Non-Technical Skills for Surgeons (NOTSS): Critical appraisal of its measurement properties

Reframing the Morbidity and Mortality Conference: The Impact of a Just Culture

ABSTRACT

Morbidity and mortality (M&M) conferences are prevalent in all fields of medicine. Historically, they arose out a desire to improve medical care. Nevertheless, the goals of M&M conferences are often poorly defined, at odds with one another, and do not support a just culture. We differentiate among the various possible goals of an M&M and review the literature for strategies that have been shown to achieve these goals. Based on the literature, we outline an ideal M&M structure within the context of just culture: The process starts with robust adverse event and near miss reporting, followed by careful case selection, excluding cases solely attributable to individual error. Prior to the M&M, the case should be openly discussed with involved members and should be reviewed using a selected framework. The goal of the M&M should be selected and clearly defined, and the presentation format and rules of conduct should all conform to the selected presentation goal. The audience should ideally be multidisciplinary and multispecialty. The M&M should conclude with concrete tasks and assigned follow-up. The entire process should be conducted in a peer review protected format within an environment promoting psychological safety. We conclude with future directions for M&Ms.

Improving Pediatric Trauma Education by Teaching Non-technical Skills: A Randomized Controlled Trial

BACKGROUND

Pediatric trauma is a significant cause of child mortality, and the absence of non-technical skills (NTS) among health providers is linked with errors in patients' care. In this study, we evaluate the effectiveness of a structured debriefing protocol in enhancing NTS during pediatric trauma simulation.

METHODS

A total of 45 medical students were successfully recruited from two medical schools, one in Brazil and one in Canada. Medical students were assigned to a control (N = 20) or intervention group (N = 25) in a randomized control trial. Following simulated scenarios, participants in the intervention group underwent NTS debriefing, while the control received standard debriefing based on the Advanced Trauma Life Support (ATLS) protocol. Students' confidence, NTS level, and performance were measured through self-assessment surveys, the Non-Technical Skills for Surgeons (NOTSS) score, and adherence to the trauma protocol, respectively. Baseline characteristics and outcomes were compared using t-tests, Mann-Whitney, Wilcoxon signed-rank Kruskal-Wallis, ANOVA, and a repeated-measures ANCOVA. A significance level was set at p < 0.05.

RESULTS

The workshop increased students' confidence in leading trauma resuscitation regardless of their assignment to condition. While controlling for covariates, students in the intervention group significantly improved their overall NOTSS compared to those in the control and in all categories: situational awareness, decision-making, communication and teamwork, and leadership. The intervention teams also demonstrated a significant increase in completing trauma protocol steps.

CONCLUSION

Implementing structured debriefing focusing on NTS enhanced these skills and improved adherence to protocol among medical students managing pediatric trauma-simulated scenarios. These findings support integrating NTS training in pediatric trauma education.

LEVEL OF EVIDENCE

I.

Objective Nontechnical Skills Measurement Using Sensor-based Behavior Metrics in Surgical Teams

OBJECTIVE

The purpose of this study was to identify objective measures that predict surgeon nontechnical skills (NTS) during surgery.

BACKGROUND

NTS are cognitive and social skills that impact operative performance and patient outcomes. Current methods for NTS assessment in surgery rely on observation-based tools to rate intraoperative behavior. These tools are resource intensive (e.g., time for observation or manual labeling) to perform; therefore, more efficient approaches are needed.

METHOD

Thirty-four robotic-assisted surgeries were observed. Proximity sensors were placed on the surgical team and voice recorders were placed on the surgeon. Surgeon NTS was assessed by trained observers using the NonTechnical Skills for Surgeons (NOTSS) tool. NTS behavior metrics from the sensors included communication, speech, and proximity features. The metrics were used to develop mixed effect models to predict NOTSS score and in machine learning classifiers to distinguish between exemplar NTS scores (highest NOTSS score) and non-exemplar scores.

