t h e s u r g e on 9 ( 2 0 1 1 ) S 3 5eS 3 7

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The Surgeon, Journal of the Royal Collegesof Surgeons of Edinburgh and Ireland

www.thesurgeon.net

Review

Teaching and assessing non-technical skills

George G. Youngson

Royal Aberdeen Children’s Hospital, Aberdeen, Scotland, UK

a r t i c l e i n f o

Article history:

Received 22 October 2010

Accepted 3 November 2010

Keywords:

Non-technical skills

Surgical education

Workplace-based assessment

E-mail address: ggyrach@abdn.ac.uk.1479-666X/$ e see front matter ª 2010 RoyalSurgeons in Ireland. Published by Elsevier Ldoi:10.1016/j.surge.2010.11.004

a b s t r a c t

The terms human factors and non-technical skills have recently been introduced to the

language of surgical education. Both tend to be used interchangeably and yet each has

a specific definition. More importantly, however, is the fact that the attributes and qualities

contained within these headings relate to behaviours, attitudes and cognitive skills. They

are recognised as crucially important in the practice of surgery, but are often poorly

articulated during surgical performance, during training, during any assessment process

and, indeed, seldom measured with reference to any metric in any of these activities. Most

research in this area addresses non-technical skills in the operating theatre and it remains

to be seen whether the same attributes and skills are used outwith theatre, particularly in

the ward setting. However, the contribution that these aspects of performance make to

a safe and successful outcome following surgery is being increasingly appreciated and

there is increasing recognition of the need to train and assess.

ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and

Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Introduction outwith theatre, particularly in theward setting. However, the

The terms human factors and non-technical skills have

recently been introduced to the language of surgical educa-

tion. Both tend to be used interchangeably and yet each has

a specific definition. More importantly, however, is the fact

that the attributes and qualities contained within these

headings relate to behaviours, attitudes and cognitive skills.

They are recognised as crucially important in the practice of

surgery, but are often poorly articulated during surgical

performance, during training, during any assessment process

and,indeed, seldommeasured with reference to any metric in

any of these activities. Most research in this area addresses

non-technical skills in the operating theatre and it remains to

be seen whether the same attributes and skills are used

College of Surgeons of Edtd. All rights reserved.

contribution that these aspects of performancemake to a safe

and successful outcome following surgery is being increas-

ingly appreciated and there is increasing recognition of the

need to train and assess.

This paper details one taxonomy, e NOTSS - non-technical

skills for surgeons, which is already in use in some sectors of

surgical education and also identifies a range of other classifi-

cations. It poses questions on whether these items are simply

traits to be enhanced or skills to be taught and developed. If the

former, then is tuition required at all or should we continue to

make some tacit acceptance that these attitudes and behav-

iours are implicit in being aneffective surgeonand if competent

in all other areas of surgery, then will non-technical skills be

gathered and incorporated through the journey of training? If

inburgh (Scottish charity number SC005317) and Royal College of

Categories Elements Situation Awareness

Gathering Information Understanding Information Projecting and anticipating future state

Decision Making Considering options Selecting and communicating option Implementing and reviewing decisions

Communication and Teamwork

Exchanging information Establishing a shared understanding Co-ordinating team

Leadership Setting and maintaining standards Coping with pressure Supporting others

Fig 1. e NOTSS Skills Taxonomy (V1.2).

t h e s u r g e on 9 ( 2 0 1 1 ) S 3 5eS 3 7S36

the latter, then is there a skills escalator that accompanies the

learning trajectory and is there confidence in the descriptors

that accompany that assessment scale? These are as yet

unanswered questions.

Perhaps the emphasis placed on these skills in other

domains which involve risk under time pressure and during

emergency situations, (eg., in aviation, nuclear power

industry, police marksmen, military) should suggest that

we, as surgeons, must not be out of line and that surgery

should take cognizance of the importance of defining these

skills and applying them to our profession and to education

and training. Currently, we have scarcely reached the end

of the first step in defining the component parts of

non-technical skills but the benefits of controlling the

environment in the operating theatre are now recognised

contributions to performance of the surgeon and outcome

for the patient.

