Industrial Psychology Research Centre
NOTSS: Non-Technical Skills for Surgeons
Development of a behavioural
marker system for
the assessment of surgeons’
non-technical skills
Project sponsored by the Royal
College of Surgeons of Edinburgh
and NHS Education Scotland (NES).
1st April 2003- 31st
March 2005
Project Team
1. Professor
Rhona Flin, Dr Steven Yule, Industrial Psychology Research Centre, Department
of Psychology, University of Aberdeen
2. Mr
Simon Paterson-Brown, Mr Peter Driscoll, Ms Anna Paisley, University Department
of Clinical & Surgical Sciences, Edinburgh Royal Infirmary
3. Dr
Nikki Maran, Dr Ronnie Glavin, Scottish Clinical Simulation Centre, Stirling
Royal Infirmary
Aim
The aim of this project is to identify the
non-technical skills necessary for good surgical practice and to develop and
evaluate a behavioural marker system that can be used to support training and
assessment of these skills. The output
from the project will be provided in the form of a user booklet providing
guidelines and recommendations for integrating the system into a training
programme
Background
Traditionally medical education and professional development has
focussed on developing clinical expertise and technical skills. Aspects of
performance such as decision-making, leadership and team working, that provide
a vital underpinning for effective performance have not been addressed
explicitly in training but rather have had to be developed along the way. This is now changing as the General Medical
Council (2000) has now identified the need to address team working skills and
the medical profession increasingly recognises there is more to good practice
than having extensive clinical knowledge and good technical skills. Indeed
studies into medical error show that it is frequently ‘behavioural’ aspects of
performance that break down rather than individuals not having the necessary
technical expertise (Fletcher et al, 2002). These aspects of performance can be
described as non-technical skills (following from European civil aviation and
now anaesthesia) as they relate to attitudes and behaviours necessary for safe
and effective practice in a clinical context but which are not directly related
to the use of medical expertise, drugs or equipment (Fletcher et al, 2001).
Thus they address the whole range of cognitive and social ‘behavioural’ skills
that underpin good performance, such as team working, task management,
situation awareness and decision making.
Within surgery, evidence from observations of performance in theatre
clearly indicates that non-technical skills constitute a critical component of
competence. Breakdowns in team working and communication, lack of situation
awareness and poor decision making (de Leval et al, 2000; Helmreich & Schaefer,1994) can lead to
poor outcomes for patients. Conversely
good practitioners can be seen to demonstrate their non-technical skills as an
integral part of their work. Given
their impact on patient safety, such areas of competence should receive
explicit attention during training to ensure individuals are aware of what
constitutes good practice and have the requisite skills to deliver this. Recognition of the importance of these non-technical
skills in anaesthesia lead to the development of aviation-style crew resource
management (Helmreich, 1997) training courses to address them, e.g. Crisis
Avoidance and Resource Management (Scotland: Maran et al, 2002) and Anesthesia
Crisis Resource Management (USA: Gaba, Fish & Howard, 1994). There have also been some joint simulator
training courses conducted for operating theatre team training (Switzerland:
Sexton et al, 1998) and for mixed specialty teams in emergency rooms (USA:
Small et al, 1999). However, while now
being discussed by surgeons (Giddings, 2001), the current UK programme for
surgical education and professional development does not yet provide equivalent
training.
The greatest challenge in developing non-technical skills training in
surgery is to identify explicitly the skills that are necessary for good
practice and hence need to be trained.
It is then essential to be able to describe these skills in sufficient
detail to allow them to be included in the syllabus and then assessed reliably
during and following the training.
Traditionally technical skills are quite clearly addressed in the
literature and are covered in educational curricula but non-technical skills
are not currently described in equivalent detail. One of the reasons for this maybe that such skills are not so
easily identified by traditional task analysis techniques, such as by direct
questioning, because they form the basis of expertise and may be difficult to
verbalise. As a result more subtle
techniques are needed to identify the range of non-technical components of
expertise. Techniques such as cognitive
task analysis are very effective for this and have been successfully used in
the medical field in an on-going Scottish research project to identify the non-technical
competencies needed by anaesthetists (Fletcher et al, 2001). Once a list of non-technical competencies
has been produced this can be used as the basis for syllabus development,
designing course materials, supporting debriefing and, most importantly, can be
used as an assessment tool for evaluating individual trainees’ non-technical
skills and the overall effectiveness of training. Assessment tools of this type are often called behavioural marker
systems as they rely on observation of behaviour to indicate level of
skill. Behavioural marker can be
defined as “observable, non-technical behaviours that contribute to superior or
substandard performance” (Klampfer et al, 2001) and are used as a method for
measuring non-technical performance in an increasing range of work domains,
e.g. aviation, shipping, military and medicine. For effective non-technical skills assessment the behavioural
marker systems used must be explicit, transparent and above all validated. Assessors must be trained to ensure the
systems are used reliably. Therefore,
in addition to identifying the non-technical skills necessary from a sound
empirical basis, it is very important that behavioural maker systems are
properly empirically evaluated.
