First, we conducted a systematic review of the existing literature on the topic “teamwork at the neurosurgical table” by searching the main medical and nursing databases, i.e., PubMed (Medline) and CINAHL, from the creation of the databases themselves until 15 July 2023. We included articles without restrictions about their publication status (fully published articles, online-ahead-of-print articles), in the English language, that could study the topic from surgeons’, trainees’, and scrub nurses’ points of view. Articles about perceptions or evaluation of the teamwork in the neurosurgical OR, or multi-specialty studies involving at least a neurosurgeon were eligible. Studies concerning interventions to improve teamwork were included when they dealt specifically with neurosurgery/neurosurgical procedures.

We excluded articles only describing multi-disciplinary surgeries (without evaluation of the value of teamwork), studies limited to other surgical domains or studying teamwork among anesthesiologists and neurosurgeons, publications about teamwork outside the OR (in the ward, in the whole healthcare system, in the rehabilitation process, and for emergent fire events). Publications that only mentioned scrub nurses working in “a wide range of specialties” or “in every specialty,” without further specification, were also excluded. We also excluded non-English articles, editorials, literature reviews, commentaries/perspectives/opinions, newspaper articles, proceedings or abstracts, and dissertations.

The systematic review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement 2020 (13) (Data Sheet 1 in the supplementary material).

We searched on PubMed for each of the following words: “teamwork”, “team building”, “team working”, and “non-technical skills”, combined with each of the following other words: “neurosurgery”, “surgery”, and “operating room”. We repeated the same procedure on CINAHL. We eliminated duplicates and then screened all titles and abstracts of the uniquely obtained articles. The publications assessed for eligibility were analyzed through reading of the full-texts and the relevant articles were finally included.

Afterward, we reviewed the references of the relevant studies as additional sources of eligible articles.

Data of the eligible works were obtained through careful analysis of full text by one author and checked by another. If a shared choice could not be reached between the two authors, a third surgeon was called to evaluate the most suitable solution.

The second part of our article focuses on a pilot, explorative study carried out at our Institution (Fondazione IRCCS San Gerardo dei Tintori) to test the utility, appreciation, and value in boosting teamwork between scrub nurses and neurosurgeons of a simulation experience (Figure 1). This experience was a single-session, hands-on, and cadaver-free activity, based on role play, and it was specifically organized for scrub nurses working in neurosurgery (dedicated neurosurgical scrub nurses and scrub nurses taking part in emergent procedures including neurosurgical ones). An organizational meeting was held 10 days before the beginning of the simulation sessions, explaining the project step by step and how to use the self-evaluation questionnaire.

On the day of the simulation, first, scrub nurse participants were asked to complete the SPLINTS (Scrub Practitioners’ List of Intraoperative Non-Technical Skills) rating form as a self-evaluation at baseline (14–17). SPLINTS is a behavioral rating system, developed by psychologists and OR teams, that was originally designed to observe and rate scrub nurses in the OR. It comprises three main categories (situation awareness, communication and teamwork, and task management), each one further developed into three more specific subcategories, as explained in the User Manual (16). It is a rating system specifically developed for scrub nurses, in the same way as NOTECHS (18), ANTS (19), and NOTSS (20) were created for pilots, anesthesiologists, and surgeons, respectively.

A briefing about the neurosurgical oncological technique and the use and working of Exoscope was then offered to the participants. For the actual simulated surgery, a role switch was performed: the scrub nurse played the role of the surgeon, while the surgeon acted like a neurosurgical scrub nurse. Then, the session was developed into three exercises, executed with an exoscopic microsurgical technique. First, the scrub nurse had to make a surgical knot with forceps and a needle holder, looking at the monitor of the Exoscope. Second, they had to perform a cerebral tumor removal onto a model of intrinsic cerebral neoplasm (Tumor Box, UpSurgeOn®), with the support of the neurosurgeon who had prepared the surgical table and is now passing instruments. They also could try and understand the use of BLUE 400 filter for 5-aminolevulinic acid (5-ALA) vision, having the model a fluorescent tracer simulating 5-ALA. Third, the simulation was further developed with the support of a second scrub nurse impersonating the assistant surgeon (Figure 2). An observer noted every relevant comment or evaluation expressed during the whole session.

At the end of the simulation, a debriefing took place, underlining the acquired skills, stressing the understanding of the other's role, and giving the participants the chance to ask questions. Every participant—scrub nurses as well as neurosurgeons—was finally asked to complete an evaluation questionnaire with seven questions with a five-point Likert scale for answers, with the possibility to freely add comments. The questionnaire was adapted from a previous article by Shapiro (21) that had proposed a similar team-building experience in another domain of medicine.

The SPLINTS rating form was re-administered as a self-evaluation after three to four weeks after the experience. Every involved scrub nurse took part in at least three neurosurgical procedures in the intervening period, to better evaluate the practical value of the experience in improving their NTS in neurosurgery. The questionnaire results were collected anonymously. Supplementary Image 1 shows the evaluation questionnaire; the SPLINTS rating form can be found at the end of the user manual (16).

An online open-source software, jamovi® (www.jamovi.org) (22), was used for statistical analyses. The sample was described by means of the usual descriptive statistics. To compare independent discrete variables, we applied the Student's t-test. A threshold of p < 0.05 was set for statistical significance.

