The development of the helicopter non-technical skills (HeliNOTS) behavioural marker systems

Behavioural marker systems (observational frameworks geared towards the assessment of non-technical skills by way of behavioural markers) exist across a variety of high-risk occupations, however, no identifiable system currently exists developed from rotary operative data. In this study, discussion groups (n = 9) were undertaken with subject matter experts (n = 20)-including pilots and technical crew operating across search and rescue and offshore transport environments-with the objective of identifying role-specific behavioural markers. Systems were reviewed on an iterative basis by the academic team and received final reviews by additional subject matter experts (n = 6). Two behavioural marker systems were constructed: HeliNOTS (O) for offshore transport pilots and HeliNOTS (SAR) for search and rescue crews; each with domain-specific behavioural markers. Both represent a significant step towards a nuanced approach to training and assessment of helicopter flight crews' non-technical skills and are the first publicly available systems tailored to these distinct mission types.Practitioner summary: There is no publicly available behavioural marker system based on data from rotary operatives. Across this study, two prototype systems were developed: HeliNOTS (SAR) for helicopter search and rescue, and HeliNOTS (O) for helicopter offshore transport. Both HeliNOTS systems represent a nuanced approach towards rotary CRM training and assessment.

Human factors in anaesthesia: a narrative review

Healthcare relies on high levels of human performance, as described by the 'human as the hero' concept. However, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. Human factors is a broad-based scientific discipline which aims to make it as easy as possible for workers to do things correctly. The human factors strategies most likely to be effective are those which 'design out' the chance of an error or adverse event occurring. When errors or adverse events do happen, barriers are in place to trap them and reduce the risk of progression to patient and/or worker harm. If errors or adverse events are not trapped by these barriers, mitigations are in place to minimise the consequences. Non-technical skills form an important part of human factors barriers and mitigation strategies and include: situation awareness; decision-making; task management; and team working. Human factors principles are not a substitute for proper investment and appropriate staffing levels. Although applying human factors science has the potential to save money in the long term, its proper implementation may require investment before reward can be reaped. This narrative review describes what is known about human factors in anaesthesia to date.

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists: Guidelines from the Difficult Airway Society and the Association of Anaesthetists

Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker well-being. The implementation of human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. To encourage the adoption of human factors science in anaesthesia, the Difficult Airway Society and the Association of Anaesthetists established a Working Party, including anaesthetists and operating theatre team members with human factors expertise and/or interest, plus a human factors scientist, an industrial psychologist and an experimental psychologist/implementation scientist. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a 'hierarchy of controls' model and classified into design, barriers, mitigations and education and training strategies. Although most anaesthetic knowledge of human factors concerns non-technical skills, such as teamwork and communication, human factors is a broad-based scientific discipline with many other additional aspects that are just as important. Indeed, the human factors strategies most likely to have the greatest impact are those related to the design of safe working environments, equipment and systems. While our recommendations are primarily provided for anaesthetists and the teams they work with, there are likely to be lessons for others working in healthcare beyond the speciality of anaesthesia.

Building a transdisciplinary expert consensus on the cognitive drivers of performance under pressure: An international multi-panel Delphi study

Introduction

The ability to perform optimally under pressure is critical across many occupations, including the military, first responders, and competitive sport. Despite recognition that such performance depends on a range of cognitive factors, how common these factors are across performance domains remains unclear. The current study sought to integrate existing knowledge in the performance field in the form of a transdisciplinary expert consensus on the cognitive mechanisms that underlie performance under pressure.

Methods

International experts were recruited from four performance domains [(i) Defense; (ii) Competitive Sport; (iii) Civilian High-stakes; and (iv) Performance Neuroscience]. Experts rated constructs from the Research Domain Criteria (RDoC) framework (and several expert-suggested constructs) across successive rounds, until all constructs reached consensus for inclusion or were eliminated. Finally, included constructs were ranked for their relative importance.

Results

Sixty-eight experts completed the first Delphi round, with 94% of experts retained by the end of the Delphi process. The following 10 constructs reached consensus across all four panels (in order of overall ranking): (1) Attention; (2) Cognitive Control-Performance Monitoring; (3) Arousal and Regulatory Systems-Arousal; (4) Cognitive Control-Goal Selection, Updating, Representation, and Maintenance; (5) Cognitive Control-Response Selection and Inhibition/Suppression; (6) Working memory-Flexible Updating; (7) Working memory-Active Maintenance; (8) Perception and Understanding of Self-Self-knowledge; (9) Working memory-Interference Control, and (10) Expert-suggested-Shifting.

