- Behaviour in the Operating Theatre: A Clinical Perspective. - As a senior anaesthetist and surgeon, we recognize that we have a great deal of influence on the atmosphere created in the operating theatre and that our behaviour influences those around us. - These were not environments in which one questioned decision- making or challenged leadership if one wished to set foot in the operating theatre again! We tended to work in small clinical teams or ‘firms’ with little turnover of staff so everyone knew each other fairly well and teams became well oiled in. - The major focus of training was in the development of good technical skills and these were honed to a high level through an apprenticeship style of training by ‘practising’ on patients.. - The system had massive training redundancy which gave us all plenty of time to ‘absorb’ the implicit skills which were not part of the curriculum – those of picking up cues in the clinical environment – Situation Awareness (SA), developing good clinical judgement – decision-making and developing our own teamwork and leadership skills by modelling our behaviours on those demonstrated to us by our seniors. - The development of non-technical skills (NTS) has therefore been an implicit, though recognized, part of the medical curriculum for generations.. - We have learned from other high reliability domains and are now aware that human factors are implicated in many of the things which go wrong in hospitals and indeed in the operating theatre.. - Thankfully, ‘bad’ behaviour in the operating theatre has improved. - Throwing of instruments and temper tantrums are now a thing of the past. - However, a recent survey of surgical trainees in Scotland revealed that in some areas as many as 50 per cent of trainees reported experiencing bullying by senior staff which made them feel unable to express their views (National Trainee Survey 2007), and this is clearly liable to influence how likely these trainees are to speak up if they observe problems in the operating theatre. - Streamlining of training has reduced the number of years for specialist training and introduction of the European Working Time Directive (EWTD) and similar limits to working hours in other countries has progressively reduced the number of hours that doctors are permitted to work. - The reduction in hours of training time means that we no longer have the luxury of training redundancy and need to make all parts of the curriculum explicit. - The fixed ‘firm’ team has been replaced by transient teams of individuals who may come together for only short periods and once again this highlights the need for individuals to develop portable team skills, or non-technical skills, which will equip them to work in these situations. - Behaviour in the Operating Theatre 447. - book brings together, for the first time, the leading researchers who are carrying out observational research in the operating theatre. - We have been lucky enough to be directly involved in the work of some of these groups and have learned much from the others. - It is useful, perhaps to consider how this work can be of relevance to the operating theatre clinician.. - 1999, Department of Health 2000) have helped us to understand the importance of human factors in adverse events and have driven much of the patient safety agenda. - All of the researchers who have contributed to this volume have helped to increase our understanding of how non-technical skills influence the way we work more specifically in the operating theatre. - Although we like to think that behaviour in the operating theatre has improved over the last ten years, it is sobering to look at the findings in observational work.. - Many problems in the operating theatre stem from the ineffectiveness or lack of communication (see Lingard et al., Chapter 17 in this volume). - This issue is now being addressed in various safety tools which are being introduced including the WHO patient safety briefing tool (World Health Organization) and the use of SBAR (Situation, Background, Assessment, Recommendation) (Leonard et al. - 2004) as part of the IHI initiatives in improving handovers.. - The non-technical skills taxonomies (Fletcher et al. - 2006) which have been developed not only give us a vocabulary with which to express and discuss non-technical skills ourselves but also a framework which can be used to give feedback to help understand where we are and improve our own non-technical skills. - The definition of non-technical skills also helps to allow us to integrate these skills into curricula (Canadian Patient Safety Institute 2005, National Patient Safety Education Framework 2004) and we will increasingly see non-technical skills being incorporated into workplace-based assessment. - Further research is needed to explore whether this can be effective and if not, this clearly has implications for selection in the future.. - Many of the research groups included in this volume