Original reportS-TEAMS: A Truly Multiprofessional Course Focusing on Nontechnical Skills to Improve Patient Safety in the Operating Theater☆
Introduction
Medicine is a team sport, with 2 exceptions: people’s lives depend on it and there are no coaches.
—Atul Gawande
In the past, it was assumed that patients got the best care if their individual surgeon possessed the appropriate knowledge and technical expertise to diagnose and treat them. Sex, class, and status divides among professions within the operating theater prevented individuals from speaking out, even if they had concerns around patient safety.
Although specialist knowledge and technical ability are still fundamental components of training and maintaining high clinical standards, good surgical care—as highlighted in the World Health Organization (WHO) Guidelines for Safer Surgery 2009, and more recently in the publication of Good Surgical Practice—depends as much now on effective teamwork and preventing simple errors as on the individual clinician’s ability.1, 2 The complexities of what we do, the changing membership of teams, and the need to provide care at all hours of the day—often in difficult situations—mean that our human fallibility can often cause us to inadvertently make mistakes. Despite this, there is an assumption that health care professionals already possess these skills and there remains little formal teaching on the nontechnical skills (NTS) required to perform well as a surgical team and under difficult situations.
Over the past few years, we have come to recognize that it is the human—rather than technical—factors that pose the greatest threat to patient safety.1, 3, 4 Studies have indicated that as many as 1 in 10 hospital inpatients have been affected by such errors.5, 6 Operative surgery, with its technical demands, potential for unstable patients, and therefore the urgency with which care is to be delivered, poses a particular challenge.1 Combined with the stress encountered in such environments, it is no surprise that human errors are made. The first step to minimizing these errors is, as psychologist Reason indicates, to accept that they exist and then to put in place systems to avoid them.7
Surgeons receive years of rigorous training to achieve the technical expertise required to operate safely and competently. However, until recently, formal teaching of NTS has been lacking. Such skills include both resource management and the social and cognitive abilities required to function as an effective member of a team.3 Cognitive aids such as checklists and standard operating procedures as well as situational awareness training may improve cognitive skills, whereas communication strategies aid the concise and timely relay of information between team members. Indeed, surgery, as identified in Good Surgical Practice, “is not a solitary activity … Patient safety and good practice certainly depend on the individual surgeon, but also on effective team-working both within the surgical team and the wider multidisciplinary.”2
A number of barriers to teamworking exist within the surgical setting. Firstly, the structure of the operating theater has meant that health care professionals tend to work autonomously in “silos” with the potential for communication breakdown between activities.8 This has further been hindered by a strong hierarchical culture whether by role, seniority, or sex, which limits shared decision-making.9 A study reported communication failures in 30% of team exchanges in the operating theater,10 another attributed 43% of errors made in surgery to poor communication,11 and a further identified the risk of complications and death increasing 4-fold in surgical teams that demonstrated fewer information-sharing procedures.12 The changing membership and instability of theater teams cause further difficulties in effective team building.3
The introduction of formalized checklists and standard operating procedures has been shown both to help teams focus during complex tasks and to open up communication around patient safety.13 However, these are seen by some surgeons as undermining traditional professional autonomy and are met with resistance, as demonstrated by the variable degrees of compliance with the WHO checklist.3 The need for a change in culture was highlighted by Professor Don Berwick, the Chairman of the National Advisory Group on Safety of Patients in England, who stated that “Culture will trump rules, standards and control strategies every single time and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime.”
Various groups have attempted to address the issue of poor team working in theater, but incorporating formal training into the curriculum is a challenge.3 In the United Kingdom, the Joint Committee on Surgical Training ask trainees to provide ePortfolio evidence for “being a good communicator,” along with “leadership” and “teamworking.” However, there is no guidance on how these should be achieved. For procedure-based assessments, trainees are scored as “satisfactory” or “development required” on their communication with the scrub team and the anesthetist. Neither of these systems use validated tools for assessing and giving feedback on NTS.4 Furthermore, the compulsory courses required for progression to higher surgical training in the United Kingdom (Basic Surgical Skills, Advanced Trauma Life Support, and Care of the Critically ill Surgical Patient) are focused exclusively on technical skills and knowledge.
Independent courses teaching NTS to the United Kingdom health care professionals have emerged over the past few years (Table1). However, these tend to be separated by professional group or aimed at senior clinicians who have acquired all the “technical knowledge” required and are now ready to hone their NTS as a separate exercise. Such courses further lack standardizing and sustainability.14 This seems a missed opportunity because, as the WHO highlights, it is the multiprofessional teamworking that needs to be addressed to improve patient safety and, therefore, it follows that training should take place in a multiprofessional environment and as a core element for training at all levels.
In the United States of America, Team STEPPS—developed by the Department of Defense (DoD) and Agency for Healthcare Research and Quality (AHRQ)—in addition to the National Center for Human Factors in Healthcare, has developed targeted systems to improve the safety culture through teamworking initiatives. Although evidence based and comprehensive, these approaches, which are tailored to the individual health care institution, often require significant local motivation, research time, and financial investment to deliver their program and achieve sustainability. In contrast, the financial pressures faced by the National Health Service (NHS) place an emphasis on accessibility, affordability, and ease of delivery.
