Nontechnical skills training for the operating room: A prospective study using simulation and didactic workshop

Simulation-based training for intraoperative posterior capsule rupture management: an analysis of nontechnical skills development and the relationship between technical and nontechnical skills

OBJECTIVES

To analyse development of individual nontechnical skills (NTS) domains after undertaking a previously developed simulation-based training model and analyse the relationship between technical skills (TS) and NTS in ophthalmic surgery.

METHODS

The simulation-based training model involved a cataract surgery case complicated by intraoperative posterior capsule rupture. Cataract surgeons underwent the simulation twice, separated by a training intervention. Two blinded independent experts assessed participants' NTS using HUFOES, NOn-Technical Skills for Surgeons (NOTSS), and the OSATS global rating scale for TS. Paired t-tests assessed differences in individual NTS domains, with p < 0.05 indicating significance. The Pearson Product Moment Correlation Coefficient was used to assess the correlation between scores from each scoring system.

RESULTS

All NTS domains within HUFOES and NOTSS demonstrated statistically significant improvements secondary to the training intervention. Positive correlations were demonstrated between HUFOES and OSATS scores in the pre- and post-training simulations, r = 0.870 (p < 0.001) and r = 0.861 (p < 0.001), respectively. Positive correlations were also demonstrated between NOTSS and OSATS scores in pre- and post-training simulations, r = 0.849 (p < 0.001) and r = 0.757 (p = 0.001), respectively. Positive correlations were demonstrated between HUFOES and NOTSS scores; r = 0.979 (p < 0.001) (n = 17) and r = 0.959 (p < 0.001) for pre- and post-training simulations, respectively.

CONCLUSION

All NTS domains contained within HUFOES and NOTSS demonstrated significant increases following the completion of the simulation-based training model. Positive correlations exist between an ophthalmic surgeon's TS and NTS. This is the first study to report these findings within ophthalmic surgery.

Advances in Pediatric Surgery Simulation-Based Training

Pediatric surgery is the diagnostic, operative, and postoperative surgical care of children with congenital and acquired anomalies and diseases. The early history of the specialty followed the classic "see one, do one, teach one" philosophy of training but has since evolved to modern methods including simulation-based training (SBT). Current trainees in pediatric surgery face numerous challenges, such as the decreasing incidence of congenital disease and reduced work hours. SBT consists of several modalities that together assist in the acquisition of technical skills and improve performance in the operating room. SBT has evolved to incorporate simulator models and video gaming technology, in parallel with the development of simulation in other surgical and non-surgical pediatric fields. SBT has advanced to a level of sophistication that means that it can improve the skills of not only pediatric surgery trainees but also practicing attending surgeons. In this review, we will discuss the history of pediatric surgery, simulation in pediatric surgery training, and the potential direction of pediatric surgical simulation training in the future.

Advancing leadership in surgery: a realist review of interventions and strategies to promote evidence-based leadership in healthcare

BACKGROUND

Healthcare systems invest in leadership development of surgeons, surgical trainees, and teams. However, there is no agreement on how interventions should be designed, or what components they must contain to be successful. The objective of this realist review was to generate a programme theory explaining in which context and for whom surgical leadership interventions work and why.

METHODS

Five databases were systematically searched, and articles screened against inclusion considering their relevance. Context-mechanism-outcome configurations (CMOCs) and fragments of CMOCs were identified. Gaps in the CMOCs were filled through deliberation with the research team and stakeholder feedback. We identified patterns between CMOCs and causal relationships to create a programme theory.

RESULTS

Thirty-three studies were included and 19 CMOCs were developed. Findings suggests that interventions for surgeons and surgical teams improve leadership if timely feedback is delivered on multiple occasions and by trusted and respected people. Negative feedback is best provided privately. Feedback from senior-to-junior or peer-to-peer should be delivered directly, whereas feedback from junior-to-senior is preferred when delivered anonymously. Leadership interventions were shown to be most effective for those with awareness of the importance of leadership, those with confidence in their technical surgical skills, and those with identified leadership deficits. For interventions to improve leadership in surgery, they need to be delivered in an intimate learning environment, consider implementing a speak-up culture, provide a variety of interactive learning activities, show a genuine investment in the intervention, and be customised to the needs of surgeons. Leadership of surgical teams can be best developed by enabling surgical teams to train together.

CONCLUSIONS

The programme theory provides evidence-based guidance for those who are designing, developing and implementing leadership interventions in surgery. Adopting the recommendations will help to ensure interventions are acceptable to the surgical community and successful in improving surgical leadership.

TRIAL REGISTRATION

The review protocol is registered with PROSPERO (CRD42021230709).

Non-technical skills simulation-based training model for managing intraoperative posterior capsule rupture during cataract surgery

OBJECTIVES

To develop and implement a simulation-based training model for the management of posterior capsule rupture (PCR) from a non-technical skills (NTS) perspective, and analyse changes in participant's NTS and technical skills (TS).

