Effective communication among healthcare professionals is a cornerstone of safe, high-quality patient care. In complex clinical environments such as the operating room (OR), communication failures can lead to preventable adverse events, delays in care, procedural errors, and compromised patient outcomes [1]. The OR is characterized by dynamic interactions among surgeons, anesthesiologists, nurses, technicians, and trainees who must coordinate their actions in real time to ensure patient safety and procedural efficiency. Consequently, interprofessional communication has been recognized as a critical non-technical skill that directly influences team performance and surgical outcomes [2].Evidence from patient safety research suggests that communication breakdowns are among the leading contributors to sentinel events and medical errors in surgical settings [3]. Reports from international patient safety organizations have consistently highlighted inadequate communication as a significant factor in wrong-site surgery, retained surgical items, medication errors, and delays in responding to intraoperative complications [4]. As surgical procedures become increasingly complex and multidisciplinary, the need for effective communication among OR personnel has become more pronounced.Interprofessional communication encompasses the exchange of information, mutual respect, shared decision-making, active listening, and collaborative problem-solving among healthcare professionals from different disciplines [5]. In the OR, communication extends beyond the mere transfer of clinical information and includes maintaining situational awareness, managing interpersonal relationships, anticipating team needs, and responding appropriately to rapidly changing clinical circumstances [6]. These communication behaviors contribute to the development of a shared mental model among team members, thereby enhancing teamwork, coordination, and patient safety.Several assessment instruments have been developed to evaluate non-technical skills in healthcare environments. Commonly used tools include the Non-Technical Skills for Surgeons (NOTSS), Anaesthetists’ Non-Technical Skills (ANTS), and Scrub Practitioners’ List of Intraoperative Non-Technical Skills (SPLINTS) systems [7]. While these instruments have demonstrated utility in assessing discipline-specific behaviors, they primarily focus on individual professional groups rather than evaluating communication processes across the entire multidisciplinary team. Consequently, they may not adequately capture the collaborative and interprofessional nature of communication within the OR.More recently, healthcare educators and patient safety experts have emphasized the importance of interprofessional education and collaborative practice to improve communication and teamwork outcomes [8]. Despite this growing emphasis, there remains a paucity of validated instruments specifically designed to assess interprofessional communication among OR professionals. Existing tools often lack contextual relevance to surgical environments, fail to address multidirectional communication among diverse professional groups, or provide insufficient coverage of critical communication domains such as emotional intelligence, relationship building, and maintenance of a positive work climate.The development of robust assessment instruments is essential for identifying communication strengths and deficiencies, guiding educational interventions, and evaluating the effectiveness of teamwork training programs [9]. Furthermore, context-specific tools can provide meaningful feedback to healthcare professionals and support quality improvement initiatives aimed at reducing communication-related errors in surgical practice.Given the limited availability of instruments specifically designed to assess interprofessional communication within operating room teams, this study aimed to develop and establish the content validity of the Interprofessional Communication Assessment Tool for Operating Room Teams (IP-CAT-OR). The instrument was designed to comprehensively evaluate communication behaviors among multidisciplinary OR professionals and provide a structured framework for assessment, training, and patient safety enhancement in surgical settings