Discussion

Our results identify a set of transdisciplinary neuroscience-informed constructs, validated through expert consensus. This expert consensus is critical to standardizing cognitive assessment and informing mechanism-targeted interventions in the broader field of human performance optimization.

State of science: models and methods for understanding and enhancing teams and teamwork in complex sociotechnical systems

This state of the science review brings together the disparate literature of effective strategies for enhancing and accelerating team performance. The review evaluates and synthesises models and proposes recommended avenues for future research. The two major models of the Input-Mediator-Output-Input (IMOI) framework and the Big Five dimensions of teamwork were reviewed and both will need significant development for application to future teams comprising non-human agents. Research suggests that a multi-method approach is appropriate for team measurements, such as the integration of methods from self-report, observer ratings, event-based measurement and automated recordings. Simulations are recommended as the most effective team-based training interventions. The impact of new technology and autonomous agents is discussed with respect to the changing nature of teamwork. In particular, whether existing teamwork models and measures are suitable to support the design, operation and evaluation of human-nonhuman teams of the future. Practitioner summary: This review recommends a multi-method approach to the measurement and evaluation of teamwork. Team models will need to be adapted to describe interaction with non-human agents, which is what the future is most likely to hold. The most effective team training interventions use simulation-based approaches.

Drillers’ Cognitive Skills Monitoring Task

Drilling incidents have emphasized that offshore drillers require a high level of cognitive skills, including situation awareness and decision making, to maintain safe and efficient well control. Although a number of tools for supporting operators’ cognition are available in other high-risk industries, there is no specific tool for drilling. We developed a prototype monitoring task simulating drilling scenarios, Drillers’ Situation Awareness Task, with drilling experts and piloted with 14 drilling personnel. Preliminary results suggest that it is viable as a tool for examining drillers’ cognition and has the potential for training and formatively assessing cognitive skills in drilling.

Car driver attitudes, perceptions of social norms and aggressive driving behaviour towards cyclists

The interaction of car drivers and cyclists is one of the main causes of cycle incidents. The role of attitudes and social norms in shaping car drivers' aggressive behaviour towards cyclists, is not well understood and merits investigation. A sample of 276 drivers completed an online questionnaire concerning their attitudes towards cyclists, attitudes towards risky driving, perception of social norms concerning aggressive driving towards cyclists, and the frequency with which they engage in such aggressive driving behaviours. The results showed that attitudes towards cyclists, as well as social norm perceptions concerning aggressive driving towards cyclists, were associated with aggressive driving towards cyclists. Negative attitudes towards cyclists were more pronounced in non-cyclists than cyclists and their association with aggressive driving behaviour was stronger in cyclists than non-cyclists. The perception of social norms concerning aggressive driving towards cyclists had a stronger association with aggressive driving in non-cyclists than cyclists. Attitudes towards risk taking did not affect aggressive driving towards cyclists. These findings can inform campaigns that aim to improve cyclist and car driver interaction on the roads, making them safer to use for cyclists.

"They seem to be able to read your mind." An interview study to identify the cognitive non-technical skills of anaesthetic assistants

The aim of this study was to identify the cognitive non-technical skills (i.e. situation awareness and decision making) used by anaesthetic assistants, as part of the development of a specialty-specific behavioural rating system for anaesthetic assistants. Semi-structured interviews were conducted with anaesthetic assistants (n=22), anaesthetic consultants (n=11) and trainee anaesthetists (n=12) in Scotland. The interviews were transcribed and thematically analysed. All 45 participants described the presence or failure of situation awareness (i.e. gathering information, its comprehension and anticipation) in 713 phrases. Decision making (i.e. considering options, selecting actions and reviewing decisions) by the anaesthetic assistants was reported much less frequently--only 34 participants described 89 phrases. Situation awareness is a key non-technical skill used by anaesthetic assistants, however decision making was less commonly described as required by anaesthetic assistants. This provides qualitative data to support the development of a non-technical skills taxonomy for anaesthetic assistants.

