Steven Yule

Measuring safety climate in health care

Aim: To review quantitative studies of safety climate in health care to examine the psychometric properties of the questionnaires designed to measure this construct. Method: A systematic literature review was undertaken to study sample and questionnaire design characteristics (source, no of items, scale type), construct validity (content validity, factor structure and internal reliability, concurrent validity), within group agreement, and level of analysis. Results: Twelve studies were examined. There was a lack of explicit theoretical underpinning for most questionnaires and some instruments did not report standard psychometric criteria. Where this information was available, several questionnaires appeared to have limitations. Conclusions: More consideration should be given to psychometric factors in the design of healthcare safety climate instruments, especially as these are beginning to be used in large scale surveys across healthcare organisations.

Leadership for safety: industrial experience

The importance of leadership for effective safety management has been the focus of research attention in industry for a number of years, especially in energy and manufacturing sectors. In contrast, very little research into leadership and safety has been carried out in medical settings. A selective review of the industrial safety literature for leadership research with possible application in health care was undertaken. Emerging findings show the importance of participative, transformational styles for safety performance at all levels of management. Transactional styles with attention to monitoring and reinforcement of workers’ safety behaviours have been shown to be effective at the supervisory level. Middle managers need to be involved in safety and foster open communication, while ensuring compliance with safety systems. They should allow supervisors a degree of autonomy for safety initiatives. Senior managers have a prime influence on the organisation’s safety culture. They need to continuously demonstrate a visible commitment to safety, best indicated by the time they devote to safety matters.

How do surgeons make intraoperative decisions

Surgeons’ intraoperative decision making is a key element of clinical practice, yet has received scant attention in the surgical literature. In recent years, serial changes in the configuration of surgical training in the UK have reduced the time spent by trainees in the operating theatre. The opportunity to replace this lost experience with active teaching of decision making is important, but there seem to have been very few studies that have directly examined the cognitive skills underlying surgical decision making during operations. From the available evidence in surgery, and drawing from research in other safety-critical occupations, four decision-making strategies that surgeons may use are discussed: intuitive (recognition-primed), rule based, option comparison and creative. Surgeons’ decision-making processes should be studied to provide a better evidence base for the training of cognitive skills for the intraoperative environment.

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.

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.

Surgeons’ Non-technical Skills

The importance of non-technical skills to surgical performance is gaining wide acceptance. This article discusses the core cognitive and social skills categories thought to underpin medical knowledge and surgical expertise, and describes the rise of non-technical skill models of assessment in surgery. Behavior rating systems such as NOTSS (Non-Technical Skills for Surgeons) have been developed to support education and assessment in this regard. We now understand more about these critical skills and how they impact surgery. The challenge in the future is to incorporate them into undergraduate teaching, postgraduate training, workplace assessment, and perhaps even selection.

Undergraduate medical students' perceptions and expectations of theatre-based learning: How can we improve the student learning experience?

OBJECTIVE Much of the student experience in theatre depends on the interaction between student and surgeon, and having the opportunity to take part in procedures. Theatre-based teaching can be seen as having little inherent benefit otherwise. We wished to identify other factors contributing to the experience of theatre-based teaching. DESIGN A questionnaire survey, using forced-choice and open questions, of undergraduate medical students with experience of surgical attachments. SETTING AND PARTICIPANTS 54 final (5th) year medical students, University of Aberdeen. ANALYSIS Responses on the closed questions are presented as percentages. The themes arising from the open questions were identified and the relationships among these themes explored. RESULTS Student expectations of learning focused on knowledge acquisition. Students learning experiences varied widely, depending on how welcome they felt in theatre. Visibility and active participation influenced the experience. Students did not feel adequately prepared for getting the most out of this learning experience. CONCLUSIONS The student experience may be skewed by unrealistic expectations of theatre-based learning. Clear and realistic learning objectives, preparation in terms of familiarity with the environment and staff roles, embedding the experience in the patients journey/care pathways, faculty expectations being clearly communicated to clinical teaching staff and, perhaps above all, approachability of theatre staff are likely to improve the learning experience.

