Advanced clinicians' experience of participation in an escape room scenario designed to consolidate crisis resource management principles: An exploratory pilot study

BACKGROUND

Intensive care outreach nurses are required to work as part of an ad hoc team to review and manage patients who are deteriorating outside of critical care environments. Nontechnical skills, such as those encompassed by crisis resource management principles, are essential when working in these situations. Used commercially for entertainment, escape rooms have recently been utilised by clinical educators to teach both technical and nontechnical skills.

OBJECTIVE

This exploratory study evaluates how advanced clinicians, intensive care outreach nurses, experience an escape room scenario designed to consolidate crisis resource management (CRM) principles.

METHODS

Three escape room sessions were conducted in a 1038-bed metropolitan tertiary referral hospital. A purposive sample of 12 intensive care outreach nurses were invited to participate. The participant's experience of the escape room scenario was determined by their responses to a post-escape room survey and focus group discussion. Transcripts of the audio recordings from focus group discussions were analysed using an inductive coding approach.

RESULTS

Two primary categories emerged from analysis of the focus group discussions: (i) the clinicians' experiences of the escape room and (ii) CRM principles. The first category included descriptions of emotions, including confusion, frustration, and a dislike for puzzles. The second category included both the participants understanding of the CRM principles, and how the principles influence the work within the escape room.

CONCLUSIONS

Escape rooms have shown promise as novel educational environments, which challenge participants. Despite initial negative descriptions of the escape room, focus group discussions demonstrated that the participants were able to recognise the impact of CRM principles and acknowledge how these affect their clinical work in an ad hoc team.

Teaching nontechnical skills in the undergraduate education of health care professionals: a nationwide cross-sectional study in Hungary

BACKGROUND

The aim of our cross-sectional study was to evaluate the current situation and curriculum of nontechnical skills (NTS) training in the undergraduate education of health care professionals in Hungary.

METHODS

All institutes with relevant NTS training in Hungarian faculties of medicine and faculties of health sciences were asked to fill out a 19-item questionnaire. Descriptive statistics were performed, and the characteristics of NTS teaching and non-NTS teaching institutes were compared. The independent predictors of teaching NTS in a particular institute were identified with multiple logistic regression.

RESULTS

Seventy-seven institutes responded (52% response rate), of which 66% trained NTS. The most frequent method of NTS training is talking about them during a practice or lecture, and less than half of NTS respondents use simulation. The most frequent cause of not teaching NTS is a lack of human or technical resources. The type of faculty (p = 0.025), academic year (p = 0.001), field of medicine (p = 0.025), and importance of teamwork (p = 0.021) differed between NTS and noNTS institutes. Teaching students in academic year two represented the only independent predictor of NTS education (p = 0.012).

CONCLUSIONS

Our findings show that the undergraduate curriculum of Hungarian universities includes some type of NTS education; however, this education requires further development.

Nontechnical Skills for Intraoperative Team Members

Nontechnical skills, defined as the set of cognitive and social skills used by individuals and teams to reduce error and improve performance in complex systems, have become increasingly recognized as a key contributor to patient safety. Efforts to characterize, quantify, and teach nontechnical skills in the context of perioperative care continue to evolve. This review article summarizes the essential behaviors for safety, described in taxonomies for nontechnical skills assessments developed for intraoperative clinical team members (eg, surgeons, anesthesiologists, scrub practitioners, perfusionists). Furthermore, the authors describe emerging methods to advance understanding of the impact of nontechnical skills on perioperative outcomes.

Gaps in plastic surgery training: A comparative literature review of assessment tools in plastic surgery and general surgery

Assessment tools for grading technical and nontechnical skills, such as operative technique and professionalism, are well established in general surgery. Less is known regarding the application of these tools in plastic surgery training. This study is a comparative review of the most prevalent assessment tools and rubrics utilized in general and plastic surgery. Two parallel systematic reviews of the literature utilizing PubMed and Cochrane were conducted for articles published between 1990 and 2022. Searches used Boolean operators specific to assessment tools in general and plastic surgery. Fourteen studies met the inclusion criteria for general surgery assessment tools, and 21 studies were included for plastic surgery assessment tools. Seven studies (50%) evaluated technical skills in general surgery, whereas 15 studies (71%) assessed technical skills in plastic surgery with commonality found in the evaluation of principles, such as tissue and instrument handling and operative flow. Task-specific evaluation tools were described for both general and plastic surgeries. Five studies evaluated nontechnical skills, such as communication and leadership in general surgery, whereas no plastic surgery studies solely examined nontechnical assessment tools. Our literature review demonstrates that standardized skill assessments in plastic surgery are lacking compared with those available in general surgery. Plastic surgery programs should consider implementing competency-based assessment tools in surgical coaching and training for technical and nontechnical skills. More research is necessary in plastic surgery to optimize the evaluation of nontechnical skills.

The making of a (new) surgeon: Opportunities for repeated messaging on NOTSS in the Canadian medical system

Proficiency in nontechnical skills (NTS) contributes to reduction in critical safety incidents and improvement in patient safety outcomes. Despite evidence demonstrating the importance of NTS in patient safety, there remains limited NTS specific curricula and formal teaching in Canadian surgical programs. We propose a three-stage longitudinal approach to education surrounding NTS using the Nontechnical skills for surgeons (NOTSS) framework.

