Lucy Mitchell

Thinking ahead of the surgeon. An interview study to identify scrub nurses’ non-technical skills

BACKGROUND Efforts to reduce adverse event rates in healthcare have revealed the importance of identifying the essential non-technical (cognitive and social) skills for safe and effective performance. Previous research on non-technical skills for operating theatre staff has concentrated on doctors rather than nursing professionals. OBJECTIVES The aim of the study was to identify the critical non-technical skills that are essential for safe and effective performance as an operating theatre scrub nurse. METHODS Experienced scrub nurses (n = 25) and consultant surgeons (n = 9) from four Scottish hospitals were interviewed using a semi-structured format. The protocols were designed to identify the main social and cognitive skills required by scrub nurses. Interviews were digitally recorded, transcribed verbatim and independently coded to extract behaviours in order to produce a list of the main non-technical skills for safe and effective scrub nurse performance. RESULTS The non-technical skills of situation awareness, communication, teamwork, task management and coping with stress were identified as key to successful scrub nurse task performance. Component sets of behaviours for each of these categories were also noted. CONCLUSION The interviews with subject matter experts from scrub nursing and surgery produced preliminary evidence that situation awareness, communication, teamwork and coping with stress are the principal non-technical skills required for effective performance as a scrub nurse.

Teamwork, communication, and anaesthetic assistance in Scotland

Teamwork involves supporting others, solving conflicts, exchanging information, and co-ordinating activities. This article describes the results of interviews with anaesthetic assistants (n=22) and consultant anaesthetists (n=11), investigating the non-technical skills involved in the effective teamwork of the anaesthetic assistants in the operating theatre. Anaesthetic assistants most commonly saw themselves as either being part of a theatre team or an anaesthetic subgroup and most commonly described the senior theatre nurse as their team leader. Examples of supporting others included the following: checking equipment, providing equipment, being a second pair of eyes, providing emotional and decision support, and supporting trainee anaesthetists. Of the 19 anaesthetic assistants who were asked if they would speak up if they disagreed with a decision in theatre, only 14 said that they would voice their concerns, and the most common approach was to ask for the logic behind the decision. The WHO checklist was described as prompting some anaesthetists to describe their anaesthetic plan to the anaesthetic assistant, when previously the anaesthetist would have failed to communicate their intentions in time for equipment to be prepared. The prioritization of activities to achieve co-ordination and the anaesthetic assistants becoming familiar with the idiosyncrasies of their regular anaesthetists were also described by anaesthetic assistants.

Non-technical skills of anaesthetic assistants in the perioperative period: a literature review

Non-technical skills (NTS), which include communication, teamwork, leadership, decision-making, and situation awareness, are important in the maintenance of patient safety. NTS frameworks have been developed for anaesthetists, surgeons, and scrub practitioners. Most studies of NTS in operating theatres to date have focused on anaesthetists and surgeons. We have attempted to identify the NTS used by anaesthetic assistants in the perioperative period. An electronic search of the NHS e-library, PubMed, BioMed Central, ScienceDirect, and Scopus databases was performed in December 2010. The abstracts of the papers identified were checked for relevance and the article examined. Out of 308 papers initially identified, there were only three papers describing the use of NTS by anaesthetic assistants. Communication and situation awareness were described in three papers, teamwork and decision-making in two, and leadership in one. This search did not reveal any comprehensive description of the NTS required by anaesthetic assistants. The benefits of developing an NTS taxonomy for anaesthetic assistants are discussed.

The non-technical skills of theatre nurses.

What are ‘non-technical’ skills and why would they be relevant to theatre practitioners? This is a new area of research for healthcare based on a well developed approach from the world of aviation. Non-technical skills are the cognitive and social skills that complement technical skills to achieve safe and efficient practice in safety-critical occupations. These skills include communication, leadership, teamwork, stress management and situation awareness.

Thinking Ahead of the Surgeon: Developing a Behavioural Rating System for Scrub Practitioners' Non-Technical Skills (SPLINTS)

Efforts to reduce adverse event rates in healthcare have revealed the importance of identifying the essential non-technical (cognitive and social) skills for safe and effective performance and developing tools for rating and training those skills. The focus of studies to date has been surgeons, anaesthetists, or the whole team, with less attention paid to other professionals. The aim of the study was to develop a behavioural rating system for non-technical skills of the scrub practitioner (nurse/technician). This paper reports an interview study, as part of a task analysis, to identify the critical non-technical skills for this role, and the development of a prototype behavioural rating system. Experienced scrub practitioners (n = 25) and consultant surgeons (n = 9), from four Scottish teaching hospitals, were interviewed using a semi-structured design. Data that described generic non-technical skills were extracted from the interview transcripts and thereafter, psychologists and panels of perioperative practitioners (n = 4) used an iterative process to develop a skills taxonomy. Three categories of non-technical skills were identified as critical for safe and effective scrub practitioner performance. These were; situation awareness, communication and teamwork, task management. Three underlying skill elements for each of the three categories were labeled by the expert panels and they provided examples of good and poor behaviours for each of these skill elements, drawing on their domain knowledge. The reliability and psychometric properties of the prototype skills taxonomy and behaviour rating system are currently being tested using standardized, simulated scenarios.

