Discrepant perceptions of communication,
teamwork and situation awareness among
surgical team members
L.S.G.L. WAUBEN1,2,†, C.M. DEKKER-VAN DOORN3,4,†, J.D.H. VAN WIJNGAARDEN3, R.H.M. GOOSSENS2,5,
R. HUIJSMAN3, J. KLEIN3,4,6AND J.F. LANGE1
1Department of Surgery, Erasmus University Medical Center, Post Box 2040, 3000 CA Rotterdam, The Netherlands,2Faculty of Industrial
Design Engineering, Delft University of Technology, Landbergstraat 15, 2628 CE Delft, The Netherlands,3Institute of Health Policy and
Management, Erasmus University Rotterdam, Post Box 738, 3000 DR Rotterdam, The Netherlands,4Department of Anaesthesiology,
Erasmus University Medical Center, Post Box 2040, 3000 CA Rotterdam, The Netherlands,5Department of Neuroscience, Erasmus
University Medical Center, Post Box 2040, 3000 CA Rotterdam, The Netherlands, and6Department of Anaesthesiology, Maasstad
Ziekenhuis, Post Box 9100, 3007 AC Rotterdam, The Netherlands
Address reprint requests to: L.S.G.L. Wauben, Faculty of Industrial Design Engineering, Delft University of Technology, Landbergstraat 15,
2628 CE Delft, The Netherlands. Tel: þ31-15-278-13-78; Fax: þ31-15-278-71-79; E-mail: firstname.lastname@example.org
Accepted for publication 14 December 2010
Objective. To assess surgical team members’ differences in perception of non-technical skills.
Design. Questionnaire design.
Setting. Operating theatres (OTs) at one university hospital, three teaching hospitals and one general hospital in the
Participants. Sixty-six surgeons, 97 OT nurses, 18 anaesthetists and 40 nurse anaesthetists.
Methods. All surgical team members, of five hospitals, were asked to complete a questionnaire and state their opinion on the
current state of communication, teamwork and situation awareness at the OT.
Results. Ratings for ‘communication’ were significantly different, particularly between surgeons and all other team members
(P ? 0.001). The ratings for ‘teamwork’ differed significantly between all team members (P ? 0.005). Within ‘situation aware-
ness’ significant differences were mainly observed for ‘gathering information’ between surgeons and other team members
(P , 0.001). Finally, 72–90% of anaesthetists, OT nurses and nurse anaesthetists rated routine team briefings and debriefings
Conclusions. This study shows discrepancies on many aspects in perception between surgeons and other surgical team
members concerning communication, teamwork and situation awareness. Future research needs to ascertain whether these
discrepancies are linked to greater risk of adverse events or to process as well as systems failures. Establishing this link would
support implementation and use of complex team interventions that intervene at multiple levels of the healthcare system.
Keywords: patient safety, quality of care, teamwork, communication, surgery
Performing safe surgery relies on the ability of surgical team
members to combine professional knowledge and technical
expertise with non-technical skills (e.g. communication, team-
work, situation awareness, leadership, decision-making) .
Mastery of both types of skill is essential . The surgical
team is a dynamic, multi-disciplinary team and consists of
surgeons, anaesthetists, operating theatre (OT) nurses and
nurse anaesthetists. Many errors that occur in the OT are
attributed to the non-technical skills of the surgical team [1,
3–12]. In order to work safely and effectively in a surgical
environment, with a minimum of technical errors, previous
studies have identified that the non-technical skills of com-
munication, teamwork and situation awareness are the most
important [1, 6, 9, 11–14]. These non-technical skills are
†Both authors contributed equally to this work.
International Journal for Quality in Health Care vol. 23 no. 2
# The Author 2011. Published by Oxford University Press in association with the International Society for Quality in Health Care
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
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International Journal for Quality in Health Care 2011; Volume 23, Number 2: pp. 159–166
Advance Access Publication: 17 January 2011
also important in other high-complex and high-risk indus-
tries such as aviation. In this industry, communication fail-
ures between team members, rather than a lack of technical
skills or malfunctioning of the aeroplane, were responsible
for ?70% of accidents [5–7, 9, 10].