RESULTS

NTS metrics were collected from 16 nurses, 12 assistants, 11 anesthesiologists, and four surgeons. Nineteen behavior features and overall NOTSS score were significantly correlated (12 communication features, two speech features, five proximity features). The random forest classifier achieved the highest accuracy of 70% (80% F1 score) to predict exemplar NTS score.

CONCLUSION

Sensor-based measures of communication, speech, and proximity can potentially predict NOTSS scores of surgeons during robotic-assisted surgery. These sensing-based approaches can be utilized for further reducing resource costs of NTS and team performance assessment in surgical environments.

APPLICATION

Sensor-based assessment of operative teams' behaviors can lead to objective, real-time NTS measurement.

Effect of mini-course training in communication and teamwork on non-technical skills score in emergency residents: a prospective experimental study

BACKGROUND

Non-technical skill (NTS) teaching is a recent development in medical education that should be applied in medical education, especially in medical specialties that involve critically ill patients, resuscitation, and management, to promote patient safety and improve quality of care. Our study aimed to compare the effects of mini-course training in NTS versus usual practice among emergency residents.

METHODS

In this prospective (non-randomized) experimental study, emergency residents in the 2021-2022 academic year at Ramathibodi Hospital, a tertiary care university hospital, were included as participants. They were categorized into groups depending on whether they underwent a two-hour mini-course training on NTS (intervention group) or usual practice (control group). Each participant was assigned a mean NTS score obtained by averaging their scores on communication and teamwork skills given by two independent staff. The outcome was the NTS score before and after intervention at 2 weeks and 16 weeks.

RESULTS

A total of 41 emergency residents were enrolled, with 31 participants in the intervention group and 10 in the control group. The primary outcome, mean total NTS score after 2 weeks and 16 weeks, was shown to be significantly better in intervention groups than control groups (25.85 ± 2.06 vs. 22.30 ± 2.23; P < 0.01, 28.29 ± 2.20 vs. 23.85 ± 2.33; P < 0.01) although the mean total NTS score did not differ between the groups in pre-intervention period. In addition, each week the NTS score of each group increased 0.15 points (95% CI: 0.01-0.28, P = 0.03), although the intervention group showed greater increases than the control (0.24 points) after adjustment for time (95% CI: 0.08-0.39, P < 0.01).

CONCLUSION

Emergency residents who took an NTS mini-course showed improved mean NTS scores in communication and teamwork skills versus controls 2 weeks and 16 weeks after the training. Attention should be paid to implementing NTS in the curricula for training emergency residents.

TRIAL REGISTRATION

This trial was retrospectively registered in the Thai Clinical Trial Registry on 29/11/2022. The TCTR identification number is TCTR20221129006.

Personal Growth and Emotional Intelligence: Foundational Skills for the Leader

Emotional intelligence (EI) has gained popularity and is being seen as a necessity, spreading beyond the business world, and becoming universal. In that shift, medicine and medical education have started to see the importance. This is evident in mandatory curriculum and accreditation requirements. EI includes 4 primary domains with several subcompetencies under each domain. This article outlines several of the subcompetencies necessary for success as a physician, competencies that can be honed with targeted professional growth. Empathy, communication, conflict management, burnout, and leadership are discussed in an application way to help identify importance of and how to improve each.

Introduction to surgical coaching

Surgical coaching is a new approach to continuous professional development (CPD). Advocates claim that coaching improves surgical and non-technical skills, leading to enhanced performance and reduced stress and burnout. Widespread acceptance of coaching in the surgical community is limited due to a paucity of evidence, surgery-specific obstacles and lack of resources. This narrative review introduces what 'surgical coaching' is and describes its origins. Coaching techniques are based on live or video observation of procedures, followed by collaborative analysis, reflection and goal planning in a non-competitive setting aided by an expert, peer or lay coach. Technical skills improvements have been reported using coaching techniques, yet long-term influence on non-technical competencies, overall performance and surgeon wellbeing are largely hypothetical. There are clear potential benefits in the application of surgical coaching to daily surgical practice. However, significant knowledge gaps remain. Dedicated research into the short-term applicability and the long-term effects of surgical coaching are required.