The non-technical skills used by anaesthetic technicians in critical incidents reported to the Australian Incident Monitoring System between 2002 and 2008

The outcome of critical incidents in the operating theatre has been shown to be influenced by the behaviour of anaesthetic technicians (ATs) assisting anaesthetists, but the specific non-technical skills involved have not been described. We performed a review of critical incidents (n=1433) reported to the Australian Incident Monitoring System between 2002 and 2008 to identify which non-technical skills were used by ATs. The reports were assessed if they mentioned anaesthetic assistance or had the boxes ticked to identify "inadequate assistance" or "absent supervision or assistance". A total of 90 critical incidents involving ATs were retrieved, 69 of which described their use of non-technical skills. In 20 reports, the ATs ameliorated the critical incident, whilst in 46 they exacerbated the critical incident, and three cases had both positive and negative non-technical skills described. Situation awareness was identified in 39 reports, task management in 23, teamwork in 21 and decision-making in two, but there were no descriptions of issues related to leadership, stress or fatigue management. Situation awareness, task management and teamwork appear to be important non-technical skills for ATs in the development or management of critical incidents in the operating theatre. This analysis has been used to support the development of a non-technical skills taxonomy for anaesthetic assistants.

Staying in the zone: offshore drillers' situation awareness

OBJECTIVE

The aim of this study was to identify the cognitive components required for offshore drillers to develop and maintain situation awareness (SA) while controlling subsea hydrocarbon wells.

BACKGROUND

SA issues are often identified as contributing factors to drilling incidents, most recently in the Deepwater Horizon blowout. Yet, there is a limited body of research investigating SA in the offshore drilling environment.

METHOD

In the first study, critical incident interviews were conducted with 18 experienced drilling personnel. Transcripts were subjected to theory-driven thematic analysis, producing a preliminary cognitive framework of how drillers develop and maintain SA during well control. In the second study, 24 hr of observations (in vivo and video) of drillers managing a high fidelity well-control simulator were analyzed to further develop the framework.

RESULTS

The cognitive components that enable drillers to build up an understanding of what is happening in the wellbore and surrounding environment, to predict how this understanding may develop, were identified. These components included cue recognition, interpretation of information in conjunction with the current mental model, and projection through mental simulation. Factors such as distracters, expectations, and information sharing between crew members can both positively and negatively influence the drillers' SA.

CONCLUSION

The findings give a preliminary understanding into the components of drillers' SA, highlighting the importance of SA for safe and effective performance and indicating that Endsley's model of SA can be applied to drilling.

APPLICATION

The results have consequences for training, task management, and work design recommendations.

Non-technical skills of the scrub practitioner: the SPLINTS system

This article describes the nontechnical skill set, and behavioural rating tool, for scrub practitioners/nurses (e.g. perioperative registered nurses; operating room technicians) known as the Scrub Practitioners' List of Intraoperative NonTechnical Skills or the SPLINTS system. The SPLINTS system was developed at the Industrial Psychology Research Centre of the University of Aberdeen, Scotland, by a research team comprising psychologists, scrub nurses, and a surgeon. Details of the system were presented, by Rhona Flin, at the ORNAC National and International Conference with IFPN, in Ottawa, in April of 2013. This article outlines the background of the research project and the method used to develop the SPLINTS system and suggests why it might be a valuable training and assessment tool for scrub practitioners in Canada.

Safety intelligence: an exploration of senior managers' characteristics

Senior managers can have a strong influence on organisational safety. But little is known about which of their personal attributes support their impact on safety. In this paper, we introduce the concept of 'safety intelligence' as related to senior managers' ability to develop and enact safety policies and explore possible characteristics related to it in two studies. Study 1 (N = 76) involved direct reports to chief executive officers (CEOs) of European air traffic management (ATM) organisations, who completed a short questionnaire asking about characteristics and behaviours that are ideal for a CEO's influence on safety. Study 2 involved senior ATM managers (N = 9) in various positions in interviews concerning their day-to-day work on safety. Both studies indicated six attributes of senior managers as relevant for their safety intelligence, particularly, social competence and safety knowledge, followed by motivation, problem-solving, personality and interpersonal leadership skills. These results have recently been applied in guidance for safety management practices in a White Paper published by EUROCONTROL.

