Understanding Cognitive Constraints and Decision-Making Processes in Modern General Surgery

INTRODUCTION: The non-technical skills (NTS) of situational awareness, decision making, leadership, and communication and teamwork, are significant for enhancing surgical safety. Considered soft skills, they can be overlooked, particularly in low-income contexts. A survey was designed to explore exposure to NTS in north central Nigeria and identify felt needs for the design of a contextualized curriculum. METHODS: Six institutions with high surgical volumes, including private nonprofit and government-owned teaching hospitals, were purposively identified. Using snowball sampling through surgical team leads, a 19-item, web-based survey was distributed to 71 surgical providers, anesthetists and perioperative nurses between August and November 2021. Data were analyzed using proportions and Fisher's exact test. RESULTS: The survey had a 95.7% completion rate. Respondents included 17 anesthetists, 21 perioperative nurses, and 29 surgeons. Over half were unaware of the concept of NTS, and 96% had never heard of a NTS framework for variable resource contexts. Only 8% had NTS training. Communication and teamwork was considered the most deficient personal skill (38, 57%), and most needed for team improvement (45, 67%). There was a high demand for training (64, 96%) motivated by expectations of improved patient safety and better team dynamics. Respondents preferred week-long, hybrid training courses with in-person and online components. Perceived barriers to attendance were time conflicts and costs. Facilitators included a desire for self-improvement and patient safety (Table). CONCLUSION: Surgical teams in north central Nigeria are strongly motivated for NTS training believing it can improve patient safety, team dynamics, and personal performance. Implementation should emphasize communication and teamwork. Table. - Barriers and Facilitators to Participating in Non-Technical Skill Training in Nigeria Themes Number Percentage Example phrases Barriers Hindrances from the perioperative and institutional work environment 40 59.7 Challenges with the "Release by my employer "; "Work stress"; Non-technical skills training may "Clash with normal duties" or be limited by "tight schedule of residency training programme"; "Scheduled time of training coinciding with work" Barriers Lack of funding to pay for non-technical skills courses 14 20.9 A barrier is "Cost"; "Financial constraints" Barriers Lack of access to non-technical skills courses, particularly if in-person 10 14.6 Limited access to courses due to the "Insecurity Nigeria is now experiencing"; "Poor Internet services in Nigeria"; "Distance if the program is not online" Facilitators The motivation of improved patient safety 34 50.7 "To improve patient outcomes"; "Quest for improvement in surgical outcome"; "Patient safety and satisfaction"; "achieving global excellence for the maximum patient benefit"; "Desire to improve surgical outcome for my patience"; "prevent errors during surgery" Facilitators A drive for self-improvement 18 26.9 Facilitated by a desire "To add value to myself"; "Skill acquisition "; "personal aim at achieving global excellence "; Desire to "To improve my skills and knowledge" Facilitators The motivation of experiencing an improved work environment 10 14.9 Motivated by "reduce toxicity in the Operating Room"; "Strengthening teamwork"; "To see the change in attitude of my colleagues and other workers"; "A better working relationship with other health professionals"; "Improving interpersonal relationships" Facilitators Funding and financial incentives for training 4 6.0 Non-technical skills training would be facilitated by "Sponsorship"; "Scholarship"; "Financial motivation" Facilitators Support from work hierarchy, and removal of workplace barriers 3 4.5 Facilitated by "Convenience"; "Permission from my work place" Facilitators The award of certificates of training or attendance 1 1.5 The award of a formal "certificate" of attendance or other certification in non-technical skills

