- This has enabled us to maximize recruitment of cases, not only through an appreciation of the practical listing of surgical cases, but by engaging with the working practices and culture of each surgical team.. - Consider the specific nature of context for implementing studies in the surgical workplace.. - Spend time working with surgical teams to maximize the success of the research.. - Videotaped patient consultations are used for training (Pendleton et al. - 1984) and assessment purposes, with videotaped consultations forming part of the current summative assessment for GP training, the new Membership of the Royal College of General Practitioners (Royal College of General Practitioners 2008). - They have been shown to be valid and reliable as an assessment method for trainees (Campbell et al. - Beard et al. - There is also evidence that giving trainees feedback on their surgical performance improves their surgical skill (Grantcharov et al. - The intention of this chapter has been to provide a study overview to demonstrate the alignment of the study design and methodology to the study aim and main research questions. - We have illustrated the implementation of the study using a descriptive analysis of our problem-solving approach. - It is hoped that valuable lessons from our team experience can be drawn upon by researchers in the field, or trainers with a responsibility for workplace assessment.. - The research team was the successful applicant for a grant provided by the NHS Research and Development Programme for research into the assessment of surgical skills in the UK.. - (2005a) Assessing the technical skills of surgical trainees. - Annals of the Royal College of Surgeons 87, 242–7.. - (1999) Reforming higher specialist training in the United Kingdom – a step along the continuum of medical education. - The report of the Working Group on Specialist Medical Training (the Calman Report).. - assessment and constructive feedback on improvement of laparoscopic performance in the operating room. - Annals of the Royal College of Surgeons . - Annals of the Royal College of Surgeons 85, 190–3.. - (1994) Reliability and construct validity of a structured technical skills assessment form. - (2008) Surgeons’ non-technical skills in the operating room. - Reliability testing of the NOTSS behaviour rating system. - Scrub Practitioners’ List of Intra-Operative Non-Technical Skills – SPLINTS. - In addition to their technical expertise, members of an operating theatre (OT) team will utilize a range of ‘non-technical’ skills. - These are the cognitive and social skills that complement technical skills to achieve safe and efficient practice. - Taxonomies of these non-technical skills have already been identified for anaesthetists’ (see Glavin and Patey, Chapter 11 in this volume, Fletcher et al. - 2004) and surgeons’ performance (see Yule et al., Chapter 2 in this volume, Yule et al. - 2006b) in the intra-operative phase of surgical procedures. - Another key member of the theatre team is the scrub (or instrument) nurse, practitioner or technician, 1 who works directly with one or more surgeons while they are operating on the patient. - As there was no taxonomy of non-technical skills for this member of the scrub team, a research project (funded 2007–2009 by NHS Education Scotland) was established to identify these skills and this chapter will describe the findings of the SPLINTS project to date.. - The aviation industry lead the way in the non-technical skills approach by developing special research programmes to identify pilots’ cognitive and interpersonal skills that influenced fight safety. - These skills are trained in special courses called Crew Resource Management (CRM) with the aim of reducing human error and improving the performance of flight crews (see Musson in Chapter 25, Wiener et al. - The effectiveness of CRM training can be evaluated by using attitude surveys or observing and rating individuals’ performance during task execution to establish whether training has resulted in knowledge transfer and improved skill execution (O’Connor et al. - To increase the reliability and objectivity of these observations, behavioural assessment tools have been developed by listing the observable non- technical skills taught in these courses and devising a rating system to assess them.. - this type of training and assessment method (Flin et al. - In recent years, there have been efforts to extend the research and training in non-technical skills into areas of acute healthcare services, such as surgery, trauma centres and intensive care units (ICUs) (Baker et al. - behaviour called NOTECHS was developed by European pilots and psychologists (see O’Connor et al. - 2002) and it has been adapted to rate teamwork in the operating theatre (see Catchpole et al. - Rather than adapt tools designed for airline pilots, some other research teams have taken a task analysis approach to identify non-technical skills, e.g., in anaesthesia (Fletcher et al. - 2004), surgery (Yule et al. - 2006b), ICU (Reader et al. - 2006) and neonatal resuscitation (Thomas et al. - These investigators have then devised behavioural rating systems, to evaluate the identified skills and these are now being used in professional training and formative assessment (see for example, Yule et al. - Some of the team-based tools include behavioural ratings of nurses (e.g., Catchpole et al. - 2008, Undre et al. - 2006a) but, despite nurses being a key member of the operating theatre team, their particular non-technical skills have not been formally identified. - The first task of our research project was to search the nursing and psychology literature for any studies of nurses’ non-technical skills.. - The literature search identified very few studies, in fact from an initial total of 424 publications identified, only 13 papers had data pertaining to non-technical skills of scrub nurses (for full details see Mitchell and Flin 2008). - Categories of Scrub nurses’ non-technical Skills Communication. - Despite the recognition that all members of a team require effective communication skills to enable the smooth running of the operating theatre (OT) (Taylor and Campbell 2000), insufficient or ineffective communication between team members in the OT setting has been recognized as a contributing factor to some adverse events (Helmreich and Schaefer 1994). - non-technical skill Paper. - Awad et al. - Baylis et al. - Flin et al. - Sevdalis et al. - Sexton et al. - Undre et al. - Table 5.1 non-technical skill categories examined in the 13 included papers. - checklists to promote team communication between the disciplines in the OT (see Lingard et al. - Studies of nurses have shown general dissatisfaction with communication in the OT (Nestel and Kidd 2006). - Case-irrelevant communications for example, questions about a previous patient, telephone calls or bleeps within the OT, particularly those which are intended for