Observation of behavioural skills by medical simulation facilitators: a cross-sectional analysis of self-reported importance, difficulties, observation strategies and expertise development

BACKGROUND

The association between team performance and patient care was an immense boost for team-based education in health care. Behavioural skills are an important focus in these sessions, often provided via a mannikin-based immersive simulation experience in a (near) authentic setting. Observation of these skills by the facilitator(s) is paramount for facilitated feedback with the team. Despite the acknowledgement that trained facilitators are important for optimal learning, insight into this observation process by facilitators is limited.

OBJECTIVES

What are the self-reported current practices and difficulties regarding the observation of behavioural skills amongst facilitators during team training and how have they been trained to observe behavioural skills?

METHODS

This cross-sectional study used a pilot-tested, content-validated, multi-linguistic online survey within Europe, distributed through a non-discriminative snowball sampling method. Inclusion was limited to facilitators observing behavioural skills within a medical team setting.

RESULTS

A total of 175 persons filled in the questionnaire. All aspects of behavioural skill were perceived as very important to observe. The self-perceived difficulty of the behavioural skill aspects ranged from slightly to moderately difficult. Qualitative analysis revealed three major themes elaborating on this perceived difficulty: (1) not everything can be observed, (2) not everything is observed and (3) interpretation of observed behavioural skills is difficult. Additionally, the number of team members health care facilitators have to observe, outnumbers their self-reported maximum. Strategies and tools used to facilitate their observation were a blank notepad, co-observers and predefined learning goals. The majority of facilitators acquired observational skills through self-study and personal experience and/or observing peers. Co-observation with either peers or experts was regarded as most learn some for their expertise development. Overall, participants perceived themselves as moderately competent in the observation of behavioural skills during team training.

CONCLUSIONS

Observation of behavioural skills by facilitators in health care remains a complex and challenging task. Facilitators' limitations with respect to attention, focus and (in)ability to perform concomitant tasks, need to be acknowledged. Although strategies and tools can help to facilitate the observation process, they all have their limitations and are used in different ways.

Collecting evidence of validity for an assessment tool for Norwegian medical students' non-technical skills (NorMS-NTS): usability and reliability when used by novice raters

BACKGROUND

The NorMS-NTS tool is an assessment tool for assessing Norwegian medical students' non-technical skills (NTS). The NorMS-NTS was designed to provide student feedback, training evaluations, and skill-level comparisons among students at different study sites. Rather than requiring extensive rater training, the tool should capably suit the needs of busy doctors as near-peer educators. The aim of this study was to examine the usability and preliminary assess validity of the NorMS-NTS tool when used by novice raters.

METHODS

This study focused on the usability of the assessment tool and its internal structure. Three raters used the NorMS-NTS tool to individually rate the team leader, a medical student, in 20 video-recorded multi-professional simulation-based team trainings. Based on these ratings, we examined the tools' internal structure by calculating the intraclass correlation coefficient (ICC) (version 3.1) interrater reliability, internal consistency, and observability. After the rating process was completed, the raters answered a questionnaire about the tool's usability.

RESULTS

The ICC agreement and the sum of the overall global scores for all raters were fair: ICC (3,1) = 0.53. The correlation coefficients for the pooled raters were in the range of 0.77-0.91. Cronbach's alpha for elements, categories and global score were mostly above 0.90. The observability was high (95%-100%). All the raters found the tool easy to use, none of the elements were redundant, and the written instructions were helpful. The raters also found the tool easier to use once they had acclimated to it. All the raters stated that they could use the tool for both training and teaching.

CONCLUSIONS

The observed ICC agreement was 0.08 below the suggested ICC level for formative assessment (above 0.60). However, we know that the suggestion is based on the average ICC, which is always higher than a single-measure ICC. There are currently no suggested levels for single-measure ICC, but other validated NTS tools have single-measure ICC in the same range. We consider NorMS-NTS as a usable tool for formative assessment of Norwegian medical students' non-technical skills during multi-professional team training by raters who are new to the tool. It is necessary to further examine validity and the consequences of the tool to fully validate it for formative assessments.

Assessing North Texas Regional Trauma Handoffs: A Multicenter Mixed-Methods Needs Assessment

INTRODUCTION

Trauma video review of Emergency Medical Services (EMS) handoffs demonstrates frequent problems including interruptions and incomplete information transfer. This study aimed to perform a regional needs assessment of handoff perceptions and expectations to guide future standardization efforts.

METHODS

A multidisciplinary team of trauma providers through consensus building created an anonymous survey which was then distributed through the North Central Texas Trauma Regional Advisory Council and four regional level-1 trauma institutions. Qualitative data underwent content analysis; quantitative data are presented with descriptive statistics.

RESULTS

Survey responses (n = 249) were submitted by trauma nurses (38%), EMS (24%), emergency physicians (14%), and trauma physicians (13%). Median overall handoff quality was rated well (4, scale 1-5) despite some variability between hospitals (3, scale 1-5). The top five most important handoff details were the same for both stable and unstable patients: primary mechanism, blood pressure, heart rate, Glasgow Coma Scale, and location of injuries. While providers felt neutral about the data order, the vast majority supported immediate bed transfer and primary survey in unstable patients. The majority of receiving providers report interrupting handoff at least once (78%); and 66% of EMS clinicians found interruptions disruptive. Content analysis revealed top priority categories for improvement: environment, communication, information relayed, team dynamics, and flow of care.