are working in simulation environments. - The fidelity of the training mannequins which are now available means that the simulator is the ideal place to study behaviour in emergency situations without having to wait for these unusual events to happen in real practice. - Although human factors training can commence in the classroom, in order to develop skills, individuals need feedback on behaviours and an opportunity to practise these skills. - The fidelity of the surgical simulators currently available is still not high enough to allow good intra-operative non-technical skills training for surgeons. - However this is likely to be overcome in the next few years as the technology develops and simulators become more widely available. - Transfer of skills from the simulator to clinical practice is vital and NTS frameworks such as ANTS and NOTSS are designed to give feedback in both the simulated environment and in the operating theatre.. - The development of our understanding of the impact of non-technical skills on patient outcomes should also be reflected in the use of systems to analyse behaviours when errors occur such as during incident reporting and morbidity and mortality meetings. - Challenges for the future include training trainers to become familiar with assessing and providing feedback on non-technical skill as (see Graham et al., Chapter 12 in this volume) have clearly demonstrated that inter-rater reliability of such systems is not high unless assessors are both experienced in the observation of skills and have been well calibrated. - The aviation model of trainer accreditation for both teaching and assessing non-technical skills (Civil Aviation Authority 2003) is one that we can only aspire to in healthcare.. - In the next ten years, non-technical skills will become an implicit part of the curriculum for doctors, nurses and all other health professionals involved in the delivery of healthcare. - As a result, the assessment of non-technical skills will become the norm, and understanding the importance of non-technical skills in certain specialties will drive the need to identify individuals with good NTS early in training for selection to certain specialities. - Future generations will find the operating theatre a very different place to work in and, as a result, ultimately a safer place for patients.. - Behaviour in the Operating Theatre 449. - events and negligence in hospitalised patients: Results of the Harvard Medical Practice Study I. - Canadian Patient Safety Institute. - (2007) Improving patient safety by identifying latent failures in successful operations. - (1999) The role and education of doctors in the delivery of healthcare.. - Department of Health (2000) An Organisation with a Memory: Learning from Adverse Events in the NHS. - (2003) Anaesthetists’ Non-Technical Skills (ANTS): Evaluation of a behavioural marker system. - (2008) Non-technical skills. - National Patient Safety Education Framework (2004) An Initiative of the Australian Council for Safety and Quality in Health Care. - (2006) Development of a rating system for surgeons’ non-technical skills. - in the operating theatre 141–4 rationale 130–36. - Anaesthetists’ Non-Technical Skills System (ANTS). - Non-Technical Skills for Surgeons (NOTSS) 14. - anaesthesia operating theatre (OT problem solving 301–16. - (MiniCEX) 180, 183 music in operating theatres 410–11 noise in operating theatres 410–11 non-technical skills (NTS) see also. - Non-Technical Skills for Surgeons (NOTSS). - orthopaedic surgery 335 patient safety 301 surgery 103. - Non-Technical Skills for Surgeons (NOTSS adverse event and mortality reviews. - NOTECHS 105 see also Non-Technical Skills for Surgeons (NOTSS);. - NOTSS see Non-Technical Skills for Surgeons. - NRE (nonroutine events) 205 NTS see non-technical skills Nurses’ NOTECHS 67–8. - operating room see operating theatre Operating Room Management Attitudes. - teamwork 153 telephones 334 OR see operating theatre. - non-technical skills (NTS) 335 patient safety 333–5. - OT see operating theatre. - paediatric cardiac surgery 105–6 patient safety. - non-technical skills (NTS) 301 orthopaedic surgery 333–5 surgery 151. - summary sheet 33 surgical environment 35 surgical skill assessment 48–9 surgical task 35. - non-technical skills 103 patient safety 151. - experimental approach 360–62, Judgement Analysis 364–6 364 knowledge elicitation modelling approach multimodal approach 358–64 observational approaches 357–8 process approaches 357–8 self-reporting 356–7 simulation structured study methods 356–8 Surgical NOTECHS 105. - programme 274–8 systems approach 353–5 Surgical Safety Checklist 164–5 surgical skills assessment 47–9 Surgical Skills Study see Sheffield. - measurement nurses operating theatre (OT) 153 patient outcomes 261–2 patient safety surgery 95–7. - audio-video recording 388–90 context of care 397–8 data collection patient safety 398
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