To support development of an effective non-technical skills training
programme in Scotland a project is proposed to identify the non-technical
skills necessary for good surgical practice and develop a behavioural
assessment tool that could be used to support surgical training across all
levels of the profession. If validated,
such a system may also be useful for future assessments in the workplace.
This work would be a cross-disciplinary collaboration drawing on
the expertise of psychologists, surgeons and anaesthetists at the Scottish
Clinical Simulation Centre who are currently involved in providing
non-technical skills training for anaesthetists in Scotland.
Description of work
To
achieve the aims described above a two year programme of work is proposed. The methodological approach for the project
will be based on the on-going University of Aberdeen/Scottish Clinical
Simulation Centre project funded by the Scottish Council for Postgraduate
Medical and Dental Education (SCPMDE)1
investigating non-technical skills in anaesthesia (Fletcher et al, 2001). Additional material on surgical skills will
be drawn from the South East of Scotland Basic Surgical Training Scheme
research funded by SCPMDE and the Royal College of Surgeons of Edinburgh into
skill requirements for surgical trainees (Baldwin, Paisley &
Paterson-Brown, 1999). The project will
be divided into four sequential workpackages (WPs) to allow for more effective
management of the work. It is anticipated
that the first year would be associated with the identification of the skills
and development of the behavioural marker system. The second year would be concentrated on evaluating the prototype
and making any necessary refinements to produce a final version and guidance
for its use.
The
project will be based in the Industrial Psychology Research Centre at the
University of Aberdeen. The work will
be conducted by a full-time psychology Research Fellow (Dr Steven Yule) under
the supervision of Professor Rhona Flin but with input and guidance from the
medical members of the project team. It
will also require access to a wider population of consultant surgeons for data
collection throughout the project.
References
Baldwin,
P.J., Paisley, A.M., & Paterson-Brown, S. (1999) Consultant surgeons’ opinion
of the skills required of basic surgical trainees. British Journal of Surgery,
86, 1078-1082
Fletcher, G., Flin, R.,
McGeorge, P., Glavin, R., Maran, N. & Patey, R. (2001) Final Report:
Development of a Behavioural Marker System for Anaesthetists' Non-Technical
Skills (ANTS). University of Aberdeen Grant Report for SCPMDE project
reference: RDNES/991/C.
Fletcher, G.C.L.,
McGeorge, P., Flin R.H., Glavin, R.J. & Maran, N. (2002) The
identification and measurement of anaesthetists’ non-technical skills: A review
of current literature. British Journal of
Anaesthesia, 88 (3), 418-429.
Flin, R., Fletcher, G.,
McGeorge, P, Sutherland, A. & Patey, R.. (in prep) Team working in the
Operating Theatre: A survey of Scottish anaesthetists' attitudes. Manuscript in
preparation.
Gaba,
D.M., Fish, S.K. & Howard, S.K. (1994) Crisis
management in anesthesiology. New York: Churchill Livingstone.
Giddings
A.E.B. Human Factors in Surgery: A discussion document prepared for the Senate
of Surgery. Presented at the Association
of Surgeons of Great Britain and Ireland, Birmingham, April 2001
General Medical Council Teamworking in medicine.
January 2000. GMC Medical
Education Website (www.gmc-uk.org/med_ed/teamwork).
Helmreich, R. (1997) Managing human error in aviation. Scientific American, 276, 40-45
Helmreich,
R. L., & Schaefer, H.-G. (1994). Team Performance in the Operating Room. In
M. Bognor (Ed.), Human Error in Medicine
(pp. 225-253). Mahwah, NJ: Lawrence Erlbaum Associates.
Klampfer,
B., Flin, R., Helmreich, R.L., Hausler, R., Sexton, B., Fletcher, G., Field,
P., Staender, S., Lauche, K., Dieckmann, P. & Amacher, A. (2001). Enhancing Performance in High Risk
Environments: Recommendations for the use of Behavioural Markers.
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Shiftung. Available from: www.psyc.abdn.ac.uk/serv02.
Maran
N., Glavin, R, & Fletcher G. (In press). Training in human factors for
anaesthetists’ in Scotland: Identifying key skills and developing a training
programme. In Proceedings of the 7th European Forum on Quality
Improvement in Health Care; 2002 Mar 21-23; Edinburgh, Scotland. London: BMJ
Publishing Group
Paisley,
A.M., Baldwin, P. & Paterson-Brown, S. (2001) Feasibility, reliability and
validity of a new assessment form for use with basic surgical. American Journal
of Surgery, 182, 24-29
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Henson & A.C. Lee (eds) Simulators in
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Sexton,
J.B., Thomas, E.J. & Helmreich, R.L. (2000). Errors, stress, and teamwork
in medicine and aviation: cross sectional surveys. British Medical Journal, 320, 745-749
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