METHODS

The simulation-based training model consisted of two identical PCR simulations with NTS stressors applied, separated by a predominantly NTS focussed training intervention. Participants' TS and NTS were evaluated by two blinded assessors using the Objective Structured Assessment of Technical Skill (OSATS) global rating scale and the HUman Factors in intraoperative Ophthalmic Emergencies Scoring System (HUFOES) respectively. Paired t-tests were used to establish the difference in mean HUFOES and OSATS scores between initial and repeat simulations; p < 0.05 indicated statistical significance. McGaghie's model of translational outcomes for simulation-based learning was used to establish the simulation model's educational status.

RESULTS

Seventeen cataract surgeons of varying training grades participated in the simulation-based training model. NTS improved with statistical significance; mean HUFOES scores increased from 48.7 ± 16.6 to 59.2 ± 14.8 (p < 0.001). Mean OSATS scores increased without statistical significance from 16.0 ± 7.3 to 17.9 ± 8.3 (p = 0.07). This simulation model achieved Level 1 (internal acceptability) and Level 2 (contained effects) according to McGaghie's model.

CONCLUSIONS

This novel simulation-based training model was designed to improve the NTS required for managing intraoperative PCR, through the provision of an interactive training session. Statistically significant improvements in participants' NTS in combination with statistically insignificant improvements in TS demonstrate that the simulation-based training model has specificity within the NTS domain.

Professional Skills Teaching within Veterinary Education and Possible Future Directions

Once ignored for their potential to take up precious time within the veterinary curriculum at the expense of hard science and technical competencies, professional skills such as ethical conduct, professional conduct, and communication skills are now considered essential in the creation of successful and employable graduates. Despite the requirement to include professional skills in veterinary curricula, limited communication among colleges and inconsistent documentation of curricular developments have led to a wide range of teaching and assessment methods with no consistent standards existing among colleges. Integration of professional competency teaching into the general curriculum is lauded widely, but barriers such as faculty buy-in have kept many colleges from moving toward a standard in which professional competencies are integrated into the general curriculum. The aim of this article is to provide veterinary educators and curriculum designers with an understanding of the rationale for including professional skills teaching within the curriculum while also presenting currently used, as well as recommended, strategies for effective instruction of professional skills.

A real-time analysis of intraoperative interruptions in relation to use of simple preventive measures including a sign on the door and a checklist-based team brief

This study aimed to evaluate intraoperative interruptions by frequency, type, interference and source, and preventive measures. The interruptions in the operating theatre were evaluated for 52 surgical procedures based on real-time recordings and divided into routine operative procedures (ROP, n = 26, without intervention) and intervened operative procedures (IOP, n = 26, observed after team brief and placement of a warning sign for unnecessary door openings) groups. Intervened operative procedures vs. routine operative procedures was associated with a significantly lower number of interruptions (p = 0.014). Implementation of preventive measures was associated with a significantly lower number of entrances and exits (p = 0.001) and equipment issues (p = 0.003), interruptions that affected the circulating nurse or anaesthesia technician/associate (p = 0.003) and those caused by team members other than assisting surgeon and scrub nurse (p-value ranged from 0.015 to 0.009). Our findings revealed significantly reduced interruptions after a simple preventive measure including team brief and the placement of a warning sign for unnecessary door openings.

The effectiveness of improving healthcare teams' human factor skills using simulation-based training: a systematic review

Background

Simulation-based training used to train healthcare teams’ skills and improve clinical practice has evolved in recent decades. While it is evident that technical skills training is beneficial, the potential of human factor training has not been described to the same extent. Research on human factor training has been limited to marginal and acute care scenarios and often to validate instruments. This systematic review aimed to investigate the effectiveness of simulation-based training in improving in-hospital qualified healthcare teams’ human factor skills.

Method

A review protocol outlining the study was registered in PROSPERO. Using the PRISMA guidelines, the systematic search was conducted on September 28th, 2021, in eight major scientific databases. Three independent reviewers assessed title and abstract screening; full texts were evaluated by one reviewer. Content analysis was used to evaluate the evidence from the included studies.

Results

The search yielded 19,767 studies, of which 72 were included. The included studies were published between 2004 and 2021 and covered research from seven different in-hospital medical specialisms. Studies applied a wide range of assessment tools, which made it challenging to compare the effectiveness of human factor skills training across studies. The content analysis identified evidence for the effectiveness. Four recurring themes were identified: (1) Training human factor skills in qualified healthcare teams; (2) assessment of human factor skills; (3) combined teaching methods, and (4) retention and transfer of human factor skills. Unfortunately, the human factor skills assessments are variable in the literature, affecting the power of the result.

Conclusion

Simulation-based training is a successful learning tool to improve qualified healthcare teams’ human factor skills. Human factor skills are not innate and appear to be trainable similar to technical skills, based on the findings of this review. Moreover, research on retention and transfer is insufficient. Further, research on the retention and transfer of human factor skills from simulation-based training to clinical practice is essential to gain knowledge of the effect on patient safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41077-022-00207-2.

Transfer of Clinical Decision-Making-Related Learning Outcomes Following Simulation-Based Education in Nursing and Medicine: A Scoping Review

PURPOSE

Simulation is often depicted as an effective tool for clinical decision-making education. Yet, there is a paucity of data regarding transfer of learning related to clinical decision-making following simulation-based education. The authors conducted a scoping review to map the literature regarding transfer of clinical decision-making learning outcomes following simulation-based education in nursing or medicine.

