The Effect of Educational Intervention on the Improvement of Nontechnical Skills in Circulating Nurses

Background

Nontechnical skills are necessary for clinicians' safe performance and prevention of errors in the operating room. Educational intervention is a useful way to improve these skills, which are a vital area for improvement. Circulating nurses are surgical team members whose work depends heavily on using nontechnical skills. This study is aimed at assessing the effect of an educational intervention on the improvement of circulating nurses' nontechnical skills.

Methods

This semiexperimental study was conducted on 300 circulating nurses divided into the intervention and no intervention groups each containing 150 participants. The nontechnical skills were assessed using the circulating practitioners' list of nontechnical skills. Then, the intervention group received training regarding these skills, and the two groups were evaluated again. After all, the data were entered into the SPSS 24 software and were analyzed using descriptive statistics and Wilcoxon and Mann–Whitney tests. Furthermore, Kendall's tau, independent sample t-test, and one-way ANOVA were used for assessment of relationship between median scores and demographics.

Results

The results revealed a significant improvement in the scores of all domains of nontechnical skills in the intervention group (p < 0.05). The highest and lowest improvements were observed in teamwork (42%) and situational awareness (16.7%), respectively. After the intervention, the scores of some of the behaviors were still below the average level or were not improved significantly.

Conclusions

Circulating nurses' nontechnical skills can be improved by educational interventions. However, regarding the low scores or no improvements in the scores of some behaviors, other intervention types such as policymaking and correcting the existing hierarchies in the operating room can be useful to complete the educational interventions.

Safety implications of fatigue and sleep inertia for emergency services personnel

Emergency services present a unique operational environment for the management of fatigue and sleep inertia. Communities request and often expect the provision of emergency services on a 24/7/365 basis. This can result in highly variable workloads and/or significant need for on-demand or on-call working time arrangements. In turn, the management of fatigue-related risk requires a different approach than in other more predictable shift working sectors (e.g., mining and manufacturing). The aim of this review is to provide a comprehensive overview of fatigue risk management that is accessible to regulators, policy makers and organisations in the emergency services sector. The review outlines the unique fatigue challenges in the emergency services sector, examines the current scientific and policy consensus around managing fatigue and sleep inertia, and finally discusses strategies that emergency services organisations can use to minimise the risks associated with fatigue and sleep inertia.

The NOTECHS+: A Short Scale Designed for Assessing the Non-technical Skills (and more) in the Aviation and the Emergency Personnel

This research presents the development of a short scale named “NOTECHS+” to measure the Non-Technical Skills (i.e., NOTECHS: Cooperation, Leadership and Managerial skills, Decision-Making, and Situational Awareness), Resilience and Emotion Regulation, in a sector that comprises the aviation and the emergency personnel: the Helicopter Emergency Medical Service (HEMS). The design process of the scale was carried out starting from a review on the behavioral markers used to detect the NOTECHS. Moreover, 70 interviews with HEMS experts have been conducted with the aim of developing Resilience and Emotion Regulation items by considering the different professional profiles (e.g., pilots, nurses, physicians, etc.) which compose the HEMS. Through a pre-assessment procedure, a Q-Sort test was performed on a sample of students (n = 30) to test the logical principles, but also intelligibility and clarity, of the items developed. Once the instrument was defined, 211 participants from the HEMS sector were surveyed to test the theoretical model behind the NOTECHS+ instrument. First exploratory and then confirmatory analysis yielded results that suggested that the 18 items selected conform to a bi-factor model composed of three skill-dimensions: Social skills (i.e., Cooperation, and Leadership and Managerial skills), Cognitive skills (i.e., Decision-Making and Situational Awareness) and Emotional skills (i.e., Resilience and Emotional Regulation). Finally, the study ends with a discussion on the results obtained, including practical implications on assessment and training based on this novel instrument.

