Thinking ahead of the surgeon. An interview study to identify scrub nurses’ non-technical skills
Introduction
Every 36 h an estimated one million people use the UK National Health Service and, although the majority receive safe and effective care, patients can be harmed, sometimes seriously or even fatally (House of Commons Health Committee, 2009). A systematic review of adverse event studies suggested that 41% of all hospital adverse events occur in the operating theatre (de Vries et al., 2008) and retrospective patient record reviews indicated that 50% of identified adverse events were preventable (Vincent et al., 2001). Underlying causes of adverse events to surgical patients are often attributable to failures in non-technical skills such as communication (Gawande et al., 2003a, Gawande et al., 2003b, Lingard et al., 2004, Neale et al., 2001) or teamwork (Catchpole et al., 2008, Sexton et al., 2000), rather than a lack of technical training or expertise.
Non-technical skills are the ‘cognitive, social and personal resource skills that complement technical skills, and contribute to safe and efficient task performance’ (Flin et al., 2008, p. 1) and they are also referred to as Crew Resource Management (CRM) skills (Civil Aviation Authority (CAA), 2006). Cognitive skills include situation awareness and decision making. Situation awareness is defined as ‘the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future’ (Endsley, 1995, p. 36). Decision-making is the process of selecting an option, or reaching a conclusion as to a course of action which is required to deal with the situation or problem with which one is faced (see Flin et al., 2008). The social skills include communication, team working and leadership and there are also skills in relation to management of stress and fatigue and task management (Flin et al., 2008).
In safety-critical industries, such as aviation and nuclear power generation, the non-technical skill sets for particular occupations have been identified in order to design training and assessment methods. Taxonomies of non-technical skills have also been developed for training and providing feedback on the behaviour of anaesthetists (Fletcher et al., 2004) and surgeons (Yule et al., 2008). Another key member of the operating theatre team is the scrub nurse.1 The scrub nurse has many responsibilities including ensuring all instruments and supplies are accounted for at the end of the surgical procedure. However, sponges and instruments are sometimes retained within patients (Gawande et al., 2003a, Gawande et al., 2003b) despite technical guidelines (Beesley and Pirie, 2005). Possible factors leading to instrument retention include communication within the nursing team and between nurses and surgeons (Riley et al., 2006). Although the instrument count is a technical duty, it is accompanied by non-technical aspects. These include; knowledge of the location of instruments and swabs once they are in the sterile field (situation awareness) and speaking up if items are misplaced (communication). A rating tool for assessing technical skills of theatre nurses has been developed (Sevdalis et al., 2009), but there does not appear to have been any taxonomy of non-technical skills produced for this professional group.
A literature review revealed limited empirical research on scrub nurses’ non-technical skills, where only 13 studies reported data pertaining to scrub nurses’ intraoperative non-technical skills (Mitchell and Flin, 2008). Situation awareness was explicitly examined in only one paper in the review where scrub nurses used ‘judicial wisdom’ to form assessments of evolving surgical situations, by understanding the behaviour and actions of other theatre team members (Riley and Manias, 2006). Insufficient or ineffective communication was linked to some adverse events (Helmreich and Schaefer, 1994) and irrelevant communications for the current surgical activity were found to be distracting for the theatre team (Sevdalis et al., 2007). Evidence for operating theatre hierarchy causing scrub nurses’ difficulty with speaking up or challenging other members of the theatre team was also found (Edmondson, 2003) and differing views of teamwork between medical and nursing staff were evident (Flin et al., 2006, Sexton et al., 2000, Undre et al., 2006a).
Despite the lack of empirical studies specifically examining scrub nurses’ non-technical skills, operating theatre teamwork assessment tools have been developed which include provision for rating the theatre nursing sub-team (Mishra et al., 2009, Undre et al., 2006b). These tools have been shown to be reliable in rating teamwork effectiveness however these instruments do not describe a full taxonomy of non-technical skills required for the scrub nurse to function effectively within the team. No empirical studies were found in the literature review that had specifically identified scrub nurses’ leadership or decision making during surgical operations as being requisite skills for the scrub nurse to acquire (see Mitchell and Flin, 2008).
A research group comprising psychologists, theatre nurses and a consultant surgeon was established to identify the non-technical skills necessary for safe and effective scrub nurse performance, using a combination of interview techniques, and then to develop a behavioural rating system for training and assessing those skills. The aim of the study was to identify the non-technical skills required for safe and effective performance as a scrub nurse, during the intraoperative phase of surgical procedures, through analyses of interviews with experienced scrub nurses and consultant surgeons.
Section snippets
Design
There were already generic non-technical skills (see Flin et al., 2008) for safety critical jobs and skill sets for anaesthetists and surgeons (see Flin and Mitchell, 2009). As these appeared to be relevant for scrub nurses (Mitchell and Flin, 2008), the two interview schedules were designed, avoiding use of the specific non-technical skills terminology as far as possible, to examine those skill categories, whilst still providing an opportunity for other skills to be identified. Generic
Results
Inter-rater reliability for coding into broad non-technical skill categories was good; k = .81 and k = .83 (nurse and surgeon interviews, respectively). More detailed coding by LM (psychologist) and KC (theatre nurse manager) into separate skills was also good; k = .73 (Altman, 1991). The results are reported by non-technical skill categories, with the analysis of scrub nurse and surgeons’ interview data reported together.
Table 1 represents a summary of the overall pattern of results with column 1
Discussion
The same non-technical skills emerged from the general questions and those using the critical incident interview technique. The scrub nurses tended to talk in general terms rather than focussing on the particular case they were recalling. Since the overriding aim for the scrub nurses in all procedures is for the case to progress smoothly or ‘flow’, the skills that enable them to do this, regardless of case difficulty, are the same.
Scrub nurses use situation awareness to gain information from
Conclusion
From interviews with experienced scrub nurses and consultant surgeons, the main categories of non-technical skills which appear important for the scrub/instrument nurse (technician or practitioner) to acquire for safe and effective practice in the intraoperative phase of surgical procedures are; situation awareness, communication, teamwork and coping with stress. Task management skills are also important although further work would be required to establish the elements of that non-technical
Acknowledgements
The authors would like to express their thanks to NHS Education for Scotland (NES) (2007–2009) and to the Scottish Funding Council, Scottish Patient Safety Research Network (2009–2011) who funded the project. The views expressed in this paper are those of the authors and should not be taken to represent the position or policy of the funding body. Thanks also to all the nurses and surgeons who took part in the study, Mr Simon Paterson-Brown and Mr John Duncan for facilitating some of the
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