CONCLUSION

Although our data demonstrated satisfaction and concordance with respect to the EMS handoff, 84% of EMS clinicians reported some to high amounts of variability across institutions. Gaps in the development of standardized handoffs identified include exposure, education, and enforcement of these protocols.

Effectiveness of nontechnical skills educational interventions in the context of emergencies: A systematic review and meta-analysis

INTRODUCTION

In recent years, the importance of training healthcare professionals in nontechnical skills using effective methodologies has been increasingly recognised as a means of preventing clinical errors in the practice of health care. The aim of this study was to evaluate the effectiveness of educational interventions on nontechnical skills in the emergency medical services and/or critical care unit settings.

METHODS

A systematic search was carried out in the PubMed, SCOPUS, CINAHL, and Web of Science databases according to predetermined inclusion and exclusion criteria. After the initial search, 7952 records were selected after duplicates removed. Finally, a selection of 38 studies was included for quantitative analysis. Separate meta-analyses of standardised mean changes were carried out for each outcome measure assuming a random-effects model. Cochran's Q-statistic and I2 index were applied to verify study heterogeneity. Weighted analyses of variance and meta-regressions were conducted to test the influence of potential moderators and funnel plots using Duval and Tweedie's trim-and-fill method, and Egger's regression test were used to examine publication bias.

RESULTS

All the variables analysed had a significant effect size, with the exception of situational awareness (d+ = -0.448; 95% confidence interval [CI] = -1.034, 0.139). The highest mean effect size was found for knowledge (d+ = -0.925; 95% CI = -1.177, -0.673), followed by the mean effect sizes for global nontechnical skills (d+ = -0.642; 95% CI = -0.849, -0.434), team nontechnical skills (d+ = -0.606; 95% CI = -0.949, -0.262), and leadership nontechnical skills (d+ = -0.571; 95% CI = -0.877, -0.264). Similar mean effect sizes were found for attitude (d+ = -0.406; 95% CI = -0.769, -0.044), self-efficacy (d+ = -0.469; 95% CI = -0.874, -0.064), and communication nontechnical skills (d+ = -0.458; 95% CI = -0.818, -0.099). Large heterogeneity among the standardised mean changes was found in the meta-analyses (I2 > 75% and p < .001), except for self-efficacy where I2 = 58.17%, and there was a nonstatistical result for Cochran's Q. This great variability is also reflected in the forest plots.

DISCUSSION

The use of simulation interventions to train emergency and critical care healthcare professionals in nontechnical skills significantly improves levels of knowledge, attitude, self-efficacy, and nontechnical skills performance.

Peer Feedback: Recommendations for Behavior Analysts' Training and Supervision

The increase in demand for behavior analysts in recent years has also increased the importance of effective supervision practices in the field of behavior analysis. A critical supervisory skill is performance feedback, which entails proficiency with two distinct, yet inseparable repertoires of technical and nontechnical skills. Supervisors report never receiving explicit training in feedback (Sellers et al., 2019) and graduate training programs provide little to no training in nontechnical skills (LeBlanc, Taylor et al., 2020b; Pastrana et al., 2018). As with any skill, to develop proficiency with feedback delivery and reception, trainees may require ample practice opportunities. One mechanism to provide trainees routine practice opportunities is to use peers as behavior change agents and peer feedback as an instructional method. The utility of peer feedback has been recognized in the organizational behavior management (OBM) literature (e.g., behavior-based safety interventions; Lebbon et al., 2012; Wirth & Sigurdsson, 2008), and has been used successfully in medical student training and evaluation for several decades. In the context of behavior analytic training and supervision peer feedback has yet to be established as a training method. Similarities in the behavioral and medical fields (e.g., significance of professional and interpersonal skills for successful therapeutic relationships) make the medical field a good model from which behavior analysts can learn. Using peer feedback in training and supervision for behavior analysts may provide trainees with similar benefits to those reported in medical student training literature.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-022-00761-1.

Virtual reality environments to train soft skills in medical and nursing education: a technical feasibility study between France and Japan

PURPOSE

To meet the urgent and massive training needs of healthcare professionals, the use of digital technologies is proving increasingly relevant, and the rise of digital training platforms shows their usefulness and possibilities. However, despite the impact of these platforms on the medical skills learning, cultural differences are rarely factored in the implementation of these training environments.

METHODS

By using the Scrub Nurse Non-Technical Skills Training System (SunSet), we developed a methodology enabling the adaptation of a virtual reality-based environment and scenarios from French to Japanese cultural and medical practices. We then conducted a technical feasibility study between France and Japan to assess virtual reality simulations acceptance among scrub nurses.

RESULTS

Results in term of acceptance do not reveal major disparity between both populations, and the only emerging significant difference between both groups is on the Behavioral Intention, which is significantly higher for the French scrub nurses. In both cases, participants had a positive outlook.

CONCLUSION

The findings suggest that the methodology we have implemented can be further used in the context of cultural adaptation of non-technical skills learning scenarios in virtual environments for the training and assessment of health care personnel.

