2013

http://informahealthcare.com/jicISSN: 1356-1820 (print), 1469-9567 (electronic)

J Interprof Care, 2013; 27(5): 380–386! 2013 Informa UK Ltd. DOI: 10.3109/13561820.2013.791670

Interprofessional non-technical skills for surgeons in disasterresponse: a literature review

Anneliese Willems1, Bruce Waxman1, Andrew K. Bacon2, Julian Smith1 and Simon Kitto3

1Department of Surgery, Monash Medical Centre, Clayton, Australia, 2Metropolitan Ambulance Service, Clayton, Australia, and 3Department of

Surgery, University of Toronto, Toronto, Ontario, Canada

Abstract

Natural disasters impose a significant burden on society. Current disaster training programmesdo not place an emphasis on equipping surgeons with non-technical skills for disasterresponse. This literature review sought to identify non-technical skills required of surgeons indisaster response through an examination of four categories of literature: ‘‘disaster"; ‘‘surgical’’;‘‘organisational management’’; and ‘‘interprofessional’’. Literature search criteria includedelectronic database searches, internet searches, hand searching, ancestry searching andnetworking strategies. Various potential non-technical skills for surgeons in disaster responsewere identified including: interpersonal skills such as communication, teamwork andleadership; cognitive strategies such flexibility, adaptability, innovation, improvisation andcreativity; physical and psychological self-care; conflict management, collaboration, profes-sionalism, health advocacy and teaching. Such skills and the role of interprofessionalism shouldbe considered for inclusion in surgical disaster response training course curricula.

Keywords

Interprofessional collaboration,interprofessional education, literaturereview, non-technical skills, surgery,teamwork

History

Received 6 March 2012Final Revision 22 January 2013Accepted 27 March 2013Published online 7 June 2013

Introduction

Current research demonstrates that an average of 230 millionpeople are affected by natural disasters each year, with 1.2 millionkilled by disasters in the last decade (International Federation ofRed Cross and Red Crescent Societies, 2012). In 2011 alone, 332natural disasters were recorded: killing a total of 30 773,impacting 244.7 million and resulting in economic damagesestimated at US$ 366.1 billion (Guha-Sapir, Vos, Below, &Ponserre, 2011).

As yet, there is no universally accepted definition of disaster(al-Madhari & Keller, 1997). There are some recognised commonelements of a disaster. These comprise of: a large loss of life,multiple injured, overwhelmed health systems or a declared stateof emergency (Centre for Research on Epidemiology of Disasters,2009). This literature review focuses on natural disasters definedby the World Health Organisation as, ‘‘the result of an ecologicaldisruption or threat that exceeds the adjustment capacity of theaffected community’’ (Lechat, 1979, p. 11). Specifically, thisreview focuses on the response phase of disasters, which is theperiod immediately following the disaster event or secondaryevent(s) (Sundnes, Birnbaum, & Birnbaum, 2003). From ahealthcare perspective this involves the gathering of resourcesin order to ‘‘minimise health consequences of the affectedpopulation’’ (Bern, 2006, p. 29). Surgeons play a significant rolein disaster response as members of the healthcare team.

In recent times, health professionals, including surgeons, havebeen called to develop their skill set for best practice in disasterresponse (Anton Breinl Centre for Public Health and TropicalMedicine (ABC), 2006). Although existing disaster trainingsystems in Australia encompass some non-technical skills, there

has not yet been an in-depth analysis in identifying the key non-technical skills for disaster personnel, in particular surgeons.

Existent training programmes are provided by governmentagencies, traditional providers and private institutions (ABC,2006). In Australia, various approaches to disaster education andtraining exist. Nationwide, there has been a greater emphasis oninstitutional training and simulated events, particularly aimed atimproving overall disaster response of a particular facility or stateas a collective whole (Smith, 2006). Programmes targeting out-of-hospital responders are diverse in nature, where styles ofdelivering educational material include drills, lectures, videorecordings, tabletop exercise and use of simulated patients(Williams, Kobayashi, & Shapiro, 2006). While there are notyet any current disaster-specific courses or programmes, medicalpersonnel, including surgeons, often participate in one or more ofthe Major Incident Medical Management and Support programme(Hodgetts, 2003), the Early Management of Severe Trauma course(Royal Australasian College of Surgeons, 2011) based on theAdvanced Trauma Life Support course (American College ofSurgeons Committee on Trauma, 2008), or the Definitive SurgicalTrauma Care course (Liverpool Hospital, Melbourne University,& Royal Australasian College of Surgeons, 2004). However,whether these non-disaster specific courses are sufficient trainingfor surgeons in disaster response remains unanswered.

