Acta Anaesthesiol Scand 2014; 58: 794–801 Printed in Singapore. All rights reserved
© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/aas.12315
Assessing Nurse Anaesthetists’ Non-Technical Skills in the operating room H. T. Lyk-Jensen, R. M. H. G. Jepsen, L. Spanager, P. Dieckmann and D. Østergaard Danish Institute for Medical Simulation, Centre for Human Resources, Capital Region of Denmark and University of Copenhagen
Background: Incident reporting and fieldwork in operating rooms have shown that some of the errors that arise in anaesthesia relate to inadequate use of non-technical skills. To provide a tool for training and feedback on nurse anaesthetists’ nontechnical skills, this study aimed to adapt the Anaesthetists’ Non-Technical Skills (ANTS) as a behavioural marker system for the formative assessment of nurse anaesthetists’ non-technical skills in the operating room. Methods: A qualitative approach with focus group interviews was used to identify the non-technical skills of nurse anaesthetists in the operating room. The interview data were transcribed verbatim. Directed content analysis was used to code and sort data deductively into the ANTS categories: task management, team working, situation awareness and decision making. The prototype named Nurse Anaesthetists’ Non-Technical Skills (N-ANTS) was presented and discussed in a group of subject matter experts to ensure face validity.
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ome errors that arise in anaesthesia relate to inadequate use of non-technical skills (NTS).1,2 NTS are social, cognitive, and emotional capabilities that complement technical skills and comprise skills such as decision making, teamwork, situation awareness, and task management.3 Studies show that staff members have difficulty in applying NTS in clinical practice.1,4,5 This has consequences for clinical performance.4 To reduce iatrogenic injury, healthcare organizations have adopted approaches from high-risk industries, most notably aviation, where for many years individuals and organizations have been trained to understand the importance of nontechnical skills.6 Also, methods for assessing NTS in aviation have inspired researchers to develop behavioural marker systems for health care. One example is the Anaesthetists’ Non-Technical Skills (ANTS).6 ANTS is a behavioural marker system for individual workplace-based assessment that has provided reliable and valid ratings of NTS.7 It is based on four categories: task management, team working, situation awareness, and decision making. Fifteen
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Results: The N-ANTS system consists of the same four categories as ANTS and 15 underlying elements. Three to five good and poor behavioural markers for each element were identified. The headings and definitions of the categories and elements were adjusted to encompass the behavioural markers in N-ANTS. The differences that emerged mainly reflected statements regarding the establishment of role, competence, and task delegation. Conclusion: A behavioural marker system, N-ANTS, for nurse anaesthetists was adapted from a behavioural marker system, ANTS, for anaesthesiologists. Accepted for publication 24 February 2014 © 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
underlying elements further describe the categories in more detail, and numerous behavioural markers illustrate positive and negative behaviours relating to safety in the operating room (OR). Behavioural marker systems have also been developed for surgeons8 (NOTSS), scrub practitioners9 (SPLINTS), and are being developed for anaesthetic assistants.10 Nurse anaesthetists administer general anaesthesia in collaboration with the anaesthesiologist during induction, and may work independently during anaesthesia of ASA I and II patients. They work according to standardized processes and provide standardized medications for general anaesthesia. They are not responsible for medical assessments and diagnosis. Nurse anaesthetists work in several countries, including Sweden, Norway, Denmark, the United States, and Switzerland. In these countries, specialist-training programmes have been developed.*
*http://www.ifna-int.org/ifna/news.php [Accessed 6 November 2013]
Nurse Anaesthetists’ Non-Technical Skills
In Denmark, the specialty-training curriculum for nurse anaesthetists includes learning objectives for both technical skills and NTS. Today, mainly technical skills are assessed. The assessments take place in the clinical workplace using workplace-based assessment tools such as competence cards.11,12 The assessments are formative throughout the education, which means that feedback and guidance from educators are provided in order to facilitate the learning of the trainees. At the end of the education, the trainees need to have passed all assessments (summative part). Developing a behavioural marker system of NTS specifically for the nurse anaesthetist would allow assessment and feedback on important individual skills. Such a system is lacking at present. This system would also foster the use of a common terminology for NTS in the anaesthesia team and thus might enhance collaboration among OR team members.13 However, the behavioural marker system for anaesthesiologists, ANTS, may not adequately describe nurse anaesthetists’ NTS as tasks and working conditions differ between the two professions. This study aimed to adapt ANTS into a behavioural marker system for nurse anaesthetists’ NTS in the OR.