Evaluation of the SPLINTS system for scrub practitioners’ non-technical skills:

Background: The Scrub Practitioners’ List of Intraoperative NonTechnical Skills (SPLINTS) system is a new tool for training and assessing scrub practitioner behaviours during surgical operations. Method: Experienced scrub practitioners (n = 34) attended a single day session where they received background training in human factors and nontechnical skills and were trained to use the SPLINTS system. They then rated the scrub practitioners’ nontechnical skill performance in seven videorecorded simulated scenarios and completed a posttraining questionnaire. Results: Withingroup agreement for all three skill categories, and for six of the nine elements, was acceptable (r wg >.70). Participants could use SPLINTS to accurately score performance compared with expert ratings and were within one scale point of expert ratings in > 90% of skill categories and elements. There was good internal consistency between elements and their categories (M<.2 of a scale point) and participants reported that the system was complete. Conclusion: The SPLINTS system was deemed adequately reliable, for rating scrub practitioners’ nontechnical skills, using standardized filmed scenarios. Usability of the SPLINTS system in the real operating theatre environment is still to be assessed.

'Pass the buzzy thing, please.' Recognising and understanding information: an essential non-technical skill element for the efficient scrub practitioner.

Adverse events are unintended injuries or complications that are caused by the management of a patients care rather than by their underlying medical condition. Research into adverse events in hospitals has demonstrated that the operating theatre is one area of healthcare where there is room for improvement, with 41% of all adverse events occurring in the operating theatre, according to one systematic review (deVries et al 2008). Despite technical guidelines, there are still instances of sponges and instruments being retained within patients (Gawande et al 2003) and the factors contributing to this may include assertiveness issues and communication between perioperative and medical staff, i.e. non-technical skills.

Scrub Practitioners' List of Intra-Operative Non-Technical Skills - SPLINTS

Modern surgery requires a group of people with a variety of skills to work together effectively to deliver patient care. in addition to their technical expertise, members of an operating theatre (OT) team will utilize a range of ‘non-technical’ skills. These are the cognitive and social skills that complement technical skills to achieve safe and efficient practice. Taxonomies of these non-technical skills have already been identified for anaesthetists’ (see Glavin and Patey, Chapter 11 in this volume, Fletcher et al. 2004) and surgeons’ performance (see Yule et al., Chapter 2 in this volume, Yule et al. 2006b) in the intra-operative phase of surgical procedures. Another key member of the theatre team is the scrub (or instrument) nurse, practitioner or technician,1 who works directly with one or more surgeons while they are operating on the patient. as there was no taxonomy of non-technical skills for this member of the scrub team, a research project (funded 2007–2009 by NHS Education Scotland) was established to identify these skills and this chapter will describe the findings of the SPLINTS project to date.

Strengths and Weaknesses of Specific Interview Methods and Qualitative Data Analysis Strategies in Identifying Team Performance Requirements

Interviews are a widely accepted method for determining team performance requirements in complex work environments. Using examples from two studies in acute patient care settings, this paper discusses the strengths and weaknesses of specific interview methods and qualitative data analysis strategies in identifying performance requirements and in establishing categories for observational research or skills assessment. Interview study 1 was carried out in cardiac anesthesia deductively applying a conceptual framework of cooperation and coordination in analyzing the data. In study 2 interviews were analyzed applying an inductive data analysis approach to establish a basic list of non-technical skills that are important to scrub practitioner performance. Both studies provide valuable insights with regards to performance requirements of the various team members and specific teamwork behaviors. Implications for the interpretation of results and the design of interview studies in the research area are discussed.

They seem to be able to read your mind. An interview study to identify the cognitive non-technical skills of anaesthetic assistants.

The aim of this study was to identify the cognitive non-technical skills (i.e. situation awareness and decision making) used by anaesthetic assistants, as part of the development of a specialty-specific behavioural rating system for anaesthetic assistants. Semi-structured interviews were conducted with anaesthetic assistants (n=22), anaesthetic consultants (n=11) and trainee anaesthetists (n=12) in Scotland. The interviews were transcribed and thematically analysed. All 45 participants described the presence or failure of situation awareness (i.e. gathering information, its comprehension and anticipation) in 713 phrases. Decision making (i.e. considering options, selecting actions and reviewing decisions) by the anaesthetic assistants was reported much less frequently – only 34 participants described 89 phrases. Situation awareness is a key non-technical skill used by anaesthetic assistants, however decision making was less commonly described as required by anaesthetic assistants. This provides qualitative data to support the development of a non-technical skills taxonomy for anaesthetic assistants.