METHOD

Based on the Joanna Briggs Institute methodology, the authors searched 5 databases (CINAHL, ERIC, MEDLINE, PsycINFO, and Web of Science) in May 2020 for quantitative studies in which the clinical decision-making performance of nursing and medical students or professionals was assessed following simulation-based education. Data items were extracted and coded. Codes were organized and hierarchized into patterns to describe conceptualizations and conditions of transfer, as well as learning outcomes related to clinical decision-making and assessment methods.

RESULTS

From 5,969 unique records, 61 articles were included. Only 7 studies (11%) assessed transfer to clinical practice. In the remaining 54 studies (89%), transfer was exclusively assessed in simulations that often included one or more variations in simulation features (e.g., scenarios, modalities, duration, and learner roles; 50, 82%). Learners' clinical decision-making, including data gathering, cue recognition, diagnoses, and/or management of clinical issues, was assessed using checklists, rubrics, and/or nontechnical skills ratings.

CONCLUSIONS

Research on simulation-based education has focused disproportionately on the transfer of learning from one simulation to another, and little evidence exists regarding transfer to clinical practice. The heterogeneity in conditions of transfer observed represents a substantial challenge in evaluating the effect of simulation-based education. The findings suggest that 3 dimensions of clinical decision-making performance are amenable to assessment-execution, accuracy, and speed-and that simulation-based learning related to clinical decision-making is predominantly understood as a gain in generalizable skills that can be easily applied from one context to another.

Evaluating Nontechnical Skills in US Emergency Departments Using Simulation: Validating and Contextualizing a UK Assessment Tool

INTRODUCTION

Nontechnical skills (NTS) in medicine are the "cognitive, social, and personal resource skills that complement technical skills contributing to safe and efficient care." We aimed to (1) evaluate the validity and reliability of a 12-element United Kingdom emergency medicine (EM) NTS assessment tool in the context of United States (US) EM practice and (2) identify behaviors unique to US clinical practice.

METHODS

This was a mixed methods study conducted in 2 phases, following Kane's validity framework. The intended use of the NTS tool is to provide formative assessment of US EM physicians (EPs) from a video of simulated clinical encounters. In phase I, a focus group assessed the appropriateness of each aspect of the tool in the context of US EM practice by reviewing and identifying the NTS of an EP in a simulated clinical scenario. In phase II, EPs (N = 208) attending a national EM conference evaluated an EP's behaviors in 1 of 2 video simulations. Reliability in the form of internal consistency was calculated using Cronbach α. All participants suggested exemplar behaviors for the 12 elements in the context of their own clinical practice and generated new assessment elements.

RESULTS

Internal consistency was acceptable (α > 0.7) for all categories, except teamwork and cooperation. Participants proposed 4 novel behavioral elements and suggested US exemplar behaviors for all 12 original elements.

CONCLUSIONS

This tool can be used to assess US EP's NTS for the purpose of formative assessment. Refinement of exemplar behaviors and inclusion of novel US-specific elements may optimize usability.

Teaching and Evaluating Nontechnical Skills for General Surgery

Surgical training programs have long used quantitative measures of knowledge, as well as subjective evaluation of technical skills, to define the competence of trainees. However, a growing body of literature has shown the importance of nontechnical surgical skills as vital components of quality surgical care. Institutions must train nontechnical surgical skills, including leadership, communication, teamwork, situational awareness, and decision making, and incorporate these attributes into their evaluative processes to maximally enhance surgical performance at every career stage.

Validity of scoring systems for the assessment of technical and non-technical skills in ophthalmic surgery-a systematic review

Evaluation and recommendation of the scoring systems for technical skills (TS) and non-technical skills (NTS) assessments in ophthalmic surgery. A literature search was performed between December 2019 and May 2020. Studies describing the development or validation of TS or NTS scoring systems in ophthalmic surgery were included. Only scoring systems for completion by hand were included. The primary outcome was the validity and reliability status for each scoring system. The secondary outcome was recommendation based on modified Oxford Centre for Evidence-Based Medicine guidelines. Nineteen and five scoring systems were identified for TS and NTS respectively. TS scoring systems exist for cataract surgery (including the steps of phacoemulsification and paediatric cataract surgery) ptosis, strabismus, lateral tarsal strip, vitrectomy, and intraocular surgery in general. NTS scoring systems apply to cataract surgery or ophthalmic surgery in general. No single scoring system satisfied all validity and reliability measures. The recommended TS scoring systems are 'International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubrics' (ICO-OSCAR) for phacoemulsification, strabismus and paediatric cataract surgery, and 'Objective Structured Assessment of Cataract Surgical Skill' (OSACSS). Non-Technical Skills for Surgeons (NOTSS), Observational Teamwork Assessment for Surgery (OTAS) and Anaesthetists Non-Technical Skills (ANTS) are recommended for NTS. There is a paucity of NTS scoring systems. Further research is required to validate all scoring systems to consistent standards. Limitations of the assessment tools included infrequent quantification of face and content validity, and inconsistency in terminology and statistical methods between studies.

