Non-Technical Skills For Surgeons Research Articles

Enhancing Meaning in Work

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Guide to the Assessment of Competence and Performance in Practising Surgeons

Surgical performance is increasingly under public scrutiny and non-technical behavioural issues are more frequently the focus of complaints. Currently, there is a lack of a suitable framework or template to assist surgeons in the assessment of their own performance or that of their colleagues. A Royal Australasian College of Surgeons (RACS) Working Party considered the methods currently available to define and assess surgical performance. The scope included assessment tools, resources available, and support for surgeons. The Non-Technical Skills for Surgeons (NOTSS) programme developed by the Royal College of Surgeons, Edinburgh and the School of Psychology, University of Aberdeen was of particular interest. This programme was reviewed, adapted and expanded. The nine RACS competencies were used as the foundation for developing a set of three behavioural patterns within each competency domain. Each behavioural pattern was then described by a set of eight behavioural markers--describing four good and four poor behaviours. A variety of resources were identified to assist surgeons, including College and other similar courses and guidelines, publications covering professionalism and health issues and support through various agencies. It was recognized that the College has a role to support its Fellows and to ensure any review of performance is conducted impartially, competently and confidentially. The resulting guide was approved by College Council in June 2008 and later distributed to Fellows and hospitals throughout Australia and New Zealand. It is intended to be used for self-reflection and self-assessment, although it could equally be used as a template for the review of an individual surgeon's performance by a clinical director of surgery or other agency. Considerable progress has been made in the assessment of performance of practising surgeons. This guide has been published to address performance issues across all RACS competencies. It also outlines a variety of assessment methods and strategies to support surgeons.

Experience matters: comparing novice and expert ratings of non‐technical skills using the NOTSS system

There is growing evidence that non-technical skills (NTS) are related to surgical outcomes and patient safety. The aim of this study was to further evaluate a behaviour rating system (NOTSS: Non-Technical Skills for Surgeons) which can be used for workplace assessment of the cognitive and social skills which are essential components of NTS. A novice group composed of consultant surgeons (n = 44) from five Scottish hospitals attended one of six experimental sessions and were trained to use the NOTSS system. They then used NOTSS to rate surgeons' behaviors in six simulated scenarios filmed in the operating room. The behaviours demonstrated in each scenario were compared to expert ratings to determine accuracy. The mode rating from the novice group (who received a short training session in behaviour assessment) was the same as the expert group in 50% of ratings. Where there was disagreement, novice raters tended to provide lower ratings than the experts. Novice raters require significant training in this emerging area of competence in order to accurately rate non-technical skills.

Surgeons’ Non‐technical Skills in the Operating Room: Reliability Testing of the NOTSS Behavior Rating System

Previous research has shown that surgeons' intraoperative non-technical skills are related to surgical outcomes. The aim of this study was to evaluate the reliability of the NOTSS (Non-technical Skills for Surgeons) behavior rating system. Based on task analysis, the system incorporates five categories of skills for safe surgical practice (Situation Awareness, Decision Making, Task Management, Communication & Teamwork, and Leadership). Consultant (attending) surgeons (n = 44) from five Scottish hospitals attended one of six experimental sessions and were trained to use the NOTSS system. They then used the system to rate consultant surgeons' behaviors in six simulated operating room scenarios that were presented using video. Surgeons' ratings of the behaviors demonstrated in each scenario were compared to expert ratings ("accuracy"), and assessed for inter-rater reliability and internal consistency. The NOTSS system had a consistent internal structure. Although raters had minimal training, rating "accuracy" for acceptable/unacceptable behavior was above 60% for all categories, with mean of 0.67 scale points difference from reference (expert) ratings (on 4-point scale). For inter-rater reliability, the mean values of within-group agreement (r (wg)) were acceptable for the categories Communication & Teamwork (.70), and Leadership (.72), but below a priori criteria for other categories. Intra-class correlation coefficients (ICC) indicated high agreement using average measures (values were .95-.99). With the requisite training, the prototype NOTSS system could be used reliably by surgeons to observe and rate surgeons' behaviors. The instrument should now be tested for usability in the operating room.

Debriefing Surgeons on Non-Technical Skills in the Operating Room - Results from a Pilot Study

Briefing and debriefing are common practices for safety in high risk industries but are not systematically done in surgery. Regular debriefing of performance after operative surgery can greatly assist surgical trainees' development and help optimize learning from the limited time they spend in the Operating Room (OR). We developed and tested the NOTSS (Non-Technical Skills for Surgeons) behaviour rating system with subject matter experts. It allows surgeons to observe trainees' behaviour in the OR and provide them with structured feedback for improvement. This paper describes process of debriefing and the results of a pilot usability trial. The majority of participants reported that the NOTSS system was useful for debriefing trainees, provided a common language to discuss non-technical skills, and was a valuable adjunct to current assessment tools. Some surgeons found interpersonal skills more difficult to rate than cognitive skills. 73% felt that routine use of the system would enhance patient safety.

Debriefing surgeons on non-technical skills (NOTSS)

Surgical trainees must maximise the educational and developmental opportunities of time spent in the operating theatre. Post-operative debriefing on performance based on observed skills is one way of achieving this and is regularly done in other high-risk professions. The non-technical skills for surgeons (NOTSS) behaviour rating system allows surgeons to observe trainees’ behaviour in the workplace and provide feedback for skill improvement in a structured manner. This paper describes the process of debriefing using NOTSS and presents the results of a usability trial. Two case studies also illustrate how the system was used. The majority of surgical trainers who participated reported that the NOTSS system provided a common language to discuss non-technical skills and was a valuable adjunct to currently available assessment tools. Some trainers found interpersonal skills more difficult to rate than cognitive skills but 73% (n = 8) felt that routine use of the system would enhance patient safety.

Experimental Evaluation of a Behavioural Marker System for Surgeons' Non-Technical Skills (NOTSS)

Non-technical skills provide a critical underpinning for good surgical practice, but they must be trained and assessed according to properly developed skills frameworks and validated measurement tools. The NOTSS (Non-Technical Skills for Surgeons) skills taxonomy was developed from cognitive task analysis with subject matter experts and has been reported previously. It comprises five categories (situation awareness, decision making, task management, communication and teamwork, and leadership) divided into fourteen elements. The aim of the present study was to evaluate this as a behavioural rating system. An evaluation was conducted with 44 consultant (attending) surgeons who were trained to use the prototype NOTSS system and then rated surgeons' behaviours in six videos of simulated surgical scenarios. Evaluation results indicate that the system is complete, the skills are observable, and can be rated with approaching acceptable levels of agreement. Responses regarding initial usability were positive.

NOTSS course (non-technical skills for surgeons)

Surgical registrar Stephen Brennan reviews a new course designed to teach non-surgical skills