Study Design and Setting A sequential exploratory mixed-methods study was conducted between January and September 2024 at the Department of Surgery and Allied in the Operating Rooms of Ayub Teaching Hospital. The study followed established guidelines for questionnaire development in health professions education and was conducted in three phases: item generation, content validation, and cognitive pretesting. Ethical Approval Ethical approval was obtained from the Institutional Review Board of Ayub Teaching Hospital before study initiation.Written informed consent was obtained from all participants. Participation was voluntary, and confidentiality of responses was maintained throughout the study. Phase I: Item Generation Literature Review A comprehensive literature review was performed to identify existing frameworks and instruments assessing communication and non-technical skills in healthcare settings. Databases including PubMed, Scopus, and Web of Science were searched for studies published in English between 2000 and 2023. Keywords included “interprofessional communication,” “operating room communication,” “teamwork,” “non-technical skills,” “assessment tool,” and “patient safety.” Relevant constructs and communication domains were extracted to inform item development. Focus Group Discussions Purposive sampling was used to recruit 22 operating room professionals, including consultant surgeons, gynecologists, anesthetists, surgical residents, anesthesia residents, and scrub nurses. Four focus group discussions (FGDs) were conducted, each comprising 5–6 participants. Discussions were moderated by a trained qualitative researcher using a semi-structured interview guide exploring experiences, barriers, facilitators, and essential components of effective interprofessional communication in the operating room.All discussions were audio-recorded, transcribed verbatim, and anonymized. Data saturation was achieved after the fourth FGD. Qualitative data were analyzed using Braun and Clarke’s six-step thematic analysis approach. Initial codes were generated independently by two researchers and subsequently grouped into categories and overarching themes. Emerging themes were used to formulate potential questionnaire items. Phase II: Instrument Development and Content Validation Item Refinement The literature review and qualitative findings generated an initial pool of 78 items. Duplicate, ambiguous, and overlapping items were removed through iterative review by the research team. Items were rephrased to ensure clarity, relevance, and applicability across all operating room professions. Delphi Expert Review Content validation was conducted using a two-round Delphi process involving six experts in health professions education, surgical education, medical education, and operating room teamwork. Experts independently evaluated each item for relevance, clarity, simplicity, and representativeness using a four-point Likert scale.Items with a Content Validity Index (CVI) ≥0.78 were retained, while items scoring below the threshold were revised or removed based on expert feedback. Consensus was defined as agreement among at least 80% of panel members. Following two Delphi rounds, the instrument was reduced from 44 to 33 items. Content Validity Assessment Item-level Content Validity Index (I-CVI) and Scale-level Content Validity Index (S-CVI) were calculated. The overall S-CVI was determined by averaging item-level scores across all retained items. A scale-level CVI of ≥0.80 was considered indicative of satisfactory content validity. Phase III: Cognitive Interviews To assess comprehensibility and response processes, cognitive interviews were conducted with 10 operating room professionals who had not participated in the focus groups or Delphi review. Participants completed the draft questionnaire and subsequently engaged in think-aloud interviews. Feedback regarding wording, interpretation, ambiguity, and response options was recorded and analyzed. Minor modifications were incorporated to improve clarity and usability. Final Instrument The final Interprofessional Communication Assessment Tool for Operating Room Teams (IP-CAT-OR) consisted of 33 items distributed across five domains: relationship building, exchange of information, emotional intelligence, situational awareness, and maintaining a positive working environment. Items were rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating better perceived interprofessional communication. Statistical Analysis Descriptive statistics were used to summarize participant characteristics and expert ratings. Content validity indices (I-CVI and S-CVI) were calculated using standard methods. Qualitative data from focus groups and cognitive interviews were analyzed thematically. Data management and statistical analyses were performed using IBM SPSS Statistics. A p-value <0.05 was considered statistically significant where applicable.

A total of 22 operating room professionals participated in the focus group discussions conducted during the instrument development phase. Participants represented multiple disciplines, including consultant surgeons, gynecologists, anesthetists, residents, and scrub nurses, ensuring broad representation of perspectives related to interprofessional communication in the operating room. Participant demographics are presented in Table 1.Qualitative analysis of the focus group discussions identified several recurring concepts related to effective communication within multidisciplinary surgical teams. Through thematic analysis, five overarching domains emerged: relationship building, exchange of information, emotional intelligence, situational awareness, and maintaining a positive working environment. These domains served as the conceptual framework for item generation and subsequent instrument development.The initial literature review identified 31 communication-related constructs and highlighted limitations in existing assessment tools regarding evaluation of interprofessional communication within operating room environments. Focus group discussions generated an additional 47 context-specific items, resulting in an initial pool of 78 candidate items. Following removal of duplicate and overlapping statements, 56 items remained for expert review. The evolution of item development is summarized in Table 2.A two-round Delphi process involving six experts in health professions education and surgical teamwork was conducted to establish content validity. During the first Delphi round, experts evaluated item relevance, clarity, and representativeness, resulting in the retention of 44 items. Items receiving inadequate consensus were either revised or removed. A second Delphi round achieved consensus on 33 items, which constituted the final version of the instrument. The overall development and validation pathway is illustrated in Figure 1.Content validity analysis demonstrated satisfactory psychometric properties for the final instrument. The highest mean item-level content validity index (I-CVI) was observed for the domain “Exchange of Information” (0.87), followed by “Relationship Building” (0.84) and “Situational Awareness” (0.82). The domains of “Emotional Intelligence” and “Maintaining a Positive Working Environment” also demonstrated acceptable content validity indices of 0.80 and 0.79, respectively. The overall scale-level content validity index (S-CVI) was 0.82, indicating good content validity for the instrument as a whole (Table 3).Subsequently, cognitive interviews were conducted with 10 operating room professionals who had not participated in the earlier phases. Participants reported that the questionnaire items were clear, relevant, and representative of communication practices encountered in routine operating room settings. Minor wording modifications were implemented to enhance readability and reduce ambiguity; however, no additional items were added or removed during this stage.The final Interprofessional Communication Assessment Tool for Operating Room Teams (IP-CAT-OR) consisted of 33 items distributed across five domains. The instrument demonstrated strong content validity and was considered feasible for assessing interprofessional communication among multidisciplinary.

