Healthcare workers' non-technical skills comprise the glue that holds together the health professionals’ technical skills, and therefore, developing standards with regard to the former and allowing healthcare workers to apply non-technical skills at the same high level as their technical skills can help towards enhancing a safer healthcare system.
These observations were made in a letter to the Editor of the Sri Lankan Journal of Nursing on “Non-technical skills: Building safer and healthier workplaces” which was authored by P.A.D. Perera, J.A. Myers, and R.F. Griffiths (all three attached to New Zealand's Otago University's Medicine Department's Occupational and Aviation Medicine Unit) and published in the same Journal's First Volume's Second Issue in December, 2022.
Human error and non-technical skills influence patient safety and overall performance in healthcare. Technical expertise is not a guarantee of patient safety, as in parallel, one must have competence in non-technical skills in order to achieve good clinical outcomes.
Adverse events in health systems are, per S.M.N.S.M. Mallawarachchi and G.S.K. Dharmarathna’s “A systematic assessment of adverse event reporting in selected State hospitals in Sri Lanka”, a major threat to patient safety and the quality of care globally. Despite medical and technological advancements, one in 10 patients experience an adverse event while in hospital, which means the safety of the patients, as mentioned in M. Amarapathy, S. Sridharan, R. Perera and Y. Handa’s “Factors affecting the patient safety culture in a tertiary care hospital in Sri Lanka”, is challenged. Healthcare is inherently complex, where major accidents are only the tip of the iceberg and the accident trajectory, as noted in J. Reason’s “The human contribution: Unsafe acts, accidents and heroic recoveries”, is multifactorial. According to L. Kohn, J. Corrigan and M.E. Donaldson’s “To err is human: Building a safer health system” and the World Health Organisation’s “Human factors in patient safety: Review of topics and tools”, nearly half of all adverse events result from human factors, external to the clinicians’ professional and technical skills. This is not unique to one particular healthcare system, but rather, a global concern as illustrated by parallel reports of fatal medical accidents from elsewhere including in Asia. The prevention of errors and adverse events should therefore be a top priority in any healthcare setting, and this requires a broader understanding of human errors, near misses, and adverse events.
Mitigating adverse events
Safety associated high performance behaviours of health professionals should be a part of routine clinical care in order to prevent or mitigate adverse events. However, human performance itself is complex. Errors are inevitable because people can be fallible, leading to slips, lapses, mistakes, and violations. In contrast, humans can also be the strength of a complex healthcare system, providing the intellectual ability and flexibility to make adjustments, compensations, recoveries, and improvisations in any healthcare setting. For example, extensive communication between multidisciplinary team members and the coordination of multiple parallel activities with high levels of situational awareness can prevent or mitigate adverse events. Such skills are known as non-technical skills, the latter which are the cognitive, social, and personal resource related skills such as situational awareness, decision making, communication, teamwork, and leadership, that complement technical skills and contribute to the safe and efficient performance of tasks, as observed in R. Flin and P. O’Connor’s “Safety at the sharp end: A guide to non-technical skills”. The concept of the importance of non-technical skills to a safe professional practice began in the aviation industry. Greater emphasis has been placed in A. Briggs, A.S. Raja, M.F. Joyce, S.J. Yule, W. Jiang, S.R. Lipsitz and J.M. Havens’ “The role of non-technical skills in simulated trauma resuscitation”, L. Brogaard, O. Kierkegaard, L. Hvidman, K.R. Jensen, P. Musaeus, N. Uldbjerg and T. Manser”s “The importance of non-technical performance for teams managing postpartum haemorrhage: Video review of 99 obstetric teams”, M. Buljac-Samardzic, K.D. Doekhie and J.D.V. Wijngaarden's “Interventions to improve team effectiveness within healthcare: A systematic review of the past decade” and S. Helo and C.A.E. Moulton’s “Complications: Acknowledging, managing, and coping with human error” on the application of non-technical skills to prevent human error and to improve the quality of care in nursing and medicine.
Importance of non-technical skills
Technical skills or competencies alone are not enough to ensure a safe and effective professional practice as they need to be complemented by, as observed in E.N.D. Vries, M.A. Ramrattan, S.M. Smorenburg, D.J. Gouma and M.A. Boermeester’s “The incidence and nature of in-hospital adverse events: A systematic review” and M. Gordon, J. Farnan, C. Grafton-Clarke, R. Ahmed, D. Gurbutt, J. McLachlan and M. Daniel’s “Non-technical skills assessments in undergraduate medical education: A focused best evidence medical education systematic review”, the exercise of high quality non-technical skills. In a number of healthcare settings, as pointed out in N. White’s “Understanding the role of non-technical skills in patient safety”, the effective application of non-technical skills has been shown to be a useful defence against human error. In contrast, the poor execution of non-technical skills such as communication, teamwork, situational awareness, and decision making accounts for up to 70-80% of medical errors in healthcare.
