- process produced a list of 150 unsorted non-technical skills such as ‘coordinates the team’, and ‘confirms understanding with assistant’ as raw input data for system development in phase 2.. - Phase 2: Development of the nOTSS System. - The goal of Phase 2 was to develop a system that could be used by surgeons to rate other surgeons’ behaviours in vivo in the operating theatre rather than to develop a comprehensive taxonomy or research instrument. - The tri-level hierarchical format used for behavioural marker systems in anaesthesia (Fletcher et al. - 2004) and European civil aviation (Flin et al. - The prototype system was developed in three stages to (i) refine the skill set that emerged from phase 1, (ii) sort those skills into a skills taxonomy, and (iii) identify observable behaviours that were indicative of each skill in the taxonomy.. - The aim of Stage 1 was to refine the skills that emerged from Phase 1 and remove duplication without diluting the conceptual breadth of the skills that emerged from the task analysis. - This process was to form the basis of the system.. - To achieve this, the multidisciplinary research group reduced and refined the list of 150 skills extracted from the transcripts, considering the results of the literature review, survey, and observations in theatre. - Translation and Elaboration of Legislation) project (Flin et al. - 2003), an expert panel on behavioural markers (Klampfer et al. - 2001) and from Cognitive Task Analysis (Seamster et al. - This ensured that the system had cognitive and interpersonal functionality, was grounded in surgery, and complied with the guidelines on system design (Gordon 1993) and criteria for development of behavioural markers mentioned earlier.. - 1 See Table 1 in Yule et al. - The NOTSS Rating Scale. - The aim of the system is to allow surgeons to rate skills they observe. - The aim of Phase 3 was to evaluate the NOTSS v1.1 system, specifically to assess its psychometric properties of (i) sensitivity, (ii) inter-rater reliability, and (iii) internal structure and consistency. - non-technical skills in general and orthopaedic surgery. - The scenarios were designed by surgeons, anaesthetists and psychologists who were experienced in non-technical skills training. - The participating surgeons attended a half-day training session on how to use the NOTSS system, with some guidance on behaviour rating (Baker et al. - They were instructed to watch each scenario and to rate the observed skills of the consultant surgeon using the NOTSS rating form. - Participants were informed of the simulated nature of the scenarios.. - Table 2.1 shows the criteria for each of the evaluation metrics used in this study and the corresponding results. - For more details on the evaluation see Yule et al. - (2008a) and Yule et al. - There were also differences in the way the scenarios were rated, two scenarios yielded either floor or ceiling ratings as the behaviours were explicitly good or poor, and other scenarios displayed more ambiguous behaviours and were rated in the mid-range of the scale. - Orthopaedic surgeons were found to agree on rated behaviours significantly more than general surgeons (Yule et al. - On the basis of the evaluation a number of changes were made to the taxonomy, the most important being the removal of ‘Task Management’. - This was done because conceptually, many of the task management behaviours were actually more reflective of situation awareness. - In this study, it represents the degree to which the groups of participants agree on the absolute ratings they give to behaviours in the scenarios that reflect the NOTSS categories and elements. - r wg was calculated for the NOTSS categories and elements ratings for each of the 6 experimental groups. - Consistency between category and element deemed very high for all categories Table 2.1 Summary of nOTSS v1.1 evaluation results (see Yule et al.. - holding a number of categories and elements in working memory while engaged in a real-time observation and rating task (Yule et al. - This produced the NOTSS taxonomy version 1.2 (see Figure 2.2).. - The NOTSS v1.2 Handbook. - A user handbook (Flin et al. - 2006b) was then written which contained background information on the development of NOTSS, advice for using system in clinical practice, definitions and behavioural examples of the NOTSS categories and elements, a set of rating forms for users, indicative good and poor behaviours for each element, and advice on how to use the rating scale. - Practical tips to aid surgeons embed non-technical skills observations into clinical practice were included, as was advice for surgical trainers planning to use NOTSS with higher surgical trainees.. - The trainers were asked to use the NOTSS rating form and supporting handbook to rate and provide feedback to trainees as soon as possible after