Anesthesiologists and otolaryngologists are specialists who share overlapping patient considerations because of the proximity of the surgical field and airway. Although many surgical environments benefit from a collegial team dynamic, the interdisciplinary otolaryngologic environment mandates collaboration from anesthesiologists and otolaryngologists for optimal patient outcomes1. Patients undergoing head and neck surgery are at high risk of potentially devastating events if the airway anatomy is distorted secondary to pathologic conditions or previous surgeries. Although many ENT Anesthesia fellowship programs provide exposure to a wide array of clinical cases and development of airway technical skills, the current simulation literature suggests that training programs focus on improvement of procedural skills in silo2–4. However, this is not optimal for prevention or management of high stress situations where crises resource management (CRM) and interdisciplinary team dynamics can affect patient outcome. We would like to encourage every ENT Anesthesia and Surgical training program to consider introducing a comprehensive simulation-based educational component to ensure proficiency in CRM, communication skills, and leadership skills to better manage the rare and critical cases. The use of simulation for interdisciplinary training amongst anesthesiologists, surgeons, and nurses offers flexibility, preserves realism, and enhances patient safety, which makes it ideal for education and assessment of practitioners, regardless of level of training. A wide variety of simulation technology exists with differing degrees of complexity and fidelity that can be used to advance technical skills. Two major classes are part-task trainers and whole-task trainers. Part-task trainers include simple models designed for a specific task. They vary from animal models and mannequins, to more advanced screen-based computer interface. Examples of airway trainers such as the Laerdal adult airway mannequin are capable of mask ventilation, supraglottic airway placement, fiberoptic intubation, as well more invasive procedures of cricothyrotomy and tracheostomy. Slightly more advanced part-task trainers include bronchoscopy devices such as GI-BRONCH Mentor (3D Systems, Littleton, CO) which provide screen-based simulation coupled with tactical psychomotor mechanics. Part-task trainers are important for clinicians to build fundamental skills that can be translated into proficiency in clinical practice. For example, studies have shown a faster acquisition of direct laryngoscopy and improved psychomotor skills on fiberoptic intubations when practiced initially on part-task trainers5,6. In contrast, whole-task trainers (Laerdal SimMan 3G, CAE HPS) are full-scale patient simulators with advanced computer-driven technology and human-modeled physiology that can be altered for desired clinical scenarios. When whole-task trainers are combined with standardized patients and part-task trainers, a hybrid learning environment can be created to incorporate high-fidelity simulation scenarios involving technical as well as nontechnical skills. Team training in the form of interprofessional education (IPE) and interprofessional learning (IPL) is critical for patient safety in the operating room in general, but more so in head and neck cases due to the shared working environment between otolaryngologists and anesthesiologists1. IPE refers to 2 or more professions learning with, from and about each other to improve collaboration and the quality of care, whereas IPL is learning that arises from interaction between members of 2 or more professions7. Rare and potentially disastrous ENT scenarios can be created and implemented, requiring interdisciplinary teamwork and communication for proper patient care. For instance, an in situ simulation course (one that uses actual clinical resources and equipment) at Boston Children’s Hospital teaches teamwork, CRM, and decision-making of high-risk, low frequency airway emergencies to a team of otolaryngology residents, anesthesia trainees, and operating room nurses8. Scenarios such as foreign body aspiration, the bleeding airway, or airway obstruction requiring a surgical airway can be simulated using a hybrid approach with mannequins and standardized patients. These complex educational modules can enhance the learning process and joint coordination of care for both specialists9,10. A rarer emergency includes the airway fire scenario, which not only tests the nontechnical skills and treatment, but also introduces the “fire triad” (oxidizer, ignition source, and fuel), and creates heightened awareness of anesthetic and surgical management to avoid such a disaster11–13. In situ simulations can also be conducted before implementation of new protocols to assess efficiency, to identify disruptions to workflow, and to evaluate various aspects of patient care such as systems-based errors and integration errors. At Johns Hopkins, an interdisciplinary difficult airway response team was created to manage hospital wide airway emergencies and incorporation of in situ simulations proved to be an invaluable tool to probe the system and to identify defects in resources14. A comprehensive, high-fidelity simulation curriculum incorporated into the ENT anesthesia fellowship allows the refinement of psychomotor skills for advanced airway as well as development of nontechnical management skills. Furthermore, when deliberate stressors are added to a fully immersive simulation involving participants in anesthesiology, otolaryngology and nursing, an opportunity is provided to enhance IPE and to facilitate multidisciplinary collaboration. A study conducted on advanced cardiac life support skills showed that adding extreme emotional stressors to a simulated scenario demonstrated an increased retention of skills and knowledge, as well as better performance of advanced cardiac life support15. Another study revealed that a negative outcome to the patient during simulated independent practice led to better retention of clinical skills upon retesting as compared with those who performed in a simulated supervised practice (where a superior helped intervene to prevent the negative outcome)16. The debriefing period that follows allowed the participants to reflect on individual practice and teamwork to identify weak links and areas of improvement for patient safety and care. Simulation has been used successfully as an assessment tool for medical students, residents, nurse anesthetists and practicing anesthesiologists17–20, as well those deemed incompetent21,22 or those retraining to reestablish competence23. Simulation is an ideal technique for fellowship training, education, and assessment of technical and nontechnical skills, especially in the subspecialty of ENT Anesthesia where unfamiliarity of rare ENT emergencies and crisis situations can have catastrophic implications. We urge that every ENT Anesthesia fellowship consider developing and incorporating simulation as part of the fellowship curriculum. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report.