While non-technical skills are a vital aspect of managing a critical situation or an emergency, they are also important in routine working environments. If healthcare workers are routinely attentive, make sound decisions, share information, and cooperate with fellow workers, S. Prineas, K. Mosier, C. Mirko and S. Guicciardi’s “Non-technical skills in healthcare” notes that errors and accidents are less likely to occur. Multidisciplinary teams need the whole team to support the building of situational awareness in order to create the big picture by absorbing cues in the clinical setting so as to think ahead, and to subsequently make sound decisions. Clear and succinct communication is another integral non-technical aspect of the practice and it requires the ability to speak up unequivocally or assertively as well as the ability to listen and accept help. Team members helping one another to detect errors is also an important non-technical skill. Health professionals should all consider whether they would speak up when it appears that things may be about to go wrong, or whether they would listen if someone said that you have got it wrong. It is also important to, as explained in J.M. Etchegaray, M.J. Ottosen, T. Dancsak and E.J. Thomas’s “Barriers to speaking up about patient safety concerns” and V. Jayasuriya-Illesinghe, S. Guruge, B. Gamage and S. Espin’s “Inter-professional work in operating rooms: A qualitative study from Sri Lanka”, consider the culture of the services and whether junior workers would feel that it is not their place to speak up when they suspect an error is about to be made, or whether senior nurses and doctors create an atmosphere where the junior staff feel safe to speak up. How one would react personally and whether one would listen and address the issue being raised or simply overrule the junior staff member should also be considered. It may be that one is failing to respond to the issue being raised because of an unconscious denial and fixation as a result of experiencing stress in an emergency situation. But, as M. Bromiley's “The husband’s story: From tragedy to learning and action” observes, the person who is speaking up may be doing so simply in order to prevent an error that is about to occur.
Challenges at present
A changing and challenging healthcare landscape in Sri Lanka requires nurses and other health-related professionals to care for more patients during their shifts than ever before. To cope with the risks and demands of their work, efforts should be made to minimise, catch, and mitigate errors by ensuring that healthcare workers not only have the specific non-technical skills required but also an appropriate organisational culture within which they can apply these skills. J.A. Myers, D.M. Powell, A. Psirides, K. Hathaway, S. Aldington and M.F. Haney's “Non-technical skills evaluation in the critical care air ambulance environment: Introduction of an adapted rating instrument – An observational study” suggests that junior clinicians are more likely to focus on technical skills as they might struggle with non-technical skills like decision making and situational awareness skills compared to experienced clinicians. However, while experienced healthcare workers would perhaps recognise effective error avoidance or crisis management behaviours if they saw them, such behaviours can be difficult to conceptualise unless they are formally addressed in training.
Non-technical skills and their effective use requires, as noted in M. Gordon, C.W. Fell, H. Box, M. Farrell and A. Stewart’s “Learning health safety within non-technical skills’ inter-professional simulation education: A qualitative study”, formal training and practice. According to A. Perera, R. Griffiths and J. Myers's “Integrative review of non-technical skills’ frameworks to apply for the air-medical transfer of pregnant women”, behavioural frameworks are now increasingly being used in healthcare in order to teach and objectively evaluate the non-technical skills of health related professionals. Therefore, to build healthier and safer workplaces, health education in Sri Lanka must begin to embrace human factors and non-technical skills training at the undergraduate and postgraduate level, and throughout inter-professional training. It is also recommended that non-technical skills education should occur at the earliest possible stage of professional education before professional attitudes are fully formed, and therefore, preferably at the undergraduate level. Using a non-technical skills measurement framework as part of this training can, as observed in R. Flin and R. Patey's “Non-technical skills for anaesthetists: Developing and applying anaesthetists' non-technical skills”, provide a useful basis for evaluating whether the skills are being transferred to an actual clinical setting.