Methods Participants A qualitative approach with focus group interviews was used for the study. Nurse anaesthetists, anaesthesiologists covering anaesthesia for all specialties in the hospital, surgeons, and scrub nurses from three specialties (orthopaedic, gynaecological/ obstetric, general surgery) took part in the interviews. The surgeons and scrub nurses were included to broaden the view on nurse anaesthetists’ NTS – a procedure successfully used previously.14 We deliberately composed four monodisciplinary focus groups to avoid dominance of some professions over others, e.g. doctors over nurses. The criterion for inclusion was that all participants were experienced OR team members. Interviews were conducted in 2011 in a Danish University-affiliated hospital. The sampling was based on convenience principles. Participants were invited by email. They received written and verbal information about the study and gave oral consent. We aimed at including four to six participants in each group to give room for intense discussions. Danish law exempts this kind of research from ethical board approval. Data were handled in
conformity with the regulations of the Danish Data Protection Agency.
Design and procedure The original English version of ANTS was translated into Danish by a native Danish consultant in anaesthesiology, bilingual in Danish and English. The research group refined the translation. A semi-structured approach was used in the focus groups. This approach enabled the facilitators to ask pre-determined questions while still remaining flexible within the present topic areas. Focus groups participants were allowed to elaborate on topics that emerged. Only the name and the translated definition of the four ANTS categories3 were presented to the participants as a starting point for discussions about each category. Neither the elements nor the behavioural markers were shown to the participants. Thus, the research group’s pre-understanding was balanced against the openness needed for an adaptation. The interviews lasted between 1 h and 1.5 h, and were conducted in a quiet setting. The interviews were audio recorded and guided by two interviewers from the research group (one registered nurse anaesthetist accompanied by either one trainee anaesthesiologist, one trainee surgeon, or one consultant anaesthesiologist). The research group further included a work and organizational psychologist.
Data analysis Table 1 illustrates the analysis process from quotations to behavioural markers. Three steps were taken during the analysis. Step 1: The interview data were transcribed verbatim and anonymized. Directed content analysis15 was used to code and sort data. Two researchers (H. T. Lyk-Jensen and R. M. H. G. Jepsen) independently coded each transcript using the categories of ANTS and discussed the coding until consensus. Approximately 30% of the transcribed text was excluded, because it was irrelevant to discussions of NTS (e.g. material on organizational issues pertaining to the participants’ work settings). The quotations that did not fit into the ANTS elements were analyzed separately using an inductive approach. During this process, it became clear that category and element definitions needed adjustment to accurately describe the behavioural markers for nurse anaesthetists. Throughout the analysis process, sortings were discussed within the research group to ensure adequate analysis. The analysis
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Task management
A, anaesthesiologists; NA, nurse anaesthetists; S, surgeons; SN, scrub nurses.