Reliability of the Behaviorally Anchored Rating Scale (BARS) for assessing non-technical skills of medical students in simulated scenarios

PURPOSE

Caring for critically ill patients requires non-technical skills such as teamwork, communication, and task management. The Behaviorally Anchored Rating Scale (BARS) is a brief tool used to assess non-technical skills. The investigators determined inter- and intra-rater reliability of the BARS when used to assess medical students in simulated scenarios.

METHOD

The investigators created simulation scenarios for medical students during their pediatric clerkship. Content experts reviewed video recordings of the simulations and assigned BARS scores for four performance components (Situational Awareness, Decision-Making, Communication, and Teamwork) for the leader and for the team as a whole. Krippendorff's alpha with ordinal difference was calculated to measure inter- and intra-rater reliability.

RESULTS

Thirty medical students had recordings available for review. Inter- and intra-rater reliability for performance components were, respectively, Individual Situational Awareness (0.488, 0.638), Individual Decision-Making (0.529, 0.691), Individual Communication (0.347, 0.473), Individual Teamwork (0.414, 0.466), Team Situational Awareness (0.450, 0.593), Team Decision Making (0.423, 0.703), Team Communication (0.256, 0.517), and Team Teamwork (0.415, 0.490).

CONCLUSIONS

The BARS demonstrated limited reliability when assessing medical students during their pediatric clerkship. Given the unique needs of this population, a modified or new objective scoring system for assessing non-technical skills may be needed for medical students.

Mitigating the stress of transition: An exploration of the effects and effectiveness of a preparatory course for junior obstetric trainees transitioning to senior training roles

BACKGROUND

Attrition amongst obstetrics trainees is high worldwide and attributed to sources of stress and burnout. The role of formal education and simulation as a means to prepare trainees for stressful periods such as transition into senior roles is underexplored.

OBJECTIVE

This study set out to explore whether the creation of a dedicated educational intervention might positively influence burnout and self-estimated preparedness for practice among obstetric trainees transitioning into more senior roles.

STUDY DESIGN

A six-week preparatory training programme for year 2 trainees was created specifically for this study. The intervention used the flipped classroom design incorporating online learning that prepared participants for six simulation-based workshops. Participants were randomised by training cluster into an intervention group (n = 4) who participated in the educational intervention and a control group (n = 7) who received standard online and workplace training. The effects on trainee well-being was assessed using the Maslach burnout inventory (MBI) and a self-report questionnaire estimating preparedness for practice. Technical and non-technical skills were assessed using standardised OSAT and NOTSS assessment tools. The primary outcomes were MBI and preparedness for practice scores. Secondary outcomes included OSAT and NOTSS scores. Group comparisons were made using by t-test or Pearson Chi² analysis where appropriate.

RESULTS

The study indicated a positive, non-significant trend in pre-post burnout scores in the intervention group. The following improving trends were noted in all subscales: emotional exhaustion 21.5 ± 2.6 (pre-intervention 23 ± 6.2); depersonalisation 9.8 ± 4.0 (pre-intervention 12.3 ± 2.8); personal accomplishment 35.5 ± 6.51 (pre-intervention 33 ± 5.5). The educational intervention engendered an increase in self estimated preparedness for practice amongst the intervention group (p = 0.006). From a training perspective, increased preparedness was noted for the following practical skills: forceps delivery (p = 0.0001), rotational forceps delivery (p = 0.02), delivery of twins vaginally (p = 0.0007) and performing a pudendal block (p = 0.001).

CONCLUSION

This is one of the first studies to investigate whether the provision of a targeted training module can improve burnout scores and preparedness for practice amongst obstetrics trainees at an important time of transition. The positive but largely non-significant findings of this study should be examined in larger longitudinal and adequately powered studies.

