Simulation-based acquisition of non-technical skills to improve patient safety

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Abstract

Traditional surgical training has focused on the acquisition of technical skills and knowledge with minimal focus on teaching nontechnical skills. Patient safety depends on both technical and nontechnical skills, with a higher rate of non-technical skills failure leading to patient harm. Many surgical training and regulatory bodies have incorporated nontechnical skills in the required competencies of a surgeon, but few have introduced formal training in nontechnical skills. Emerging research shows simulation-based education to be a powerful tool to teach nontechnical skills to individual surgeons and surgeons in training, and to interprofessional surgical teams with subsequent improvement of patient safety outcomes.

Introduction

Patient safety depends on both nontechnical and technical skills of healthcare professionals, but more frequently the risk to the patient is from failure of nontechnical skills rather than technical skill.1,2 Until recently nontechnical skills have not been appropriately recognised, taught or assessed.

Nontechnical skills are defined as “the cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance”.3 Key nontechnical skills required by surgeons within this definition are:

  • Social skills: communication, teamwork, leadership

  • Cognitive skills: decision making, situational awareness

  • Personal resource skills: managing stress, coping with fatigue.

Simulation-based education (SBE) has been used successfully as a modality for acquisition of technical skills for surgeons in training, and for established surgeons to learn new techniques, or familiarize themselves with new equipment. Increasingly simulation is proving advantageous in the assessment and teaching of non-technical skills. Paediatric surgeons are likely to benefit significantly from nontechnical skills training as we face additional nontechnical challenges for example: the child-parent- clinician relationship, rare conditions and highly emotional situations such as antenatal counselling. Surveys of paediatric surgical trainees show a perception of inadequate training in these areas.4 The past two decades have seen an explosion in research in both SBE and patient safety initiatives, but limited research that combines the two. This article will look at the intersection of patient safety and non-technical skills, then identify simulation options available for nontechnical skills training and assessment, followed by the evidence for improvements in patient outcomes with SBE for nontechnical skills, and finally future directions.

Section snippets

Patient safety and non-technical skills

There had long been a perception in health care that poor patient outcomes were related to disease related factors, patient related factors, an element of bad luck, or failure of an individual surgeon's technical or diagnostic skill. Nearly 20 years ago landmark publications, including To Err is Human from the USA and An organisation with a Memory from the UK, showed that human error is a significant contributor to patient harm.5,6 There has since been an imperative to try to reduce harm with

Simulation-based education for non-technical skills

Non-technical skills is one of five topics identified for focus in health care simulation to improve patient safety.25 Simulation allows practice of difficult or rarely used skills in a low risk environment with feedback, where mistakes have few consequences and there is opportunity to repeat the practice until improvement is seen.

Until the last few decades the focus of surgical training has been based on technical skills, and knowledge. Nontechnical skills have been assumed to have been

Efficacy of simulation-based education for non-technical skills in improving patient safety

There is a relative paucity of research that takes a patient outcomes approach to simulation and nontechnical skills, and none in paediatric surgery.44 One of the more compelling examples of improved patient outcomes with team training is the Veterans Health Administration studies.45,46 They implemented a program consisting of a two month preparation and planning phase, a 1-day learning session in situ, and 4 quarterly follow up phone interviews into 42 facilities across America with 32

Future directions

Medical schools have recognized a need to formally teach nontechnical skills and many have incorporated this into their curricula, often with the use of simulation-based education.8,44 Where previously only communication with patients may have been taught with a deficit in other skills such as communication with other health professionals, and teamwork. Now there is frequent exposure to simulation education and increasingly interprofessional education. This may provide great cultural change in

Conclusion

Nontechnical skills training is essential for improving patient safety, and simulation is an excellent modality for implementing this. Simulation based nontechnical skills training for individuals and teams should be incorporated into surgical training programs, quality improvement projects and continuing medical education.

There is a need for institutional and clinical leaders to drive the change that is required to improve patient safety, as increasing evidence accumulates on the cost savings

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