In the context of the OT communication is defined as
‘skills for working in a team context to ensure that the team
has an acceptable shared picture of the situation and can
complete the tasks effectively’, and teamwork is defined as
‘skills for working in a group context, in any role, to ensure
effective joint tasks completion and team member satisfac-
tion’ . Furthermore, situation awareness is defined as
‘developing and maintaining a dynamic awareness of the situ-
ation in theatre based on assembling data from the environ-
ment, understanding what they mean and thinking ahead
what might happen next’ .
Procedures in the OT are complex and demand intense
interaction between team members. Surgical teams should be
cohesive and have similar perceptions of communication and
teamwork to collaborate effectively, establish common goals
for improving team performance, and ensure patient safety
[9, 16]. Therefore, work processes should emphasize the
interdependency of team members and support a good
understanding of each team member’s tasks, roles and
responsibilities within the surgical process. This facilitates
effective teamwork, ensures that action is linked to reflection,
and creates a culture that is open to change [6, 9, 13, 17, 18].
The aim of this study was to assess surgical team
members’ perception of their non-technical skills, specifically
communication, teamwork and situation awareness. Research
questions were aimed at identifying the category or categories
on which team members differed most and where these
differences in perception existed. It is important to identify
these discrepancies before introducing interventions for
improvement and adjust implementation strategies accord-
ingly [1, 3, 12, 13, 16, 19, 20].
This study was designed as a multiple case study among five
Dutch hospitals, covering 6% of all hospitals in the
Netherlands. The researchers (L.W., C.D.) visited each hospi-
tal and gave surgical team members oral and written infor-
mation on the project and provided a questionnaire for all
surgical team members to complete and elicit their opinion
on the current state of communication, teamwork and situation
awareness in the OT. Approximately 600 questionnaires were
distributed by mail/email by the contact persons of the parti-
cipating hospitals to the team members; surgeons, anaesthe-
tists, OT nurses and nurse anaesthetists. In this article, the
surgeon is defined as: ‘a medical specialist who performs
surgery: a physician qualified to treat those diseases that are
amenable to or require surgery’ .
The questionnaire elicited background information, such as
date and details on the respondent (age category, gender and
function within the hospital), and the respondent’s opinion
on statements about communication, teamwork and situation
awareness. The statements were based on two rating systems:
the non-technical skills of surgeons and the anaesthetists’
non-technical skills [15, 22]. These rating systems are devel-
oped for use during observations to identify the main non-
technical skills associated with good surgical practice of
anaesthetists and surgeons that can be used for clear and
transparent assessment of training needs . The rating
systems’ accompanying handbooks provided examples of
good and poor behaviour for each category and subcategory,
which were translated into statements. As these rating
systems are validated instruments, and comparable to other
validated instruments on team skills ([6, 23]), they provided a
reliable source to develop the questionnaire used in this
study. Table 1 presents the definitions of categories and sub-
categories used in the questionnaire.
The questions were randomly distributed over the ques-
tionnaire using a five-point Likert scale ranging from ‘1’
(strongly disagree) to ‘5’ (strongly agree) for each statement.
The questionnaires were voluntary and anonymous to team
member’s name, but not to team member’s function or hos-
pital. All data were analysed confidentially.
Statistical analyses were performed using SPSS 16.0 for
Mac. Comparisons between surgical team members per sub-
category were performed using the Mann–Whitney U-test.
The five hospitals that volunteered to participate comprised
one university hospital, three teaching hospitals and one
general hospital. In total, 235 questionnaires were returned.
Response rates per hospital ranged between 29 and 60%,
with an average response rate of 39% (Table 2).
The respondents represented
involved in surgical procedures: 66 surgeons (and residents),
18 anaesthetists (and trainee anaesthetists), 97 OT nurses
and 40 nurse anaesthetists (for distribution between hospi-
tals, see Table 2). Fourteen participants did not include their
function and were therefore excluded from the study.
Overall, 77% of surgeons were male, 58% of nurse anaesthe-
tists were male and 85% of OT nurses were female. Within
the anaesthetic disciplines, men and women were represented
equally. No significant differences were seen for gender
between hospitals. Within the surgical discipline most sur-
geons were between 36 and 45 years old. Within the other
disciplines age categories were divided.