Objective Measures of Surgeon Non-Technical Skills in Surgery: A Scoping Review

OBJECTIVE

The purpose of this study was to identify, synthesize, and discuss objective behavioral or physiological metrics of surgeons' nontechnical skills (NTS) in the literature.

BACKGROUND

NTS, or interpersonal or cognitive skills, have been identified to contribute to safe and efficient surgical performance; however, current assessments are subjective, checklist-based tools. Intraoperative skill evaluation, such as technical skills, has been previously utilized as an objective measure to address such limitations.

METHODS

Five databases in engineering, behavioral science, and medicine were searched following PRISMA reporting guidelines. Eligibility criteria included studies with NTS objective measurements, surgeons, and took place within simulated or live operations.

RESULTS

Twenty-three articles were included in this review. Objective metrics included communication metrics and measures from physiological responses such as changes in brain activation and motion of the eye. Frequencies of content-coded communication in surgery were utilized in 16 studies and were associated with not only the communication construct but also cognitive constructs of situation awareness and decision making. This indicates the underlying importance of communication in evaluating the NTS constructs. To synthesize the scoped literature, a framework based on the one-way communication model was used to map the objective measures to NTS constructs.

CONCLUSION

Objective NTS measurement of surgeons is still preliminary, and future work on leveraging objective metrics in parallel with current assessment tools is needed.

APPLICATION

Findings from this work identify objective NTS metrics for measurement applications in a surgical environment.

Evaluating teamwork development in combat training settings: An exploratory case study utilising the Junior Leaders' Field Gun competition

A behaviourally-anchored observational rating scale (BAORS) of teamwork based upon the 'Big Five' teamwork model (Salas et al., 2005) was selected and adapted for use in a combat training setting - a UK military field gun competition. The teamwork development of 16 newly-formed teams training to master a historic tactical drill was evaluated over the course of a week-long residential programme. Training culminated in a timed field gun competition. Teams were trained and mentored in respects to teamwork and taskwork by experienced military instructors. Teamwork was assessed at the outset and end of training. Significant improvements were evident on all teamwork process dimensions, with the greatest improvement seen in teams' shared understanding of teamwork roles and strategies (shared mental models). The lack of an association between teamwork development and final drill performance is explored, as is the utility of the measurement protocol developed for teamwork assessment in other settings.

Surgeons Are Not Pilots: Is the Aviation Safety Paradigm Relevant to Modern Surgical Practice?

Error in surgery is common, although not always consequential. Surgical outcomes are often compared to safety data from commercial aviation. This industry's performance is frequently referenced as an example of high-reliability that should be reproduced in clinical practice. Consequently, the aviation-surgery analogy forms the conceptual framework for much patient safety research, advocating for the translation of aviation safety tools to the healthcare setting. Nevertheless, overuse or incorrect application of this paradigm can be misleading and may result in ineffective quality improvement interventions. This article discusses the validity and relevance of the aviation-surgery comparison, providing the necessary context to improve its application at the bedside. It addresses technical and human factors training, as well as more novel performance domains such as professional culture and optimization of operators' condition. These are used to determine whether the aviation-surgery analogy is a valuable source of cross-professional learning or simply another safety cliché.

The Multifocal Approach to Sharing in Shared Decision Making: A Critical Appraisal of the MAPPIN'SDM

OBJECTIVE

Shared decision making integrates health care provider expertise with patient values and preferences. The MAPPIN'SDM is a recently developed measurement instrument that incorporates physician, patient, and observer perspectives during medical consultations. This review sought to critically appraise the development, sensibility, reliability, and validity of the MAPPIN'SDM and to determine in which settings it has been used.

METHODS

This critical appraisal was performed through a targeted review of the literature. Articles outlining the development or measurement property assessment of the MAPPIN'SDM or that used the instrument for predictor or outcome purposes were identified.

