically, medical and aviation workers have been
expected to function without error.6 26 27
In aviation,
perceptions of fatigue, stress, and error continue to be
topics of training and targets for improvement. Much
progress has been made to create a culture in aviation
that deals effectively with error, whereas in medicine
substantial pressures still exist to cover up mistakes,
thereby overlooking opportunities for improvement.
We found that susceptibility to error is not universally
acknowledged by medical staff, and many report that
error is not handled appropriately in their hospital.
Medical staff also play down the effects of stress and
fatigue. The denial of stress and its effects on perform-
ance may help individuals adapt to medical school and
residency, but a healthy recognition of stressor effects
reduces the likelihood of error20 and increases the use
of threat and error management strategies. For
instance, tired pilots who acknowledge their own limi-
tations manage their fatigue by saying that they are
tired, asking other crew members to keep an eye on
them, increasing caffeine intake, and reallocating work-
load as necessary during the flight. Many tragedies,
such as flying accidents, military defeats, and recent
incidents on the space station MIR, are linked to the
failure of individuals to perform appropriate well
rehearsed actions under stress.28 Research in aviation
Surgical residents
Consultant surgeons
Consultant anaesthetists
Surgical nurses
Anaesthetic residents
Anaesthetic nurses
20 30
50 60
70 80
90 100
Fig 1 Rating of teamwork with consultant surgeons
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shows that individuals can be trained to recognise
stress as an error inducer—for example, by crew
resource management training21—and continue to
improve with recurrent training.29
Measuring teamwork attitudes and behaviour
Ratings of teamwork and communication differed sub-
stantially among groups of respondents. The percep-
tion of poor teamwork by one team member, whether
actual or perceived, is enough to change the dynamics
within that team, causing that team member to
withdraw. Preliminary data from behavioural observa-
tions of teamwork by trained observers of operating
theatre teams suggest that these attitudes are represen-
tative of behaviour (particularly with respect to
teamwork between surgical and anaesthetic staff; fig
2).12 27 30 Future research should investigate teamwork
in medicine, and its relationship to error rates and
error severity. In addition to being an error-
management technique, effective teamwork and
communication also has several positive side effects,
such as fewer and shorter delays, and increases in
morale, job satisfaction, and efficiency. Behaviour was
observed in 3204 commercial flights, from before
departure to landing, and in 96 randomly selected sur-
gical procedures from patient arrival to transfer to the
recovery room. Examples of a poor rating would be
failed communication of skin incision or removal of
the aortic-cross clamp or implementation of Trendle-
burg position without notifying the surgeon.
There is a relationship between perceptions of
teamwork and status in the team. Surgeons are most
supportive of steep hierarchies in which junior staff do
not question senior staff. Surgeons also perceive team-
work and communication in the team to be of a higher
quality than the rest of the team. Similarly, in intensive
care, doctors rated teamwork with nurses higher than
did nurses with doctors. However, future research
should not focus exclusively on consultants. Indeed,
our experience in aviation tells us that poor communi-
cation does not equate to an obstinate captain but to
poor threat and error management at the team level.
Highly effective cockpit crews use one third of their
communications to discuss threats and errors in their
environment, regardless of their workload, whereas
poor performing teams spend about 5% of their time
doing the same.31
The most important limitation of our study was the
small sample of hospitals, and these data should there-
fore be considered preliminary. As more data are
collected, the issues of hospital to hospital variation
and non-response biases can be addressed empirically.
Our research in aviation found no significant
differences between cockpit crew responders and non-
responders on demographic variables such as sex,
years experience, background (military or civilian), and
position (captain, first officer, second officer).
Survey data are limited by reliance on self
reporting, are potentially biased by non-responders
(little is known about non-response biases in
healthcare surveys such as these), and are not the
panacea for what ails a safety critical system. However,
they can be used to diagnose the strengths and
weaknesses of an organisation, to create data driven
training interventions, and to assess the effect of train-
ing. Survey data also help to tailor training interven-
tions to address local issues.