Non-technical skills: enhancing safety in operating theatres (and drilling rigs)

On April 20th 2010, a large Transocean drilling rig called the Deepwater Horizon was operating in the Gulf of Mexico to drill the Macondo well, for the oil company BP. The job was six weeks behind schedule and $58 million over budget and had not been without difficulty: it was a high pressure well, 2.5 miles below the seabed. At 5.45 am, the Halliburton cementing engineer sent an email to say: 'We have completed the job and it went well'. At 9.43 pm, 16 hours later, there was a release of hydrocarbons into the well bore and the drilling rig experienced a catastrophic blowout as the high pressure oil and gas escaped onto the rig and into the ocean. The resulting explosions and fire killed 11 of the crew of 126, injured many more and created an enormous oil spill across the Gulf.

Eye movements in surgery : A literature review

h recent advances in eye tracking technology, it is now possible to track surgeons’ eye movements while engaged in a surgical task or when surgical residents practice their surgical skills. Several studies have compared eye movements of surgical experts and novices, developed techniques to assess surgical skill on the basis of eye movements, and examined the role of eye movements in surgical training. We here provide an overview of these studies with a focus on the methodological aspects. We conclude that the different studies of eye movements in surgery suggest that the recording of eye movements may be beneficial both for skill assessment.

The epistemology of patient safety research

Patient safety has only recently been subjected to wide-spread systematic study. Healthcare differs from other high risk industries in being more diverse and multi-contextual, and less certain and regulated. Also many patient safety problems are low-frequency events associated with many, varied contributing factors. The subject of this paper is the epistemology of patient safety (the science of the method of finding out about patient safety). Patient safety research is considered here on the background of a risk management framework which requires researchers to: •  Understand the context - as a subset of healthcare quality, services and systems research, with technical and human behavioural (cultural) components and a range of external and internal organisational influences, a wide range of research disciplines is necessary •  Identify the risks - identify the things that go wrong and the frequency and nature of different types of incidents from sources such as medical record review, observational studies, audit, incident and medico-legal reports •  Analyse the risks - deconstruct the things that go wrong, identifying contributing factors and trying to detect trends and patterns in contributing factors, detection, mitigation factors, ameliorating factors and actions taken to reduce risk •  Evaluate the risks - decide on priorities, identifying preventive and corrective strategies and judging the risk- and cost-benefit of potential corrective strategies such as standardisation or simplification of a process or device •  Manage the risk - evaluate and scope preventive and/or corrective strategies and then implement these, or place the problem on a risk register pending solution, or accept that what is needed is unaffordable •  Communicate and consult - use interactive sessions, audit, on-going feedback, reminders and patient mediated prompts •  Monitor and review the state of the problem - get baseline trends and patterns so that changes can be tracked and properly attributed to an intervention A hierarchy of levels of evidence has been proposed for clinical research and we argue that insufficient weighting has been given to lower ranked levels of research and to qualitative research, although critical interpretive synthesis is now gaining acceptance in mainstream thinking (e.g. by the Cochrane Collaboration). Fundamental challenges remain including how to grasp the elusive concept of patient safety, how to quantify, characterise and cost the problems, how to judge the extent to which harm can be attributed to errors, violations or system failures, how to identify contributing factors and the extent to which they can be implicated, how to judge whether incidents or their precursors are preventable, how to generate strong evidence to make healthcare safer and how to translate research into practice. Future directions include addressing the mundane as well as rare, dramatic events, and developing further research in non-hospital settings and in developing countries. In summary, a mixture of qualitative and quantitative methods, using information from all available data sources and combining retrospective, real time and prospective study designs, is necessary to address some of the more difficult patient safety problems.

Intra-operative decision making by ophthalmic surgeons

PURPOSE

Research on surgical decision making and risk management usually focuses on peri-operative care, despite the magnitude and frequency of intra-operative risks. The aim of this study was to examine ophthalmic surgeons' intra-operative decisions and risk management strategies in order to explore differences in cognitive processes.

METHOD

Critical decision method interviews were conducted with 12 consultant ophthalmologists who recalled cases and selected important decisions during the operations. These decisions were then discussed in detail in relation to decision making style and risk management. Transcripts were coded according to decision making strategy (analytical, recognition primed decision, creative and rule-based) and risk management (threats, risk assessment and risk tolerance).