Despite the availability of these courses (Campbell, 2005),reviews have found current methods of training health personnelin disaster medicine to be inadequate (Hsu et al., 2004; Milsten,2000; Williams, Nocera, & Casteel, 2008). These findings havecaused a push to review the efficacy of such training and innovatethe development of new programmes (ABC, 2006). Calls havebeen made to professionalise the field of disaster responsethrough further development of evidence-based disaster skilltraining for health professionals (Southeast Asia Regional Office/World Health Organization, 2006).

Correspondence: Simon Kitto, Department of Surgery, University ofToronto, Toronto, Ontario, Canada. E-mail: Simon.Kitto@utoronto.ca

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Alongside these developments, the importance of the conceptand practice of interprofessionalism is gathering recognitionwithin education and training in disaster medicine. The terminterprofessionalism refers to a collaborative partnership workingtowards a common goal (Oandasan & Reeves, 2005a). It isdescribed as knowledge of the roles of other professional groups,and the ability to work with them (Finch, 2000). In particular, thedevelopment of an international working group by the WorldAssociation of Disaster and Emergency Medicine focuses onelements of interprofessionalism in multidisciplinary educationand training (ABC, 2006).

In response to these needs, the objective of this review was toidentify the non-technical skills required of surgeons and exploreinterprofessional best practice for surgeons in disaster response.Identification, appraisal and discussion of such skills in thesurgical literature as well as analysis of disaster literature wereundertaken.

Methods

Literature searches were comprehensive and detailed, but notsystematic due to time and resource constraints. Five searchmethods, as suggested by Chaffee (2009), were used to identifyliterature for this research as shown in Table I.

Literature searches took place in 2009, wherein initial searchesrevealed 617 abstracts. Of these, 287 articles were includedencompassing four categories: disaster literature (n¼ 180), sur-gical literature (n¼ 37), organisational management literature(n¼ 27) and interprofessional literature (n¼ 43). The ‘‘disasterliterature’’ category, in contrast to the other literature categories,encompassed the use of both peer-reviewed literature and ‘‘greyliterature’’, referring to literature which has not been peer-reviewed (Chaffee, 2009). The criteria put forward by Benzies,Premji, Hayden, & Serrett (2006) for the inclusion of greyliterature in research are met in the field of disaster medicine, andhence in this research. The ‘‘grey’’ literature set includes case

reports, non-government organisation (NGO) reports and personalaccounts.

Disaster-related electronic and Internet search terms centredon individual disasters with analysis of abstracts for relevantsubject matter. At the time of search, there had been 25 disasters,or ‘‘overwhelming’’ events in the last three decades according toSmith, Wasiak, Sen, Archer & Burkle (2009). This researchprioritised literature from natural disasters as shown in the firstcolumn (Table II). Exclusion criteria included those which werenot directly disaster or emergency response related, narrative stylearticles which did not discuss non-technical skills and disaster-related articles which were not related to surgical or healthpersonnel.

While not the focus of this research, the literature set alsoincludes publications discussing human-made and complexhumanitarian emergencies (CHE) as well as the smaller scalemass casualty incidents. There are similarities in practiceenvironment, including descriptions of chaos, disorganisationand austerity, which signify that knowledge in these areas mayassist in developing theory for management within the naturaldisaster context (Albala-Bertrand, 2000; Dressler & Hozid, 1994).

RESULTS

Current role of surgery in disaster response

Surgical services are often vital following a disaster, whereresponsibilities may include performing surgery, assisting intriage or coordinating hospital management (Ciraulo et al., 2006;Lennquist, 2007). The demand for surgical intervention, and thetiming and form of such intervention, is dependent on themagnitude and form of disaster (Milsten, 2000; Sundnes et al.,2003). Surgical needs change over the hours, days and weeksfollowing a disaster, where the majority of lives are generallysaved within the first 48 hours (Noji et al., 1990). The type andamount of surgery performed will be linked to the capacity of thelocal and regional surgical and medical systems (Russbach, 1990).Local surgeons encounter the burden of immediate emergencycare, particularly as external assistance usually arrives days afterthe event (Redmond, 2005).