the nurse or anaesthetist were also found to be distracting to the OT team (Sevdalis et al. - In the USA, CRM principles were used in an attempt to improve communication through medical team training which included didactic instruction, interactive participation, training films, role-play and team briefings. - After this intervention surgeons and anaesthetists reported that communication had improved although there was no significant improvement in nurses’ perception of team communication (Awad et al. - In another study (Edmondson 2003), the ability of team members to voice concerns or speak up within the hierarchical structure of the OT was examined during implementation of new technology in cardiac surgery. - Since use of the new equipment required interdisciplinary communication, difficulties staff reported were more behavioural than technical. - Nurses reported that nursing staff in the team had not been accustomed to speaking up – in the past, they would not have dared do so – but that surgeons had become more amenable to being questioned and team members listened more to others despite this being contrary to the previous power-based communication norms. - Researchers have examined teamwork in the field of medicine to try to develop ways to enhance patient safety and increase team cohesion to reduce error. - Nurses largely felt that the theatre team was a single unit, in contrast with surgeons’ impressions of being a member of a team which comprised several highly specialized sub-teams (Undre et al. - (2000) found low ratings of teamwork by surgical nurses in the USA and Europe when they rated interactions with consultant surgeons. - In a Scottish study, surgeons rated their quality of relationships with other consultants and nurses equally, whereas nurses rated teamwork and communication with other nurses higher than between themselves and surgeons (Flin et al. - as a ‘game’ which involved nurses learning the art of making suggestions to doctors without appearing to do so, several researchers have considered how this relationship has evolved (e.g., Hughes 1988, Mackay 1993, Porter 1991, Stein et al. - Still, ten years later, scrub nurses perceived their main responsibility as ‘not upsetting’ the surgeon or ‘keeping the surgeons happy’. - Teams in the OT can either be flexible, where personnel are rotated, or stable, where members become used to working together as a unit. - A study in Finland, UK and the USA by Silen- Lipponen et al. - When interviewed, less experienced nurses admitted that in a strange team they felt unable to prepare or participate in the planning of the surgery. - There was also frustration from nurses towards the attitude of some surgeons, who seemed unaware that their operating style differed from that of their colleagues when they assumed that nurses would automatically know what equipment they required, resulting in the nurses becoming flustered and liable to make errors, causing concern for patient safety. - Baylis et al.. - (2006) concluded that staff on unplanned leave being replaced in the team by temporary staff resulted in a higher incidence of complications. - Situation Awareness. - Situation awareness is defined as ‘the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future’ (Endsley 1995, p. - Perceptual and anticipatory cognitive skills are clearly critical for scrub nurses as an element of their expertise is to ‘think ahead of the surgeon’. - The scrub nurse uses situation awareness, in addition to technical knowledge, to assess the stages of the surgical task correctly in order to select the appropriate instrument for the next phase of the operation. - Situation awareness is not a term which has been used in the nursing literature, although an Australian study observing theatre nurses used the term ‘judicial wisdom’ to describe the way nurses combine their personal expertise, ability to read surgeons’ demeanour and knowledge of surgical procedures to make sense of situations rather than interrupting surgery by asking questions. - Surgeons’ preference cards are used as an aide memoire for theatre nurses to gather the instrumentation the surgeon has indicated in the past that s/he prefers to use while performing the different procedures within his or her surgical speciality.. - This was taken as indicative of the changeable nature of surgeons’ requirements, making anticipating their needs much more difficult. - That paper was the only one found directly studying scrub nurse situation awareness but since situation awareness has only recently been investigated in relation to surgeons (Way et al. - Scrub nurses were also interviewed about surgeons’ non-technical skills during non-routine procedures and they referred more often to surgeons’. - interpersonal skills than cognitive skills as being important to the success of the procedure. - Nurses said they were able to judge the mood and concentration level of the operating surgeon by observing and understanding their behaviour, and nurses also demonstrated situation awareness by reporting that they were able to comprehend that a patient’s state was deteriorating by perceiving changes on physiological readouts (Yule et al. - Similarly, nurses’ leadership was a skill which although studied in other areas of the hospital. - So, from the literature we could see that although there was some evidence of the non-technical skills of scrub nurses having been examined, they were usually extracted where nurses had been interviewed or observed with regard to the theatre team as a whole or as a consequence of investigating surgeons’ skills, improving safety or reducing error within the OT. - Since such a small number of papers identified scrub nurses’ non-technical skills in the course of the literature review, the next step in the project, to provide more examples, was to use a different method of task analysis (see Flin et al. - Observing task execution and semi- structured interviews with experienced scrub nurses were two of the methods available. - range 2–33 years) were conducted at three Scottish hospitals to extract the non-technical skills required to do their job effectively.. - The interview protocol consisted of general questions designed to elicit responses which would provide details of non-technical skills used in general, day-to- day working as a scrub nurse during surgery. - These questions were designed by drawing on knowledge of the generic non-technical skill categories (e.g., communication, decision-making, leadership, situation awareness) which had emerged from previous skill taxonomy development (Flin et al. - Table 5.2 gives a sample of the questions asked in the interviews. - 6 How do you keep track of the status of an operation?. - 7 What factors affect the working atmosphere in the operating theatre?. - 8 What do you do to keep others in the team informed of what you are doing or requiring?
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