Closed loop communication in the trauma bay: identifying opportunities for team performance improvement through a video review analysis

Objectives

Communication among trauma team members in the trauma bay is vulnerable to errors, which may impact patient outcomes. We used the previously validated trauma-non-technical skills (T-NOTECHS) tool to identify communication gaps during patient management in the trauma bay and to inform development strategies to improve team performance.

Methods

Two reviewers independently assessed non-technical skills of team members through video footage at Sunnybrook Health Sciences Centre. Team performance was measured using T-NOTECHS across five domains using a five-point Likert scale (lower score indicating worse performance): (1) leadership; (2) cooperation and resource management; (3) communication and interaction; (4) assessment and decision making; (5) situation awareness/coping with stress. Secondary outcomes assessed the number of callouts, closed loop communications and parallel conversations.

Results

The study included 55 trauma activations. Injury severity score (ISS) was used as a measure of trauma severity. A case with an ISS score ≥ 16 was considered severe. ISS was ≥ 16 in 37% of cases. Communication and interaction scored significantly lower compared to all other domains (p < 0.0001). There were significantly more callouts and completed closed loop communications in more severe cases compared to less severe cases (p = 0.017 for both). Incomplete closed loop communications and parallel conversations were identified, irrespective of case severity.

Conclusion

A lower communication score was identified using T-NOTECHS, attributed to incomplete closed loop communications and parallel conversations. Through video review of trauma team activations, opportunities for improvement in communication can be identified by the T-NOTECHS tool, as well as specifically identifying callouts and closed loop communication. This process may be useful for trauma programs as part of a quality improvement program on communication skills and team performance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43678-022-00295-z.

Anatomy Scholars Program for Medical Students Entering a Surgical Residency

A near-peer teaching experience for upper-level medical students could help prepare them for surgical residency by providing specific education opportunities and exposure to the field of surgery. Five medical students were selected to be near-peer teachers (NPTs) in gross anatomy, and then they reflected on their experiences. The NPTs spent the majority of effort in a teaching role, and reported improved NTS, anatomy knowledge, and dissection skills. MS1s and faculty also reported on the value of the ASP. Further development and evaluation of the ASP may be an excellent opportunity for future surgeons.

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.

Supporting laparoscopic general surgery training with digital technology: The United Kingdom and Ireland paradigm

Surgical training in the UK and Ireland has faced challenges following the implementation of the European Working Time Directive and postgraduate training reform. The health services are undergoing a digital transformation; digital technology is remodelling the delivery of surgical care and surgical training. This review aims to critically evaluate key issues in laparoscopic general surgical training and the digital technology such as virtual and augmented reality, telementoring and automated workflow analysis and surgical skills assessment. We include pre-clinical, proof of concept research and commercial systems that are being developed to provide solutions. Digital surgical technology is evolving through interdisciplinary collaboration to provide widespread access to high-quality laparoscopic general surgery training and assessment. In the future this could lead to integrated, context-aware systems that support surgical teams in providing safer surgical care.

Operating room team training using simulation: Hope or hype?

BACKGROUND

This study sought to determine the long-term impact of multidisciplinary simulated operating room (OR) team training.

METHOD

Two-wave survey study (immediate post-training survey 2010-2017, follow-up 2018). Differences across time, specialty, and experience with adverse events were assessed using chi-square and t -tests.

RESULTS

Immediately after training, more than 90% of respondents found simulation scenarios realistic and reported team training would provide safer patient care. However, follow-up participants reported less enthusiasm toward training, with 58% stating they would like to take similar training again. A majority of participants (77%) experienced adverse events after training; those reporting adverse events reported more positive long-term evaluations.

CONCLUSIONS

Simulated OR team training is initially highly valued by participants and is perceived as contributing to patient safety. Diminution of participant enthusiasm over time suggests that repeat training requirements be reconsidered, and less costly, alternative methods (such as asynchronous learning or virtual reality) should be explored.

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.

The Trainee's Role in Patient Safety: Training Residents and Medical Students in Surgical Patient Safety

"The focus on patient safety offers a new framework not only for delivering health care but also for training physicians. Medical school and surgical graduate medical education must transition to a more holistic approach by teaching technical and nontechnical skills. Formalized safety curricula can be developed by adopting recommended guidelines and content from national and international organizations, existing validated practices of training programs, frequent simulation exercises, and objective evaluation tools."

Teamwork and Surgical Team-Based Training

Effective teamwork, both in and out of the operating room, is an essential component of safe and efficient surgical performance. There are multiple available assessment tools for evaluating teamwork and important contributors to teamwork such as safety culture and nontechnical skills. Multiple types of interventions exist to improve and train providers on teamwork, and many have been demonstrated to improve not only teamwork but also patient outcomes. Teamwork strategies can be adapted to different contexts, based on provider needs and resources.