The organisation of disaster response

Health professionals, including surgeons, who travel into adisaster-affected region, originate from a diverse range oforganisational backgrounds. Such organisations may be nationallyor internationally based, and include the military, internationalNGOs or smaller local and overseas domestic-based NGOs(Hanfling, Llewellyn, & Burkle, 2006).

Representing or working alongside these organisations aredisaster medical assistance teams (DMATs) (Bern, 2006). DMATstravel to regions affected by disasters, and comprise professional

Table II. Disasters of the last three decades.

Natural Human-made/Technological Conflict/CHE

Alaska Earthquake (1964) Three Mile Island (1979) Haiti (1991)Hurricane Andrew (1992) Bhopal (1984) Iraq (1991)Japan Earthquake (1995) Exxon Valdez (1989) Somalia (1993)Turkey Earthquake (1999) Oklahoma City Bombings (1995) Sudan (1994)Iran Earthquake (2003) 9/11 (2001) Rwanda (1994)Indian Ocean Earthquake/Tsunami (2004) Bali Bombings (2002) East Timor (1999)Pakistan Earthquake (2005) Madrid Bombings (2004)Hurricane Katrina (2005) Bali Bombings (2005)Sichuan Earthquake (2008) London Bombings (2005)Myanmar Cyclone/Cyclone Nargis (2008)

Erin Smith et al. (2009). Used with permission.

Table I. Literature search methods.

Technique Description/Examples

1. Electronic databasesearches

Conducted on Ovid and Medline

2. Internet searches Conducted on Google and Google Scholar3. Hand searching Hand searching of journals and disaster

publications, where hardcopies wereavailable.

4. Ancestry searching References from publications wereexplored for additional relevantliterature.

5. Networking strategies Individuals known to be involved withinthe topic areas were contacted foradditional literature.

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(e.g. surgeons) and paraprofessional medical personnel, as well assupport personnel. These teams may be civilian, military orinstitutionally mixed (ABC, 2006). The number of team membersper DMAT varies according to the country and the capacity levelof the team (Morrissey, 2001). Of note, Australia is becomingincreasingly involved in the delivery of relief through DMATs as aconsequence of the recent disasters in the Asia-Pacific region(Chambers, Campion, Courtenay, Crozier, & New, 2006; Garner& Harrison, 2006; Grantham, 2005; Jackson & Little, 2006;Robertson, Dwyer, & Leclercq, 2005). Given the development ofDMATs in Australia and the potential deployment of surgeonswithin these teams, the identification of non-technical corecompetencies within this literature review is an important stepin developing appropriate training to assist surgeons consideringengagement in this form of disaster response.

Variations in surgery in the disaster response context

As ‘‘each disaster will generate its own set of needs’’ (Alexander,1993, p. 428), the surgical environment is necessarily modified inorder to best respond to them. The operating theatre (OT) mayremain in the local hospital; however, depending on the nature ofthe disaster and damage to hospital infrastructure, a shift to otherless-damaged buildings or field hospitals may be necessary(Smith et al., 2005). While medical professionals routinely workin a ‘‘constant’’ highly controlled hospital environment, suchstructure is lost in a disaster, and the environment is oftenpervaded by hazards, disorganisation, and chaos (Bissell, Becker,& Burkle, 1996). Surgery following a disaster is characterised bylimited resources and equipment, where running water, electricityand, in tropical environments, air conditioning may be absent(Grantham, 2005; Roccaforte & Cushman, 2007; Taylor,Emonson, & Schlimmer, 1998).

In particular, the regions and countries most affected bydisaster are less wealthy, often with poorly developed healthcaresystems and inadequate disaster planning (Keim & Rhyne, 2001).Teams travelling into these areas may encounter pre-existentresource deficits further compounded by the disaster event.The degree of variation to the norm correlates to the magnitude ofthe disaster, the ratio of those injured compared to those killed,and the devastation to the pre-existing healthcare systems(Ciottone, 2006).