SN: ‘It’s important to break members down by tasks and responsibilities’
S: ‘They have to be helping out where it’s needed, knowing what task they have right now, doing what we didn’t have the time to do’ NA: ‘Knowing my team members is first and all about knowing my own duties and qualifications in relation to team members’
S: ‘That they’re good at sorting out all the unimportant details’ NA: ‘Maybe someone can help me with some of it, but there are certain things that I have to have in my hands’ A: ‘Basis for successful and respectful teamwork is when you shortly clarify your qualifications’
NA: ‘I call for help when I can’t figure out what’s the problem and when the patient doesn’t react as I expected’ A: ‘If it’s critical and the nurse thinks it’s relevant, she should calm people down’
S: ‘I cannot dislike someone who in time recognises own limitations. That the most beautiful skill to have’
Decision making
Judging own and others’ skills and abilities. Being alert to contributors to workload or factors that may limit performance
Using ongoing evaluation whether there’s a need to change priorities
Considering and understanding consequences of various options
Knowing how to use gathered information to act accordingly
Situation awareness
S: ‘A fine almost musical feeling of what is going on in the theatre. Catches when the surgeon turns silent, giving short answers or shows signs of being in trouble’
NA: ‘Saying “when you are ready, let me know and we’ll send for the patient”. I think that is part of team work, but also something about having the feeling and understanding of other team members’ work’ SN: ‘If there is someone who recognizes and sees it, and shows “yes I can see you’re busy, but as soon as you’re ready, let me know”, then you get the feeling that somebody sees and understands you’ A: ‘It’s not that they become sloppy but when they’re tired and cannot concentrate’, they send each other out’ (offers colleagues a break)
Paraphrases
Category
Quotations from focus groups
Good performance Declines tasks that exceed own competences
Assessing and weighing up options
Assessing roles and competences
Setting priorities
Good performance Adapts behaviour to the situation and creates a good atmosphere around the task to be carried out Poor performance Fails to register own and other team members’ critical periods
Recognising and understanding contexts
Poor performance Does not seek a professional dialogue or is not willing to have own decisions challenged concerning execution of tasks
Poor performance Does not solve important tasks Good performance Exhibits awareness of own role in relation to the rest of the team
Good performance Distinguishes between important and less important tasks
Poor performance Does not exhibit awareness of own limitations
Behavioural markers
Elements
The table shows the analytical process, how quotations are summed, and condensed and written as observable behavioural examples.
Table 1
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Nurse Anaesthetists’ Non-Technical Skills Table 2 Demographic data on the participants from the four focus groups shown by profession. Interview participants
Number
Gender female/male
Experience in specialty (years)
Nurse anaesthetists Anaesthesiologists Scrub nurses Surgeons
4 4 4 4
3/1 2/2 4/0 1/3
3–17 5–21 5–10 4–8
resulted in the prototype of the Danish version of ANTS for nurse anaesthetists and was given the title Nurse Anaesthetists’ Non-Technical Skills (N-ANTS). Step 2: To ensure face validity, the N-ANTS prototype was presented to a group of 12 clinical supervisors and nurse anaesthetists responsible for education from one out of the four educational regions in Denmark during a workshop. This region educates more than half of the nurse anaesthetists as they take in trainees twice a year, contrasted by once a year in the other regions. Participants discussed the wording, whether the framework was easy to understand and if the language was specific for the profession and illustrated observable behaviour.† Behavioural markers that were judged to be too similar to each other were removed, and seven new markers were formulated by the workshop participants to supplement the results from the focus groups. Further, workshop participants suggested changing the wording in two of the element headings and in 12 of the markers. Overall, the workshop participants found the tool comprehensive, representative and relevant for assessing and providing feedback on nurse anaesthetists’ NTS. Step 3: On the basis of the input from the workshop (Step 2), the research group adjusted the N-ANTS prototype. The final N-ANTS was then returned to the original focus group and the workshop participants by mail. No further suggestions for change were made during this step.
Translation and back-translation of N-ANTS To be able to use the tool for nurse anaesthetists outside Scandinavia a translation from Danish to English was carried out by a professional translator. A second professional translator carried out backtranslation from English to Danish to ensure that the English version of the N-ANTS tool was correct. A Danish speaker and a subject matter expert (HTLJ) †http://www.abdn.ac.uk/iprc/papers [Accessed 4 July 2013]
reviewed the back-translation and revised the English version accordingly.