RESULTS

The key decision in each case was made using either a rapid, intuitive mode of thinking (n=6, 50%) or a more deliberate comparison of alternative courses of action (n=6, 50%). Rule-based or creative decision making was not used. Risk management involved the perception of threats and assessment of threat impact but was also influenced by personal risk tolerance. Risk tolerance seemed to play a major role during situations requiring a stopping rule. Risk management did not appear to be influenced by time pressure.

CONCLUSIONS

Surgeons described making key intra-operative decisions using either an intuitive or an analytical mode of thinking. Ophthalmic surgeons' risk assessment, risk tolerance and decision strategies appear to be influenced by personality.

Patient safety climate and worker safety behaviours in acute hospitals in Scotland

OBJECTIVES

To obtain a measure of hospital safety climate from a sample of National Health Service (NHS) acute hospitals in Scotland and to test whether these scores were associated with worker safety behaviors, and patient and worker injuries.

METHODS

Data were from 1,866 NHS clinical staff in six Scottish acute hospitals. A Scottish Hospital Safety Questionnaire measured hospital safety climate (Hospital Survey on Patient Safety Culture), worker safety behaviors, and worker and patient injuries. The associations between the hospital safety climate scores and the outcome measures (safety behaviors, worker and patient injury rates) were examined.

RESULTS

Hospital safety climate scores were significantly correlated with clinical workers' safety behavior and patient and worker injury measures, although the effect sizes were smaller for the latter. Regression analyses revealed that perceptions of staffing levels and managerial commitment were significant predictors for all the safety outcome measures. Both patient-specific and more generic safety climate items were found to have significant impacts on safety outcome measures.

CONCLUSION

This study demonstrated the influences of different aspects of hospital safety climate on both patient and worker safety outcomes. Moreover, it has been shown that in a hospital setting, a safety climate supporting safer patient care would also help to ensure worker safety.

IMPACT ON INDUSTRY

The Scottish Hospital Safety Questionnaire has proved to be a usable method of measuring both hospital safety climate as well as patient and worker safety outcomes.

Development of a behavioural marker system for scrub practitioners' non-technical skills (SPLINTS system)

RATIONALE, AIMS AND OBJECTIVES

Adverse events still occur despite ongoing efforts to reduce harm to patients. Contributory factors to adverse events are often due to limitations in clinicians' non-technical skills (e.g. communication, situation awareness), rather than deficiencies in technical competence. We developed a behavioural rating system to provide a structured means for teaching and assessing scrub practitioners' (i.e. nurse, technician, operating department practitioner) non-technical skills.

METHOD

Psychologists facilitated focus groups (n = 4) with experienced scrub practitioners (n = 16; 4 in each group) to develop a preliminary taxonomy. Focus groups reviewed lists of non-technical-skill-related behaviours that were extracted from an interview study. The focus groups labelled skill categories and elements and also provided examples of good and poor behaviours for those skills. An expert panel (n = 2 psychologists; n = 1 expert nurse) then used an iterative process to individually and collaboratively review and refine those data to produce a prototype skills taxonomy.

RESULTS

A preliminary taxonomy containing eight non-technical skill categories with 28 underlying elements was produced. The expert panel reduced this to three categories (situation awareness, communication and teamwork, task management), each with three underlying elements. The system was called the Scrub Practitioners' List of Intraoperative Non-Technical Skills system. A scoring system and a user handbook were also developed.

CONCLUSION

A prototype behavioural rating system for scrub practitioners' non-technical skills was developed, to aid in teaching and providing formative assessment. This important aspect of performance is not currently explicitly addressed in any educational route to qualify as a scrub practitioner.

Team communication during patient handover from the operating room: more than facts and figures

OBJECTIVE

This study was aimed at examining team communication during postoperative handover and its relationship to clinicians' self-ratings of handover quality.

BACKGROUND

Adverse events can often be traced back to inadequate communication during patient handover. Research and improvement efforts have mostly focused on the information transfer function of patient handover. However, the specific mechanisms between handover communication processes among teams of transferring and receiving clinicians and handover quality are poorly understood.