In addition, in travelling to these countries, cultural sensitivitymust also be considered (Ha-Redeye, 2005). Cultural competence,in surgery, has been described as ‘‘a set of congruent behaviours,attitudes, and policies that come together’’ (to enable) ‘‘profes-sionals to work effectively in cross-cultural situations’’ (Cross,Bazron, Isaacs, & Dennis, 1989, p. 13). The importance of suchcompetence has been highlighted by past events where respondershave provided inappropriate aid or caused offense in affectedcommunities due to ‘‘lack of knowledge of cultural issues’’(Seyedin, Aflatoonian, & Ryan, 2009, p. 173).

Non-technical skills in surgery

In exploring non-technical skills for surgeons in disaster response,these skills and associated challenges within the everyday surgicalenvironment were explored and contrasted. In Australia, surgicaltraining adheres to a competency-based model through theSurgical Education and Training (SET) programme (Dickinson,Watters, Graham, Montgomery, & Collins, 2009). This isgoverned through the Royal Australasian College of Surgeons(RACS), which forms the training and regulatory body forSurgeons in Australia and New Zealand (Dickinson et al., 2009).Within this framework, as adapted from the CanMEDs 2005Physician Competency Framework (Frank & Langer, 2003), ninecore competencies are assessed including, medical expert,

technical expert, judgement/clinical decision-making, communi-cator, collaborator, manager/leader, professional, health advocateand scholar-teacher (Royal Australasian College of Surgeons,2008b). These competencies are relevant not only to trainees butalso for the life-long journey of a surgeon’s practice.

Of these competencies, the latter six are non-technical. Non-technical skills are noted as comprising a combination ofcognitive and social skills, which complement knowledge andtechnical skills to contribute to safe clinical practice (Flin,O’Connor, & Crichton, 2008). These competencies acknowledgethat a good surgeon is more than a technician (Gruen et al., 2003),and that technical skill alone is not enough for safe surgicalpractice (Royal Australasian College of Surgeons, 2008a).Recognition of these skills arose in response to studies of adverseevents, and surgeons’ behaviour in the operating theatre, whichsuggested that non-technical behaviours were frequently involvedin surgical mishap and complaints (Gawande, Zinner, Studdert, &Brennan, 2003; Lingard, Espin, et al., 2004; Sutcliffe, Lewton, &Rosenthal, 2004). RACS’ assessment of trainees’ non-technicalcompetencies is modelled on the Non-Technical Skills forSurgeons (NOTSS) programme, developed by the University ofAberdeen (Dickinson et al., 2009). NOTSS identifies ‘‘behaviourmarkers’’ by breaking down competencies into 3–4 componentbehaviours and providing examples of ‘‘good’’ or ‘‘poor’’ non-technical performances of these (Flin, Yule, Paterson-Brown,Rowley, & Maran, 2006).

Of the non-technical competencies defined by RACS, four inparticular (communicator, collaborator, manager-leader andscholar-teacher) encompass interpersonal skills, cognizant thatsurgeons’ professional environment lies within a complexhealthcare system comprised of multiple players (Undre et al.,2007). Such competencies, put forward by ‘‘silo-based’’ uni-professional training programmes, aid in defining surgeons’ roleidentities within the OT (Kitto, Gruen, & Smith, 2009), wheresurgeons are branded as having cognitive expertise equippingthem in the areas of ‘‘focus, problem solving, commitments tostandards and leadership’’ (Gruen et al., 2003, p. 607). Suchunderstandings imply that the surgical profession stands at thepeak of the health profession hierarchy (Kitto et al., 2009).Societal valuing of surgery and medicine in general, alongside thepopular media and stakeholders in surgical practice, reinforce this‘‘prestigious’’ professional role identity (Gruen et al., 2003).However, there is debate regarding whether surgeons should beadopting a leadership role, or whether they should be team players(Hall, 2005; Lingard, Reznick, DeVito, & Espin, 2002; Oandasan& Reeves, 2005a). Leadership in surgery is a dynamic role, whichhas been described as adopting components of authoritative,coaching, affiliative, democratic, pacesetting and commandingleadership styles. A varied approach is argued as necessary ingood surgical leadership (Halverson, Walsh, & Rikkers, 2012).For example, good leadership at one stage in the operative processmay involve an affiliative approach in order to foster a ‘‘safesupportive. . .environment’’ wherein other professionals maycarry out their respective duties. However, other leadershipstyles, for example authoritative, may be more appropriate atother times such as during the event of a surgical complication.Some interpret surgical leadership to extend beyond the OT, to thegreater management of the organisation in which they workincorporating ‘‘service redesign and healthcare improvement’’(Patel et al., 2010, p. 878, 880). In contrast to calls for surgicalleadership, it has been reasoned that for ‘‘collaborative practice tooccur a sense of equal status must be inculcated amongst healthcare team members’’ (Kitto et al., 2009, p. 186). As a result fromthis, misunderstanding and contestation of professional roleidentity(s) may lead to conflict in the OT (Lingard, Garwood,& Poenaru, 2004).