each of ten cases where the trainee had contributed significantly to the operation. - Inguinal hernia repair and laparoscopic cholecystectomy were typical operations observed during this trial but it was recommended that specific use of NOTSS be determined by the educational needs of the trainees. - For example, with junior trainees, the focus of training is on developing basic surgical expertise, so it was advised that the NOTSS system Figure 2.2 nOTSS skills taxonomy v1.2. - be used for general discussion of non-technical skills and their importance to clinical practice. - For more senior trainees such as specialist registrars (SpRs), it was suggested that the NOTSS system be used to rate skills and provide feedback during increasingly challenging cases.. - Most of the consultant surgeons had been trained to use the system in the three- hour group session for the system evaluation study reported previously. - Trainees attended an information session about non-technical skills and the usability trial at their hospital. - During this session, it was explained that the NOTSS system has been designed to aid the development of professional skills and that we were evaluating the system rather than assessing their skills during the study. - The NOTSS system was used to observe and debrief on non-technical skills during a total of 43 cases (mean 4 per consultant, range 1–8 cases). - The majority of trainers (90 per cent) thought that they had received enough training to use the system and preferred to conduct the debrief immediately after the operation (81 per cent) in the operating theatre suite. - Some categories were not used by some trainers due to the level of the trainee and the complexity of the procedure being completed.. - The majority of surgical trainers thought that the NOTSS system was useful for debriefing trainees and a valuable adjunct to currently available assessment tools.. - The trainers were all in agreement that NOTSS provided a common language to discuss non-technical skills and was useful to support reflective practice, but there were mixed opinions regarding the ease of rating non-technical skills. - to rate, 27 per cent found interpersonal skills difficult to rate compared with only 9 per cent who felt cognitive skills were difficult to rate (Yule et al. - Time can be a precious commodity in the operating theatre but only 9 per cent of trainers thought using NOTSS to debrief added too much time to their operating list and 73 per cent thought that routine use of NOTSS would enhance safety in the operating theatre.. - Comments from trainers indicated that positive aspects of the system for surgical education were the transparent structure. - ease of use in real-life situations, and that using the system made time to discuss aspects of surgical performance that are ‘usually ignored’. - These related to understanding some descriptors in the NOTSS handbook. - The aims of the NOTSS project was to develop and evaluate a behavioural marker system for surgeons’ non-technical skills using human factors methods and basing the system development and associated rating scale on a skills taxonomy. - Further development of the tool is required and there remain some unanswered questions such as the amount of training required for a practising surgeon to be able to use the tool reliably, and whether observations and ratings have to be made by surgeons (as opposed to anaesthetists, nurses or even psychologists) to be valid and meaningful. - Other research teams have developed tools to observe and rate the behaviours of surgical teams (Undre et al.. - 2007 – Imperial College) or have adapted the NOTECHS tool from civil aviation (Flin et al. - 2003) for use with surgeons in operating theatre (Sevdalis et al. - 2008 – Imperial College, Mishra et al. - These lines of research differ in concept and approach but nonetheless enrich our understanding of non-technical skills in surgery.. - The adoption of specific training in non- technical areas of expertise is still done on an ad hoc basis although the Royal Colleges of Surgery in Great Britain and Ireland all provide training in this emerging area to some extent. - As part of the NOTSS evaluation, it emerged that training in using the system was not sufficient for many users as they did not have background knowledge in psychology and human factors. - This developed into a two-day course, specifically on the NOTSS system in 2006, run with the Royal College of Surgeons of Edinburgh. - These courses were designed for higher trainee and consultant surgeons only and were based on task analysis of surgeons’ non-technical skills, the NOTSS behaviour rating system, and underlying psychology (Flin et al. - The Future of non-Technical Skills in Surgical education. - Although not formally achieved yet, the future of surgical training will need to encompass