A Prospective, Observational, Multicentre Study Concerning Nontechnical Skills in Robot-assisted Radical Cystectomy Versus Open Radical Cystectomy

Introduction and hypotheses

valuation of surgical skills, both technical and nontechnical, is possible through observations and video analysis. Besides technical failures, adverse outcomes in surgery can also be related to hampered communication, moderate teamwork, lack of leadership, and loss of situational awareness. Even though some surgeons are convinced about nontechnical skills being an important part of their professionalisation, there is paucity of data about a possible relationship between nontechnical skills and surgical outcome. In robot-assisted surgery, the surgeon sits behind the console and is at a remote position from the surgical field and team, making communication more important than in open surgery and conventional laparoscopy. A lack of structured research makes it difficult to assess the value of the different analysis methods for nontechnical skills, particularly in robot-assisted surgery. Our hypothesis includes the following: (1) introduction of robot-assisted surgery leads to an initial decay in nontechnical skills behaviour during the learning curve of the team, (2) nontechnical skills behaviour is more explicitly expressed in experienced robot-assisted surgery teams than in experienced open surgery teams, and (3) introduction of robot-assisted surgery leads to the development of different forms of nontechnical skills behaviour compared with open surgery.

Design

This study is a prospective, observational, multicentre, nonrandomised, case-control study including bladder cancer patients undergoing either an open radical cystectomy or a robot-assisted radical cystectomy at the Catharina Hospital Eindhoven, the Netherlands, or at the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital Amsterdam. All patients are eligible for inclusion; there are no exclusion criteria. The Catharina Hospital Eindhoven, the Netherlands, performs on average 35 radical cystectomies a year. The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital Amsterdam, performs on average 100 radical cystectomies a year.

Protocol overview

The choice of treatment is at the discretion of the patient and the surgeon. Patient results will be obtained prospectively. Pathology results as well as complications occurring within 90 d following surgery will be registered. Surgical complications will be registered according to the Clavien-Dindo system.

Measurements

Nontechnical skills will be observed using five different methods: (1) NOTSS: Nontechnical Skills for Surgeons; (2) Oxford NOTECHS II: a modified theatre team nontechnical skills scoring system; (3) OTAS: Observational Teamwork Assessment for Surgery; (4) Interpersonal and Cognitive Assessment for Robotic Surgery (ICARS): evaluation of nontechnical skills in robotic surgery; and (5) analysis of human factors. Technical skills in robot-assisted radical cystectomy will be analysed using two different methods: (1) GEARS: Global Evaluative Assessment of Robotic Skill and (2) GERT: Generic Error Rating Tool.

Safety criteria and reporting

Formal ethical approval has been provided by Medical research Ethics Committees United (MEC-U), The Netherlands (reference number W19.048). We hope to present the results of this study to the scientific community at conferences and in peer-reviewed journals.

Statistical analysis

Frequency statistics will be calculated for patient demographical data, and a Shapiro-Wilk test with p > 0.05 will be used to define normal distribution. Univariate analysis will be conducted to test for statistically significant differences in observation scores between open radical cystectomy and robot-assisted radical cystectomy cohorts across all variables, using independent sample t tests and Mann-Whitney U testing, as appropriate. A variable-selection strategy will be used to create multivariate models. Binary logistic regression will be conducted to calculate odds ratios and 95% confidence intervals for significant predictors on univariate analysis and clinically relevant covariates. Statistical significance is set at p < 0.05 based on a two-tailed comparison.

Summary

This study uses a structured approach to the analysis of nontechnical skills using extracorporeal videos of both open radical cystectomy and robot-assisted radical cystectomy surgeries, in order to obtain detailed data on nontechnical skills during open and minimally invasive surgeries. The results of this study could possibly be used to develop team-training programmes, specifically for the introduction of the surgical robot in relation to changes in nontechnical skills. Additional analysis of technical skills using the intracorporeal footage of the surgical robot will be used to elucidate the role of surgical skills and surgical events in nontechnical skills.

Standardising communication to improve in-hospital cardiopulmonary resuscitation

AIM

Recommendations for standardised communication to reduce chest compression (CC) pauses are lacking. We aimed to achieve consensus and evaluate feasibility and efficacy using standardised communication during cardiopulmonary resuscitation (CPR) events.

METHODS

Modified Delphi consensus process to design standardised communication elements. Feasibility was pilot tested in 16 simulated CPR scenarios (8 scenarios with physician team leaders and 8 with chest compressors) randomized (1:1) to standardised [INTERVENTION] vs. closed-loop communication [CONTROL]. Adherence and efficacy (duration of CC pauses for defibrillation, intubation, rhythm check) was assessed by audiovisual recording. Mental demand and frustration were assessed by NASA task load index subscales.

RESULTS

Consensus elements for standardised communication included: 1) team preparation 15-30 s before CC interruption, 2) pre-interruption countdown synchronized with last 5 CCs, 3) specific action words for defibrillation, intubation, and interrupting/resuming CCs. Median (Q1,Q3) adherence to standardised phrases was 98% (80%,100%). Efficacy analysis showed a median [Q1,Q3] peri-shock pause of 5.1 s. [4.4; 5.8] vs. 7.5 s. [6.3; 8.8] seconds, p < 0.001, intubation pause of 3.8 s. [3.6; 5.0] vs. 6.9 s. [4.8; 10.1] seconds, p = 0.03, rhythm check pause of 4.2 [3.2,5.7] vs. 8.6 [5.0,10.5] seconds, p < 0.001, median frustration index of 10/100 [5,20] vs. 35/100 [25,50], p < 0.001, and median mental demand load of 55/100 [30,70] vs. 65/100 [50,85], p = 0.41 for standardised vs. closed loop communication.