METHOD

We conducted a prospective, cross-sectional observation study using a taxonomy for handover behaviors developed on the basis of established approaches for analyzing teamwork in health care. Immediately after the observation, transferring and receiving clinicians rated the quality of the handover using a structured tool for handover quality assessment. Handover communication during 117 handovers in three postoperative settings and its relationship to clinicians' self-ratings of handover quality were analyzed with the use of correlation analyses and analyses of variance.

RESULTS

We identified significantly different patterns of handover communication between clinical settings and across handover roles. Assessments provided during handover were related to higher ratings of handover quality overall and to all four dimensions of handover quality identified in this study. If assessment was lacking, we observed compensatory information seeking by the receiving team.

CONCLUSION

Handover quality is more than the correct, complete transmission of patient information. Assessments, including predictions or anticipated problems, are critical to the quality of postoperative handover.

APPLICATION

The identification of communication behaviors related to high-quality handovers is necessary to effectively support the design and evaluation of handover improvement efforts.

Using Videos to Determine the Effect of Stage of Operation and Intraoperative Events on Surgeons’ Intraoperative Leadership

Background Leadership is a key component for the successful functioning of teams and the achievement of task goals. During the intraoperative phase of surgery, the attending surgeon can be likened to a team leader with responsibility for task accomplishment by a small team. This study identified and evaluated surgeons’ leadership behaviors during operations, with particular reference to any changes that occurred following two types of events. Method Videos of live operations ( n=29) from the operating rooms of three teaching hospitals in the UK were analyzed to identify and code surgeons’ intraoperative leadership behaviors using the Surgeons’ Leadership Inventory (SLI). The frequency and quality of the leadership behaviors were compared before and after the point of no return (PONR) (n=24) and before and after an unexpected intraoperative event (n=5). Results Most leadership behaviors were directed toward the resident during an operation. No significant differences were found for the overall frequency or quality of leadership behaviors pre- and post-PONR. The frequency of leadership behaviors classified as ‘training’ and ‘Supporting others’ significantly decreased after an unanticipated intraoperative event. Discussion This study provides a detailed description of surgeons’ intraoperative leadership during different types of operative situations and stages. During the intraoperative period, the attending surgeon seemed to lead the surgical trainee almost exclusively, and not other members of the operative team. Leadership was highly focused on the surgical task.

Paramedics' non-technical skills: a literature review

Healthcare organisations have started to examine the impact that the human worker has on patient safety. Adopting the Crew Resource Management (CRM) approach, used in aviation, the CRM or non-technical skills of anaesthetists, surgeons, scrub practitioners and emergency physicians have recently been identified to assist in their training and assessment. Paramedics are exposed to dynamic and dangerous situations where patients have to be managed, often with life-threatening injuries or illness. As in other safety-critical domains, the technical skills of paramedics are complemented by effective non-technical skills. The aim of this paper was to review the literature on the non-technical (social and cognitive) skills used by paramedics. This review was undertaken as part of a task analysis to identify the non-technical skills used by paramedics. Of the seven papers reviewed, the results have shown very little research on this topic and so reveal a gap in the understanding of paramedic non-technical skills.

Surgeons' leadership in the operating room: an observational study

BACKGROUND

There is widespread recognition in high-risk organizations that leadership is essential for efficient and safe team performance. However, there is limited empiric evidence identifying specific leadership skills and associated behaviors enacted by surgeons during surgery.

METHODS

Observational data on surgeons' intraoperative leadership behaviors were gathered during surgeries (n = 29) in 3 hospitals. Observations were coded using 7 leadership elements identified from the literature on surgeons' leadership. Surgeries were categorized by complexity using British United Provident Association ratings.

RESULTS

A total of 258 leadership behaviors were observed during more than 63 hours of observation. Surgeons most frequently showed guiding and supporting (33%), communicating and coordinating (20%), and task management behaviors (15%). In many instances the surgeons' leadership was directed to the room rather than to a specific team member. Surgeons engaged in leadership behaviors significantly more frequently during cases of high complexity compared with cases of lower complexity.

CONCLUSIONS

This study is the first step in developing an empirically derived taxonomy to identify and classify surgeons' intraoperative leadership behaviors.

The importance of preparation for doctors' handovers in an acute medical assessment unit: a hierarchical task analysis

AIM

To examine the ideal and actual processes of doctors' handovers in an acute medical assessment unit by means of a hierarchical task analysis (HTA) to identify any discrepancies between the ideal shift handover process as described by doctors, and the actual shift handover process as observed by the researcher.