Team training has been shown to be effective in improving teamworking in both health care and other high-risk industries.15 This has been demonstrated quantitatively in 2 meta-analyses which showed that team training had a moderate positive effect on team functioning and could explain a 12% to 19% variance in a team’s performance.16, 17 Within health care, team-based approaches, including simulation and use of standardized procedures, for example, checklists, could have a significant effect on improving patient safety.3
A recent review of patient safety interventions, health care teams, and team training recommended the next step in team training to be regular, multidisciplinary, and multiprofessional simulation.3
Section snippets
Methods and Materials
We designed a 1-day course—“S-TEAMS”—to introduce theater teams to the concept of human factors and NTS. To ensure a truly multiprofessional and multidisciplinary representation, we invited scrub nurses, operating department practitioners (ODPs or surgical technologists), and health care assistants to join core surgical and anesthetic trainees from South West London on regional training days.
S-TEAMS was based on a previously successful model, “Advanced Teamworking in Emergency and Acute Medical
Results
Thus far, 68 health care professionals at our Trust have participated in S-TEAMS, with good representation from each professional group (Fig. 2). In total, 8 (27.5%) of the 29 doctors had received some form of human factors training before S-TEAMS as opposed to only 1 of 39 (3%) of nursing staff. This nurse had, in fact received their training within an aviation context, rather than in the health care setting. In all previous human factors training courses, attendance was not compulsory. In
Discussion
S-TEAMS uses interprofessional collaboration on multiple levels to achieve improved teamworking. Being devised by a multiprofessional and multidisciplinary group, welcoming faculty from various professional backgrounds and actively sourcing participants to represent the range of professional groups within theaters not only makes for realistic simulation but also engenders an ethos of shared responsibility and collaborative working.
Although the relatively little experience of human factors
Conclusion
S-TEAMS provides an opportunity to learn and practice NTS in a safe and realistic multiprofessional environment. Its simple format is reproducible, and sustainability can be secured through training participants as faculty members. Team training has been shown to work in improving patient safety, and the success of S-TEAMS lies in its inclusion of theater team members from all levels and professional backgrounds.
S-TEAMS learning resources are currently being packaged up for use in other Trusts.
References (21)
- et al.
Improving patient safety in the operating theatre and perioperative care: obstacle, interventions, and prioritites for accelerating progress
Br J Anaesth
(2012) - et al.
Analysis or errors reported by surgeons at three teaching hospitals
Surgery
(2003) - et al.
Surgical team behaviours and patient outcomes
Am J Surg
(2009) - et al.
Observation of behavioural markers of non-technical skills in the operating room and their relationship to intra-operative incidents
Surgeon
(2016) - et al.
Non-technical skills for surgeons in the operating room: a review of the literature
Surgery
(2005) - et al.
Adverse events in British hospitals: preliminary retrospective record review
Br Med J
(2001(3)) - et al.
Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I
N Engl J Med
(1991) Human Error
(1992)
Cited by (19)
BEST of Surgical Training: the pan-London Core Surgical Training induction programme: “There's no I in team, but there is a me.”
2022, SurgeonCitation Excerpt :Although we have not assessed longer-term efficacy, a previous study of the S-TEAMS course – on which BEST simulation is based - revealed that at 6 months 97% (n = 31/32) of participants continued to use the NTS taught, with 88% (n = 28/32) believing that these had averted errors.9 94% (n = 30/32) felt patient safety had improved following the course and 91% (n = 29/32) had observed improved teamworking.9 The notion of teamworking and collaboration not competition is central to BEST's ethos.
Managing a team in the operating room: The science of teamwork and non-technical skills for surgeons
2022, Current Problems in SurgeryCitation Excerpt :Other members of teams that have been included on rare occasions include perfusionists,79, pharmacists,80 respiratory therapists,80 and other allied health professionals.80-83 The vast majority of interprofessional OR team training simulation programs are designed for surgical trainees across postgraduate year levels,80-82,84-87 with a much smaller number of programs combining both trainees and attending surgeons,83,88 and a few designed specifically for attending surgeons.79,89–91 There remains room to develop ongoing, longitudinal programs targeting surgical learners across the novice to expert continuum.
Interventions promoting employee “speaking-up” within healthcare workplaces: A systematic narrative review of the international literature
2021, Health PolicyCitation Excerpt :The heterogeneous nature of interventions and outcomes measured contributed significantly to this. In terms of intervention characteristics, in those studies reporting only positive outcomes several involved interventions targeting multi-disciplinary team-working [43,46,67,70,71]. Notable others have reported that enrolling different occupational types, or specialities, during implementation decision making is positively associated with successful implementation [72].
Simulation-based acquisition of non-technical skills to improve patient safety
2020, Seminars in Pediatric SurgeryCitation Excerpt :This may reflect the changing medical culture and the increasing focus on nontechnical skills at a more junior level. Equipment requirements need not be excessive for simulations to teach nontechnical skills, as they may not need as high fidelity surgical models as those required to acquire technical skills.37 There is potential for hybrid models to allow fidelity for all team members which can decrease costs and increase environments that would be suitable for delivery.34
Challenging authority and speaking up in the operating room environment: a narrative synthesis
2019, British Journal of AnaesthesiaCitation Excerpt :The impact of educational interventions on speaking up has been studied extensively. The majority of these studies do show an increased probability of challenging authority and improved teamwork and collaboration of the perioperative team, which is known to improve patient outcomes, as a result of the intervention.8,16,35–39 Multidisciplinary courses have been a popular way to test this hypothesis through assessment of the ability to speak up using self-assessment surveys before and after the teaching intervention.
The significance of interprofessional collaboration in enhancing patient safety within healthcare
2023, Salud, Ciencia y Tecnologia
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The authors would like to acknowledge South West London Core Surgical Training Team and Croydon University Hospital Simulation Centre for the support.