Evaluating non-technical skills and mission essential competencies of pilots in military aviation environments

To develop and validate a classification of non-technical skills (NTS) in military aviation, a study was conducted, using data from real operations of F16 aircraft formations. Phase 1 developed a NTS classification based on the literature review (e.g. NOTECHS) and a workshop with pilots. The Non-TEChnical-MILitary-Skills (NOTEMILS) scheme was tested in Phase 2 in a series of Principal Component Analysis with data from After-Action-Review sessions (i.e. 900 records from a wide range of operations). The NTS were found to make a good prediction of Mission Essential Components (R² > 0.80) above the effect of experience. Phase 3 undertook a reliability analysis where three raters assessed the NOTEMILS scheme with good results (i.e. all r_wg > 0.80). To look into the consistency of classifications, another test indicated that, at least, two out of three raters were in agreement in over 70% of the assessed flight segments. Practitioner Summary: A classification scheme of Non-Technical Skills (NTS) was developed and tested for reliability in military aviation operations. The NTS scheme is a valuable tool for assessing individual and team skills of F-16 pilots in combat. It is noteworthy that the tool had a good capability of predicting Mission Essential Competencies.

What went right? An analysis of the protective factors in aviation near misses

Learning from successful safety outcomes, or what went right, is an important emerging component of maintaining safe systems. Accordingly, there are increasing calls to study normal performance in near misses as a part of safety management activities. Despite this, there is limited guidance on how to accomplish this in practice. This article presents a study in which using Rasmussen's risk management framework to analyse 16 serious incidents from the aviation domain. The findings show that a network of protective factors prevents accidents with factors identified across the sociotechnical system. These protective networks share many properties with those identified in accidents. The article demonstrates that is possible to identify these networks of protective factors from incident investigation reports. The theoretical implications of these results and future research opportunities are discussed. Practitioner Statement: The analysis of near misses is an important part of safety management activities. This article demonstrates that Rasmussen?s risk management framework can be used to identify networks of protective factors which prevent accidents. Safety practitioners can use the framework described to discover and support the system-wide networks of protective factors.

Non-technical skills of surgical trainees and experienced surgeons

Background

In addition to technical expertise, surgical competence requires effective non-technical skills to ensure patient safety and maintenance of standards. Recently the Royal Australasian College of Surgeons implemented a new Surgical Education and Training (SET) curriculum that incorporated non-technical skills considered essential for a competent surgeon. This study sought to compare the non-technical skills of experienced surgeons who completed their training before the introduction of SET with the non-technical skills of more recent trainees.

Methods

Surgical trainees and experienced surgeons undertook a simulated scenario designed to challenge their non-technical skills. Scenarios were video recorded and participants were assessed using the Non-Technical Skills for Surgeons (NOTSS) scoring system. Participants were divided into subgroups according to years of experience and their NOTSS scores were compared.

Results

For most NOTSS elements, mean scores increased initially, peaking around the time of Fellowship, before decreasing roughly linearly over time. There was a significant downward trend in score with increasing years since being awarded Fellowship for six of the 12 NOTSS elements: considering options (score −0·015 units per year), implementing and reviewing decisions (−0·020 per year), establishing a shared understanding (−0·014 per year), setting and maintaining standards (−0·024 per year), supporting others (−0·031 per year) and coping with pressure (−0·015 per year).

Conclusion

The drop in NOTSS score was unexpected and highlights that even experienced surgeons are not immune to deficiencies in non-technical skills. Consideration should be given to continuing professional development programmes focusing on non-technical skills, regardless of the level of professional experience.

The Development and Deployment of a Maintenance Operations Safety Survey

OBJECTIVE

Based on the line operations safety audit (LOSA), two studies were conducted to develop and deploy an equivalent tool for aircraft maintenance: the maintenance operations safety survey (MOSS).

BACKGROUND

Safety in aircraft maintenance is currently measured reactively, based on the number of audit findings, reportable events, incidents, or accidents. Proactive safety tools designed for monitoring routine operations, such as flight data monitoring and LOSA, have been developed predominantly for flight operations.

METHOD

In Study 1, development of MOSS, 12 test peer-to-peer observations were collected to investigate the practicalities of this approach. In Study 2, deployment of MOSS, seven expert observers collected 56 peer-to-peer observations of line maintenance checks at four stations. Narrative data were coded and analyzed according to the threat and error management (TEM) framework.

RESULTS

In Study 1, a line check was identified as a suitable unit of observation. Communication and third-party data management were the key factors in gaining maintainer trust. Study 2 identified that on average, maintainers experienced 7.8 threats (operational complexities) and committed 2.5 errors per observation. The majority of threats and errors were inconsequential. Links between specific threats and errors leading to 36 undesired states were established.