Non-technical skills - classifications

The Royal Australasian College of Surgeons integrates the

importance of communication (gathering and understanding

information/discussing and communicating options/

communicating effectively) withmanagement and leadership

(setting into training standards/leading inspires others/sup-

porting others) as well as judgement and decision making

(considering options/planning ahead/implementing and

reviewing decisions). This inclusion was derived from

research performed at Aberdeen University where the work

carried out by the Industrial Psychology Research Centre, in

concert with local clinicians and the Royal College of Surgeons

of Edinburgh, developed into a framework (NOTSS-non-tech-

nical skills for surgeons), which was accompanied by other

similar frameworks -one for anaesthesia (ANTS), and one for

scrubnurses (Splints-Surgical Practitioners List of Non-Technical

Skills). This trilogy made explicit the non-technical skills

required of individuals working within the surgical team and

received endorsement through appropriate research method-

ology. (www.abdn.ac.uk/iprc/notss).

Other tools exist. Judgement analysis modelling has been

used to characterise the decision-making processes used by

novices, trainees and experts and the establishment of a gold

standard through experience and through pattern recognition

is considered to be intuitive in part, but also in part to benefit

from feedback and context setting. Similarly, harmony within

the surgical team and optimising team performance has been

based on the crew resource management policy of the avia-

tion industry (CRM) and has been measured and made more

reliable by training as shown by the Oxford team through the

use of their NOTECHS classification. By contrast, the NOTSS

taxonomy focuses on the individual and uses the 4 categories

of situation awareness, decision-making, communication and

teamwork and leadership (Fig. 1); within each there are 3

elements. Whilst this taxonomy has been endorsed through

its utilisation with established consultants, the pace of

acquisition of these skills throughout surgical training is not

yet clear, nor is it clear how much of this is acquired through

explicit training and how much simply "rubs off" by waiting

and watching. Research to date suggests that they are skills

and that induction, development and feedback through

debriefing enhances them. However, the constraints of

Working Time Regulations suggest that learning by a random

opportunity of simply being present for many hours is no

longer a model that will satisfy the need of the current

training environment and climate. The need, therefore, for an

acceptance of the importance of these attributes and the

acceptance of a common language with integration into the

curriculum as an intentional act, is the next step in ensuring

their inclusion in surgical training.

Implicit, however,in the discussions around human factors

and non-technical skills is the agreement that definition is

imprecise and elusive; there is a poorly articulated, - difficult

to characterise - commodity which identifies that specific

surgeon to be chosen by his or her peers as the surgeon for self

or for family and indeed those features that are rapidly rec-

ognised when a new trainee joins the team,- that he/she has

“got it” or not, - that these features are part of the package of

non-technical skills.

The ability to work in harmony to detect problems

almost before they happen and to maintain team cohesion

are all types of behaviours that fall into the NOTSS

taxonomy of situation awareness, communication and

leadership, good decision-making and are a blend of

cognitive and social functions. The benefits, therefore, of

any of the above classifications are that they provide

a currency for exchange of ideas, - a vocabulary which

indicates the values of these attributes, and the basis of

a tool for teaching and assessing.

Assessment

For non-technical skills to be accepted, used and evaluated, it

is highly desirable that the assessment tools which are

already in use (and in which there is a degree of confidence)

are applied. These tools have already been evaluated and

endorsed for their validity in relation to surgical practice and

there is reason to believe that the cognitive component of

non-technical skills (decision-making in situation awareness)

could be evaluated utilising the procedural based assessment

(PBA) techniques and that the social skills integral to NOTSS

t h e s u r g e on 9 ( 2 0 1 1 ) S 3 5eS 3 7 S37

(teamwork communication and leadership), for example,

could be evaluated through multisource feedback. Addition-

ally, it must not be forgotten that self assessment is the most

commonly used, albeit informal, method of evaluation and

that provision of a taxonomy now allows self reflection

against each category and each element and, through that,

self-improvement.

While skill acquisition is one element of competence, skill

retention is another and one which is less well defined.

Indeed, the variableswhich are associatedwith degradation of

skills (such as stress, age), have not been intensively studied

but it is perhaps of note that introduction of crises even into

a simulated environment appears to result in degradation of

non-technical skills.

Conclusion

Surgical excellence is a composite of dexterity, intellectual

and cognitive ability and behaviours and attitudes. There is

no one area of primacy in the production of excellence and

the ability to measure progress and accomplishment

against defined standards and criteria can only be achieved

when those criteria receive universal acceptance.

Conflict of interest

None declared.