Gathering Validity Evidence to Adapt the Non-technical Skills for Surgeons (NOTSS) Assessment Tool to the United States Context

BACKGROUND

Nontechnical skills are of increasing focus for safe and effective performance in the operating room. Assessment tools have been developed in Europe, Africa, and Asia but not adapted to the unique aspects of surgical delivery in the United States. Our objective was to use the Non-Technical Skills for Surgeons (NOTSS) assessment tool as a basis to establish consensus on essential nontechnical skills for surgical trainees and practicing surgeons in the U.S surgical context.

STUDY DESIGN

A mixed-methods research design was used in the form of a modified Delphi process to build consensus on essential NOTSS. A panel of surgical experts from hospitals across the U.S used this iterative process in 4 rounds to generate, rate, and classify behaviors. The primary outcome was consensus on behaviors as being essential for surgeons to achieve the best patient outcomes in the operating room, with a median rating of ≥6 on a 7-point scale for inclusion.

RESULTS

A total of 10 surgical experts participated. One hundred and thirty eight behaviors were generated in Round 1, and reduced to 100 behaviors in Rounds 2 and 3 based on application of inclusion criteria. The final skill list consisted of behaviors in Situation Awareness (n = 26), Decision Making (n = 18), Teamwork (n = 25), and Leadership (n = 31). No additional NOTSS categories or elements emerged from the analysis. In Round 4, all 100 behaviors were successfully grouped into 12 nontechnical skills elements. Labels and definitions were reworded to reflect the U.S. context, and an appropriate assessment scale was selected.

CONCLUSIONS

A panel of surgical experts from across the U.S. reached consensus on the essential NOTSS to achieve the best patient outcomes in the operating room. These behaviors form an empirical basis for the first context-specific nontechnical skills assessment and training tool for practicing surgeons in the U.S.

Leadership and surgical training part 1: preparing to lead the way?

Every day surgeons lead teams on the wards, in clinics and operating theatres, but most trainees and some surgeons do not consider themselves as leaders. Leadership skills are increasingly important for surgeons, who need knowledge of organizational structure and policy, management strategy and team dynamics to deliver and improve health care in resource-constrained environments. The Royal Australasian College of Surgeons recognizes leadership as one of 10 core surgical competencies but leadership curricula within surgical training programmes are not well defined. There is limited opportunity for formal leadership training and development prior to becoming a consultant.

Nontechnical skills training in cardiothoracic surgery: A pilot study

OBJECTIVE

The importance of nontechnical skills in surgery is widely recognized. We demonstrate the feasibility of administering and assessing the results of a formal Non-Technical Skills in Surgery (NOTSS) curriculum to cardiothoracic surgery residents.

METHODS

Eight cardiothoracic surgery residents participated in the NOTSS curriculum. They were assessed on their cognitive (situation awareness, decision-making) and social (communication and teamwork, leadership) skills based on simulated vignettes. The residents underwent pretraining NOTSS assessments followed by self-administered confidence ratings regarding the 4 skills. Subsequently, a formal NOTSS lecture was delivered and additional readings from the NOTSS textbook was assigned. A month later, the residents returned for post-training NOTSS assessments and self-administered confidence ratings. Changes across days (or within-day before vs after curriculum) were assessed using Wilcoxon signed rank test.

RESULTS

There was a significant improvement in the overall NOTSS assessment score (P = .01) as well as in the individual categories (situation awareness, P = .02; decision-making, P = .02; communication and teamwork, P = .01; leadership, P = .02). There was also an increase in resident self-perception of improvement on the post-training day (P = .01).

CONCLUSIONS

We have developed a simulation-based NOTSS curriculum in cardiothoracic surgery that can be formally integrated into the current residency education. This pilot study indicates the feasibility of reproducible assessments by course educators and self-assessments by participating residents in nontechnical skills competencies.

Comprehensive Literature Search to Identify Assessment Tools for Operating Room Nontechnical Skills to Determine Common Critical Components

BACKGROUND

Effective use of nontechnical skills (NTS) contributes to the provision of safe, quality care in the fast-paced, dynamic setting of the operating room (OR). Inter-professional education of NTS to OR team members can improve performance. Such training requires the accurate measurement of NTS in order to identify gaps in their utilization by OR teams. Although several instruments for measuring OR NTS exist in the literature, each tool tends to define specific NTS differently.

AIM

We aimed to determine commonalities in defined measurements among existing OR NTS tools.

METHODS

We undertook a comprehensive literature review of assessment tools for OR NTS to determine the critical components common to these instruments. A PubMed search of the literature from May 2009 to May 2019 combined various combinations of keywords and Medical Subject Headings (MeSH) related to the following subjects: teamwork, teams, assessment, debriefing, surgery, operating room, nontechnical, communication. From this start, articles were selected describing specific instruments. Three reviewers then identified the common components measured among these assessment tools. Reviewers collated kin constructs within each instrument using frequency counts of similarly termed and conceptualized components.

RESULTS

The initial PubMed search produced 119 articles of which 24 articles satisfied the inclusion criteria. Within these articles, 10 assessment tools evaluated OR NTS. Kin constructs were grouped into six NTS categories in the following decreasing frequency order: communication, situation awareness, teamwork, leadership, decision making, and task management/decision making (equal).