This figure illustrates the sequential exploratory mixed-methods process used for the development and content validation of the IP-CAT-OR. Phase I involved a literature review, focus group discussions with operating room professionals (n=22), and initial item generation, resulting in 78 candidate items. Following item refinement, Phase II comprised a two-round Delphi content validation process conducted by six health professions education experts, reducing the instrument to 33 items. Phase III involved cognitive interviews with operating room professionals (n=10) to assess item clarity, relevance, and comprehensibility. The final instrument consisted of 33 items organized into five domains: relationship building, exchange of information, emotional intelligence, situational awareness, and maintaining a positive working environment.

Table 1. Demographic Characteristics of Focus Group Participants (n = 22)

Distribution of operating room professionals participating in focus group discussions for item generation.

Table 2. Evolution of Item Development During Instrument Construction

Progressive refinement of questionnaire items during the development of the IP-CAT-OR instrument.

Table 3. Final Domains and Content Validity Indices of IP-CAT-OR

Content validity assessment of the final 33-item Interprofessional Communication Assessment Tool for Operating Room (IP-CAT-OR).

Effective communication among operating room (OR) professionals is increasingly recognized as a fundamental determinant of patient safety, team performance, and surgical efficiency. The present study describes the development and content validation of the Interprofessional Communication Assessment Tool for Operating Room Teams (IP-CAT-OR), a novel instrument specifically designed to assess communication behaviors among multidisciplinary surgical team members. Through a rigorous mixed-methods approach incorporating literature review, qualitative exploration, expert consensus, and cognitive interviewing, the final instrument demonstrated satisfactory content validity and strong conceptual relevance to contemporary surgical practice.One of the principal findings of this study was the identification of five key domains of interprofessional communication: relationship building, exchange of information, emotional intelligence, situational awareness, and maintaining a positive working environment. These domains align closely with current theories of teamwork and non-technical skills in healthcare, which emphasize that effective communication extends beyond the transfer of information to include interpersonal relationships, mutual respect, and shared understanding among team members [10,11].

Similar multidimensional communication frameworks have been reported in studies evaluating teamwork within high-risk healthcare environments, including operating rooms, emergency departments, and intensive care units [12].The domain of exchange of information demonstrated the highest content validity score among all domains. This finding is consistent with previous research showing that accurate, timely, and structured information exchange remains the cornerstone of safe surgical practice [13]. Communication failures during patient handovers, surgical briefings, and intraoperative coordination have been repeatedly identified as major contributors to adverse events and preventable errors [14].

Studies evaluating surgical safety initiatives have demonstrated that structured communication processes improve team coordination and reduce the likelihood of misunderstandings during complex procedures [15].Relationship building emerged as another important component of interprofessional communication. Previous investigations have shown that positive professional relationships promote trust, collaboration, and psychological safety among healthcare workers [16].