Table 3 presents the statements where at least half of the
respondents per discipline rated the statement as inadequate
(rating ‘1’ or ‘2’). Table 4 presents the mean ratings, standard
deviation, median and missing data per subcategory. Table 4
shows a large amount of missing data for the surgeons for
‘Teamwork’ and ‘Situation awareness 1, 2 and 3’. This was
Wauben et al.
mainly attributable to the university hospital, where incom-
plete questionnaires, missing one page, were distributed.
Mean ratings, standard deviation and median were calculated
for the remaining data. Additionally, Table 5 presents the sig-
nificant differences of the team members’ ratings per subca-
tegory using the Mann–Whitney U-test. Here, application of
the Bonferroni correction for multiple comparisons suggests
an appropriate level of P, 0.008.
Within communication, three different subcategories are
addressed, which will be elaborated in the following paragraphs.
C1 j Exchanging information. Surgeons rated this subcategory
as adequate; the mean rating was 3.95 (Table 4). The other team
Communication: skills for working in a team context to
ensure that the team has an acceptable shared picture of the
situation and can complete the tasks effectively
C1—Exchanging information: giving and receiving
knowledge and information in timely matter to aid
establishment of a shared understanding among team
members (n ¼ 6)
C2—Establishing a shared understanding: ensuring that
the team not only has necessary and relevant information to
carry out the operation, but that they understand it and that
an acceptable shared ‘big picture’ of the case is held by team
member (n ¼ 7)
C3—Co-ordinating team activities: working together with
other team members to carry out cognitive and physical
activities in a simultaneous and collaborative manner (n ¼ 5)
Teamwork: skills for working in a group context, in any role,
to ensure effective joint tasks completion and team member
satisfaction. The focus is particularly on the team rather than
the task (n ¼ 11)
Situational awareness: developing and maintaining a dynamic
awareness of the situation in theatre based on assembling
data from the environment (patient, team, time, displays and
equipment): understanding what they mean and thinking
ahead what might happen next
S1—Gathering information: seeking information in the
OT from the operative findings, theatre environment,
equipment and people (n ¼ 5)
S2—Understanding information: updating one’s mental
picture by interpreting the information gathered, and
comparing it with existing knowledge to identify the match
or mismatch between the situation and the expected state
(n ¼ 2)
S3—Projecting and anticipating future state: predicting
what may happen in the near future as a result of possible
actions, interventions or non-interventions (n ¼ 1)
Table 1 Definitions for communication, teamwork and
situation awareness [15, 22]
(Sub)categories and number of statements in questionnaire
Table 2 Response to questionnaire
response rate (%)
Response per discipline
(and in training)
26 M, 7 F
4 M, 3 F
3 M, 24 F
6 M, 3 F
13 M, 2 F
2 M, 2 F
3 M, 12 F, 3 md
3 M, 8 F
1 M, 2 F, 3 md
2 M, 2 F
1 M, 17 F
7 M, 3 F, 1 md
1 M, 2 F
5 M, 3 F
1 M, 2 F
1 M, 20 F
4 M, 1 F
4 M, 2 F, 1 md
4 M, 9 F
3 M, 1 F
51 M (77)
14 F (21)1 md (2)
9 M ¼ 50%,
9 F ¼ 50%
12 M ¼ 12%,
82 F ¼ 85%,
3 md ¼ 3%
23 M ¼ 58%,
16 F ¼ 40%,
1 md ¼ 2%
5 M ¼ 36%,
6 F ¼ 43%,
3 md ¼ 21%
Age categories per discipline
M, male; F, female; md, missing data.
Age categories: C1, 18–25 years, C2, 26–35 years, C3, 36–45 years, C4, 46–55 years, C5, 56–65 years.
Discrepant perceptions among surgical team members
Quality improvement in surgery
members rated this lower: mean 3.12–3.34. This difference of
opinion between surgeons and other team members was
significant (P, 0.001, Table 5). No significant differences were
found between the OT nurses and anaesthetists (P ¼ 0.215),
between the OT nurses and nurse anaesthetists (P ¼ 0.011), or
between anaesthetists and nurse anaesthetists (P ¼ 0.677).
The statement ‘anaesthetist/nurse anaesthetist keeping the
surgeon informed on the administered medication during
surgery’ was rated as inadequate by the anaesthetists (78%),
OT nurses (71%) and nurse anaesthetists (67%, Table 3).