Assessing nontechnical skills in operating rooms (ORs) is crucial for enhancing surgical performance and patient safety. However, automated and real-time evaluation of these skills remains challenging. To explore the feasibility of using motion features extracted from surgical video recordings to automatically assess nontechnical skills during cardiac surgical procedures. This cross-sectional study used video recordings of cardiac surgical procedures at a tertiary academic US hospital collected from January 2021 through May 2022. The OpenPose library was used to analyze videos to extract body pose estimations of team members and compute various team motion features. The Non-Technical Skills for Surgeons (NOTSS) assessment tool was employed for rating the OR team's nontechnical skills by 3 expert raters. NOTSS overall score, with motion features extracted from surgical videos as measures. A total of 30 complete cardiac surgery procedures were included: 26 (86.6%) were on-pump coronary artery bypass graft procedures and 4 (13.4%) were aortic valve replacement or repair procedures. All patients were male, and the mean (SD) age was 72 (6.3) years. All surgical teams were composed of 4 key roles (attending surgeon, attending anesthesiologist, primary perfusionist, and scrub nurse) with additional supporting roles. NOTSS scores correlated significantly with trajectory (r = 0.51, P = .005), acceleration (r = 0.48, P = .008), and entropy (r = -0.52, P = .004) of team displacement. Multiple linear regression, adjusted for patient factors, showed average team trajectory (adjusted R2 = 0.335; coefficient, 10.51 [95% CI, 8.81-12.21]; P = .004) and team displacement entropy (adjusted R2 = 0.304; coefficient, -12.64 [95% CI, -20.54 to -4.74]; P = .003) were associated with NOTSS scores. This study suggests a significant link between OR team movements and nontechnical skills ratings by NOTSS during cardiac surgical procedures, suggesting automated surgical video analysis could enhance nontechnical skills assessment. Further investigation across different hospitals and specialties is necessary to validate these findings.

Human factors and non-technical skills (NTS) have been identified as essential contributors to both the propagation and prevention of medical errors in the operating room. Despite extensive study and interventions to nurture and enhance NTS in anesthesiologists, gaps to effective team practice and patient safety remain. Furthermore, the link between added NTS training and clinically significant improved outcomes has not yet been demonstrated. We performed a narrative review to summarize the literature on existing systems and initiatives used to measure and nurture NTS in the clinical operating room setting. Controlled interventions performed to nurture NTS (N.=13) were identified and compared. We comment on the body of current evidence and highlight the achievements and limitations of interventions published thus far. We then propose a novel education and training framework to further develop and enhance non-technical skills in both individual anesthesiologists and operating room teams. We use the cardiac anesthesiology environment as a starting point to illustrate its use, with clinical examples. NTS is a key component of enhancing patient safety. Effective framing of its concepts is central to apply individual characteristics and skills in team environments in the OR and achieve tangible, beneficial patient outcomes.