Results Eight physicians and eight nurses participated in four focus group interviews. The scheduled time proved adequate to cover the material. Table 2 shows the demographic data of the participants. All quotations could be placed into one of the categories in ANTS. The majority of quotations also fitted into one of the elements of ANTS. Approximately, 30% of the quotations did not fit into any of the elements. In the analysis process, it became clear that the wording of some of the elements needed adjustment after sorting the matching quotations into them. The definitions of elements and categories were also revised. These adjustments were necessary to describe the nurse’s role, competence, and task. In the following sections, an overall summary of the changes made in the heading of the elements is provided. The N-ANTS heading of the elements ‘recognising and understanding contexts’ and ‘anticipating and thinking ahead’ in the category of situation awareness were extended with the words ‘contexts’ and ‘thinking ahead’. This was to emphasize that good situation awareness is the ability to adapt behaviour to dynamically changing contexts,9 and to maintain awareness of information that might be associated with potential problems. The wording in the heading of the elements ‘assessing and weighing up options’ and ‘reassessing decisions’ in the decision-making category were adjusted to address the circumstance that decisionmaking processes of nurse anaesthetists not only depend on the competence and task delegation of this profession but also depend on the fact that decisions made by anaesthesiologists must be considered and understood.
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H. T. Lyk-Jensen et al. Table 3 Shows the N-ANTS categories and elements as well as one good and one poor example of each element. Category
Element
Examples of good behavioural markers
Examples of poor behavioural markers
Situation awareness
Gathering information
Intensifies awareness when the situation requires it
Recognizing and understanding contexts
Aware of how to integrate the information from surgery and anaesthesia in handling the situation Thinks ahead during the operation and plans the solution of potential problems Exhibits knowledge of when it is necessary to call for help or seek a professional dialogue Declines tasks that exceed own competences Exhibits knowledge about when it is necessary to switch from Plan A to Plan B Departs follow a structured procedure when it is necessary to act differently Uses a systematic approach in prioritizing tasks Works on more than one task at a time when required Knows guidelines for hygiene, treatment regimes, documentation requirements, etc Communicates assessments and observations that are relevant for team members
Is inattentive and not concentrated when updating information about anaesthesia and surgery Does not adapt the anaesthesia if changes are introduced in the surgical plan
Anticipating and thinking ahead Decision making
Identifying options Assessing and weighing up options Reassessing decisions
Task management
Planning Setting priorities Making use of resources Maintaining standards
Team working
Exchanging information
Assessing roles and competences Coordinating activities Displaying authority and strength Exhibiting team behaviour and support for members of the team
Clarifies what the anaesthesia and operation teams expect of each other in carrying out the task Is flexible and helpful across specialization boundaries when the situation permits Clearly expresses disapproval to the team if safety is threatened Is accommodating and responsive
The wording in the heading of the elements ‘planning’, ‘setting priorities’, ‘making use of resources’, and ‘maintaining standards’ in the task management category were changed to emphasize a nonleading role in the overall task management. Finally, the wording in the heading of the elements ‘assessing roles and competences’, ‘coordinating activities’, displaying authority and strength’, and ‘exhibiting team behaviour and support for members of the team’ in the category of team working describes the role of nurse anaesthetists as a subordinate member of the team, not the leader.
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Fails to consider potential problems associated with small details that may herald problems Is not open to input for decisions Does not exhibit awareness of own limitations Does not assess whether the plan is proceeding as anticipated Departs from a systematic procedure without giving reasons for this Allows him/herself to be distracted when prioritizing tasks Does not work parallel with the team on carrying out tasks Fails to follow guidelines, and does not explain departures from them Does not communicate or warn about problems and thus fails to make the seriousness of the situation clear for team members Does not attune to what the others do and will do Does not coordinate own or others’ tasks Communicates or argues unprofessionally when facing problems in carrying out tasks Does not respect the fields of work and responsibility of other team members
In the discussion section, the basis for these changes will be presented in more detail. Table 3 shows the N-ANTS system, consisting of four categories, 15 underlying elements, for which one good and one poor example are given – the full version of N-ANTS is available as a user guide.‡ The two cognitive categories – situation awareness and decision making – are presented before the social categories of task management and team working to ‡http://www.regionh.dk/dims/menu/Forskning/NonTechnical+Skills/N-ANTS.htm [Accessed 15 January 2014]
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emphasize that social aspects of performance feed on essential cognitive skills.