Changing the professional culture in aviation
After the introduction of jet transport in the 1950s,
accident rates due to mechanical failure dropped
steeply. As data on accidents accumulated, it became
obvious that most accidents were related to break-
downs in crew coordination, communication, and deci-
sion making. The resulting shift toward a more open
culture that accommodated questioning and recog-
nised human limitations was a gradual but steady
The change came about through the involvement
of the research community, National Aeronautics and
Space Administration, regulatory agencies, and the use
of data driven initiatives to raise awareness of the
limitations of human performance and the importance
of effective teamwork. For the first time there were
instruments to collect reliable human factors data—a
combination of individual attitudes, organisational
norms, and assessments of behaviour before and after
training interventions determined if change was
actually taking place without having to rely on
retrospective data from accident investigation. Data
collection instruments such as the cockpit manage-
ment attitudes questionnaire were used to show
changes in safety related attitudes before and after
training, and these changes mapped on to actual
behaviour in the cockpit.19
Selection and training processes were amended.
Pilots began to be selected not only for technical skills
but also their ability to coordinate activities, learn from
error, and recognise that others can contribute to
problem solving. Airlines initiated a new approach to
training and assessing pilot skills by moving away from
training the individual pilot to training the entire
crew—recognising that safety and good performance
was not just a function of the captain but of the
captain using all available resources. The aviation
approach is to deal with errors non-punitively and
proactively, and this approach defines behavioural
strategies taught in crew resource management train-
ing (currently in its fifth generation)32
as error
countermeasures that are used to avoid error
whenever possible, to trap errors when they do occur,
90 100
Between anaesthesia
and surgery
Fig 2 Trained observers’ ratings of teamwork in aviation, surgery,
anaesthesia, and between surgery and anaesthesia
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and to mitigate the consequences of error before they
escalate into undesirable states.
Much research is needed to gain a full understand-
ing of attitudes and behaviours and their relationship
with outcomes in medicine. Although many
approaches to team training used in aviation are likely
to be useful in medicine, their design and effect need to
be fully validated to avoid haphazard approaches of
limited utility.
This article is dedicated to the late Dr Hans-Gerhard Schaefer,
whose personal quest to find and solve the human problems at
the core of medical care made a lasting impression on us. We
thank Lou Montgomery and Jennipher Mulhollen for help with
administration and data management and Elisa Rhoda for help
in collecting the medical data from Italy.
Contributors: JBS (guarantor) coordinated the data collec-
tion across hospitals and several of the airlines, formulated the
core ideas, and participated in the analyses and writing of the
paper. EJT collected data and participated in the analysis and
writing. RLH has overseen most of this research since the early
1980s, analysed and interpreted data, and contributed to writing
the paper. John Wilhelm has archived all the data collected by
the University of Texas human factors research project and also
helped in interpretation of the results. Ashleigh Merritt coordi-
nated most of the aviation data collection as part of her disserta-
tion research.
Funding: Gottlieb-Daimler and Karl-Benz Foundation
(RLH), the Memorial Hermann Centre for Healthcare
Improvement and the Robert Wood Johnson Foundation
generalist physician faculty scholar programme (EJT). RLH ini-
tiated this attitudinal research in the early 1980s under National
Aeronautics and Space Administration and Federal Aviation
Authority sponsorship.
Competing interests: None declared.
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What is already known on this topic
Much attention has been given to medical error in
recent years
No formal studies have compared perceptions of
error, stress, and teamwork in medicine and
What this study adds
Medical staff are more likely than aviation staff to
deny the effects of stress and fatigue
Cockpit crews and intensive care staff advocate flat
hierarchies but surgeons are less likely to do so
Error is difficult to discuss in medicine and not all
staff accept personal susceptibility to error
When I use a word ... nice?
Nice—a complimentary acronym you might think.
But it originally meant stupid (Latin nescius) and
later wanton, strange, lazy, unwilling, or fastidious.
By the 16th century it came to mean precise and
accurate, but other meanings included slender,
trivial, uncertain, and delicate. Chambers Twentieth
Century Dictionary (1959 edition) lists among
possible meanings “calling for very fine
discrimination”; “done with great care and
exactness”; “accurate”; and then puts the boot in:
“used in vague commendation by those who are
not nice.”
Submitted by Jeff Aronson, clinical pharmacologist,
BMJ VOLUME 320 18 MARCH 2000
on 16 January 2008
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