title: Contextual Challenges to Safe Surgery in a Resource-limited Setting: A Multicenter, Multiprofessional Qualitative Study.
abstract: Safe surgery should be available to all patients, no matter the setting. The purpose of this study was to explore the contextual-specific challenges to safe surgical care encountered by surgeons and surgical teams in many in low- and middle-income countries (LMICs), and to understand the ways in which surgical teams overcome them.
  
  
  
  Optimal surgical performance is highly complex and requires providers to integrate and communicate information regarding the patient, task, team, and environment to coordinate team-based care that is timely, effective, and safe. Resource limitations common to many LMICs present unique challenges to surgeons operating in these environments, but have never been formally described.
  
  
  
  Using a grounded theory approach, we interviewed 34 experienced providers (surgeons, anesthetists, and nurses) at the 4 tertiary referral centers in Rwanda, to understand the challenges to safe surgical care and strategies to overcome them. Interview transcripts were coded line-by-line and iteratively analyzed for emerging themes until thematic saturation was reached.
  
  
  
  Rwandan-described challenges related to 4 domains: physical resources, human resources, overall systems support, and communication/language. The majority of these challenges arose from significant variability in either the quantity or quality of these domains. Surgical providers exhibited examples of resilient strategies to anticipate, monitor, respond to, and learn from these challenges.
  
  
  
  Resource variability rather than lack of resources underlies many contextual challenges to safe surgical care in a LMIC setting. Understanding these challenges and resilient strategies to overcome them is critical for both LMIC surgical providers and surgeons from HICs working in similar settings.
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, MA.|Department of Surgery, Brigham and Women's Hospital, Boston, MA.|Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA.
authors.forename: John W
authors.initials: JW
authors.lastname: Scott
authors.affiliation: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA.|Department of Surgery, University of Colorado, Aurora, CO.
authors.forename: Yihan
authors.initials: Y
authors.lastname: Lin
authors.affiliation: Department of Surgery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
authors.forename: Georges
authors.initials: G
authors.lastname: Ntakiyiruta
authors.affiliation: Department of Surgery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
authors.forename: Zeta A
authors.initials: ZA
authors.lastname: Mutabazi
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, MA.
authors.forename: William Austin
authors.initials: WA
authors.lastname: Davis
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, MA.
authors.forename: Megan A
authors.initials: MA
authors.lastname: Morris
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, MA.|Department of Surgery, Brigham and Women's Hospital, Boston, MA.|STRATUS Center for Medical Simulation, Brigham and Women's Hospital, Boston, MA.
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Smink
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, MA.|Department of Surgery, Brigham and Women's Hospital, Boston, MA.|Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA.|STRATUS Center for Medical Simulation, Brigham and Women's Hospital, Boston, MA.
authors.forename: Robert
authors.initials: R
authors.lastname: Riviello
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, MA.|Department of Surgery, Brigham and Women's Hospital, Boston, MA.|STRATUS Center for Medical Simulation, Brigham and Women's Hospital, Boston, MA.
authors.forename: Steven
authors.initials: S
authors.lastname: Yule
mesh_terms: D001291:Attitude of Health Personnel; D002983:Clinical Competence / Q000592:standards*; D003906:Developing Countries; D066296:Grounded Theory; D006295:Health Resources / Q000600:supply & distribution*; D006297:Health Services Accessibility; D006801:Humans; D007407:Interviews as Topic; D061214:Patient Safety / Q000592:standards*; D036301:Qualitative Research; D012432:Rwanda; D013514:Surgical Procedures, Operative / Q000592:standards*