Anaesthetists' non-technical skills.

This review presents the background to the development of the anaesthetists' non-technical skills (ANTS) taxonomy and behaviour rating tool, which is the first non-technical skills framework specifically designed for anaesthetists. We share the experience of the anaesthetists who designed ANTS in relation to applying it in a department of anaesthesia, using it in a simulation centre, and the process of introducing it to the profession on a national basis. We also consider how ANTS is being applied in relation to training and research in other countries and finally, we discuss emerging issues in relation to the introduction of a non-technical skills approach in anaesthesia.

Teaching surgeons about non-technical skills.

BACKGROUND: Analyses of adverse events in surgery reveal that underlying causes are often behavioural, such as communication failures, rather than technical. Non-technical (i.e. cognitive and interpersonal) skills, whilst recognised, are not explicitly addressed in surgical training. However, surgeons need to demonstrate high levels of these skills, as well as technical proficiency, to maximise safety and quality in the operating theatre. This article describes a prototype training course to raise surgeons' awareness of non-technical skills. METHODS: The course syllabus was based on a new taxonomy of surgeons' non-technical skills (NOTSS) which has four principal categories: situation awareness, decision-making, communication and teamwork, and leadership. Three, one-day training courses were attended by 21 surgeons. RESULTS: All surgeons reported that they found explicit review and discussion of these skills and component behaviours helpful for self-reflection. They rated the content as interesting and relevant and the majority declared their intention to make some changes to their behaviour during surgery. CONCLUSIONS: It was concluded that this type of training could enhance the surgical training portfolio and should be an integral feature of the development and assessment of operative skills.

Development of a rating system for surgeons' non-technical skills.

BACKGROUND: Analyses of adverse events in surgery reveal that many underlying causes are behavioural, such as communication failure, rather than technical. Non-technical (i.e. cognitive and interpersonal) skills are not addressed explicitly in surgical training. However, surgeons need to demonstrate these skills, which underpin their technical excellence, to maximise patient safety in the operating theatre. This paper describes the method used to identify surgeons' non-technical skills, and the development of a skills taxonomy and behavioural rating system to structure observation and feedback in surgical training. METHODS: Cognitive task analyses (critical incident interviews) were conducted with 27 consultant surgeons in general, cardiac and orthopaedic surgery. The interviews were coded and a multidisciplinary group of surgeons and psychologists used an iterative process to develop a skills taxonomy. This was supported by data gathered from an attitude survey, literature review, analysis of surgical mortality reports and observations in theatre. RESULTS: Five categories of non-technical skills were identified, including situation awareness, decision making, task management, leadership and communication and teamwork. This provided a structure for a prototype skill taxonomy (v1.1), which comprised 14 non-technical skill elements. Observable behaviours (markers) indicative of good and poor performance were developed for each element by 16 consultant surgeons to form a prototype behaviour rating system. CONCLUSIONS: The prototype skills taxonomy and behaviour rating system are grounded empirically in surgery. The reliability of the system is currently being tested using standardised scenarios. If this evaluation proves successful, the system could be used to structure feedback and guide non-technical skills training.

Attitudes to teamwork and safety in the operating theatre.

BACKGROUND: A survey was undertaken to assess surgical team members' attitudes to safety and teamwork in the operating theatre. METHOD: The Operating Room Management Attitudes Questionnaire (ORMAQ) measures attitudes to leadership, teamwork, stress and fatigue and error. A version of the ORMAQ was distributed to surgical teams in 17 hospitals in Scotland. A total of 352 responses were analysed, 138 from consultant surgeons, 93 from trainee surgeons and 121 from theatre nurses. RESULTS: Respondents generally demonstrated positive attitudes to behaviours associated with effective teamwork and safety. Attitudes indicating a belief in personal invulnerability to stress and fatigue were evident in both nurses and surgeons. Consultant surgeons had more positive views on the quality of surgical leadership and communication in theatre than trainees and theatre nurses. While the ubiquity of human error was well recognised, attitudes to error management strategies (incident reporting, procedural compliance) suggest that they may not be fully functioning across hospitals. While theatre staff placed a clear priority on patient safety against other business objectives (e.g. waiting lists, cost cutting), not all of them felt that this was endorsed by their hospital management. CONCLUSIONS: Attitude surveys can provide useful diagnostic information relating to behaviour and safety in surgical units. Discrepancies were found between the views of consultants compared with trainees and nurses, in relation to leadership and teamwork. While attitudes to safety were generally positive, there were several areas where theatre staff did not seem to appreciate the impact of psychological factors on technical performance.