C2 j Establishing a shared understanding. Surgeons rated this
subcategory as adequate: the mean was 3.68 versus a mean of
2.73 for the anaesthetists and 2.74 for the nurse anaesthetists.
The OT nurses’ mean ratings were lowest: 2.35. The difference
of opinion between surgeons and other team members, and
between OT nurses and other team members was significant
(P, 0.001). No significant difference was found between
anaesthetists and nurse anaesthetists (P ¼ 0.811).
Anaesthetists, OT nurses and nurse anaesthetists rated
inadequate (72–90% of respondents). OT nurses (61–62%)
also rated communication of the planned procedure and
actions by the anaesthetist as inadequate.
C3 j Co-ordinating team activities. Once more, these results
showed the same overall pattern: the surgeons rated this
anaesthetists (3.33) and nurse anaesthetists (3.04). Again, the
OT nurses’ ratings were lowest: 2.77. The difference of
opinion between surgeons and other team members was
significant (P ? 0.001), as was the difference between OT
nursesand anaesthetists(P , 0.001).
differences were found between the remaining team members.
Checking the readiness of the team pre-operatively by the
surgeon as well as by the anaesthetist was rated as inadequate
by OT nurses (73 and 81%, respectively). ‘Stopping the pro-
cedure when asked by the OT nurse’ was rated as inadequate
by 53–72% of team members, except the surgeons.
3.83), followedby the
Within this subcategory, the differences between all team
members were significant (P ? 0.005). Most surgeons and
anaesthetists perceived ‘teamwork’ as adequate (group mean:
C1 j Exchanging information
Anaesthetist/nurse anaesthetist keeping the surgeon informed on
the administered medication during surgery
Surgeon communicating that surgery is not going according to
C2 j Establishing a shared understanding
Surgeon communicating planned procedure
Anaesthetist communicating planned procedure
Anaesthetist communicating planned actions
Pre-operative briefings with the whole team on the procedure
Debriefings with the whole team, discussing what problems
C3 j Co-ordinating team activities
Surgeon checking pre-operatively whether the whole team is ready
to start the procedure
Anaesthetist checking pre-operatively whether the whole team is
ready to start the procedure
Stopping the procedure when asked by the OT nurse
T j Teamwork
Contentment with communication and teamwork in OT
Surgeon being a team player
S1 j Gathering information
Exchanging relevant patient data pre-operatively with the whole
Surgeon asking the anaesthetic team for update on the patient’s
S2 and S3 not applicable
Table 3 Statements within communication, teamwork and situation awareness where at least half of the respondents per
discipline rated the statement as inadequate
Statements Percentage rated as inadequate per discipline
5 51 49
6 78 37 58
Wauben et al.
3.78 and 3.47). The ratings of nurse anaesthetists and OT
nurses were significantly lower (mean: 3.26 and 3.06).
All respondents perceived themselves as team players, felt
comfortable about expressing their opinion, and perceived
the OT nurse and nurse anaesthetist as team players.
However, 51% of OT nurses did not see the surgeon as
team player and 72% of OT nurses were not content with
communication and teamwork in OT.
Within situation awareness three subcategories are addressed,
which will be elaborated in the following paragraphs.
S1 j Gathering information. The ratings for this subcategory
showed similar results to most (sub)categories within
communication and teamwork. Surgeons awarded this
subcategory an average rating of 3.84; the average ratings for
the OT nurses and nurse anaesthetists were 3.15 and 3.14.
The anaesthetists’ ratings were lowest: 2.84. The only
significant difference found was between the surgeons and
other team members (P , 0.001).
Overall, 78–94% of anaesthetists, OT nurses and nurse
anaesthetists rated exchanging relevant patient data pre-
operatively with the whole team as inadequate, in contrast to
the surgeon (35% rated this as inadequate). The surgeon
asking the anaesthetic team for an update on the patient’s
condition was rated as inadequate by 58% of nurse anaesthe-
tists and 78% of anaesthetists.
S2 j Understanding information. Most team members rated
this subcategory as adequate: mean ratings for the groups
ranged from 3.91 to 4.35. Significant differences were found
only between the surgeons and OT nurses (P, 0.001), and
between the surgeons and nurse anaesthetists (P ¼ 0.001).
