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Non-technical skills

Developing these skills is good for patients and doctors, say Naomi Engel and colleagues


Poor or inadequate use of these skills has been identified as key causes of many industrial disasters, like the Chernobyl nuclear disaster, and were first examined after a series of aircraft crashes in the 1970s

Mention of “non-technical skills” is typically met with a blank stare or a dismissive rejection of “soft skills.” Hopefully this article will change your perceptions and inspire you to develop these skills before you graduate.

The concept of non-technical skills has only recently been introduced to health care—its origins are non-medical. In the 1970s, after several aeroplane crashes, investigators looked for causes. They found that these weren’t related to poor knowledge or technical problems: failure in the pilot and crews’ non-technical skills were the key underlying factors.1 Subsequently, poor or inadequate use of these skills has been identified as a key cause of many industrial disasters. Well known examples include the explosion at the Chernobyl nuclear power plant, the explosion on the Piper Alpha oil platform, and the crush at Hillsborough football stadium.2

Non-technical skills are a combination of cognitive (for example, decision making) and social skills (for example, team working), which complement knowledge and technical skills and contribute to safe performance (box).2

    Tips for good practice

    Situation awareness

  • Gathering information—Consult all appropriate sources (for example, patient, notes, results, nurses, textbooks)
  • Recognising and understanding—Clarify ambiguities
  • Anticipating—What is likely to happen next and can you prepare for it?

    • Decision making

  • Defining the problem—If you can’t then reconsider or ask for help
  • Identifying options—Consider all the options and solutions available
  • Balancing risks and selecting options—Consider pros and cons. Are there helpful guidelines? Can you justify your decision?
  • Reassessing—Did the situation change? If things are worse or unchanged check that you understood the problem

    • Communication skills

  • Giving information—Make verbal and written communication unambiguous and concise. Write legibly, using capitals if necessary
  • Including context and intent—Plan for handovers to ensure completeness
  • Receiving information—When listening avoid interrupting. Paraphrase and clarify ambiguities
  • Identifying and tackling barriers to communication—Overcome barriers when possible—for example, noise, poor light, time constraints

    • Team working

  • Supporting others—Give help when asked. Offer help if you think a colleague needs it
  • Solving conflicts—Keep the solution patient centred
  • Exchanging information—Let team members know your plan
  • Coordinate activities—Ensure each person’s role is clear, especially when there are multiple tasks

    • Leadership skills

  • Using authority and assertiveness—Speak up (confidently and politely) if you think something is wrong. Begin statements with “I”
  • Maintaining standards—Strive for the highest level of care possible
  • Planning and prioritising—Make a jobs list and prioritise
  • Managing workload and resources—Ignore non-essential distractions and interruptions. Time is a precious resource

    • Stress management

  • Identifying symptoms—Fight, flight, or freezing are severe symptoms. Try to recognise stress earlier, and take supportive action. Offer others help if they seem to need it
  • Recognising effects—Some stress can improve performance, but too much can lead to mistakes and negative personal effects. Everyone has different thresholds
  • Implementing coping strategies—Identify and modify the stressors. It is often helpful to talk to colleagues and friends, or consult professional sources—for example, occupational health, BMA, the Doctors for Doctors counselling service (tel 08459 200 169)

    • Fatigue management

  • Identifying symptoms—May manifest as feeling drained, irritable, overly emotional, poor concentration, or obsessing about sleep
  • Recognising effects—Fatigue is generally a more important factor for error than stress. Do not underestimate its effect on your work
  • Implementing coping strategies—Where sleep or help is unavailable, consider caffeine containing drinks, eating, splashing cold water on your face, brightening the light

Why are they important?

Industrial research shows that human error is involved in about 70% of accidents.3 The consequences of error in health care can be devastating, and junior doctors have reported making at least one mistake a month.4 Contrary to popular belief, only a few of these mistakes were the result of stress or long hours: most were attributed to inexperience or limited knowledge. Most errors are minor, but some cause serious harm or death.5

A growing volume of literature shows that good use of non-technical skills in health care can improve patient safety by reducing the number of errors and increasing early recognition and correction of potential harm. These skills are important in everyday activities as well as in clinical emergencies. Good use during laparoscopic cholecystectomy has been shown to be associated with improved outcomes.6 The role of these skills in adverse events has been most extensively studied in surgery,7 anaesthesia,8 intensive care,9 and acute medicine.10 In anaesthesia and surgery, non-technical skills are thought to be so important that rating systems have been developed to help provide feedback during training.11 12

Inexperienced doctors are at particularly high risk of making mistakes and perhaps have the most to gain from good non-technical skills.4 5 In the clinical examples that follow the relevant skills and components (box) where problems arose are in brackets. These examples serve to remind us that we are human and therefore fallible.