Discussion The adaptation of ANTS to describe the NTS required for the nurse anaesthetists resulted in a behavioural marker system for nurse anaesthetists’ NTS in the OR, called N-ANTS. To the best of our knowledge, this is the first tool thoroughly describing the non-technical skills of nurse anaesthetists. The N-ANTS system comprises a three-level hierarchy of categories, elements, and behavioural markers. At the highest level, the tool has four main skill categories: situation awareness, decision making, task management, and team working. The categories overlap to a certain degree. One example is the marker ‘assesses and communicates decisions on the basis of knowledge of advantages and disadvantages’, which could be placed in the teamworking category, as well as in the decision-making category. Overall, N-ANTS address many of the same key NTS required for anaesthesiologists as represented in ANTS. Those similarities are plausible given the overlap in tasks of nurse anaesthetists and anaesthesiologists: providing anaesthesia. The differences in the behavioural markers may reflect the roles, tasks, and competence of the nurse anaesthetists that do differ compared to anaesthesiologists. These are discussed in more detail in the following: The nurse anaesthetists are not allowed to diagnose the patient. They use only medication needed to induce and maintain anaesthesia. The nurse anaesthetist always needs to monitor when her or his competence is not sufficient for the task at hand and call the anaesthesiologist if needed. Several of the behavioural markers in N-ANTS in the category of decision making reflect this: ‘asks for help when in doubt or uncertain about decisions’ and ‘declines tasks that exceed own competence’. Furthermore, nurse anaesthetists have less leadership responsibility than anaesthesiologists. This is reflected in N-ANTS with behavioural markers such as ‘identifies own and team members’ resources, so the task is carried out optimally’ under the element ‘making use of resources’ in the task management category and ‘gets team members to be receptive for input’, under the element ‘displaying authority and strength’ in the team-working category. The behavioural markers in the decision-making category indicate the specific role of the nurse anaesthetist in the anaesthesia team. Under the element
‘assessing and weighing up options’, the marker ‘assesses and communicates decisions on the basis of knowledge of advantages and disadvantages’ indicates that the nurse anaesthetist participates in the decision-making process. The anaesthesiologist has the overall responsibility for case planning and medical assessments of the patient, and might oversee several ORs at the same time. Therefore, he or she is dependent on the nurse anaesthetist’s ability to stay focused and to allocate attention to cues that might evolve subtly.16 Bringing this continuous situation awareness into the decision making makes the nurse anaesthetist a co-decision maker. The differences between N-ANTS and ANTS may also be related to differences in professional and/or national culture. In Denmark the power distance is low.17,18 Consequently, nurses may find it relatively easy to speak up to the team when in doubt or having concerns.17 The behavioural marker ‘clearly expresses approval or disapproval to the team if safety is threatened’ within the team-working category is one example of this. This finding is in agreement with Rabøl et al,17 who also identified the perception of a flat hierarchy, which allows everyone to speak up in Denmark. Several studies have concluded that hierarchy influences values in the workplace and that this varies across national cultures.13,18 The differences over time in patient safety culture may also provide an explanation of the differences between the systems. N-ANTS was developed 10 years later than ANTS and the organizational and professional culture may have changed during this period, reflecting new standards for acceptable behaviours.
Strengths and limitations Focus groups were chosen to collect as much information as possible without potentially influencing how the task was performed.19 Focus groups were chosen because we hoped that participants would inspire each other and provide a broad coverage of NTS. One challenge in the cognitive categories of situation awareness and decision making is the assumption that mental processes are always analytical, purely rational, and can be described verbally.20 The total number of participants was small, and it can be questioned whether saturation was obtained. However, 12 clinical educators refined the prototype. The final feedback round (Step 3) did not result in changes.