CONCLUSION

This research demonstrates that observations of routine maintenance operations are feasible. TEM-based results highlight successful management strategies that maintainers employ on a day-to-day basis.

APPLICATION

MOSS is a novel approach for safety data collection and analysis. It helps practitioners understand the nature of maintenance errors, promote an informed culture, and support safety management systems in the maintenance domain.

Error management for musicians: an interdisciplinary conceptual framework

Musicians tend to strive for flawless performance and perfection, avoiding errors at all costs. Dealing with errors while practicing or performing is often frustrating and can lead to anger and despair, which can explain musicians’ generally negative attitude toward errors and the tendency to aim for flawless learning in instrumental music education. But even the best performances are rarely error-free, and research in general pedagogy and psychology has shown that errors provide useful information for the learning process. Research in instrumental pedagogy is still neglecting error issues; the benefits of risk management (before the error) and error management (during and after the error) are still underestimated. It follows that dealing with errors is a key aspect of music practice at home, teaching, and performance in public. And yet, to be innovative, or to make their performance extraordinary, musicians need to risk errors. Currently, most music students only acquire the ability to manage errors implicitly – or not at all. A more constructive, creative, and differentiated culture of errors would balance error tolerance and risk-taking against error prevention in ways that enhance music practice and music performance. The teaching environment should lay the foundation for the development of such an approach. In this contribution, we survey recent research in aviation, medicine, economics, psychology, and interdisciplinary decision theory that has demonstrated that specific error-management training can promote metacognitive skills that lead to better adaptive transfer and better performance skills. We summarize how this research can be applied to music, and survey-relevant research that is specifically tailored to the needs of musicians, including generic guidelines for risk and error management in music teaching and performance. On this basis, we develop a conceptual framework for risk management that can provide orientation for further music education and musicians at all levels.

Hangar talk survey: using stories as a naturalistic method of informing threat and error management training

OBJECTIVE

The current study developed an online hangar talk survey (HTS) to solicit narratives describing challenging scenarios that professional pilots encountered during the hours-building phase of their career.

BACKGROUND

The predicted pilot shortage will effectively reduce the minimum flying hours required for pilots to be hired at an airline, resulting in less opportunity to develop nontechnical skills naturalistically. To compensate, threat and error data from the hours-building phase of a pilot's career are required to inform training development. Pilots often share stories of such experiences, colloquially termed "hangar talk".

METHOD

The HTS gathered 132 narrative descriptions of general aviation (GA) events from pilots along with the event's impact and whether the pilots would react differently if the scenario were encountered again.

RESULTS

The distribution of threats reported by GA pilots was similar to that reported at the airline level. Logistic regression analysis revealed that decision-making errors were associated with recognition of the need to react differently in the future, and decision-making errors and proficiency errors were associated with greater perceived impact on skill development.

CONCLUSION

The current HTS solicited an array of data similar to the findings of airline-based threat and error observations. Pilots perceive decision-making and proficiency errors as impactful on skill development.

APPLICATION

An HTS can be used to gather naturalistic threat and error data and to create a database of operational stories that can be used to develop nontechnical training based on narrative thought.

Developing a Single-Pilot Line Operations Safety Audit

A single-pilot form of the line operations safety audit was trialed with a mid-sized emergency medical service air operator using two observers with a sample of pilots flying 14 sectors. The conceptual basis for observing pilot performance and analyzing data was the threat and error management model, focusing on threats, errors, undesired aircraft states, and their management. Forty-six threats and 42 crew errors were observed. Pilots generally used sound strategies to prevent errors and to manage successfully those that occurred. Threats resulting from operational pressures were well managed. The study achieved its objective of determining whether a single-pilot line operations safety audit could be successfully developed and used as a basis for systematic data collection.