Case study 1—In 2001 during treatment for acute lymphoblastic leukaemia, Wayne Jowett was mistakenly given vincristine intrathecally instead of intravenously and subsequently died. Although failures were identified at almost every stage of care, inadequacies in non-technical skills were crucial.13 When vincristine was given, the junior doctor didn’t challenge the registrar’s instructions to give it intrathecally despite thinking that this was wrong (leadership skills, using authority and assertiveness). Afterwards he said, “I was a junior doctor and did what I was told to do by the registrar . . . I did not intend to challenge him.” Appropriate use of authority and assertiveness is an essential part of leadership, but it can be difficult to point out mistakes to senior colleagues. However, medical students have the potential to act as safety nets to prevent error by speaking up.14

Case study 2—An intensive care nurse saw a junior doctor remove a central line from a patient who was sitting rather than supine. An air embolus left the patient neurologically damaged.15 Although several factors (for example, no procedural policy) were implicated, good use of non-technical skills could have prevented this. The doctor did not fully understand the task (situation awareness, recognising and understanding). The nurse realised that the doctor was making a mistake (situation awareness, recognising and understanding) but felt unable to correct him (leadership skills, using authority and assertiveness). The nurse failed to support the junior doctor in his role (team working, supporting others) and communication between the two was deficient (communication). As is often the case there were multiple opportunities to prevent this incident. However, the consistent poor use of non-technical skills by the nurse and doctor eliminated many chances to avert danger.

Skills to help doctors

Use of non-technical skills can be important for junior doctors’ wellbeing. Management of stress and fatigue are key non-technical skills that can help junior doctors to cope with a demanding job. New doctors can be stressed and fatigued,16 and the suicide rate among doctors is one of the highest of any profession.17 Stress is often difficult to admit to,18 posing a barrier to seeking help.1920 In one study almost half the doctors surveyed said that they wanted counselling.21 Stress management is rarely taught to undergraduates,22 but such training has been shown to work.23 Perhaps compulsory stress management classes for undergraduates would better equip newly qualified doctors to deal with stress and to ask for help. Non-technical skills can also be vital after an error has occurred. It enables doctors to respond better and to manage better any subsequent stress.24

Teaching and learning

This evidence indicates the relevance and importance of non-technical skills for medical students, junior doctors, and their patients. Awareness of these skills, learning when they are used in clinical practice, and specific instruction on how to develop them are needed.

It is frustrating that such training is not embraced in undergraduate or postgraduate medical curriculums. Although communication is a core part of teaching at UK medical schools, other non-technical skills receive far less attention. Teaching need not be extensive or costly—junior doctors reported that just one day of training in team working and leadership improved their abilities as doctors.25 Simulation training with focused debriefing has also been shown to improve skills.26 Non-technical skills can improve with training and deliberate practice. The University of Aberdeen has developed a programme of teaching that focuses on non-technical skills. These include observation of non-technical skills in clinical areas, students reflecting on their use of non-technical skills during acute care simulation, and online discussion.27 The programme, starting in 2009, will be integrated with current teaching.

A report from the Postgraduate Medical Education and Training Board describes such skills as “essential” to postgraduate teaching.28 The board’s definition is broader than that used here and in other industries, but the report says, “Trainees, trainers, and organisations need to recognise the importance of non-technical skills and make a conscious effort to integrate non-technical skills into clinical learning and teaching.”

