N. Maran

Identifying and training non-technical skills for teams in acute medicine

The aviation domain provides a better analogy for the ”temporary” teams that are found in acute medical specialities than industrial or military teamwork research based on established teams. Crew resource management (CRM) training, which emphasises portable skills (for whatever crew a pilot is rostered to on a given flight), has been recognised to have potential application in medicine, especially for teams in the operating theatre, intensive care unit, and emergency room. Drawing on research from aviation psychology that produced the behavioural marker system NOTECHS for rating European pilots’ non-technical skills for teamwork on the flightdeck, this paper outlines the Anaesthetists Non-Technical Skills behavioural rating system for anaesthetists working in operating theatre teams. This taxonomy was used as the design basis for a training course, Crisis Avoidance Resource Management for Anaesthetists used to develop these skills, based in an operating theatre simulator. Further developments of this training programme for teams in emergency medicine are outlined.

Rating non-technical skills: developing a behavioural marker system for use in anaesthesia

Studies of performance in medicine are often based on observation. Videotape provides a valuable tool for recording events from both real environments and simulators. When analysing observational data it is important that robust tools are used, particularly when investigating non-technical (cognitive and social) skills. This paper describes the method used to identify the key non-technical skills required in anaesthesia and to develop a behavioural marker system for their measurement. A prototype taxonomy was designed on the basis of a literature review; an examination of existing marker systems; cognitive task analysis interviews; an iterative development process involving workshops; and cross-checking in theatre. The resulting anaesthetists’ non-technical skills (ANTS) system comprises four skill categories (task management, team working, situation awareness, and decision making) that divide into 15 elements, each with example behaviours. Preliminary evaluation using ratings of videotaped scenarios indicated that the skills were observable and could be rated with reasonable agreement.

Experience matters: comparing novice and expert ratings of non-technical skills using the NOTSS system

There is growing evidence that non‐technical skills (NTS) are related to surgical outcomes and patient safety. The aim of this study was to further evaluate a behaviour rating system (NOTSS: Non‐Technical Skills for Surgeons) which can be used for workplace assessment of the cognitive and social skills which are essential components of NTS. A novice group composed of consultant surgeons (n = 44) from five Scottish hospitals attended one of six experimental sessions and were trained to use the NOTSS system. They then used NOTSS to rate surgeons’ behaviors in six simulated scenarios filmed in the operating room. The behaviours demonstrated in each scenario were compared to expert ratings to determine accuracy. The mode rating from the novice group (who received a short training session in behaviour assessment) was the same as the expert group in 50% of ratings. Where there was disagreement, novice raters tended to provide lower ratings than the experts. Novice raters require significant training in this emerging area of competence in order to accurately rate non‐technical skills.

Observation of behavioural markers of non- technical skills in the operating room and their relationship to intra-operative incidents

BACKGROUND The importance of non-technical skills in improving surgical safety and performance is now well recognised. Better understanding is needed of the impact that non-technical skills of the multi-disciplinary theatre team have on intra-operative incidents in the operating room (OR) using structured theatre-based assessment. The interaction of non-technical skills that influence surgical safety of the OR team will be explored and made more transparent. METHODS Between May-August 2013, a range of procedures in general and vascular surgery in the Royal Infirmary of Edinburgh were performed. Non-technical skills behavioural markers and associated intra-operative incidents were recorded using established behavioural marking systems (NOTSS, ANTS and SPLINTS). Adherence to the surgical safety checklist was also observed. RESULTS A total of 51 procedures were observed, with 90 recorded incidents - 57 of which were considered avoidable. Poor situational awareness was a common area for surgeons and anaesthetists leading to most intra-operative incidents. Poor communication and teamwork across the whole OR team had a generally large impact on intra-operative incidents. Leadership was shown to be an essential set of skills for the surgeons as demonstrated by the high correlation of poor leadership with intra-operative incidents. Team-working and management skills appeared to be especially important for anaesthetists in the recovery from an intra-operative incident. CONCLUSION A significant number of avoidable incidents occur during operative procedures. These can all be linked to failures in non-technical skills. Better training of both individual and team in non-technical skills is needed in order to improve patient safety in the operating room.

Surgeons' Attitudes to Teamwork and Safety

Attitudes towards human and organizational factors can have an impact on effective team performance and consequently on patient safety. The Operating Room Management Attitudes Questionnaire (ORMAQ) measures attitudes to leadership, communication, teamwork, stress and fatigue, work values, and organizational climate. Data were collected from 231 consultant and trainee surgeons, and 121 surgical nurses from 17 Scottish Hospitals using a customized version of the ORMAQ. The respondents generally demonstrated positive attitudes to teamwork, leadership and safety and were similar to those reported in previous ORMAQ surveys of anaesthetists in Scotland and of surgeons in other countries. However, consultant and trainee surgeons differed in their attitudes to briefings, critical situations, and competence acknowledgement.