RESULTS

Thirteen studies were included. The MAPPIN'SDM was developed by both adapting and building on previous shared decision making measurement instruments, as well as through creation of novel items. Content validity, face validity, and item quality of the MAPPIN'SDM are adequate. Internal consistency ranged from 0.91 to 0.94 and agreement statistics from 0.41 to 0.92. The MAPPIN'SDM has been evaluated in several populations and settings, ranging from chronic disease to acute oncological settings. Limitations include high reading levels required for self-administered patient questionnaires and the small number of studies that have employed the instrument to date.

CONCLUSION

The MAPPIN'SDM generally shows adequate development, sensibility, reliability, and validity in preliminary testing and holds promise for shared decision making research integrating multiple perspectives. Further research is needed to develop its use in other patient populations and to assess patient understanding of complex item wording.

Gathering Validity Evidence to Adapt the Non-technical Skills for Surgeons (NOTSS) Assessment Tool to the United States Context

BACKGROUND

Nontechnical skills are of increasing focus for safe and effective performance in the operating room. Assessment tools have been developed in Europe, Africa, and Asia but not adapted to the unique aspects of surgical delivery in the United States. Our objective was to use the Non-Technical Skills for Surgeons (NOTSS) assessment tool as a basis to establish consensus on essential nontechnical skills for surgical trainees and practicing surgeons in the U.S surgical context.

STUDY DESIGN

A mixed-methods research design was used in the form of a modified Delphi process to build consensus on essential NOTSS. A panel of surgical experts from hospitals across the U.S used this iterative process in 4 rounds to generate, rate, and classify behaviors. The primary outcome was consensus on behaviors as being essential for surgeons to achieve the best patient outcomes in the operating room, with a median rating of ≥6 on a 7-point scale for inclusion.

RESULTS

A total of 10 surgical experts participated. One hundred and thirty eight behaviors were generated in Round 1, and reduced to 100 behaviors in Rounds 2 and 3 based on application of inclusion criteria. The final skill list consisted of behaviors in Situation Awareness (n = 26), Decision Making (n = 18), Teamwork (n = 25), and Leadership (n = 31). No additional NOTSS categories or elements emerged from the analysis. In Round 4, all 100 behaviors were successfully grouped into 12 nontechnical skills elements. Labels and definitions were reworded to reflect the U.S. context, and an appropriate assessment scale was selected.

CONCLUSIONS

A panel of surgical experts from across the U.S. reached consensus on the essential NOTSS to achieve the best patient outcomes in the operating room. These behaviors form an empirical basis for the first context-specific nontechnical skills assessment and training tool for practicing surgeons in the U.S.

Surgeon stress negatively affects their non-technical skills in the operating room

BACKGROUND

Poor surgeons' non-technical skills (NTS) and excessive stress and workload are known contributors to surgical errors. Our aim was to examine the relationship between surgeons' stress and workload, and their observed NTS intraoperatively.

METHODS

Surgeon's NTS were rated in the operating room (OR) by trained observers. Surgeon stress, workload, familiarity with the OR team, prior experience, and case difficulty were captured. Relationships between variables were assessed.

RESULTS

Fifteen surgeons participated in our study. Agreement among raters was high for NTS observations (ICC range = 0.56-0.96). Stress was negatively correlated with situation awareness, and workload was negatively correlated with decision making. Less familiarity among the team was correlated with higher stress.

CONCLUSIONS

Surgeons' stress and workload negatively affected their NTS in the OR. Further, unfamiliarity with the surgical team contributed to surgeon's stress. Methods to reduce surgeons' stress and workload such as mental skills training should be considered.

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.

Non-technical skills and device-related interruptions in minimally invasive surgery

BACKGROUND

Device-related interruptions in the operating room (OR) may create stress among health care providers and delays. Although non-technical skills (NTS) of the OR teams, such as situational awareness and communication, are expected to influence device-related interruptions, empirical data on this relationship are limited.