CONCLUSION

NTS OR assessment tools in the literature have a variety of kin constructs related to the specific measured components within the instruments. Such kin constructs contain thematic cohesion across six primary NTS groupings with some variation in scale and scope. Future plans include using this information to develop an easy-to-use assessment tool to assist with debriefing in the clinical environment.

A Low-Cost Synthetic Abdominal Wall Model ("Raj Model") for the Training of Laparoscopic Port Insertion

OBJECTIVE

To assess the content validity of a low-cost bench-top model ("Raj Model") for the training of laparoscopic port insertion at the Urology Simulation Bootcamp course (USBC).

MATERIALS AND METHODS

A low-cost abdominal wall model of 40 × 40 cm was created to simulate laparoscopic port placement. The model was made using different synthetic materials to represent layers (skin-vinyl sheet, subcutaneous fat-10 mm soft foam, anterior rectus sheath and muscle-floor mat, posterior rectus sheath-masking wall tape, peritoneum-sellotape). Each model was used by up to 3 trainees to practise laparoscopic port placement. The model was assessed for content validity by trainees and experts using a 5-point Likert scale.

RESULT

In total, 88 trainees and 6 experts participated in the study. For all aspects of the synthetic abdominal wall, good (4) or very good (5) scores ranged from 52.7-69.2%, whereas very poor (1) rating ranged from 0 to 4.3%. There was no significant difference in responses for the content validity of the model between trainees and experts. There was a high intraclass correlation amongst responses from trainees (0.89) and experts (0.79). Approximately 76.3% of trainees and experts felt that the model is suitable for training.

CONCLUSION

This is the first validation study of a low-cost abdominal wall model for teaching laparoscopic port placement for trainees. Our study demonstrates that this synthetic model has high content validity and is useful for surgical training.

Development of the HUman Factors in intraoperative Ophthalmic Emergencies Scoring System (HUFOES) for non-technical skills in cataract surgery

BACKGROUND

Nontechnical skills (NTS) are fundamental for successfully managing intraoperative complications. We aimed to develop the HUman Factors in intraoperative Ophthalmic Emergencies Scoring System (HUFOES); an NTS assessment system for posterior capsule rupture (PCR) during cataract surgery.

METHODS

A literature review and a focus group consisting of three cataract surgeons and one NTS researcher elicited the important NTS for the management of intraoperative cataract surgery complications. A novel taxonomy of NTS specific for PCR management was generated. Questionnaires were distributed to ophthalmologists in one UK training region. Delphi methodology was used to develop a final HUFOES draft. One further questionnaire was used to gain feasibility, educational impact and validity data.

RESULTS

All HUFOES components achieved a mean importance rating of >8/10 and achieved high interrater agreement ratings (α = 0.953). Interrater agreement scores for HUFOES categories were: teamwork and communication (α = 0.819), leadership (α = 0.859), decision making (α = 0.753), situational awareness (α = 0.840) and professionalism (α = 0.890). In all, 92.8% (n = 13) rated HUFOES as specific for use, 85.7% (n = 12) agreed it contains appropriate assessment measures, 92.8% (n = 13) agreed that training with HUFOES would enhance preparation for PCR management and 78.6% (n = 11) declared HUFOES as the preferable training system for NTS in intraoperative ophthalmic emergencies when compared with the current gold standard.

CONCLUSIONS

HUFOES has been developed and validated as a tool for the training and assessment of NTS in PCR. An NTS training programme integrated with HUFOES should be considered in order to enhance surgical NTS for managing intraoperative complications, and improve performance and outcomes following PCR.

Educational Interventions to Enhance Situation Awareness: A Systematic Review and Meta-Analysis

STATEMENT

We conducted a systematic review to evaluate the comparative effectiveness of educational interventions on health care professionals' situation awareness (SA). We searched MEDLINE, CINAHL, HW Wilson, ERIC, Scopus, EMBASE, PsycINFO, psycARTICLES, Psychology and Behavioural Science Collection and the Cochrane library. Articles that reported a targeted SA intervention or a broader intervention incorporating SA, and an objective outcome measure of SA were included. Thirty-nine articles were eligible for inclusion, of these 4 reported targeted SA interventions. Simulation-based education (SBE) was the most prevalent educational modality (31 articles). Meta-analysis of trial designs (19 articles) yielded a pooled moderate effect size of 0.61 (95% confidence interval = 0.17 to 1.06, P = 0.007, I = 42%) in favor of SBE as compared with other modalities and a nonsignificant moderate effect in favor of additional nontechnical skills training (effect size = 0.54, 95% confidence interval = 0.18 to 1.26, P = 0.14, I = 63%). Though constrained by the number of articles eligible for inclusion, our results suggest that in comparison with other modalities, SBE yields better SA outcomes.

Simulation-based acquisition of non-technical skills to improve patient safety

Traditional surgical training has focused on the acquisition of technical skills and knowledge with minimal focus on teaching nontechnical skills. Patient safety depends on both technical and nontechnical skills, with a higher rate of non-technical skills failure leading to patient harm. Many surgical training and regulatory bodies have incorporated nontechnical skills in the required competencies of a surgeon, but few have introduced formal training in nontechnical skills. Emerging research shows simulation-based education to be a powerful tool to teach nontechnical skills to individual surgeons and surgeons in training, and to interprofessional surgical teams with subsequent improvement of patient safety outcomes.