The Role of Nontechnical Skills in Simulated Trauma Resuscitation

OBJECTIVE Trauma team training provides instruction on crisis management through debriefing and discussion of teamwork and leadership skills during simulated trauma scenarios. The effects of team leaders nontechnical skills (NTSs) on technical performance have not been thoroughly studied. We hypothesized that teams and team leaders NTSs correlate with technical performance of clinical tasks. DESIGN Retrospective cohort study. SETTING Brigham and Womens Hospital, STRATUS Center for Surgical Simulation PARTICIPANTS A total of 20 teams composed of surgical residents, emergency medicine residents, emergency department nurses, and emergency services assistants underwent 2 separate, high-fidelity, simulated trauma scenarios. Each trauma scenario was recorded on video for analysis and divided into 4 consecutive sections. For each section, 2 raters used the Non-Technical Skills for Surgeons framework to assess NTSs of the team. To evaluate the entire teams NTS, 2 additional raters used the Modified Non-Technical Skills Scale for Trauma system. Clinical performance measures including adherence to guidelines and time to perform critical tasks were measured independently. RESULTS NTSs performance by both teams and team leaders in all NTS categories decreased from the beginning to the end of the scenario (all p < 0.05). There was significant correlation between teams and team leaders cognitive skills and critical task performance, with correlation coefficients between 0.351 and 0.478 (p < 0.05). The NTS performance of the team leader highly correlated with that of the entire team, with correlation coefficients between 0.602 and 0.785 (p < 0.001). CONCLUSIONS The NTSs of trauma teams and team leaders deteriorate as clinical scenarios progress, and the performance of team leaders and teams is highly correlated. Cognitive NTS scores correlate with critical task performance. Increased attention to NTSs during trauma team training may lead to sustained performance throughout trauma scenarios. Decision making and situation awareness skills are critical for both team leaders and teams and should be specifically addressed to improve performance.

How can we prepare medical students for theatre-based learning?

Context  The quality of medical undergraduate operating theatre‐based teaching is variable. Preparation prior to attending theatre may support student learning. Identifying and agreeing key skills, competences and objectives for theatre‐based teaching may contribute to this process of preparation.

Complementing Operating Room Teaching With Video-Based Coaching

Importance Surgical expertise demands technical and nontechnical skills. Traditionally, surgical trainees acquired these skills in the operating room; however, operative time for residents has decreased with duty hour restrictions. As in other professions, video analysis may help maximize the learning experience. Objective To develop and evaluate a postoperative video-based coaching intervention for residents. Design, Setting, and Participants In this mixed methods analysis, 10 senior (postgraduate year 4 and 5) residents were videorecorded operating with an attending surgeon at an academic tertiary care hospital. Each video formed the basis of a 1-hour one-on-one coaching session conducted by the operative attending; although a coaching framework was provided, participants determined the specific content collaboratively. Teaching points were identified in the operating room and the video-based coaching sessions; iterative inductive coding, followed by thematic analysis, was performed. Main Outcomes and Measures Teaching points made in the operating room were compared with those in the video-based coaching sessions with respect to initiator, content, and teaching technique, adjusting for time. Results Among 10 cases, surgeons made more teaching points per unit time (63.0 vs 102.7 per hour) while coaching. Teaching in the video-based coaching sessions was more resident centered; attendings were more inquisitive about residents’ learning needs (3.30 vs 0.28, P = .04), and residents took more initiative to direct their education (27% [198 of 729 teaching points] vs 17% [331 of 1977 teaching points], P < .001). Surgeons also more frequently validated residents’ experiences (8.40 vs 1.81, P < .01), and they tended to ask more questions to promote critical thinking (9.30 vs 3.32, P = .07) and set more learning goals (2.90 vs 0.28, P = .11). More complex topics, including intraoperative decision making (mean, 9.70 vs 2.77 instances per hour, P = .03) and failure to progress (mean, 1.20 vs 0.13 instances per hour, P = .04) were addressed, and they were more thoroughly developed and explored. Excerpts of dialogue are presented to illustrate these findings. Conclusions and Relevance Video-based coaching is a novel and feasible modality for supplementing intraoperative learning. Objective evaluation demonstrates that video-based coaching may be particularly useful for teaching higher-level concepts, such as decision making, and for individualizing instruction and feedback to each resident.