METHODS

We performed a prospective cohort study of 144 consecutive elective laparoscopic operations during 13 months. A data capture system called the OR Black Box® was used to characterize device-related interruptions, NTS, and distractions. Device-related interruptions were classified according to a priori established categories. Positive and negative NTS instances were identified according to validated measurement tools specific for nurses and surgeons. We assessed the relationship between NTS and device-related interruptions after adjusting for potential confounders.

RESULTS

A total of 86 device-related interruptions occurred in 48 of 144 operations (33%). They were most frequently classified as device failure (54%) followed by improper assembly (19%) and disconnection (14%). Medians of 1 [interquartile range (IQR) 0-3] and 1 (IQR 0-2) negative NTS instance per operation were demonstrated by nurses and surgeons, respectively. Medians of 28 (IQR 15-38) and 40 (IQR 28-118) positive NTS instances per operation were demonstrated by nurses and surgeons. In a multivariable analysis, a higher frequency of negative NTS instances demonstrated by nurses was associated with device-related interruptions after risk adjustment (Odds Ratio 1.33, p = 0.02).

CONCLUSIONS

In elective laparoscopic operations, an increased likelihood of device-related interruptions in the OR was associated with more frequent negative NTS demonstrations by nursing teams.

Continuing surgical education of non-technical skills

Background

The non-technical skills for surgeons (NOTSS) system was developed as a tool to assess surgical skills for patient safety during surgery. This study aimed to develop a NOTSS-based training system for surgical trainees to acquire non-technical skills using a chest surgery scenario in a wet lab.

Materials and methods

Trainees were categorized into three subgroups according to the years of experience as follows: Level A: 6 years or more; Level B: 3–5 years; and Level C: 1–2 years. Three stages of surgical procedure were designed: 1. chest wall resection and right upper lobe lobectomy, 2. right middle lobe sleeve lobectomy, and 3. right lower lobe lobectomy. One instructor was assigned to each operation table, who evaluated each participant's NOTSS scores consisting of 16 elements.

Results

When comparing average NOTSS score of all the three procedures, significant differences were observed between Level A, B, and C trainees. As an example of varying elements by procedure, Level A trainees demonstrated differences in Situation Awareness, and a significant difference was observed in Level C trainees regarding the elements of Decision Making. On the contrary, no significant difference was observed among Level B trainees. In the comparison between first-time and experienced participants, a significant improvement was observed in some elements in Level B and C trainees.

Conclusion

This study highlights the usefulness and feasibility of the NOTSS scoring system for surgeons with different experiences and the effectiveness of providing feedback to trainees during intraoperative handoffs in a wet lab.

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Team training was effective for trainees of different levels.

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Surgeons need continuing education of a non-technical skills.

Pushing boundaries of video review in trauma: using comprehensive data to improve the safety of trauma care

Adverse events and lapses in safety are identified after the fact and often discussed through postevent review. These rounds rely on personal recollection, information from patient charts and incident reports that are limited by retrospective data collection. This results in recall bias and inaccurate or insufficient detail related to timeline, incidence and nature adverse events. To better understand the interplay of the complex team and task-based challenges in the trauma bay, we have developed a synchronized data capture and analysis platform called the Trauma Black Box (Surgical Safety Technologies, Toronto). This system continuously acquires audiovisual, patient physiological and environmental data from a sophisticated array of wall-mounted cameras, microphones and sensors. Expert analysts and software-based algorithms then populate a data timeline of case events from start to finish, retaining a handful of anonymized video clippings to supplement the review. These data also provide a consistent and reliable method to track specific quality metrics, such as time to trauma team assembly or time to blood product arrival. Furthermore, data can also be linked to patients’ electronic medical records to explore relationships between initial trauma resuscitation and downstream patient-oriented outcomes. A video capture and data analysis system for the trauma bay overcomes the inherent deficiencies in the current standard for evaluating patient care in the trauma bay and offers exciting potential to enhance patient safety through a comprehensive data collection system.