As mentioned previously, we searched first on PubMed, and then on CINAHL. We obtained a total of 6,415 articles (4,145 from PubMed, 2,270 from CINAHL), of which 2,066 were duplicated. At this point, all titles and abstracts of the unique 4,349 articles were screened. A total of 292 studies were selected, but 47 of them were not retrievable. We finally assessed 245 articles for eligibility, analyzing full-texts, and excluded 211 of them for the following reasons: 88 because they specifically involved specialties other than neurosurgery; 51 because they did not specify involved surgical specialties; 57 because they were types of articles to be excluded; 15 treated irrelevant themes; and 3 were not in English.

From the references of the relevant studies, we further evaluated 11 eligible articles, and 3 were included.

The publications finally included in the study amounted to 34 (Figure 3).

We divided the included studies into two groups: the ones dealing with our theme exclusively in neurosurgery in Table 1 (23–36), and the ones studying teamwork and possible other NTS in many specialties, neurosurgery included, in Table 2 (8, 9, 37–54).

Table 1 shows that only one studied the specific relationship among scrub nurses and neurosurgeons at the table (23), while the others globally looked at teamwork in the whole neurosurgical OR environment (24, 26, 27, 29, 32, 34–36), focusing on neurosurgeons (28, 30, 31), or studied exclusively nurses’ tasks or points of view (25, 33).

Similarly, only 4 out of 14 studies tried an intervention to improve teamwork (24–26, 33). The interventions included (1) the production of a video, (2) a virtual reality simulation in which nurses had to find errors in the preparation of a craniotomy, and (3) and (4) the introduction of a checklist.

Very interestingly, the work by McLaughlin et al. concluded that the time-out process may improve safety, but not teamwork—the only “negative” report about teamwork in this group of articles (27).

In Table 2, it is evident that similarly to exclusively neurosurgical reports, the majority of publications (13 out of 20) globally looked at teamwork among the whole staff; 3 focused primarily on surgeons (38, 46, 52), 3 on nurses (47, 51, 53), and 1 on residents (44). The interventional activities are also limited: 3/20, including aviation-style teamwork training (40), a training program in Norway for Malawian nurses (47), and crew resource management training (48).

In all the articles, the theme of safety is often stressed: teamwork and NTS, in general, are considered above all as tools to improve safety in the OR.

A total of 10 scrub nurses and 5 neurosurgeons participated in the simulation experience. Six of the nurses worked exclusively in neurosurgery, four were part of the emergency staff and were involved also in emergent neurosurgical cases. Nine were women and one, man. Every nurse had at least 2 years of experience in the OR. The five neurosurgeons included four attending surgeons and one final-year resident.

The results of the comparison between the pre- and post-experience self-evaluations are provided in Table 3. Very interestingly, the rating scrub nurses gave themselves in the macro-categories “Situation Awareness” and “Communication and Teamwork” showed a statistically significant improvement from the pre- to the post-evaluation. The overall score also improved significantly (A in Table 3).

When looking at the rating scrub nurses wrote in every single item, three showed statistically significant improvement (“Recognizing and understanding information”, “Anticipating”, “Exchanging information”) and all showed improvement tending toward statistical significance (B in Table 3).

Among the items in the evaluation questionnaire, the last four questions specifically concerned teamwork training [4. The quality of the final debriefing for my understanding of the surgeon's work was high, 5. The experience was useful to understand the surgeon's point of view, 6. The experience helped improve my teamwork skills, 7. I would redo the activity to further improve my teamwork skills].

The results of the questionnaire administered to scrub nurses are shown in Figure 4, whereas the surgeons’ evaluations are represented in Figure 5.

As shown by the graphs, the results of the four items about teamwork were all positive in both groups (agree and strongly agree). The nurses scored items 5, 6, and 7 even higher than the surgeons. The surgeons were globally not satisfied by the ease of immersion in the simulation (four neurosurgeons answered “neutral”; one answered “disagree”), whereas half of the scrub nurses were satisfied to some extent (five agreed or strongly agreed with the sentence).

Every relevant comment orally expressed by participants during the sessions and noted by an external observer was qualitatively analyzed, in the same way as every possible note written at the end of the final evaluation questionnaire (Table 4).

We grouped them into three main themes. The first group of comments was about repeating and improving the simulation experience. As already evident from the Likert items, five scrub nurses further underlined their desire to repeat the experience. Moreover, one suggested trying other boxes from UpSurgeOn® and exercises within neurosurgery, and another one mentioned the possible value of extending such an experience to other specialties. One nurse asked for a possible improvement in the realism of the global scenario and another suggested repeating the experience with all the surgeons, in particular the ones perceived as stricter and/or shyer, to try and strengthen a friendly and trusting relationship.

The second theme in free comments regarded the pleasure of participating in such a simulation, which was stressed by two participants. They felt they had agency and enjoyed the chance to ask questions, understand, and learn in a “safe,” tension-free setting.

The third group of comments was about the surgeons’ work. Two other nurses in particular commented on it: “I now understand how difficult it is to use the Exoscope”; “How many things do you surgeons have to think about, while operating!” Moreover, very interestingly, during each session, every single participant was light-heartedly mocking the other group's typical expressions and comments. For example, every nurse playing the surgeon exaggeratingly complained about the blockage of the aspirator, a typical complaint of the surgeon during everyday surgical cases.