The importance of non-technical skills in modern surgical practice

The significance of technical skills and manual dexterity for surgeons is an indisputable fact. However, the systematic study of medical errors has revealed that a significant percentage of these errors are caused by factors related to non-technical skills. The review presented in this article intends to describe and explore the relevance of these non-technical skills, including: situational awareness, decision-making, leadership and communication. In conclusion, the authors propose that adequate importance needs to be given to these aptitudes to provide safe clinical care.

Nontechnical Skills in Surgery: A Systematic Review of Current Training Modalities

BACKGROUND

The complexity of the operating room requires a surgeon to have both technical ability and an array of nontechnical skills. The emphasis on technical skills during surgical training is well established, however it is deficiencies in nontechnical skills that have been identified as the main cause of errors in the operating room.

OBJECTIVE

This systematic review aims to identify current methods used to teach nontechnical skills and how these methods are assessed to determine their validity, evidence, and role in training.

METHODS

MEDLINE and Embase databases were searched for English language articles between 2000 and 2017 for nontechnical surgical skills training. Original research articles were included if they described non-technical surgical skills training modalities and their assessment. Results were assessed for the level of evidence and each modality was awarded a level of recommendation, using a modified educational Oxford Centre for Evidence-Based Medicine classification, as adapted by the European Association of Endoscopic Surgery.

RESULTS

A total of 19 studies were identified pertaining to high fidelity simulation (n = 8), low fidelity simulation (n = 6), didactic teaching (n = 2) and crisis resource management (n = 3). Of the included studies 1 was classified Level 1b, 1 level 2b, 7 level 2b, 2 level 2c, and 8 level 3.

CONCLUSION

With the importance of nontechnical skills being increasingly recognized, it is essential for surgeons to receive adequate training in nontechnical skills. Therefore the most valuable teaching modalities such as high and low fidelity simulation needs to be implemented into surgical training curricula.

Construct and criterion validity testing of the Non-Technical Skills for Surgeons (NOTSS) behaviour assessment tool using videos of simulated operations

Background

Surgeons' non-technical skills are an important part of surgical performance and surgical education. The most widely adopted assessment tool is the Non-Technical Skills for Surgeons (NOTSS) behaviour rating system. Psychometric analysis of this tool to date has focused on inter-rater reliability and feasibility rather than validation.

Methods

NOTSS assessments were collected from two groups of consultant/attending surgeons in the UK and USA, who rated behaviours of the lead surgeon during a video-based simulated crisis scenario after either online or classroom instruction. The process of validation consisted of assessing construct validity, scale reliability and concurrent criterion validity, and undertaking a sensitivity analysis. Central to this was confirmatory factor analysis to evaluate the structure of the NOTSS taxonomy.

Results

Some 255 consultant surgeons participated in the study. The four-category NOTSS model was found to have robust construct validity evidence, and a superior fit compared with alternative models. Logistic regression and sensitivity analysis revealed that, after adjusting for technical skills, for every 1-point increase in NOTSS score of the lead surgeon, the odds of having a higher versus lower patient safety score was 2·29 times. The same pattern of results was obtained for a broad mix of surgical specialties (UK) as well as a single discipline (cardiothoracic, USA).

Conclusion

The NOTSS tool can be applied in research and education settings to measure non-technical skills in a valid and efficient manner.

The impact of fatigue on the non-technical skills performance of critical care air ambulance clinicians

BACKGROUND

The relationship between fatigue-related risk and impaired clinical performance is not entirely clear. Non-technical factors represent an important component of clinical performance and may be sensitive to the effects of fatigue. The hypothesis was that the sum score of overall non-technical performance is degraded by fatigue.

METHODS

Nineteen physicians undertook two different simulated air ambulance missions, once when rested, and once when fatigued (randomised crossover design). Trained assessors blinded to participants' fatigue status performed detailed structured assessments based on expected behaviours in four non-technical skills domains: teamwork, situational awareness, task management, and decision making. Participants also provided self-ratings of their performance. The primary endpoint was the sum score of overall non-technical performance.

RESULTS

The main finding, the overall non-technical skills performance rating of the clinicians, was better in rested than fatigued states (mean difference with 95% CI, 2.8 [2.2-3.4]). The findings remained consistent across individual non-technical skills domains; also when controlling for an order effect and examining the impact of a number of possible covariates. There was no difference in self-ratings of clinical performance between rested and fatigued states.

CONCLUSION

Non-technical performance of critical care air transfer clinicians is degraded when they are fatigued. Fatigued clinicians may fail to recognise the degree to which their performance is compromised. These findings represent risk to clinical care quality and patient safety in the dynamic and isolated environment of air ambulance transfer.

Diagnostic radiographers working in the operating theatre: An action research project

INTRODUCTION

Failures in interprofessional communication are well-documented and are an established cause of medical error and negative health outcomes. Socio-historical issues like imbalances in power and status are particularly prevalent in the operating theatre environment, adding complications to interprofessional working. Simulation, used in healthcare education, may impact positively on interprofessional working.