Accident and emergency training perspectives in Scotland.

OBJECTIVE: To determine the perspectives of Scottish accident and emergency (A&E) trainees and trainers on current training in the speciality, in order to help develop a simulator based training programme to complement existing training. METHODS: Questionnaires were sent to all Scottish A&E trainees and consultants responsible for training. They were presented with various clinical challenges. Trainees were asked to rate their confidence, experience, knowledge, and training on a Likert scale of 1 to 5. Trainers were asked to identify those areas where they felt trainees' performance consistently failed to meet a desired standard, and whether this was the result of lack of training, lack of exposure, or both. RESULTS: Trainees' response rate was 75%; consultants' was 59.4%. Overall trainees gave scores of 4/5 for confidence and knowledge, 3/5 for experience, and 2/5 for training. The highest scores were for medical, anaesthetics, and interpersonal skills. Consultants attributed lack of exposure to underperformance more frequently than lack of training. CONCLUSIONS: Trainees and trainers agree on the level of exposure to various clinical challenges, but disagree on training. Trainees' levels of confidence and knowledge outweigh their experience and training, suggesting that trainees associate knowledge with clinical competence.

Non-technical skills for surgeons in the operating room: a review of the literature.

BACKGROUND: This review examines the surgical and psychological literature on surgeons' intraoperative non-technical skills. These are the critical cognitive and interpersonal skills that complement surgeons' technical abilities. The objectives of this paper are (1) to identify the non-technical skills required by surgeons in the operating room and (2) assess the behavioral marker systems that have been developed for rating surgeons' non-technical skills. METHODS: A literature search was conducted against a set of inclusion criteria. Databases searched included BioMed Central, Medline, EDINA BIOSIS, Web-of-Knowledge, PsychLit, and ScienceDirect. RESULTS: A number of "core" categories of non-technical skills were identified from 4 sources of data: questionnaire and interview studies, observational studies, adverse event analyses, and the surgical education/competence assessment literature. The main skill categories were communication, teamwork, leadership, and decision making. The existing frameworks used to measure surgeons' non-technical skills were found to be deficient in terms of either their psychometric properties or suitability for rating the full range of skills in individual surgeons. CONCLUSIONS: Further work is required to develop a valid taxonomy of individual surgeons' non-technical skills for training and feedback.

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.

Low- to high-fidelity simulation - a continuum of medical education?

CONTEXT: Changes in medical training and culture have reduced the acceptability of the traditional apprenticeship style training in medicine and influenced the growth of clinical skills training. Simulation is an educational technique that allows interactive, and at times immersive, activity by recreating all or part of a clinical experience without exposing patients to the associated risks. The number and range of commercially available technologies used in simulation for education of health care professionals is growing exponentially. These range from simple part-task training models to highly sophisticated computer driven models. AIM: This paper will review the range of currently available simulators and the educational processes that underpin simulation training. The use of different levels of simulation in a continuum of training will be discussed. Although simulation is relatively new to medicine, simulators have been used extensively for training and assessment in many other domains, most notably the aviation industry. Some parallels and differences will be highlighted.

Integrating human factors into the medical curriculum.

