The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy

Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
Surgical Endoscopy (Impact Factor: 3.31). 02/2008; 22(1):68-73. DOI: 10.1007/s00464-007-9346-1
Source: PubMed

ABSTRACT Evidence from other professions suggests that training in teamwork and general cognitive abilities, collectively described as non-technical skills, may reduce accidents and errors. The relationship between non-technical teamwork skills and technical errors was studied using a behavioural marker system validated in aviation and adapted for use in surgery.
26 elective laparoscopic cholecystectomies were observed. Simultaneous assessments were made of surgical technical errors, by observation clinical human reliability assessment (OCHRA) task analysis, and non-technical performance, using the surgical NOTECHS behavioural marker system. NOTECHS assesses four categories: (1) leadership and management, (2) teamwork cooperation, (3) problem-solving and decision-making, (4) situation awareness. Each subteam (nurses, surgeons and anaesthetists) was scored separately on each of the four dimensions. Two observers - one surgical trainee and one human factors expert - were used to assess intra-rater reliability.
The mean NOTECHS team score was 35.5 (95% C.I. +/- 1.88). The mean subteam scores for surgeons, anaesthetists and nurses were 13.3 (95% C.I. +/- 0.64), 11.4 (95% C.I. +/- 1.05), and 10.8 (95% C.I. +/- 0.87), respectively, with a significant difference between surgeons and anaesthetists (U = 197, p = 0.009), and surgeons and nurses (U = 0.134, p <or= 0.001). Inter-rater reliability was found to be strong (alpha = 0.88). There were between zero and six technical errors per operation, with a mean of 2.62 (95% C.I. +/- 0.55), which were negatively correlated with the surgeons situational awareness scores (rho = -0.718, p < 0.001).
Non-technical skills are an important component of surgical skill, particularly in relation to the development and maintenance of a surgeon's situational awareness. Experience from other industries suggests that it may be possible to improve the ability of surgeons to manage their own situation awareness, through training, intraoperative briefings and intraoperative workload management. In the future, it may be possible to use non-technical performance as a surrogate measure for technical performance, either for early identification of surgical difficulties, or as a method of evaluation by which non-surgically trained observers.