METHODS

The aim of this action research study was to develop, pilot and run a simulation experience for Diagnostic Radiography (DRAD) students. Action research was used to structure this study. The first phase of the action research was to look at the problem; this was undertaken using critical incident technique. Findings from the critical incident technique influenced the simulation event. A focus group was held immediately after the event for reflection. A second simulation using a cohort of 48 students and a reflection after a period of three months formed the second round of the project. The simulation took place in a hi-fidelity simulated operating theatre. Thematic content analysis was undertaken of the focus group, data from the critical incident technique, and the reflections.

RESULTS

The findings are discussed under the themes; identification, clarity, preparation, and the expert. Identification and lack of clarity in communication were seen as an important issue in the operating theatre. Lack of preparation of the working environment was also highlighted. Lack of confidence in the operating theatre inhibits interprofessional working.

CONCLUSION

Simulation can help prepare students for working in the operating theatre. Realism is important as is scheduling the event to ensure maximum benefit.

Training Tools for Nontechnical Skills for Surgeons-A Systematic Review

OBJECTIVE

Development of nontechnical skills for surgeons has been recognized as an important factor in surgical care. Training tools for this specific domain are being created and validated to maximize the surgeon's nontechnical ability. This systematic review aims to outline, address, and recommend these training tools.

DESIGN

A full and comprehensive literature search, using a systematic format, was performed on ScienceDirect and PubMed, with data extraction occurring in line with specified inclusion criteria.

SETTING

Systematic review was performed fully at King's College London.

RESULTS

A total of 84 heterogeneous articles were used in this review. Further, 23 training tools including scoring systems, training programs, and mixtures of the two for a range of specialities were identified in the literature. Most can be applied to surgery overall, although some tools target specific specialities (such as neurosurgery). Interrater reliability, construct, content, and face validation statuses were variable according to the specific tool in question.

CONCLUSIONS

Study results pertaining to nontechnical skill training tools have thus far been universally positive, but further studies are required for those more recently developed and less extensively used tools. Recommendations can be made for individual training tools based on their level of validation and for their target audience. Based on the number of studies performed and their status of validity, NOTSS and Oxford NOTECHS II can be considered the gold standard for individual- and team-based nontechnical skills training, respectively, especially when used in conjunction with a training program.

Non-technical skills of surgeons and anaesthetists in simulated operating theatre crises

Background

Deficiencies in non-technical skills (NTS) have been increasingly implicated in avoidable operating theatre errors. Accordingly, this study sought to characterize the impact of surgeon and anaesthetist non-technical skills on time to crisis resolution in a simulated operating theatre.

Methods

Non-technical skills were assessed during 26 simulated crises (haemorrhage and airway emergency) performed by surgical teams. Teams consisted of surgeons, anaesthetists and nurses. Behaviour was assessed by four trained raters using the Non-Technical Skills for Surgeons (NOTSS) and Anaesthetists' Non-Technical Skills (ANTS) rating scales before and during the crisis phase of each scenario. The primary endpoint was time to crisis resolution; secondary endpoints included NTS scores before and during the crisis. A cross-classified linear mixed-effects model was used for the final analysis.

Results

Thirteen different surgical teams were assessed. Higher NTS ratings resulted in significantly faster crisis resolution. For anaesthetists, every 1-point increase in ANTS score was associated with a decrease of 53·50 (95 per cent c.i. 31·13 to 75·87) s in time to crisis resolution (P &lt; 0·001). Similarly, for surgeons, every 1-point increase in NOTSS score was associated with a decrease of 64·81 (26·01 to 103·60) s in time to crisis resolution in the haemorrhage scenario (P = 0·001); however, this did not apply to the difficult airway scenario. Non-technical skills scores were lower during the crisis phase of the scenarios than those measured before the crisis for both surgeons and anaesthetists.

Conclusion

A higher level of NTS of surgeons and anaesthetists led to quicker crisis resolution in a simulated operating theatre environment.

Non-technical skills of surgical trainees and experienced surgeons

Background

In addition to technical expertise, surgical competence requires effective non-technical skills to ensure patient safety and maintenance of standards. Recently the Royal Australasian College of Surgeons implemented a new Surgical Education and Training (SET) curriculum that incorporated non-technical skills considered essential for a competent surgeon. This study sought to compare the non-technical skills of experienced surgeons who completed their training before the introduction of SET with the non-technical skills of more recent trainees.

Methods

Surgical trainees and experienced surgeons undertook a simulated scenario designed to challenge their non-technical skills. Scenarios were video recorded and participants were assessed using the Non-Technical Skills for Surgeons (NOTSS) scoring system. Participants were divided into subgroups according to years of experience and their NOTSS scores were compared.

Results

For most NOTSS elements, mean scores increased initially, peaking around the time of Fellowship, before decreasing roughly linearly over time. There was a significant downward trend in score with increasing years since being awarded Fellowship for six of the 12 NOTSS elements: considering options (score −0·015 units per year), implementing and reviewing decisions (−0·020 per year), establishing a shared understanding (−0·014 per year), setting and maintaining standards (−0·024 per year), supporting others (−0·031 per year) and coping with pressure (−0·015 per year).

Conclusion

The drop in NOTSS score was unexpected and highlights that even experienced surgeons are not immune to deficiencies in non-technical skills. Consideration should be given to continuing professional development programmes focusing on non-technical skills, regardless of the level of professional experience.

