Key content
The non-technical skills (NTS) as identified in the literature.
Developments in NTS training.
Current assessment practices and approaches to skills assessment
in obstetrics and gynaecology.
Potential use of assessments of NTS in obstetrics and gynaecology.
Objectives
Describe the NTS required in obstetrics and gynaecology and their
relationship to performance.
Develop an awareness of how these skills may be formally assessed
and the potential role of NTS feedback.
Ethical issues
What are the ethical issues relating to the involvement of trainees in
education research at the same time as performing an assessment?
Is another assessment feasible within the constraints of our
training programme?
Keywords: competence / error / human factors / non-technical
skills / patient safety
Introduction
Non-technical skills (NTS) are important and underpin
technical ability. They include the social skills of
communication, team-working and leadership and the
cognitive skills of situational awareness and decisionmaking,
as well as the important influences of managing
stress and coping with fatigue. Such skills are of particular
relevance in our specialty, where multiple tasks are often
required simultaneously, the woman is usually awake, her
partner is usually present and the clinical circumstances may
be stressful.
Key non-technical skills
The language used to describe NTS may vary. A number of
key categories or concepts have been described and these may
be inter-relational. These categories were originally written
with reference to aviation, and although not formally agreed
for medicine, may apply equally. The set was derived through
interviews, observations and accident report analyses.
NOTSS skill taxonomy
Category Element Examples of good behaviours for category *
Situation awareness Gathering information Awareness of workload and staffing levels, review of notes
Prepares team for arrival of emergency
Understanding information Ensures that relevant investigations have been ordered and reviewed
Projecting and anticipating future state Verbalises equipment required in advance, recognises implications of
busy triage area
Decision making Considering options Recognises and articulates problems
Selecting and communicating option Appropriate options generated
Asks for opinions of senior colleagues if necessary
Implementing and reviewing decisions Has a ‘plan B’
Communication and teamwork Exchanging information Listens to concerns of team members, seeks advice if unsure
Establishing a shared understanding Clear and concise handovers given with no missing information
Co-ordinating team activities Allocates tasks appropriately
Communicates that procedure is not going to plan
Leadership Setting and maintaining standards Shows respect to the woman and her birth partner
Supporting others Establishes rapport with team members
Ensures delegation of tasks is appropriate
Coping with pressure Modifies behaviour according to situation
Appears comfortable when challenged
Non-technical skills for surgeons in
obstetrics and gynaecology
Behavioural marker systems, such as those described, should
ideally be used in the environment for which they were
designed. However, this can take many years and significant
resources to develop and at present there is no
psychometrically robust tool to assess NTS specifically in
obstetrics and gynaecology.
Thus, it may be more pragmatic to pilot the usability of an
appropriately adapted version of an existing tool for use in
obstetrics and gynaecology. The RCOG has taken the
decision to adapt NOTSS and this has been approved by
the original authors. Behaviours have been defined specific to
the specialty and in line with proposed changes to other
assessment tools within the current training portfolio.
Rankings have been removed to concentrate on anchor
statements and feedback. The modified tool has been piloted
for delivery suite and gynaecological surgery in two UK
deaneries in 2012/2013 with evaluations from trainers and
trainees. The findings from the pilot are expected by the end
of 2013 and preliminary reports suggest that these will be
positive although there may be implementation challenges
to overcome.
It is widely recognised that both trainer and trainee
training is essential in order to use the tools to assess NTS.26
The concept of the assessment tools must be understood
clearly with a basic level of training if they are to work in the
real-life environment, and training programmes are likely to
be required to deliver this in a measurable way in the future.
Helping trainers identify important aspects of the
constructs under scrutiny and the inter-relationships
between these may be improved through the provision of
short online simulation scenarios demonstrating poor and
excellent team behaviours. Similarly, information about
performance expectations might be useful.27 Recorded
feedback from skills drills may be useful in this respect in
order to teach and reflect whilst working through assessments
in a constructive manner.
Whether NOTSS is used in obstetrics and gynaecology as a
formative tool added to the assessment portfolio or whether
it will become a summative one will clearly depend on
feedback, reliability data, and ultimately deliverability in a
real life setting.
The move towards NTS training and assessment may
improve attitudes to NTS, but the effects will vary. More
stable teams (e.g. smaller units with fewer staff) may have a
better baseline level of NTS and perceived changes may thus
be less apparent.27 With anything new, there is likely to be a
degree of cultural resistance. Honest debriefing and
challenging authority appear to be particular areas of
difficulty found in previous studies28 and institutional
support will be required to sustain changes in attitude
and culture.
It should also be noted that NTS assessment tools are
sufficient to identify individual behaviours only and not the
mechanisms that lead to harm through NTS failure. In any
clinical situation it is evident that team interaction is essential
and the performance of the obstetrician or gynaecologist can
be enhanced or impeded by the midwives/nurses and
anaesthetists working with them.
Hence, whilst focussing on the obstetrician or
gynaecologist alone is important in order to assess an
individual in training, it is not a true reflection of teamwork
and may not be sufficient alone to effect patient safety.
Measures such as STORC’S clinical teamwork scale, which is
a self-assessment of the efficacy of teamwork, may be a useful
innovation in this respect, although it is yet to be linked
to outcomes.
Conclusion
Non-technical skills are the cognitive, social and personal
resource skills that complement clinical and technical skills.
They are a vital part of the skill set required to become a
competent obstetrician or gynaecologist. Non-technical skills
are currently not adequately integrated within, or assessed as
part of the curriculum, although the interest in this area is
growing, in part as a result of leadership and patient safety
initiatives within the NHS.
NOTSS is the most widely evaluated NTS assessment tool
for the individual and has been tested in the real world. An
adapted version is being piloted by the RCOG following
appropriate educational training and may form part of the
future training portfolio.
NTS concepts should be incorporated into training,
including both simulation and real-life operating room/
delivery suite settings in order to provide formative
evaluation and feedback with the aim of improving quality
of care.