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    03/2011; 3(2):86-89. DOI:10.1136/flgastro-2011-100048
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    ABSTRACT: The objective of the study was to evaluate the effectiveness of structured training on junior trainees' nontechnical performance in an operating room (OR) environment. Nontechnical skills (NTS) have been identified as critical competencies of surgeons in the OR, and regulatory bodies have mandated their integration in postgraduate surgical curricula. Strong evidence supporting the effectiveness of curricular NTS training, however, is lacking. Junior surgical residents were randomized to receive either conventional residency training or additional NTS training in a 2-month curriculum. Learning was assessed through a knowledge quiz and an attitudes survey. Nontechnical performance was evaluated by blinded assessment of standardized OR crisis simulations at baseline (BL) and posttraining (PT) using the Nontechnical Skills for Surgeons (NOTSS) and Objective Structured Assessment of Nontechnical Skills (OSANTS) rating systems. Results are reported as median (interquartile ranges). Of 23 participants, 22 completed BL and PT assessments. Groups were equal at BL. At PT, curriculum-trained residents (n = 11) scored higher than conventionally trained residents (n = 11) in knowledge [12 (11-13) vs 8 (6-10), P < 0.001] and attitudes [4.58 (4.37-4.73) vs 4.20 (4.00-4.50), P = 0.008] about NTS. In a simulated OR, nontechnical performance of curriculum-trained residents improved significantly from BL to PT [NOTSS: 10 (7-11) vs 13 (10-15), P = 0.012; OSANTS: 23 (17-28) vs 31 (25-33), P = 0.012] whereas conventionally trained residents did not improve [NOTSS: 10 (10-13) vs 11 (9-14), P = 1.00; OSANTS: 26 (24-32) vs 24 (23-32), P = 0.713]. The results demonstrate the effectiveness of structured curricular training in improving nontechnical performance in the first year of surgical residency, supporting routine implementation of nontechnical components in postgraduate surgical curricula.
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    ABSTRACT: Introduction This thesis describes a program of research showing that team formation, individuals’ team behaviours and overall team performance are all improved when an appropriately designed cognitive aid is provided to health professionals dealing with clinical emergencies. The purpose of the research was to examine how both education and cognitive aids could affect team behaviours and processes. Much has been written on the effects of education on team functioning, but apparently little on the effects of cognitive aids on teams. Structure of the thesis The thesis is in the format of a thesis including publications. There are five main sections to the thesis: a) A review of how team training is currently undertaken and the problems that may occur by using education alone to improve teams b) An exploration of the evidence to support cognitive aids being used to improve teams and to discover how and when they might fail c) Investigations around how cognitive aids may aid calling for help and early team formation d) How cognitive aids affect individuals’ team behaviours e) How cognitive aids affect the overall team processes such as leadership, communication and coordination and whether the design of the cognitive aid affects these processes. First, existing approaches to team training are reviewed within the context of emergency medicine. Many types of team training were identified and several meta-analyses in health and other domains have shown that team training does improve team behaviours. Many different types of team training are available, and health uses only a few of the types used in other industries. Second, a review of cognitive aids in anaesthesia emergencies discovered 22 cognitive aids that had been evaluated in 23 studies. The review demonstrated that in most cases a cognitive aid improved technical performance. The effect of cognitive aids on team performance was less clear with only two studies having investigated team function. Cognitive aids might not be used because of a lack of familiarity or a lack of education in their use, a lack of cultural support for their use or because they are perceived to impair rather than assist with the work to be done. Cognitive aid design is often not given as much consideration as the content. The cognitive aids that were not used or that induced errors had arguably not been designed with the context of an anaesthetic emergency in mind. Designs must be simple, easy to use and should support both the individuals and the team. When implementing cognitive aids, testing must be performed to ensure the cognitive aids do not induce errors, and education is required on how to most effectively use the cognitive aids. Third, the effect of cognitive aids on team formation was examined in a parallel research program and has been included as supplemental material. The context of the emergency in this instance was the Medical Emergency Team (MET) also termed Rapid Response System (RRS). When patients deteriorate on the wards of a hospital there might not be senior help immediately available and junior staff are expected to activate the RRS to send for senior assistance. The research program identified sociocultural barriers to RRS activation. One of the solutions to prompt calling for help was the provision of a cognitive aid that detailed the expected actions by the junior clinicians and allowed them to attempt treatment within defined boundaries. These interventions improved clinical outcomes without increasing the number of RRS calls. Fourth, a simulation-based randomised study was designed and run to determine the effect of cognitive aids on individuals’ team behaviours during an airway emergency. The study found that individuals scored higher on a non-technical skills rating system when they were provided with a cognitive aid. Furthermore, the number of times the cognitive aid was used was positively correlated with the non-technical skills scores. Fifth, a simulation-based repeated measures study was performed to determine the effect of cognitive aids on team processes. In this study, two types of cognitive aid or no cognitive aid were presented to each of 24 teams during simulated intraoperative anaphylaxis emergencies. This study demonstrated that the design of the aid has an effect on the team functioning, with both aids leading to improved performance than when no aid was available. In conclusion, the research performed for the thesis demonstrates the importance of other methods of improving team behaviour beyond education alone. Cognitive aids can improve the ability of junior clinicians to call for help, can enhance the team behaviours of individuals and lead to more effective team processes. However, cognitive aids should be carefully designed and tested before introduction, as there is now evidence that the design of cognitive aids can affect the way teams perform in emergency situations.
    03/2015, Degree: Doctor of Philosophy, Supervisor: Penelope Sanderson, Cate McIntosh