"Hand-it-on": an innovative simulation on the relation of non-technical skills to healthcare

Non-technical skills (NTS) are an integral part of the abilities healthcare professionals need to optimally care for patients. Integrating NTS into the already complex tasks of healthcare can be a challenge for clinicians. Integrating NTS into simulation-based training increases the demands for simulation instructors with regard to scenario design, conduct, and debriefing. We introduce a simulation game, Hand-it-on, that can trigger discussions on how NTS can influence work processes. Hand-it-on aims to help clinicians and simulation instructors alike to improve their understanding of NTS concepts and where they can apply them in their work. It complements existing approaches to teaching NTS by limiting the complexity of the game and by removing medical content, allowing learners to concentrate on NTS. Hand-it-on is relevant for groups and teams working across the range of different healthcare contexts. During Hand-it-on, participants stand in a circle and hand on everyday objects to each other according to simple rules, resulting in many events that can be debriefed in relation to safe patient care. We describe both the conduct of Hand-it-on and ideas on how to debrief participants. We provide variations that can be used in different contexts, focusing the exercise on different learning goals. We also offer the theoretical rationale for using an out-of-context simulation in combination with other forms of teaching. Although we did not evaluate Hand-it-on formally, oral feedback from participants and the replication of Hand-it-on by many simulation teams support its value.

Effects of Technological Advances in Surgical Education on Quantitative Outcomes From Residency Programs

OBJECTIVES

The purpose of this article is to review the literature on current technology for surgical education and to evaluate the effect of technological advances on the Accreditation Council of Graduate Medical Education (ACGME) Core Competencies, American Board of Surgery In-Training Examination (ABSITE) scores, and American Board of Surgery (ABS) certification.

DESIGN

A literature search was obtained from MEDLINE via PubMed.gov, ScienceDirect.com, and Google Scholar on all peer-reviewed studies published since 2003 using the following search queries: technology for surgical education, simulation-based surgical training, simulation-based nontechnical skills (NTS) training, ACGME Core Competencies, ABSITE scores, and ABS pass rate.

RESULTS

Our initial search list included the following: 648 on technology for surgical education, 413 on simulation-based surgical training, 51 on simulation-based NTS training, 78 on ABSITE scores, and 33 on ABS pass rate. Further, 42 articles on technological advances for surgical education met inclusion criteria based on their effect on ACGME Core Competencies, ABSITE scores, and ABS certification. Systematic review showed that 33 of 42 and 26 of 42 publications on technological advances for surgical education showed objective improvements regarding patient care and medical knowledge, respectively, whereas only 2 of 42 publications showed improved ABSITE scores, but none showed improved ABS pass rates. Improvements in the other ACGME core competencies were documented in 14 studies, 9 of which were on simulation-based NTS training.

CONCLUSIONS

Most of the studies on technological advances for surgical education have shown a positive effect on patient care and medical knowledge. However, the effect of simulation-based surgical training and simulation-based NTS training on ABSITE scores and ABS certification has not been assessed. Studies on technological advances in surgical education and simulation-based NTS training showing quantitative evidence that surgery residency program objectives are achieved are still needed.

Non-technical skills evaluation in the critical care air ambulance environment: introduction of an adapted rating instrument--an observational study

BACKGROUND

In the isolated and dynamic health-care setting of critical care air ambulance transport, the quality of clinical care is strongly influenced by non-technical skills such as anticipating, recognising and understanding, decision making, and teamwork. However there are no published reports identifying or applying a non-technical skills framework specific to an intensive care air ambulance setting. The objective of this study was to adapt and evaluate a non-technical skills rating framework for the air ambulance clinical environment.

METHODS

In the first phase of the project the anaesthetists' non-technical skills (ANTS) framework was adapted to the air ambulance setting, using data collected directly from clinician groups, published literature, and field observation. In the second phase experienced and inexperienced inter-hospital transport clinicians completed a simulated critical care air transport scenario, and their non-technical skills performance was independently rated by two blinded assessors. Observed and self-rated general clinical performance ratings were also collected. Rank-based statistical tests were used to examine differences in the performance of experienced and inexperienced clinicians, and relationships between different assessment approaches and assessors.

RESULTS

The framework developed during phase one was referred to as an aeromedical non-technical skills framework, or AeroNOTS. During phase two 16 physicians from speciality training programmes in intensive care, emergency medicine and anaesthesia took part in the clinical simulation study. Clinicians with inter-hospital transport experience performed more highly than those without experience, according to both AeroNOTS non-technical skills ratings (p = 0.001) and general performance ratings (p = 0.003). Self-ratings did not distinguish experienced from inexperienced transport clinicians (p = 0.32) and were not strongly associated with either observed general performance (r(s) = 0.4, p = 0.11) or observed non-technical skills performance (r(s) = 0.4, p = 0.1).

DISCUSSION

This study describes a framework which characterises the non-technical skills required by critical care air ambulance clinicians, and distinguishes higher and lower levels of performance.

CONCLUSION

The AeroNOTS framework could be used to facilitate education and training in non-technical skills for air ambulance clinicians, and further evaluation of this rating system is merited.