more than just clinical and technical skills (Davidson 2002). - If the aviation model was to be adopted in surgery then experienced consultant surgeons would be taken off clinical work for a period to concentrate on assessing other consultants’ non-technical skills. - Assessments would be done using a framework such as NOTSS to rate observable skills in a simulated environment and during real cases in the operating theatre (similar to LOSA checks in aviation, see Chapter 25 in this volume by Musson). - This would require courses to be developed (e.g., Flin et al. - This process would apply to consultant surgeons although senior trainee surgeons would be assessed and given feedback on their non-technical skills as part of their ongoing training and may have to pass a non-technical skills assessment as part of the selection process into consultant grades. - Research teams may be involved in the training and assurance of assessors, instructors and practising surgeons, and would be interested in the development of measures of behaviour and performance.. - This model may not be appropriate for surgery and competence assessment at this time, but in the near future, recertification will be introduced as a part of revalidation, which will require global assessment of professional performance including the skills referred to above. - with observational tools, appraisals are commonplace, and the introduction of Procedure-Based Assessment (PBAs) has demonstrated that there is more to surgery than technical skills, and that workplace assessment is the method by which consultant surgeons of the future will be assessed. - Perhaps as important is that in some hospitals non-technical language is becoming common parlance both intra-operatively and in the coffee room. - However, the surgeons who use behaviour rating scales and discuss non-technical skills with their trainees are still in the minority. - In order for widespread change in practice, a trigger is required, such as official endorsement by the Postgraduate Medical Education and Training Board (PMETB) or the Intercollegiate Surgical Curriculum Programme (ISCP), or inclusion in the processes of revalidation of doctors which is currently being discussed.. - The Future of nOTSS Research: integrating Systemic issues in the Operating Theatre. - NOTSS has been widely cited in the clinical literature, adopted by professional bodies for training, and the system is being used by other research groups around the world. - However, a reliance solely on individual skills or even those of the surgical team will not achieve the levels of safety required by patients. - Feedback from users of the NOTSS system indicated that aspects of surgery such as scheduling, anaesthetic care, competence and experience of other staff, availability of equipment in theatre, new technology and training also have an impact on surgical performance and surgical outcomes. - There is emerging research on the impact of distractions (Sevdalis et al. - 2007) and latent failures (Catchpole et al. - 2007) on patient safety in the operating theatre, and tools for understanding the systemic causes of adverse events in the operating theatre (Taylor-Adams and Vincent 2004) but we do not yet have a complete understanding of the systems aspects that affect patient safety.. - The Accreditation Council for Graduate Medical Education in the USA explicitly demands that resident trainee surgeons obtain specific knowledge, skills and attributes to demonstrate ‘systems-based practice’ (ACGME, 2007).. - In addition to the dangers that systems pose for safety, there are also strengths embedded in surgical systems that make surgeons and surgical teams resilient in the face of dynamic, error-producing conditions. - A new project, funded by the Royal College of Surgeons of Edinburgh is attempting to make these aspects of the surgical system explicit and measurable. - With this research strategy, in time we will understand more about individual skills, the role of the. - team and how they interact with the system to protect or harm patients, and have evidence-based tools and training to support the surgeons of the future.. - (1999) Consultant surgeons’. - opinions of the skills required of basic surgical trainees. - (2006) A prospective study of patient safety in the operating room. - (2002) The surgeon of the future and implications for training. - (2003) Speaking up in the operating room: How team leaders promote learning in interdisciplinary action teams. - (2004) Rating non-technical skills: Developing a behavioural marker system for use in anaesthesia. - Flin, R., Goeters, K., Amalberti, R., et al. - (2003) The development of the NOTECHS system for evaluating pilots’ CRM skills. - (2006a) Attitudes to teamwork and safety in the operating theatre
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