S3 j Projecting and anticipating future states. This subcategory
entailed the statement ‘during laparoscopic procedures, the
instruments for a possible conversion are always present in
OT’. Within this subcategory, a lot of missing data were
found: 49% of surgeons, 29% of anaesthetists and 20% of
Surgeons Anaesthetists OT nurses
Communication C1 Mean (SD)3.95 (1.05)
C2 Mean (SD) 3.68 (1.14)
C3Mean (SD)3.83 (1.16)
TeamworkTMean (SD) 3.78 (1.07)
S2Mean (SD)4.35 (0.80)
S3 Mean (SD)3.41 (1.23)
Table 4 Team members’ ratings for the subcategories of communication, teamwork and situation awareness: mean (on 1–5
scale, higher score ¼ higher quality), standard deviation (SD), median and missing data
S1Mean (SD)3.84 (1.03) 2.84 (1.24)
aFinal page of the questionnaire from the university hospital was not distributed.
Discrepant perceptions among surgical team members
Quality improvement in surgery
nurse anaesthetists did not answer this question. In contrast,
the OT nurses showed a near full response (98%) and most
nurses rated this item as adequate (mean 3.74). If rated at all,
the surgeons rated this statement as adequate, the mean
being 3.41, which was not significantly higher than the mean
of 3.28 awarded by the nurse anaesthetists. The anaesthetists’
ratings were lowest: mean 2.67.
Significant differences were found only between the OT
nurses and anaesthetists (P, 0.001) and between OT nurses
and nurse anaesthetists (P ¼ 0.002).
The purpose of this study was to analyse the discrepan-
cies in team members’ perception of communication,
teamwork and situation awareness. Overall, this study
showed a significant discrepancy between the surgical
team members in all three categories. Throughout the
questionnaire the surgeons rated most items as adequate
(mean: 3.41–4.35) in contrast to all other team members
where more differences in opinion were found. Within
the communication category results showed a large vari-
ation in opinion between team members. The largest dis-
crepancy in this study was found in ‘establishing a shared
understanding’ (C2), which is an important factor when
performing complex procedures, such as surgery . The
between surgical team members. Most surgeons and
anaesthetists rated theseas
majority of both OT nurses and nurse anaesthetists rated
these as inadequate. Within the situation awareness cat-
egory, the ‘understanding information’ subcategory was rated
as adequate. However, all team members, except the sur-
geons, rated ‘gathering information’ as inadequate.
The discrepancies we found may have a negative effect on
patient safety. A first step to improve patient safety is
acknowledging that errors are made and discussing these
errors. Although errors are inevitable, team members are
often reluctant to discuss these failures, especially human
errors. Surgeons might be hesitant to discuss failures because
they are educated to ‘do the right thing and do it right’ and
thus find it hard to acknowledge that errors are made .
Other team members might be discouraged to speak up
because of traditional hierarchical structures, authority, social
barriers or differences in professional training and responsi-
bility [3, 17, 19, 24]. Also poor teamwork could lead to team
members’ withdrawal from discussions and could lead to
decreased job satisfaction and efficiency, which in turn could
result in communication failures and poor performance. Not
taking time out to discuss complications as a team or to
perform a thorough analysis of what went wrong and why
results in poorly performing teams. Research in aviation
shows that, regardless of workload, poorly performing teams
spend only 5% of their time discussing possible compli-
cations compared with 33% of time spend by effective teams
. Research has also shown that similar perceptions of the
current situation will result in effective collaboration and
patient safety [7, 9, 16]. Similar perceptions of the future state;
on what to improve and why, will support implementation of
quality improvement initiatives and improve collective learn-
ing [1, 3, 12, 13, 16, 19, 20, 26]. All team members should
understand and be well informed about the surgical pro-
cedure and about specific patient-related subjects, such as
allergies or co-morbidity. A lack in this ‘shared understand-
ing’ among team members might result in adverse events,
such as wrong site surgery or wrong person surgery [7, 16,
20]. Many of our respondents experience a lack of shared
perception both on the current and the future state, with the
exception of the surgeons. One method to improve shared
understanding is by means of pre-operative briefings. These
create an opportunity, just before the start of the surgical
intervention, to exchange information on the patient and on
the surgical procedure with the whole team in order to
prevent errors . This establishes a shared mental model
among team members.