Skills measuring framework
Non-technical skills measurement frameworks provide a common language and structure for discussing non-technical skills in teaching, training, and debriefing, and some are being used in the medical and nursing curricula. For example, per S. Yule, R. Flin, S. Paterson-Brown, N. Maran and D. Rowley's “Development of a rating system for surgeons’ non-technical skills”, L. Mitchell, R. Flin, S. Yule, J. Mitchell, K. Coutts and G. Youngson’s “Development of a behavioural marker system for scrub practitioners’ non-technical skills” and K. Murray, K. McKenzie and M. Kelleher's “The evaluation of a framework for measuring the non-technical ward round skills of final year nursing students: An observational study”, there are validated non-technical skill assessment frameworks for individual professionals such as non-technical skills for surgeons, the scrub practitioners list of intraoperative non-technical skills for theatre nurses, and the ward round non-technical skills of final year nursing students. There are also assessment frameworks for multidisciplinary teams in different clinical settings such as, per S. Cooper, R. Cant, C. Connell, L. Sims, J.E. Porter, M. Symmons, D. Nestel and S.Y. Liaw's “Measuring teamwork performance: Validity testing of the team emergency assessment measure with clinical resuscitation teams” and P.A.D. Perera's “Non-technical skills of health professionals and teams in the high acuity maternity aero-medical transport setting”, the team emergency assessment measure and non-technical skills in obstetrics aero-medical transfers. Such frameworks provide a method for comprehensively and consistently measuring non-technical skills specific to the clinical setting in which they are applied, through assessing observable behaviours. Once appropriately adapted and validated to health related professionals and teams in Sri Lankan health settings, these frameworks could be used as a reference point to discuss and debrief non-technical skills, to scaffold structured teaching and training, and for policy developers to make evidence-based decisions.
Practical setting
Regardless of the teaching and training of non-technical skills, the clinicians’ ability to effectively apply those skills in a real clinical setting is influenced by, according to a Rwandan study (E. Abahuje, A. Bartuska, R. Koch, G. Youngson, G. Ntakiyiruta, W. Williams, R.D. Dias, C. Rosu and R. Riviello's “Understanding barriers and facilitators to behaviour change after the implementation of an interdisciplinary surgical non-technical skills training programme in Rwanda”), the organisational culture. In other countries, ineffective methods of communication, the lack of fatigue management systems, the lack of policies and protocols, inadequate joint training, the lack of risk assessment processes, work overload, inadequate leadership, and issues in the hierarchical structure, per a study in Denmark (R.S. Andersen, P. Vedsted, F. Olesen, F. Bro and J. Søndergaard's “Does the organisational structure of healthcare systems influence care seeking decisions? A qualitative analysis of Danish cancer patients’ reflections on care seeking”), have all been shown to be significant barriers to the execution of good non-technical skills and the provision of safe patient care.
The shortage of the nursing workforce is a concerning issue, and in Sri Lanka, that significantly increases the workload and fatigue of the existing workforce. S.W. Lockley, L.K. Barger, N.T. Ayas, J.M. Rothschild, C.A. Czeisler and C.P. Landrigan's “Effects of healthcare provider work hours and sleep deprivation on safety and performance” and J.A. Myers, D.M.C. Powell, S. Aldington, D. Sim, A. Psirides, K. Hathaway and M.F. Haney's “The impact of fatigue on the non-technical skills’ performance of critical care air ambulance clinicians” observe that when health professionals are fatigued, their complex cognitive non-technical skills such as decision making and situational awareness and interpersonal non-technical skills like communication and the teamwork based performance, deteriorate. Therefore, G.D. Roach, A. Fletcher and D. Dawson's “A model to predict work related fatigue based on the hours of work” recommended fatigue management mechanisms such as the fatigue audit interdyne which could be useful in ensuring safe staffing and scheduling. Although Sri Lanka has an established system to report near misses and adverse events, which is the Directorate of Healthcare Quality and Safety, incidents are often under-reported due to the fear of blame and a lengthy paper based reporting process. The facts and statistics are therefore seldom given the attention that they deserve. Therefore, in order to create a robust safety based culture, healthcare systems must move away from blaming and shaming for personal failures, and instead identify system failures that contribute to those human failures.
Arguably, B.S.S. De Silva and C. Rolls's “Healthcare system and nursing in Sri Lanka: An ethnography study” notes that healthcare staffing in Sri Lanka does have a hierarchical structure. A New Zealand study (S. Pullon, E. McKinlay and K. Dew's “Primary healthcare in New Zealand: The impact of organisational factors on teamwork”) emphasised that when parallel lines of professional authority are added to the number of hierarchies within a hospital, health related professionals perceive that they are not empowered in their role, thus affecting the implementation of non-technical skills such as teamwork, communication and decision making. The belief that good teamwork in healthcare only occurs with familiar people also should be challenged; instead, Perera et al. believe that safety at the highest possible level can be achieved through maintaining a clear focus on joint team training, in order to enhance a quality collaboration based on mutual understanding between professionals. A study in England (C. Dyer's “Failure to work collaboratively and learn from incidents led to deaths of babies and mothers at Shrewsbury and Telford trust, review finds”) noted that a particularly important aspect to address during the training would be raising awareness about how human factors and non-technical skills can affect the overall performance. In this manner, team members have a good anticipation of how other professionals are likely to work, think, and react regardless of whether they have worked with one another or not.