'Human factors' (non-technical skills such as communication and teamwork) have been strongly implicated in adverse events during labour and delivery. The importance of shared 'situation awareness' between team members is highlighted as a key factor in patient safety. Arising from an ethnographic study of safety culture in the delivery suites of four UK hospitals, the aim of this study is to describe the main mechanisms supporting team situation awareness (TSA) and examine contrasting configurations of supports. Stage I: 177 hours of lightly structured non-participant observation (sensitizing concepts: safety culture, non-technical skills, teamwork and decision making) analysed to identify a core organizing concept, main supporting categories and preliminary conceptual models. Stage II: (approximately 11 months after first observations) 104 hours of observation to test and elaborate stage I analyses. Handover, whiteboard use and a coordinator role emerged as the key processes facilitating work and team coordination. The interplay between these supporting processes and the contextual features of each site promoted or inhibited TSA. Three configurations of supports for TSA were evident. These are described. Context configurations of supporting mechanisms and artefacts influence TSA, with implications for the maintenance of patient safety on delivery suites. A balanced model of supports for TSA is commended. Examining contrasting configurations helps reveal how local mechanisms or organizational, environmental and temporal factors might be manipulated to improve TSA.

It is becoming increasingly apparent that the technical proficiency of a surgeon is only one of many factors that influence surgical outcomes. Boyle et al. [1] have highlighted what has been termed a ‘systems approach’ which acknowledges the contribution of non-technical skills, such as stress-coping ability, to safe surgical practice. Unlike many other high-risk industries, such as aviation and the military, there is currently no stress/crisis management training to safeguard surgeons against the detrimental effects of excessive stress [2]. It is, therefore, important to address this issue through the use of consistent measures to identify and assess the stress during surgery. Interestingly, through the use of a general self-efficacy (GSE) questionnaire, Boyle et al. [1] found a lack of correlation between trainees’ GSE scores and surgical performance on laparoscopic and bench model-type stations. Whilst this demonstrates the inherent difficulty in measuring non-technical skills, it also emphasises the need for a reliable and accurate tool for assessing the overall effect of stress on surgical performance. Arora et al. [3] have recently proposed the imperial stress assessment tool (ISAT) which is a three-component stress measure consisting of salivary cortisol, heart rate and self-reported stress levels. It was demonstrated that both objective markers correlated well with self-reported stress, with high specificity and sensitivity. Notably, ISAT measures stress not only before, but also during the operative procedure. This overcomes the limitations inherent in self-reporting questionnaires which rely heavily upon the student’s ability to reliably assess their own stress levels prior to the surgery. Importantly, the ISAT is a non-intrusive method, taking no more than 10 min of the surgeon’s time. This is integral to the implementation of such a measure, as it renders it feasible for use within the busy operating theatre setting. Its practicality and validity make ISAT a good tool for assessing stress in surgery, allowing for detailed feedback to be given to surgeons, and facilitating targeted training in stress management. Not only will further factual evidence encourage the surgical community to acknowledge stress as a relevant issue, but it will also help formulate simulation-based training programs that closely mimic real-life experiences. The use of ISAT alongside validated measures of other non-technical (e.g. decision-making and leadership) and technical skills will be fundamental to the application of a ‘systems approach’ to such programs. The adoption of a holistic strategy to improving the skills required during surgery will enhance the surgical performance and ultimately lead to improved patient care.

There is growing evidence that non-technical skills (NTS) are related to surgical outcomes and patient safety. The aim of this study was to further evaluate a behaviour rating system (NOTSS: Non-Technical Skills for Surgeons) which can be used for workplace assessment of the cognitive and social skills which are essential components of NTS. A novice group composed of consultant surgeons (n = 44) from five Scottish hospitals attended one of six experimental sessions and were trained to use the NOTSS system. They then used NOTSS to rate surgeons' behaviors in six simulated scenarios filmed in the operating room. The behaviours demonstrated in each scenario were compared to expert ratings to determine accuracy. The mode rating from the novice group (who received a short training session in behaviour assessment) was the same as the expert group in 50% of ratings. Where there was disagreement, novice raters tended to provide lower ratings than the experts. Novice raters require significant training in this emerging area of competence in order to accurately rate non-technical skills.