CONCLUSION

This pilot study demonstrated feasibility of using consensus-based standardised communication that was associated with shorter CC pauses for defibrillation, intubation, and rhythm checks without increasing frustration index or mental demand compared to current best practice, closed loop communication.

Effectiveness of an In-Service Education Program to Improve Patient Safety Directed at Surgical Residents: A Randomized Controlled Trial

BACKGROUND

Patient safety is a critical issue in healthcare services particularly in surgical units and operation rooms because of the high prevalence and risk of medical errors in such settings. This study was conducted to determine whether a 1-day educational intervention can change the attitude and behavior of surgical residents regarding patient safety.

METHODS

A total of 90 surgical residents were recruited from 6 university hospitals located in Tehran and Qazvin, Iran, and were randomized to either the intervention or a control group. Those in the intervention group participated in a 1-day workshop on patient safety, whereas the control group received no intervention. Both groups were followed for 3 months after the intervention was completed. The Safety Attitude Questionnaire and Oxford Non-Technical Skills scale were administered at 3 points in time (baseline, 1 month after the intervention, and 3 month later). The data were analyzed using repeated measures analysis of variance.

RESULTS

Total score on the Safety Attitude Questionnaire improved from 54.5 (SD = 14.4) at baseline to 58.3 (SD = 13.8) 3 months after the intervention in the intervention group; all dimensions, with the exception of working condition, showed significant changes. In addition, the Oxford Non-Technical Skills scale - as assessed by attending surgeons - improved significantly in all domains (p < 0.05). More than 60% of participants in the intervention group scored in the positive range for items assessing safety and teamwork climate.

CONCLUSIONS

A 1-day interactive educational workshop may be effective in changing the attitude and practice of surgical residents regarding patient safety. Further assessment of this intervention in other healthcare settings involving health professionals from various specialties and use of an objective measure such as number of reported medical errors are needed to corroborate these findings.

The Alternative Surgical Curriculum

Surgical training has focused on the development of technical competency. Interpersonal and cognitive skills are essential to working as an interdisciplinary team, which translates into safety for the patient and well-being for the surgeon and colleagues. This article offers an "alternative" surgical curriculum topic list to augment the technical skill sets traditionally taught to trainees.

Nontechnical skills and decision making in operative vaginal delivery

Nontechnical skills are defined as social, cognitive and personal resource skills that are necessary to conduct any technical skill safely. Whilst the skills are categorised into three domains: social, cognitive and personal resources, these are dependent on each other and the development and effectiveness of one relies on the other two. Effective nontechnical skills are essential in the safe care of patients in any setting, and their importance can be clearly demonstrated in the safe development of skills in many areas of medicine and surgery. Increasingly the importance of these skills is being recognised in outcomes for patients and staff, and training courses and assessment tools are being developed and used in obstetrics. Understanding of the role of nontechnical skills in labour and especially in operative vaginal births should be embedded across the specialty. Further research is needed in validation of assessment tools for these skills when used in obstetrics.

Improving quality and safety during intrahospital transport of critically ill patients: A critical incident study

BACKGROUND

Intrahospital transport is a high-risk procedure for critically ill patients, yet there is little known about how the transport team manages critical incidents that occur.

OBJECTIVES

The aim of this study was to explore critical care nurses' and physicians' experiences and practices associated with critical incidents during the transfer process in critically ill patients.

METHODS

As a part of an ethnographic study, semistructured interviews were performed using the critical incident technique. Data were collected in two intensive care units at one university hospital in a Swedish metropolitan city. Critical care nurses (n = 15) and physicians (n = 5) were interviewed, together describing a total of 46 critical incidents. Data were analysed using qualitative content and thematic analysis approaches.

RESULTS

Content analysis of nurses' and physicians' practices resulted in a description of requirements for safe transports, including organisational prerequisites, professional skills and attributes, as well as actions and behaviours of safely performing transfers. Exploring the experiences of nurses and physicians in transporting critically ill patients yielded three main themes. The first theme, a hazardous process, revealed how caring for critically ill patients during intrahospital transfers was perceived as an unsafe, demanding task that presents several threats to the patient's safety. However, despite worries and concerns, participants trusted their own abilities to handle unexpected events, resulting in the second theme, performing when it matters. The third theme, towards safe practice, captured suggestions for improvement and attitudes towards existing safety hazards.

CONCLUSIONS

To prevent and manage critical incidents during intrahospital transport, findings of this study suggest that nontechnical skills such as situational awareness and teamwork are essential. In addition, the team must possess the requisite technical skills and knowledge to undertake transports. Finally, organisations are required to provide a supportive and sustainable transport environment that includes fewer transport-related hazards.

An Innovative Approach for Familiarizing Surgeons with Malpractice Litigation

OBJECTIVE

Familiarize surgery residents with medicolegal knowledge and skills required when facing the prospect of being sued through a simulation session.

DESIGN

The general surgery residency, hospital risk management, and malpractice attorneys collaboratively organized an educational intervention, consisting of an introductory lecture followed by a mock lawsuit. Two medical malpractice attorneys acted as defense and plaintiff attorneys while an attending surgeon experienced in litigation acted as defendant. Experience, attitudes, and preintervention/postintervention competency were evaluated via retrospective self-assessment.