382 A. Willems et al. J Interprof Care, 2013; 27(5): 380–386

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Conflict, referring to the ‘‘process of social interactioninvolving a struggle over claims to resources, power and status,beliefs, and other preferences and desires’’ (Bisno, 1988) hasimplications for the individuals concerned, the overall efficiencyof the team and patient safety and outcomes (Rogers & Lingard,2006). Conflict can be classified as task conflict or relationshipconflict. Relationship conflict is typified by ‘‘friction, frustration,and personality clashes within the group’’ (Jehn, 1994, p. 224),whereas task conflict concerns disagreement in viewpointsregarding a task and how it may be performed (Rogers &Lingard, 2006). Both forms of conflict may be present within theOT where aside from role identity, key triggers are resources,safety, time, sterility and situation control (Lingard, Garwood,et al., 2004; Rogers & Lingard, 2006). Most importantly, in astudy of conflict in hospitals, surgeons were reported as havingthe greatest amount of conflict compared to other professions(Skjorshammer & Hofoss, 1999).

Communication breakdown, as a form of conflict involvingsurgeons in the OT, is suggested to be common (Rogers & Lingard,2006) and has been attributed to being the ‘‘primary behaviour’’that increases risk of surgical mishap or mistakes with surgicalpatients (Lingard, Garwood, et al., 2004; Sexton, Thomas, &Helmreich, 2000). Reinforcing this, research has suggested thatsurgical care is associated with one-half to two-thirds of adverseevents in hospitals (Thomas et al., 2000). Given the potentialcomplications of conflict and communication challenges in theOT, interprofessional practice is emerging in surgical training ashaving the potential to improve patient outcomes, in additionto increasing satisfaction in the work environment (Bleakley,Boyden, Hobbs, Walsh, & Allard, 2006; Reeves et al., 2008).

Interprofessionalism in surgery

In the broader health literature, interprofessional practice is alsogathering increasing recognition (Canadian InterprofessionalHealth Collaborative, 2007; International Association ofMedical Colleges, 2003; Yan, Gilbert, & Hoffman, 2007). Thefirst phase of education in interprofessionalism has been argued tobe the fostering of mutual respect and breaking down the ‘‘oldfashioned demarcations’’ between various specialities (Centre forthe Advancement of Interprofessional Education, 2002). Suchdemarcations may be linked back to the socialisation of healthprofessionals (Oandasan & Reeves, 2005b), where individualsentering a particular health profession already have ‘‘a series ofattitudes, beliefs and understandings of what that professionmeans to them’’, and their future role within that profession(Oandasan & Reeves, 2005b).

Various training methods, under the banner ofInterprofessional Education (IPE), have been identified as theideal method for interprofessional initiatives to be implemented(Oandasan & Reeves, 2005a). A shift towards competency-basedIPE training is underway, where competency-based frameworkshave been introduced by numerous professional bodies (CanadianInterprofessional Health Collaborative, 2007). There remains,however, diversity in what are recognised to be the necessarycompetencies for collaborative practice according to the differentprogrammes (Lingard et al., 2005). For example, methods ofpromoting interprofessional practice in the OT which have beenfound to be effective include interprofessional simulation-basedteam training and the implementation of preoperative teamcommunication checklists (Oandasan & Reeves, 2005b).