The overall findings of this study are consistent with pre-
vious research, the most common pattern being that sur-
geons have a positive perception of communication and
teamwork and that nurses have the most negative perception
[3, 7, 8, 11, 16, 18, 19]. OT nurses who have a poor percep-
tion of communication sometimes have difficulty in speaking
up, and are afraid of confrontation. This could also prevent
other team members from correcting errors before patients
are harmed and inhibit discussing and learning from errors
as a team [5, 7, 17–19].
Anaesthetists –OT nurses0.215
Anaesthetists–nurse anaesthetists 0.6770.811
OT nurses–nurse anaesthetists 0.011
Table 5 Significant differences between surgical team members (Mann–Whitney U-test with Bonferroni correction)a
Disciplines comparedCommunicationTeamwork Situation awareness
aBonferroni correction for multiple comparisons suggests an appropriate level of P , 0.008.
Wauben et al.
A limitation of this study was the number of centres
involved; only five hospitals participated of the ?90 hospi-
tals in the Netherlands (6%). However, these hospitals rep-
resent the whole spectrum of hospital types at a regional
level and are comparable for quality of care. On the national
list of quality indicators for patient care, the hospitals that
volunteered ranked from average to good, but change pos-
itions annually when compared over the last 5 years .
Comparing response rates to similar studies is complicated
because of the large differences in results/outcome measure-
ments [3, 8, 16]. This study showed large discrepancies in
response rate, both between hospitals and between disci-
plines. The surgeons’ response rate was 45%, which is com-
parable to Flin et al.  (48%) and higher than Mills et al.
 (12%). The OT nurses’ response rate was higher: 40%
versus 19% (Flin et al.) and 36% (Mills et al.). Makary et al.
 showed a much higher response rate for all different dis-
ciplines (surgeons, anaesthetists, OT nurses, nurse anaesthe-
tists). Future research should include results on differences
between hospitals, and study which factors contribute to
such high discrepancies in response rates.
The large amount of missing data for the surgeons
(Table 4) was caused by human error. At the university hos-
pital, the last page was not distributed, which resulted in
unreliable answers for this discipline. To prevent errors like
these, it is recommended that hard copies be distributed or
to a web-based version (including required fields) used. The
missing data concerning the statement about ‘Projecting and
anticipating future state’ (S3) was directly related to a specific
task: anticipating conversion. Apart from the high response
from the OT nurses, being responsible for this task, most
team members did not see this as part of their job, which
might be the reason for the low response.
This study shows the differences in perception of surgical
team members in relation to the non-technical skills com-
munication, teamwork and situation awareness. Although
these skills are considered the most important ones to work
safely and effectively [1, 6, 9, 11–14, 28], skills such as lea-
Therefore, a follow-up study was set up including these
items in the questionnaire to get a more complete picture of
the whole spectrum of non-technical skills.
Future research also needs to ascertain whether discre-
pancies of non-technical skills are linked to greater risk of
adverse events or latent failures in the healthcare system.
Establishing this link would support the use of complex
team interventions that encompass the whole care process
and support systems. Team interventions for improvement
should support the dialogue between team members to
create a shared mental model, and focus on team, process
and system problems [1, 3–5, 7, 9, 12, 14, 17, 20, 29].
Additionally, research on patient safety should combine
non-technical and technical skills. As surgical procedures
are complex and error prone, mastering non-technical skills
is as important as mastering technical skills in order to
perform safe surgery [2, 30]. Although so far research
shows very little quantitative evidence on positive results of
team interventions on team effectiveness, there is emerging
evidence that team interventions that include technical as
well as non-technical skills might lead to better outcomes
[20, 31]. If teams strengthen their ability to reflect collec-
tively on problems encountered, it will improve learning
from experience and create a shared understanding between
team members. These are all necessary preconditions to
prevent adverse events . Interventions like a pre-
operative briefing and post-operative debriefing based on
dialogue, discussing the surgery before and after perform-
ing the procedure with the whole team might be successful
and improve team performance and patient outcomes [3, 7,
12, 14, 20]. Interventions to improve communication and
teamwork should thus include multiple objectives related to
the team and to the different organizational levels in the
The authors would like to thank all contact persons from the
participating hospitals for distributing and collecting the
Funding to pay the Open Access publication charges for this
article was provided by the Delft University of Technology.
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