Summary

There is nothing soft about non-technical skills. They are essential, and we all need to learn, practise, and use them well to keep our patients safe. And if we do this we are likely to cope better with stress. Hopefully leaders in undergraduate and postgraduate medical training will recognise this and incorporate more core teaching and opportunities for practise into the curriculum. The use of non-technical skills by junior doctors, who may have the most to gain if their skills are well developed, has received little attention and research targeting this is needed.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Naomi Engel third year medical student University of Aberdeen
naomi.engel.06@aberdeen.ac.uk
Rona E Patey consultant anaesthetist Clinical Skills Centre, Westburn Centre, Aberdeen AB25 2XG
Sarah Ross clinical lecturer, division of medical and dental education University of Aberdeen
Lucy Wisely clinical lecturer, centre of academic primary care University of Aberdeen
Student BMJ 2008;16:425468-ISSN 0966-6494 | December
  1. Helyar V. Flight school:Learning lessons from aviation. SBMJ. 2006 June 2006;14(6):252-4.
  2. Flin R, O’Connor P, Crichton M. Safety at the sharp end: A guide to non-technical skills. Hampshire, England: Ashgate Publishing; 2008.
  3. Helmreich RL. On error management: Lessons from aviation. BMJ. 2000 March 18;320(7237):781-5.
  4. Baldwin P, Dodd M, Wrate R. Junior doctors making mistakes. The Lancet. 1998 3/14;351(9105):804-.
  5. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991 Apr 24;265(16):2089-94.
  6. Mishra A, Catchpole K, Dale T, McCulloch P. The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy. Surg Endosc. 2008 01/29;22(1):68-73.
  7. Yule S, Flin R, Paterson-Brown S, Maran N. Non-technical skills for surgeons in the operating room: A review of the literature. Surgery. 2006 2;139(2):140-9.
  8. Fletcher GCL, McGeorge P, Flin RH, Glavin RJ, Maran NJ. The role of non-technical skills in anaesthesia: A review of current literature. Br J Anaesth. 2002 March 1;88(3):418-29.
  9. Reader T, Flin R, Lauche K, Cuthbertson BH. Non-technical skills in the intensive care unit. Br J Anaesth. 2006 May 1;96(5):551-9.
  10. Flin R, Maran N. Identifying and training non-technical skills for teams in acute medicine. Qual Saf Health Care. 2004 October 1;13(suppl_1):i80-84.
  11. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R. Anaesthetists’ non-technical skills (ANTS): Evaluation of a behavioural marker system{dagger}. Br J Anaesth. 2003 May 1;90(5):580-8.
  12. Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D. Development of a rating system for surgeons’ non-technical skills. Med Educ. 2006 11/30;40(11):1098-104.
  13. Toft B. External inquiry into the adverse incident that occurred at Queen’s medical centre, nottingham, 4th january 2001. Department of Health; 2001.
  14. Seiden SC, Galvan C, Lamm R. Role of medical students in preventing patient harm and enhancing patient safety. Qual Saf Health Care. 2006 August 1;15(4):272-6.
  15. Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: Practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004 June 15;140(12):1025-33.
  16. Paice E, Rutter H, Wetherell M, Winder B, McManus I. Stressful incidents, stress and coping strategies in the pre-registration house officer year. Med Educ. 2002;36:56-65.
  17. Meltzer H, Griffiths C, Brock A, Rooney C, Jenkins R. Patterns of suicide by occupation in england and wales: 2001-2005. The British Journal of Psychiatry. 2008 July 1;193(1):73-6.
  18. Firth-Cozens J, Morrison LA. Sources of stress and ways of coping in junior house officers. Stress Med. 1989;5(2):121-6.
  19. Chew-Graham CA, Rogers A, Yassin N. ‘I wouldn’t want it on my CV or their records’: Medical students’ experiences of help-seeking for mental health problems. Med Educ. 2003;37(10):873-80.
  20. Davies RH. Junior doctors and stress. Lancet. 1998 Nov 28;352(9142):1780; author reply 1781.
  21. Garrud P. Counselling needs and experience of junior hospital doctors. BMJ. 1990 Feb 17;300(6722):445-7.
  22. Redwood SK, Pollak MH. Student-led stress management program for first-year medical students. Teach Learn Med. 2007 Winter;19(1):42-6.
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  24. David L. B. Schwappach DLB, Boluarteb TA. The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountability. Swiss Medical Weekly 2008 Oct 14. www.smw.ch/docs/pdf200x/aop/smw-aop12417.pdf
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EDUCATION
Non-technical skills
      (Naomi Engel and colleagues, December 2008)