While there is not yet research to demonstrate as such, it wasassumed within this review that such skills and related challengeswithin a professional environment had the potential to also applyto disaster environments. Professionals working in disasterresponse are expected to first specialise in the standard medical

system prior to working in disasters (Ciottone, 2006).Socialisation processes incorporated in the training systems ofspecialties has been linked to the formation of issues ininterprofessional relations (Telford & Cosgrove, 2006).Professionals working in an area – such as one affected bydisaster – bring with them their own training backgrounds thatinclude values, clinical behaviours and approaches to conflict(Moore & Blasser, 1991), suggesting that there is a need for thisto be addressed in surgical teams working in disaster response.

Interprofessional non-technical skills for all health per-sonnel in disasters

The disaster literature includes a variety of non-technical skills asnecessary for health professionals working in disaster response.These include interpersonal skills such as communication,humour, teamwork and leadership. Communication is broadlyreferenced in disaster publications and, using the Indian OceanTsunami Evaluation as an example, ‘‘communication’’ referencesmay encompass intra-agency, inter-agency, civil/military andinternational communication (Bolton & Weiss, 2001). At anintra-group organisational level, good communication in disastersis suggested to involve improved exchange of vital informationbetween groups (Hsu et al., 2006). Alongside these, languageskills facilitate practice between linguistically diverse affectedpopulations (Bolton & Weiss, 2001). Humour, as a personalattribute, is both discussed and sought after in disaster andhumanitarian assistance, and has been suggested as providing arelease mechanism within highly stressful environments (Moran& Massam, 1997).

Teamwork is emphasised within disaster literature and issought in disasters between ‘‘organisations, departments, profes-sional groups and individuals’’ (Seynaeve et al., 2004). Teamworkin disasters has been discussed as requiring improved multidis-ciplinary work (Finch, 2000). In this, the need for collaborativepractice has also been specified, suggesting that in disastersinterprofessional practice may also need to be better developed(Cuny, 2000b).

Leadership in disasters has been described as requiring a‘‘considerable conscious effort’’ (Grantham, 2005, p. s114).Reviews have suggested that team leaders need to understandgroup dynamics, conflict resolution and people management,which may involve adopting various leadership styles accordingto the variables of the disaster environment (Cuny, 2000a).

Other skills and attributes discussed in disaster literatureinclude skills and cognitive strategies, which assist in theadjustment and well being of professionals within an austereenvironment. ‘‘Flexibility’’ and ‘‘adaptability’’, two of theseskills, are frequently discussed in disaster literature (Webb, 2004).Such skills also are explored through several publications indiscussion of selection requirements (Giannou & Baldan, 2009).Innovation and improvisation are also described as being keyskills within disaster environments (Giannou & Baldan, 2009;Read & Ashford, 2004). Improvisation refers to extemporisingprofessional roles (Gaudette, Schnitzer, George, & Briggs, 2002;Palmer, 2005), surgical procedures (Webb, 2006) and materials orpharmaceuticals used in treatments (Kendra, 2002). Discussion ofinnovation tends to refer to the development and practice of newways of approaching tasks (ABC, 2006). Creativity underpins theskill which is a cognitive strategy discussed in disaster publica-tions as involving inventing new solutions, or adapting oldsolutions to new situations (Birch & Miller, 2005). In addition tothese skills, self-care, both physical and psychological, have beendiscussed as of key importance in disaster response (ABC, 2006;Paton, 1996), where if neglected the toll on workers may be high.Even prior to deployment, it has been stated that team members

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should prepare physically and psychologically, where only thosein good physical and mental health should deploy (McCall &Salama, 1999).

Concluding comments

Several non-technical skills have been identified as significant forsurgeons in disaster response. These include, interpersonal skillssuch as communication, teamwork and leadership; cognitivestrategies such flexibility, adaptability, innovation, improvisationand creativity; physical and psychological self-care, conflictmanagement, collaboration, professionalism, health advocacy andteaching. Such skills should be considered for curriculum incourses that train surgeons for disaster response. The relevance ofhow these skills are implemented by surgeons in a disasterresponse requires further evaluation.

Declaration of interest

The authors report no conflicts of interest. The authors alone areresponsible for the content and writing of this article.

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