In multidisciplinary surgical teams, effective relationships facilitate open discussion, encourage team members to voice concerns, and support collaborative decision-making. The inclusion of this domain highlights the importance of interpersonal dynamics in achieving optimal team performance and patient outcomes.The incorporation of emotional intelligence as a distinct communication domain reflects growing recognition of its role in healthcare teamwork. Emotional intelligence influences an individual's ability to recognize, understand, and manage emotions in oneself and others. Recent studies have demonstrated that emotionally intelligent healthcare professionals exhibit superior communication skills, conflict management abilities, and collaborative behaviors [17]. Within the operating room, where stress levels may be elevated and clinical situations can change rapidly, emotional intelligence contributes to maintaining professionalism and facilitating constructive interactions among team members.Situational awareness also emerged as a critical theme during qualitative exploration. Situational awareness refers to the ability to perceive, interpret, and anticipate events within a clinical environment. Previous research has consistently linked high levels of situational awareness with improved patient safety and reduced medical errors [18].

Effective communication plays a central role in maintaining shared situational awareness among surgical team members by ensuring that relevant information is communicated promptly and accurately. The inclusion of this domain strengthens the instrument's ability to assess communication behaviors directly associated with safe operative practice.Another notable finding was the identification of maintaining a positive working environment as a core communication domain. Contemporary evidence suggests that workplace culture significantly influences communication quality, teamwork effectiveness, staff well-being, and patient safety outcomes [19]. Operating rooms characterized by mutual respect, supportive leadership, and collaborative communication have been associated with improved staff satisfaction and fewer adverse events [20]. The inclusion of this domain therefore broadens the scope of communication assessment beyond individual behaviors to encompass organizational and environmental influences.A major strength of the present study lies in its methodological rigor. The use of a sequential exploratory mixed-methods design ensured that instrument development was grounded in both empirical evidence and stakeholder perspectives.

The involvement of surgeons, anesthetists, residents, and scrub nurses enhanced the comprehensiveness and contextual relevance of the generated items. Furthermore, the Delphi process provided systematic expert evaluation, resulting in a scale-level content validity index of 0.82, which exceeds commonly accepted thresholds for newly developed instruments [21].he findings of this study are consistent with recent efforts to develop context-specific assessment tools for interprofessional practice. Several authors have argued that generic teamwork instruments often fail to capture the unique communication challenges encountered in surgical environments [22]. Unlike existing tools that primarily focus on discipline-specific non-technical skills, the IP-CAT-OR was specifically designed to assess communication across professional boundaries, thereby addressing an important gap in current assessment practices.The study also has important implications for surgical education and quality improvement initiatives. The instrument may be used to identify communication deficiencies, evaluate training programs, and monitor improvements in team performance over time. Interprofessional communication training has been shown to enhance teamwork behaviors, reduce communication errors, and improve patient outcomes in surgical settings [23].

Therefore, a valid assessment instrument is essential for measuring the effectiveness of such interventions and guiding future educational strategies.Future research should focus on further psychometric evaluation of the IP-CAT-OR, including assessment of construct validity, reliability, factor structure, and responsiveness across diverse healthcare settings. Multi-center studies involving larger samples of operating room professionals would strengthen evidence regarding the generalizability and applicability of the instrument [24]. Such investigations may also facilitate the development of benchmark scores and support broader implementation in surgical education and patient safety programs.

Limitations

This study has several limitations. First, the instrument was developed and content validated at a single tertiary care teaching hospital, which may limit the generalizability of the findings to other healthcare settings. Second, the relatively small number of experts involved in the Delphi process, although consistent with recommended practices for content validation studies, may have influenced item selection. Third, the study focused primarily on content validity and cognitive testing; additional psychometric properties such as construct validity, internal consistency, test-retest reliability, and factor structure were not evaluated. Finally, participants were recruited using purposive sampling, which may have introduced selection bias. Future multicenter studies are warranted to further establish the validity and reliability of the IP-CAT-OR across diverse surgical settings,

The Interprofessional Communication Assessment Tool for Operating Room

(IP-CAT-OR) was systematically developed using a rigorous mixed-methods approach and demonstrated satisfactory content validity. The final 33-item instrument encompasses five key domains of interprofessional communication: relationship building, exchange of information, emotional intelligence, situational awareness, and maintaining a positive working environment. By addressing a significant gap in existing assessment tools, the IP-CAT-OR provides a context-specific framework for evaluating communication among multidisciplinary operating room professionals. The instrument has the potential to support educational interventions, quality improvement initiatives, and patient safety efforts aimed at enhancing teamwork and communication within surgical environments.

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