Johnny Boylan
(January 22nd, 2009)
 4th year medical student,  Queen's University, Belfast johnnyboylan@hotmail.com

TOP


Engel et al(1) outline a comprehensive list of tips for good practice in relation to the acquisition of non-technical skills. Within leadership skills they refer to prioritisation. However I believe that this generic skill underpins many of the other non-technical skills described. For example prioritisation is an integral part of decision making, team working, and stress management. Therefore this crucial skill is one of the core non-clinical competencies that the medical undergraduate or foundation doctor should strive to master in order to be effective and efficient medical practitioners.

Many prioritisation methods have been suggested including Paired Comparison Analysis, Grid analysis, The Action Priority Matrix, The Ansoff and Boston Matrices and Pareto Analysis(2). However a simple method which I have used, and which I feel has particular relevance for healthcare professionals, is the Urgent-Important Matrix(3) in which activities are prioritised as :

  1. Important and Urgent: that is tasks where the outcome is important in relation to the achievement of our goals and where action has to be taken immediately. For example responding to a cardiac arrest.
  2. Important but not Urgent: that is tasks where the outcome is important to us but where we are less time constrained.For example writing up the observations on a stable patient.
  3. Urgent but not Important: that is tasks where our attention is demanded immediately but where the outcome is more related to the achievement of someone else's goals than our own. For example a scheduled talk from a drug rep who needs a certain number of medical attendees at his/her meeting in order to hit a target set by his/her manager.
  4. Not Important and Not Urgent: these are the tasks we can chose to ignore or address at our leisure only if the others have been addressed. Of course not all tasks fall neatly into these categories and we may need to reflect on, or check, just how important a task is to the achievement of our goals but nevertheless the grid does provide a handy framework to use when addressing our to-do list.

The importance of prioritisation has been recognised in medical education. Frameworks of generic competencies have highlighted this skill(4) while the ability to prioritise is assessed as part of the GP Training Scheme process(5). Moreover young doctors have written about how medical training did not help them develop this crucial skill(6). Therefore I feel that universities and deaneries should ensure that medical students and junior doctors are able to prioritise the clinical and academic tasks they have to juggle every day, thereby helping them to become better and safer doctors.

  1. Engel E et al. Non-technical skills. StudentBMJ 2008, 16:454-455. December.
  2. http:/www.mindtools.com accessed on 21/01/09.
  3. Butler G, Hope T. Managing your mind. Oxford:OUP,1995.
  4. Epstein R.M, Hundert E.M. Defining and assessing professional competence. JAMA, 2002;287:226-235.January.
  5. http:// www.gprecruitment.org.uk/download/gp accessed on 21/01/09.
  6. Cooper N. Medical training did not teach me what I really need to know. StudentBMJ 2004,12:45-88. February.


EDUCATION
Non-technical skills
      (Naomi Engel and colleagues, December 2008)

Cathy Holt-Kentwell
(February 17th, 2009)
 N/A - layperson, recent experience of hospital,  N/A cathyholtkentwell@hotmail.com

TOP


I have read quite a few very interesting articles in my daughter's Student BMJ. As a layperson I would suggest that the most important things a doctor needs to learn is respect for others and communication skills. I was recently admitted to hospital for a week with a severe diverticulitis flare up. During this time I reckon I gleaned enough information to be able to write a book about what it's like to be on the receiving end of patient care in the UK! Most of the consultants treated the junior doctors and nurses with absolute contempt,belittling them in front of me - including shouting with unnecessary rage about minor slip-ups.Of the myriad of nurses,junior doctors, consultants and night house officers who visited my bedside over the week, only the nurses bothered to actually address me by my name and smile at me, provided reassurance and treated me like a human being. To the rest I just appeared to be 'the patient in 12A'. I realise that doctors cannot get emotionally inv!

olved with their patients,or you'd all be in the psych ward before long, but surely someone, somewhere during the seven years of intense medical training could teach you to address all your patients by their name and smile once in a while. Yes I know you're all tired, but you have no idea how important this is when you lying in an uncomfortable bed, in agony, and feeling very scared. Please keep this in mind when you see your next patient?