SETTING

Weekly departmental educational conference.

PARTICIPANTS

Forty residents and attending surgeons.

RESULTS

Among the participants, 27.5% had been named in a law suit before. Most surgeons (70.0%) are worried about malpractice. Physicians who had been sued were no more likely to worry about malpractice (18.6 vs 25.0%, p = 0.82) than their colleagues who had never been sued. Results from the retrospective preintervention/postintervention competency assessments demonstrated significant improvement in all measured competencies after the mock lawsuit. In comparison with attending faculty, residents obtained greater improvements in understanding the essential elements of a medical claim (1.9 vs 1.1, p = 0.03), gaining confidence doing a deposition for medical litigation (1.9 vs 0.9, p < 0.01) and understanding the do's and don'ts when named in a lawsuit (2.0 vs 1.1, p = 0.01).

CONCLUSIONS

The novel educational format effectively familiarized surgery faculty and residents with the process of litigation and improved their confidence and mental preparedness when facing the prospect of a lawsuit. It is a valuable educational tool that can be incorporated in residency training and faculty development curricula.

A Method to Evaluate Trainee Progression During Simulation Training at the Urology Simulation Boot Camp (USBC) Course

OBJECTIVES

To evaluate skills progression at the Urology Simulation Boot Camp (USBC), a course intended to provide urology trainees with 32 hours of 1:1 training on low and high-fidelity simulators.

DESIGN

In this single-group cohort study, trainees rotated through modules based on aspects of the United Kingdom urology residency curriculum and undertook a pre and postcourse MCQ. Specific procedural skill was evaluated by an expert and graded as either: "A"-Good (≥4 on a 5-point Likert Scale) or "B"-Poor (Likert scale of 1-3). Competence progression was calculated as the change in score between baseline and final assessments.

SETTING

The USBC was held at St James' University Hospital, Leeds, U.K.

PARTICIPANTS

Of the 34 trainees attended the second USBC, 33 trainees participated in all the pre and postcourse assessments. The mean duration of urology training prior to undertaking the USBC was 15 months.

RESULTS

Competence progression was assessed in 33 urology trainees. Mean MCQ scores improved by 16.7% (p < 0.001) between pre and postcourse assessment. At final assessment, 87.9% of trainees scored "A" in instrument knowledge and assembly compared to 44.4% at baseline (p < 0.001). There was a mean improvement of 439s (p < 0.001) in the time taken to complete the European-Basic Laparoscopic skills assessment.

CONCLUSIONS

The USBC has shown to aid trainees in competence progression during the simulation on a variety of urological skills; however, retention of skill in the long-term was undetermined. The use of our grading system is simple to understand and may be used in other simulation courses to guide participants with their future training needs.

Virtual Reality and Simulation for Progressive Treatments in Urology

In urology technologies and surgical practices are constantly evolving and virtual reality (VR) simulation has become a significant supplement to existing urology methods in the training curricula of urologists. However, new developments in urology also require training and simulation for a wider application. In order to achieve this VR and simulation could play a central role. The purpose of this article is a review of the principal applications for VR and simulation in the field of urology education and to demonstrate the potential for the propagation of new progressive treatments. Two different cases are presented as examples: exposure therapy for paruresis and virtual cystoscopy for diagnosis and surgery of bladder cancer. The article uses research and publications listed in openly accessible directories and is organized into 3 sections: The first section covers features of VR and simulation technologies. The second one presents confirmed applications of current technologies in urology education and showcases example future applications in the domain of bladder treatment and surgery. The final section discusses the potential of the technology to improve health care quality.

A mixed methods evaluation of paediatric trainee preparedness to manage cardiopulmonary arrests

Paediatric cardiopulmonary arrest (CPA) survival rates are strongly linked to the training of the doctors responding to the event. This study sought to characterise the level of experience in managing CPAs among paediatric trainees and to investigate the nontechnical (NTS) required to effectively lead a paediatric CPA team. A mixed-methods research design was used. For the quantitative phase, a questionnaire was developed to assess training, confidence, and experiences related to CPA management. During the qualitative phase, 17 paediatric trainees participated in a series of critical incident technique (CIT) interviews to explore the NTS used during the management of paediatric CPAs. A total of 56 of 131 (37.1% response rate) trainees responded to the preparedness questionnaire. A total of 48.2% of respondents expressed low confidence in their skill as a team leader during the management of a CPA. The CIT interviews highlighted deficiencies in specific NTS (identifying options, prioritising, and identifying and utilising resources).

CONCLUSION

Our results indicate that there is a desire for more training in CPA management among paediatric trainees, in particular as a team leader, which includes a focus on key NTS. What is Known • Levels of preparedness to be a paediatric cardiopulmonary arrests team member/leader are generally lower than desirable. • The importance of nontechnical skills to the effective performance of adult cardiopulmonary arrests teams has been identified. What is New • Levels of preparedness to be a cardiopulmonary arrests team member were higher than reported in US studies. • There is a need for greater training in cardiopulmonary arrest management which includes a focus on key nontechnical skills to include identifying options, prioritising, identifying and utilising resources.