BackgroundThe issue of surgical safety has increased significantly over the last few decades. Several studies have established that it is linked to non-technical performance, rather than clinical competencies. Non-technical skills can be blended with technical training in the surgical profession to improve surgeons’ abilities and enhance patient care and procedural skills. The main goal of this study was to determine orthopedic surgeons’ requirements of non-technical skills, and to identify the most pressing issues.MethodsWe conducted a self-administered online questionnaire survey in this cross-sectional study. The questionnaire was piloted, validated, pretested, and clearly stated the study’s purpose. After the pilot, minor wording and questions were clarified before starting the data collection. Orthopedic surgeons from the Middle East and Northern Africa were invited. The questionnaire was based on a five-point Likert scale, the data were analyzed categorically, and variables were summarized as descriptive statistics.ResultsOf the 1713 orthopedic surgeons invited, 60% completed the survey (1033 out of 1713). The majority demonstrated a high likelihood of participating in such activities in the future (80.5%). More than half (53%) of them preferred non-technical skills courses to be part of major orthopedic conferences, rather than independent courses. Most (65%) chose them to be face-to-face. Although 97.2% agreed on the importance of these courses, only 27% had attended similar courses in the last three years. Patient safety, infection prevention and control, and communication skills were ranked at the top as topics to be addressed. Moreover, participants indicated they would most likely attend courses on infection prevention and control, patient safety and teamwork, and team management.ConclusionThe results highlight the need for non-technical skills training in the region and the general preferences regarding modality and setting. These findings support the high demand from orthopedic surgeons’ perspective to develop an educational program on non-technical skills.

Teaching nontechnical skills in surgical residency: A systematic review of current approaches and outcomes

Background: The safety of patients and improvement in medical care to minimize the occurrence of adverse events is a widely discussed topic. In neurological emergencies, stroke stands out as a major concern. The time from recognition of the event to the initiation of treatment is crucial for outcomes, considering morbidity and mortality. Due to the emergency environment, there is a higher propensity for adverse events. Therefore, continuous education for team training is of utmost importance. For adults, the learning process differs from children, as they need to understand the reasons for their learning, motivated by problem-solving and active involvement in the learning process; in this aspect, realistic simulation becomes relevant. Objective: To evaluate the effectiveness of Realistic Simulation as a teaching and training method for stroke care teams. Methods: For the conduction of this review, the methodology proposed by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was used. Experimental studies of the type Clinical Trial, Quasi-Experimental, Cohort Studies and Case-Control studies were included; the study population was health professionals and the intervention was the use of Realistic Simulation as a training method in acute stroke care. The databases used were MEDLINE (PubMed), LILACS and Cochrane. The search was carried out in October 2023, by two independent evaluators, using the following search strategy: ("Realistic Simulation" OR "Simulation Training") AND ("Acute Stroke" OR Stroke). Results: A total of 159 studies were identified, of which 90 were selected and 17 included. Among the 17 studies evaluated, seven had the primary outcome of Door-to-Needle Time before and after team training through realistic simulation. All studies observed a reduction in Door-to-Needle Time, with some findings being statistically significant. Two studies assessed knowledge on the topic through pre and post-testing, both demonstrating an increase in score on the evaluation after training with Realistic Simulation. Another important concept addressed was Patient Safety, improvement in non-technical skills such as Leadership and Team Communication, which were also proven. Additionally, there was an improvement in personal perception of training capacity, greater learning of the topic, increased confidence in decision-making, and indication for thrombolysis. One of the limitations of this review was that, due to the diversity of study designs and primary outcomes, a meta-analysis was not performed. Conclusion: The results obtained through this systematic review allow us to conclude that training through Realistic Simulation for stroke patient care is associated with improved personal learning perception, acquisition of technical and non-technical skills, directly influencing important markers in acute stroke care, such as Door-to-Needle Time and higher thrombolysis rates.

