Elsevier

Journal of Surgical Education

Volume 73, Issue 2, March–April 2016, Pages 222-229
Journal of Surgical Education

Original Reports
Assessing the Nontechnical Skills of Surgical Trainees: Views of the Theater Team

https://doi.org/10.1016/j.jsurg.2015.10.008Get rights and content

Objective

This study aims to explore the views of members of theater teams regarding the proposed introduction of a workplace-based assessment of nontechnical skills of surgeons (NOTSS) into the Intercollegiate Surgical Curriculum Programme in the United Kingdom. In addition, the previous training and familiarity of the members of the surgical theater team with the concept and assessment of NOTSS would be evaluated.

Design

A regional survey of members of theater teams (consultant surgeons, anesthetists, scrub nurses, and trainees) was performed at 1 teaching and 2 district general hospitals in South Yorkshire.

Results

There were 160 respondents corresponding to a response rate of 81%. The majority (77%) were not aware of the NOTSS assessment tool with only 9% of respondents reporting to have previously used the NOTSS tool and just 3% having received training in NOTSS assessment. Overall, 81% stated that assessing NOTSS was as important as assessing technical skills. Trainees attributed less importance to nontechnical skills than the other groups (p ≤ 0.016). Although opinion appears divided as to whether the presence of a consultant surgeon in theater could potentially make it difficult to assess a trainee’s leadership skills and decision-making capabilities, overall 60% agree that the routine use of NOTSS assessment would enhance safety in the operating theater and 80% agree that the NOTSS tool should be introduced to assess the nontechnical skills of trainees in theater. However, a significantly lower proportion of trainees (45%) agreed on the latter compared with the other groups (p = 0.001).

Conclusions

Our survey demonstrates acceptability among the theater team for the introduction of the NOTSS tool into the surgical curriculum. However, lack of familiarity highlights the importance of faculty training for assessors before such an introduction.

Introduction

In the UK, the last decade has seen major reform in postgraduate medical education, notably a national move toward competency-based curricula. For the surgical specialties this has led to the launch of the Intercollegiate Surgical Curriculum Programme (ISCP) (www.iscp.ac.uk), which has transformed postgraduate training. ISCP enables the surgical trainee to record evidence of their training progression through the accumulation of specialty specific workplace-based assessments (WBAs) in technical surgical skills (Direct Observation of Procedural Skills and Procedure-Based Assessment [PBA]), Clinical diagnosis and management (mini-Clinical Evaluation Exercise) and an overall assessment of behavior and attitudes by colleagues (mini-Peer Assessment Tool). Recently, an assessment tool to assess trainee’s nontechnical skills has been introduced to ISCP as a pilot. Currently, nontechnical skills are informally acquired by surgical trainees through apprenticeship and observation rather than being explicitly addressed in training.1, 2 It is felt that this passive learning style needs transition to one of active knowledge acquisition with behavioral change. One of the key assessment tools of nontechnical skills available in literature is the nontechnical skills for surgeons (NOTSS), adapted from aviation Crew Resource Management.3, 4 It is a rating system based on skill taxonomy, with examples of good and poor behavioral markers. Ratings and feedback are given on 4 categories of nontechnical skills; situation awareness, decision making, communication and teamwork, and leadership.

There are, however, various questions that need to be addressed before the integration of NOTSS assessment in the surgical curriculum, namely, whom should take on the role of assessor (should they exclusively be surgeons or should nonsurgeons be recruited); should raters obtain formal training in NOTSS assessment and the effect of the presence of a more senior surgeon in theater, during the assessment on the rating of the trainee’s nontechnical skills. Engagement with NOTSS and how to ensure “buy-in” from members of the theater team, particularly trainees, is also an important consideration.

In this study, we present a survey among the surgical theater team that explores current views regarding the need to introduce an assessment tool of nontechnical skills of surgical trainees in the theater environment. In addition, the familiarity of members of the surgical theater team with the concept of NOTSS as well as their previous training in this area is explored.

Section snippets

Data Collection

This survey was conducted in South Yorkshire, UK between November 2014 and February 2015. Ethical approval was granted by University of Sheffield Medical School (No. SMBRER287). Theater teams at 1 teaching and 2 district general hospitals were invited to participate in the survey and to provide their views on NOTSS assessment as well as their experience of nontechnical skills. The participants were divided into 4 professional groups: consultant surgeons, surgical trainees, consultants

Results

In all, 198 staff members were approached and 160 responded, corresponding to a response rate of 81% (25 consultant surgeons, 51 trainees (grades CT1-ST8), 26 anesthetists, and 58 theater staff (Fig. 2). A total of 38 staff members did not return the questionnaires (5 consultant surgeons, 12 trainees, 3 anesthetists, and 18 theater staff).

Overall, 123 respondents (77%) were not aware of the NOTSS assessment tool with only 14 (9%) reporting to have previously used the NOTSS tool and just 4 (3%)

Discussion

Analyses of adverse events in healthcare have revealed that there is more often failure in nontechnical aspects of performance rather than a lack of technical expertise.6, 7 It has been shown that poor nontechnical skills in the operating theater result in a reduction in technical skill8 adverse events and poor clinical outcomes.9, 10, 11, 12 Communication has been found to be a causal factor in 43% of errors made in surgery.12 One of the key outcomes for all surgical trainees is “professional

Conclusion

Our survey demonstrates acceptability among the theater team for the introduction of the NOTSS tool into the surgical curriculum. Adequate provision of training on assessing NOTSS is required before an introduction and the findings of this survey can inform appraisal of the utility of NOTSS assessment tool that is being piloted via the ISCP.

Acknowledgments

The authors would like to thank members of South Yorkshire Surgical Research Group Collaborative who facilitated data collection in South Yorkshire, namely, Charlotte Gunner, Matthew Lee, Khalil Madbak, Mohamed El-Sharif, Emma Nofal, Vicky Proctor, and Stuart Stokes.

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On behalf of the South Yorkshire Surgical Research Group (SYSuRG) Collaborative.

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