A systems perspective of managing error recovery and tactical re-planning of operating teams in safety critical domains

INTRODUCTION

Research in human error has provided useful tools for designing procedures, training, and intelligent interfaces that trap errors at an early stage. However, this "error prevention" policy may not be entirely successful because human errors will inevitably occur. This requires that the error management process (e.g., detection, diagnosis and correction) must also be supported. Research has focused almost exclusively on error detection; little is known about error recovery, especially in the context of safety critical systems. The aim of this paper is to develop a research framework that integrates error recovery strategies employed by experienced practitioners in handling their own errors.

METHOD AND RESULTS

A control theoretic model of human performance was used to integrate error recovery strategies assembled from reviews of the literature, analyses of near misses from aviation and command & control domains, and observations of abnormal situations training at air traffic control facilities. The method of system dynamics has been used to analyze and compare error recovery strategies in terms of patterns of interaction, system affordances, and types of recovery plans. System dynamics offer a promising basis for studying the nature of error recovery management in the context of team interactions and system characteristics.

IMPACT ON INDUSTRY

The proposed taxonomy of error recovery strategies can help human factors and safety experts to develop resilient system designs and training solutions for managing human errors in unforeseen situations; it may also help incident investigators to explore why people's actions and assessments were not corrected at the time.

The breakdown of coordinated decision making in distributed systems

OBJECTIVE

This article aims to explore the nature and resolution of breakdowns in coordinated decision making in distributed safety-critical systems.

BACKGROUND

In safety-critical domains, people with different roles and responsibilities often must work together to make coordinated decisions while geographically distributed. Although there is likely to be a large degree of overlap in the shared mental models of these people on the basis of procedures and experience, subtle differences may exist.

METHOD

Study 1 involves using Aviation Safety Reporting System reports to explore the ways in which coordinated decision making breaks down between pilots and air traffic controllers and the way in which the breakdowns are resolved. Study 2 replicates and extends those findings with the use of transcripts from the Apollo 13 National Aeronautics and Space Administration space mission.

RESULTS

Across both studies, breakdowns were caused in part by different types of lower-level breakdowns (or disconnects), which are labeled as operational, informational, or evaluative. Evaluative disconnects were found to be significantly harder to resolve than other types of disconnects.

CONCLUSION

Considering breakdowns according to the type of disconnect involved appears to capture useful information that should assist accident and incident investigators. The current trend in aviation of shifting responsibilities and providing increasingly more information to pilots may have a hidden cost of increasing evaluative disconnects.

APPLICATION

The proposed taxonomy facilitates the investigation of breakdowns in coordinated decision making and draws attention to the importance of considering subtle differences between participants' mental models when considering complex distributed systems.

The advancement of a new human factors report--'The Unique Report'--facilitating flight crew auditing of performance/operations as part of an airline's safety management system

This paper presents the findings of research relating to the specification of a new human factors report, conducted as part of the work requirements for the Human Integration into the Lifecycle of Aviation Systems project, sponsored by the European Commission. Specifically, it describes the proposed concept for a unique report, which will form the basis for all operational and safety reports completed by flight crew. This includes all mandatory and optional reports. Critically, this form is central to the advancement of improved processes and technology tools, supporting airline performance management, safety management, organisational learning and knowledge integration/information-sharing activities. Specifically, this paper describes the background to the development of this reporting form, the logic and contents of this form and how reporting data will be made use of by airline personnel. This includes a description of the proposed intelligent planning process and the associated intelligent flight plan concept, which makes use of airline operational and safety analyses information. Primarily, this new reporting form has been developed in collaboration with a major Spanish airline. In addition, it has involved research with five other airlines. Overall, this has involved extensive field research, collaborative prototyping and evaluation of new reports/flight plan concepts and a number of evaluation activities. Participants have included both operational and management personnel, across different airline flight operations processes. Statement of Relevance: This paper presents the development of a reporting concept outlined through field research and collaborative prototyping within an airline. The resulting reporting function, embedded in the journey log compiled at the end of each flight, aims at enabling employees to audit the operations of the company they work for.

Crew Resource Management

Healthcare organizations continue their struggle to establish a culture of open communication and collaboration. Lessons are learned from the aviation industry, which long ago acknowledged that most errors were the result of poor communication and coordination rather than individual mistakes. The author presents a review of how some healthcare organizations have successfully adopted aviation's curriculum called Crew Resource Management, which promotes and reinforces the conscious, learned team behaviors of cooperation, coordination, and sharing.