Surgery in Safe Hands

The impact of stress on surgical performance: A systematic review of the literature

BackgroundPatients’ involvement in patient safety has increased in healthcare. Use of checklists may improve patient outcome in surgery, though few have attempted to engage patients’ use of surgical checklist. To identify risk elements of complications based on patients’ and healthcare workers’ experiences is warranted. This study aims to identify what the patients and healthcare workers find to be the risk elements that should be included in a patient-driven surgical patient safety checklist.MethodA qualitative study design where post-operative patients, surgeons, ward physicians, ward nurses, and secretaries from five surgical specialties took part in focus group interviews. Eleven focus groups were conducted including 25 post-operative patients and 27 healthcare workers at one tertiary teaching hospital and one community hospital in Norway. Based on their experiences, participants were asked to identify perceived risks before and after surgery. The interviews were analysed using content analysis.ResultsSafety risk factors were categorised as pre-operative information: pre-operative preparations, post-operative information, post-operative plans and follow-up. The subcategories under pre-operative information and preparations were: contact information, medication safety, health status, optimising health, dental status, read information, preparation two weeks before surgery, inform your surgical ward, planning your own discharge, preparation on admission and just before surgery. The subcategories under post-operative information, further plans and follow-up were: prevention and complications, restriction and activity, medication safety, pain relief, stomach functions, further care and appointments. Both healthcare workers and patients express the need for a surgical patient safety checklist.ConclusionA broad spectre of risk elements for a patient safety checklist were identified. Developing a surgical safety checklist based on these risk elements might reduce complications and unwanted errors.Trail registrationThe study is registered as part of a clinical trial in ClinicalTrials.gov: NCT03105713.

Mini 'C'-arm machine is an advanced medical imaging device used primarily for intraoperative imaging during surgical, orthopaedic and emergency care procedures. Since the technology is based on ionising radiation, safe usage of Mini 'C'-arm machine is mandatory to protect patients and operating personnel. The main objective is to describe the various components related to patients, operator and equipment to ensure safe usage of Mini 'C'-arm machine. A comprehensive search strategy using the PEO (Population, Exposure, Outcome) framework was conducted using Embase, PubMed, Google Scholar and ResearchGate databases to identify suitable literature. The keywords used for the search included 'Fluoroscopy', 'Ionising Radiation' and 'surgical safety'. Safe usage of Mini 'C'-arm equipment involves components of operator training, operator safety, patient safety, radiation dose, operating room logistics, handling of images and auditing of Mini 'C'-arm use. Mini 'C'-arm provides an invaluable, portable imaging tool in a spectrum of general surgical and orthopaedic interventional procedures. However, safe usage of Mini 'C'-arm machine requires a multifaceted approach including operator responsibility and safety, patient protection, equipment maintenance, radiation dose awareness, documentation and sound reporting mechanisms.

Background Non-technical skills include situational awareness, decision-making, communication, teamwork and leadership.1,2 The role of simulation-based training is gradually developing within the orthopaedic community but the focus is predominantly centred on technical skills such as dexterity and hand-eye coordination with little emphasis on human factors. Our aims were to produce a course tailored to teach non-technical skills to orthopaedic registrars and to analyse participants’ perceptions and feedback. Methodology A Delphi technique was used to develop a course in human factors specific to orthopaedic residents with challenging real-life situations in order to assess non-technical skills. These used high-fidelity mannequins and simulated patients in environments incorporating a simulated operating suite, a clinic room and a ward setting. A multidisciplinary healthcare team trained in Crisis Resource Management then used these videos as the basis for structured feedback and review. Participants completed a 5-point Likert scale questionnaire before and after the course. Results 27 orthopaedic residents took part. Pre-course questionnaires demonstrated a lack of foundation in non-technical skills. There was a significantly greater appreciation after the course and the perceived importance of these skills was reported as good or very good in 100%. Participants also felt that patient care, patient safety and team working would all improve with further human factors training (4.4–4.6). The course was reported to be enjoyable and provided an unthreatening learning environment (96%). Conclusions We have developed and piloted what we believe to be the first non-technical skills course that specifically caters to some of the unique needs and issues that affect orthopaedic surgeons. Participants demonstrated an improved understanding of the importance of non-technical performance, recognised its relevance to improving patient safety and expressed a desire for it to become an integral in training. Non-technical skills training may also go on to provide a means of identifying and supporting trainees in difficulty.