Assessment of the Non-Technical Skills for Surgeons (NOTSS) framework in the USA

Background

Surgeons' non-technical skills are important for patient safety. The Non-Technical Skills for Surgeons assessment tool was developed in the UK and recently adapted to the US surgical context (NOTSS-US). The aim of this study was to evaluate the reliability and distribution of non-technical skill ratings given by attending (consultant) surgeons who underwent brief online training.

Methods

Attending surgeons across six specialties at a large US academic medical centre underwent a 10-min online training, then rated 60-s standardized videos of simulated operations. Intraclass correlation coefficient (ICC), and mean(s.d.) values for NOTSS-US ratings were determined for each non-technical skill category (score range 1–5, where 1 indicates poor, 3 average and 5 excellent) and for total NOTSS-US score (range 4–20; sum of 4 category scores). Outcomes were adjusted for rater characteristics including sex, specialty and clinical experience.

Results

A total of 8889 ratings were submitted by 81 surgeon raters on 30 simulated intraoperative videos. The mean(s.d.) total NOTSS-US score for all videos was 9·5(4·8) of 20. The within-video ICC for total NOTSS-US score was 0·64 (95 per cent c.i. 0·57 to 0·70). For individual non-technical skill categories, the ICC was highest for social skills (communication/teamwork: 0·63, 95 per cent c.i. 0·56 to 0·71; leadership: 0·64, 0·55 to 0·72) and lowest for cognitive skills (situation awareness: 0·54, 0·45 to 0·62; decision-making: 0·50, 0·41 to 0·59). Women gave higher total NOTSS-US scores than men (adjusted mean difference 0·93, 95 per cent c.i. 0·44 to 1·43; P = 0·001).

Conclusion

After brief online training, the inter-rater reliability of the NOTSS-US assessment tool achieved moderate strength among trained surgeons rating simulated intraoperative videos.

Performance assessment - The knowledge, skills and attitudes of surgical performance

Pediatric surgical education has traditionally focused on the hard cognitive and psychomotor (technical) skills. While more and more attention is being paid to softer skills such as communication, collaboration, leadership, health advocacy, professionalism and scholarship, the bulk of curricula remain focused on the hard skills. An intricate part of education is the assessment of performance. This article reviews the current literature on the assessment of cognitive and psychomotor skills, focusing particularly on the assessment of technical skills in the realm of simulation.

Leading article: What can we do to improve individual and team situational awareness to benefit patient safety?

It is increasingly being recognised that human factors can contribute to error in complex safety systems. Healthcare, however, has a long way to go before the promotion of training in, and awareness of, human factors will catch up with other high-risk organisations. A critical component that is deemed essential both for improving clinical performance and reducing medical error is situational awareness (SA). This is dynamic and can reduce quickly or be lost entirely, particularly when the workload is heavy. Tunnel vision, in which healthcare professionals concentrate on a single aspect of a patient's care, is just one example of reduced awareness that can be detrimental to safety. As in aviation and other high-risk organisations, a reduction in SA, if not recognised by individuals or the wider team, can lead to serious or potentially fatal outcomes. We therefore give an overview of SA and show how it can easily be reduced. We also suggest some simple but effective ways to improve it and in turn improve patient safety. We emphasise the importance of clinical teams looking out for each other, particularly in the operating theatre.

The importance of non-technical skills in modern surgical practice

The significance of technical skills and manual dexterity for surgeons is an indisputable fact. However, the systematic study of medical errors has revealed that a significant percentage of these errors are caused by factors related to non-technical skills. The review presented in this article intends to describe and explore the relevance of these non-technical skills, including: situational awareness, decision-making, leadership and communication. In conclusion, the authors propose that adequate importance needs to be given to these aptitudes to provide safe clinical care.