BACKGROUND: The study of human factors is a scientific discipline that deals with the interactions between human beings and the elements of a system. This is important because shortcomings in these areas, if unchecked, can result in adverse outcomes. Research into human factors in industries where safety is paramount has provided the basis of countermeasures against human error. Adverse outcomes in medicine resulting from human error exact a high cost in both patient suffering and financial outlay. CRM TRAINING: One of the approaches used to minimise the effect of human error is to train people in a set of knowledge, skills and attitudes that underpin the domain-specific competencies for that profession. These are referred to as non-technical skills (NTS). In aviation, such an approach has been shown to be both translatable from the training environment to the workplace and effective in reducing adverse outcomes. DISCUSSION: Medicine has incorporated this style of training, usually centred around simulator-based courses, but as yet in a piecemeal, episodic fashion which relies on participants volunteering to attend courses. Unlike other industries there is no systematic approach to linking the content of this teaching with the more conventional range of topics. As a consequence it is difficult to assess the impact of human factors training in medicine. This is partly because very little work has been done to date in identifying the key non-technical skills required in medicine, and the overall experience of workplace based assessment is limited. Lessons from other high reliability organisations may help to address the main challenges of developing the content, integrating it into the curriculum, reinforcing the concepts in the workplace through staff development and establishing its role in summative assessment.

Anaesthetists' Non-Technical Skills (ANTS): evaluation of a behavioural marker system.

BACKGROUND: Non-technical skills are critical for good anaesthetic practice but are not addressed explicitly in normal training. Realization of the need to train and assess these skills is growing, but these activities must be based on properly developed skills frameworks and validated measurement tools. A prototype behavioural marker system was developed using human factors research techniques. The aim of this study was to conduct an experimental evaluation to establish its basic psychometric properties and usability. METHOD: The Anaesthetists' Non-Technical Skills (ANTS) system prototype comprises four skill categories (task management, team working, situation awareness, and decision making) divided into 15 elements, each with example behaviours. To investigate its experimental validity, reliably and usability, 50 consultant anaesthetists were trained to use the ANTS system. They were asked to rate the behaviour of a target anaesthetist using the prototype system in eight videos of simulated anaesthetic scenarios. Data were collected from the ratings forms and an evaluation questionnaire. RESULTS: The results showed that the system is complete, and that the skills are observable and can be rated with acceptable levels of agreement and accuracy. The internal consistency of the system appeared sound, and responses regarding usability were very positive. CONCLUSIONS: The findings of the evaluation indicated that the ANTS system has a satisfactory level of validity, reliability and usability in an experimental setting, provided users receive adequate training. It is now ready to be tested in real training environments, so that full guidelines can be developed for its integration into the anaesthetic curriculum.

A comparison of non-invasive methods of blood pressure measurement in normotensive and hypertensive pregnant women.

We compared two types of automatic non-invasive blood pressure measuring device with sphygmomanometey in 47 normotensive and 38 hypertensive women in the third trimester of pregnancy. An automatic oscillometric device (Accutor) and a volume-clamp device (Finapres) significantly underestimated the diastolic pressure as measured by the fourth Korotkoff sound using a Hawksley random zero sphygmomanometer. The mean difference between the sphygmomanometer and Accutor measurement of diastolic blood pressure was +3.1 mmHg in the normotensive women and +8.3 mmHg in the hypertensive women (P = 0.001). The mean difference between the sphygmomanometer and Finapres measurement of diastolic blood pressure was +6.1 mmHg in the normotensive women and +11.5 mmHg in hypertensive women (P = 0.003). The increased use of continuous non-invasive devices to monitor blood pressure in women with hypertension should be accompanied by sound knowledge of their limitations in this group of patients.

Acoustic reflectometry for airway measurements in man: implementation and validation.

A practical implementation of acoustic reflectometry for determining airway areas in routine clinical use is described. Advances over previous systems include portability, free breathing during measurements, no need to equilibrate with helium/oxygen, and real-time display of airway areas. Validation of the reflectometer with an airway model gave accuracies and reproducibilities (coefficient of variation (CV)) in the range 5-10%. With human volunteers, the within-run CV was typically 10%, and the day-to-day CV was 20%. The effect of breathing pattern on airway areas is demonstrated. In ten normal volunteers, acoustic and magnetic resonance imaging (MRI) methods of assessing pharyngeal and glottal areas were compared. The results (mean +/- SD) for the oropharynx were 1.0 +/- 0.3 cm2 acoustically and 0.9 +/- 0.5 cm2 by MRI (p = 0.77). The corresponding figures for glottal areas were 1.3 +/- 0.3 cm2 and 1.1 +/- 0.4 cm2 (p = 0.09).