Integration of Hands-On Team Training into Existing Curriculum Improves Both Technical and Nontechnical Skills in Laparoscopic Cholecystectomy

OBJECTIVE

Nontechnical skills are an essential component of surgical education and a major competency assessed by the ACGME milestones project. However, the optimal way to integrate nontechnical skills training into existing curricula and then objectively evaluate the outcome is still unknown. The aim of this study was to determine the effect laparoscopic team-based task training would have on the nontechnical skills needed for laparoscopic surgery.

DESIGN

9 PGY-1 residents underwent an established training curriculum for teaching the knowledge and technical skills involved in laparoscopic cholecystectomy. Initial training involved a didactic session, expert-led practice on a porcine model in a simulated operating room and laparoscopic skills practice on a virtual reality trainer. Residents then performed a laparoscopic cholecystectomy on the same porcine model as a preintervention test. Three to four months following this, residents were subjected to specific nontechnical skills training involving 2 simple team-based laparoscopic tasks. They then practiced a further 4 to 6 hours on the virtual reality trainer. A repeat postintervention laparoscopic cholecystectomy was then performed 3 to 4 months after nontechnical skills training. Both the preintervention and postintervention laparoscopic cholecystectomies were audiovisually recorded and then evaluated by 2 independent surgeons in a blinded fashion. Technical skills were assessed using objective structured assessment of technical skills (OSATS) and a technique specific rating scale (TRS) that we developed for laparoscopic cholecystectomy. Nontechnical skills were assessed using nontechnical skills for surgeons (NOTSS). Residents also completed a survey at the beginning and end of the training.

SETTING

Tertiary care, university based teaching institution.

PARTICIPANTS

A total of 9 general surgery residents at the intern level.

RESULTS

The mean OSATS score improved from 13.7 ± 1.24 to 26.7 ± 0.31 (p < 0.001), the mean TRS score improved from 6 ± 0.46 to 13.1 ± 0.36 (p < 0.001) and the mean NOTSS score improved from 21.7 ± 1.83 to 36.3 ± 0.87 (p < 0.001) following the training. There was a strong correlation between OSATS and NOTSS scores (Pearson's R = 0.98) and TRS and NOTSS (R = 0.94). The inter-rater agreement was 0.79 for NOTSS, 0.9 for OSATS, and 0.82 for TRS. Following completion of the training, residents self-reported improvements in exchanging information (p < 0.01), coordinating activities (p < 0.01) and coping with pressure in the operating room (p < 0.001).

CONCLUSION

Simple, team-based nontechnical skills training for laparoscopic cholecystectomy that was separate from technical skills training led to a sustained increase in residents' nontechnical skills 3 to 4 months after training. This was associated with a self-reported improvement in many nontechnical skills based on resident survey. Based on these results, we recommend that such designated nontechnical skills training is a valid alternative to other methods such as coaching and debriefing. We, therefore, plan to continue our efforts to develop team-based simulation tasks aimed at improving nontechnical skills for multiple surgical modalities.

Advances in Teaching and Assessing Nontechnical Skills

The importance of surgeons' nontechnical skills is gaining widespread recognition as a critical element of high-quality and safe surgical care. This article reviews the knowledge base on training and assessing surgeons, and operating room (OR) teams, in nontechnical aspects of their performance. Nontechnical skills are defined in the context of the OR and key assessment instruments that have been developed to capture these skills are reviewed. Key developments that have taken place in the past decade on formal skills training are discussed, and recommendations to further advance nontechnical skills and team-based training and assessment in surgery are presented.

Current Status of Simulation-Based Training in Graduate Medical Education

The use of simulation in Graduate Medical Education has evolved significantly over time, particularly during the past decade. The applications of simulation include introductory and basic technical skills, more advanced technical skills, and nontechnical skills, and simulation is gaining acceptance in high-stakes assessments. Simulation-based training has also brought about paradigm shifts in the medical and surgical education arenas and has borne new and exciting national and local consortia that will ensure that the scope and impact of simulation will continue to broaden.

Facilitating the implementation of the American College of Surgeons/Association of Program Directors in Surgery phase III skills curriculum: training faculty in the assessment of team skills

BACKGROUND

Effective teamwork is critical to safety in the operating room; however, implementation of phase III of the American College of Surgeons (ACS) and Association of Program Directors in Surgery (APDS) Curriculum that focuses on team-based skills remains worryingly low. Training and assessing the complexities of teamwork is challenging. The objective of this study was to establish guidelines and recommendations for training faculty in assessing/debriefing team skills.

METHODS

A multistage survey-based consensus study was completed by 108 experts responsible for training and assessing surgical residents from the ACS Accredited Educational Institutes.

RESULTS

Experts agreed that a program to teach faculty to assess team-based skills should include training in the recognition of teamwork skills, practice rating these skills, and training in the provision of feedback/debriefing. Agreement was reached that faculty responsible for conducting team-based skills assessment should be revalidated every 2 years and stringent proficiency criteria should be met.

CONCLUSIONS

Faculty development is critical to ensure high-quality, standardized training and assessment. Training faculty to assess team-based skills has the potential to facilitate the effective implementation of phase III of the ACS and APDS Curriculum.