METHOD

The HTA was constructed using information gathered from interviews (n=13) describing the activities doctors said they should ideally perform in preparation for the shift handover meeting, during the meeting and after the meeting has finished. Observations (n=32) were made pre handover, during handover and post handover to capture the actual handover process in the acute medical assessment unit. Furthermore, a focus group discussion was included to validate the researcher's observations of the actual handover process and to provide content validity to the constructed HTA of the ideal handover process.

RESULTS

Findings as represented by the HTA diagram showed the complexity of the process. The diagram revealed critical tasks that should be completed at each phase of the handover process, but observations revealed that these were sometimes omitted, mainly due to work demands and time pressure. These omissions were most apparent in the pre-handover stage, resulting in interrupted, extended and/or delayed handover meetings.

CONCLUSION

The pre-handover phase is critical in providing a foundation for a thorough handover meeting and potentially helping doctors who have started a shift to prioritise patient care. These findings suggest that quality improvements for clinical handovers should include a designated time for preparation of care transfer information.

Hospital survey on patient safety culture: psychometric analysis on a Scottish sample

OBJECTIVE

To investigate the psychometric properties of the Hospital Survey on Patient Safety Culture on a Scottish NHS data set.

METHODS

The data were collected from 1969 clinical staff (estimated 22% response rate) from one acute hospital from each of seven Scottish Health boards. Using a split-half validation technique, the data were randomly split; an exploratory factor analysis was conducted on the calibration data set, and confirmatory factor analyses were conducted on the validation data set to investigate and check the original US model fit in a Scottish sample.

RESULTS

Following the split-half validation technique, exploratory factor analysis results showed a 10-factor optimal measurement model. The confirmatory factor analyses were then performed to compare the model fit of two competing models (10-factor alternative model vs 12-factor original model). An S-B scaled χ(2) square difference test demonstrated that the original 12-factor model performed significantly better in a Scottish sample. Furthermore, reliability analyses of each component yielded satisfactory results. The mean scores on the climate dimensions in the Scottish sample were comparable with those found in other European countries.

CONCLUSIONS

This study provided evidence that the original 12-factor structure of the Hospital Survey on Patient Safety Culture scale has been replicated in this Scottish sample. Therefore, no modifications are required to the original 12-factor model, which is suggested for use, since it would allow researchers the possibility of cross-national comparisons.

Safe eye surgery: non-technical aspects

The traditional training of surgeons focused exclusively on developing knowledge, clinical expertise, and technical (surgical) skills. However, analyses of the reasons for adverse events in surgery have revealed that many underlying causes originate from behavioural or non-technical aspects of performance (eg, poor communication among members of the surgical team) rather than from a lack of surgical (ie, technical) skills. Therefore, technical skills appear to be necessary but not sufficient to ensure patient safety. Paying attention to non-technical skills, such as team working, leadership, situation awareness, decision making, and communication, will increase the likelihood of maintaining high levels of error-free performance. Identification and training of non-technical skills has been developed for high-risk careers, such as civil aviation and nuclear power. Only recently, training in non-technical skills has been adopted by the surgical world and anaesthetists. Non-technical skills need to be tailored to the environment where they are used, and eye surgery has some substantial differences compared with other surgical areas, for example, high volume of surgery, use of local anaesthetics, and very sophisticated equipment. This review highlights the need for identification of the non-technical skills relevant to eye surgeons and promotion of their use in the training of eye surgeons.

Doctors' handovers in hospitals: a literature review

AIM

To review studies on hospital doctors' handovers to identify the methods and main findings.

METHOD

A literature search of electronic databases Medline and Embase (via Ovid) was conducted against a set of inclusion criteria.

RESULTS

A total of 32 papers were identified. The most common methods of studying handovers were observations and interviews, which typically focused on the sign-out (ie, handover meeting). This is just one stage of the handover process: pre- and posthandover phases were rarely examined. Although providing useful descriptive information, the studies rarely evaluated the quality of handover practices. While communication is generally recognised as the critical component, there has been little training of this skill.

CONCLUSION

The handover literature does not fully identify where communication failures typically occur or influencing conditions, thus hampering the design of effective handover training and tools. A systematic analysis of all the stages of doctors' handovers is required.

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.