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In this study, as opposed to the original ANTS study, we included the perspectives of the full OR team to broaden the perspective of nurse anaesthetists’ NTS since the NTS of one team member influence the task management of others.1 Various studies have documented differences of opinions regarding the perceived quality of teamwork in OR teams.21,22 By expanding the overall understanding of what safe anaesthetic behaviour is, there is a risk, however, that we have overemphasized the perspectives of the collaborating team members. It may be argued that composing mixed focus groups might have captured more inter-professional aspects such as different attitudes across professions. However, the scope of the study was to achieve a broad description of nurse anaesthetist behaviours rather than exploring differences of opinion – and we therefore consider the chosen group composition adequate for the purpose. Our decision to present the translated ANTS categories to the focus group may have generated a bias. Our method might have more readily resulted in data supportive of the initial framework rather than non-supportive. Given the similarities in the task (providing anaesthesia) however, it seemed reasonable to build on the previous extensive development work behind ANTS. Furthermore, using ANTS as a starting point may have blinded the research group to other aspects of nurse anaesthetists’ NTS. A thorough task analysis may have captured new or other aspects and concepts. Not all behavioural markers present the de facto standard for a mature safety culture. ‘Works on more than one task at a time when required’ and ‘does not follow a structured procedure when it is necessary to act differently’ are two such behaviours. Both markers mirror clinical reality in which a trade-off between efficiency and thoroughness is often required.23 Revisions of N-ANTS may become necessary at a later point in time to adjust for changes such as improved human factor’s knowledge. The interviews were conducted in a single university hospital in Denmark. However, we presented and discussed the first edition of N-ANTS with regional subject matter experts. It might not be fully representative, but we suggest that the N-ANTS system could be used initially for formative assessment in the clinical setting in all the regions of Denmark.
Perspectives The N-ANTS behavioural marker system has the potential to facilitate learning and assessment for
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nurse anaesthetists’ NTS during intra-operative cases. The system allows educators to provide feedback on the strengths and weaknesses of the participants’ NTS and in this way enable them to reflect on their own NTS. Complementary to Danish workplace-based assessment tools such as competence cards,11,12 N-ANTS has the potential to help trainees and educators structure training, assess competence, and provide feedback. Our study adds to existing scientific knowledge by providing a framework for the description of the behaviours of nurse anaesthetists in the OR. This is necessary in order to be able to make reliable and valid assessments of nurse anaesthetists’ NTS, and it provides a tool that can be used to evaluate potential training interventions. Training of educators in using the tool will be necessary to obtain the best result.†24 When adapting tools for other countries, cultural differences at the organizational, professional or national level should be taken into account.† Cultures similar to the Danish culture are found within Scandinavia, and N-ANTS may need only a few adjustments in order to be used in these countries. It will remain to be investigated further what differences in tasks, roles, responsibilities, and culture would require a further adaptation of N-ANTS.
Conclusion A behavioural marker system, N-ANTS, for nurse anaesthetists was adapted from the behavioural marker system, ANTS, for anaesthesiologists. The necessity for the modification was explained by differences in tasks, roles, and responsibilities of Danish nurse anaesthetists as opposed to Scottish anaesthesiologists. National cultures may also have an influence on the needs for adaptation. Conflicts of interest: Authors declare no conflicts of interest. Funding: None.
References 1. Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, Bohnen J, Orser B, Doran D, Grober E. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care 2004; 13: 330–4. 2. Flin R, Maran N. Identifying and training non-technical skills for teams in acute medicine. Qual Saf Health Care 2004; 13: i80–4. 3. Flin R, Patey R, Glavin R, Maran N. Anaesthetists’ nontechnical skills. Br J Anaesth 2010; 105: 38–44. 4. Rabøl LI, Andersen ML, Østergaard D, Bjørn B, Lilja B, Mogensen T. Descriptions of verbal communication errors
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5. 6. 7. 8. 9.
10. 11.
12.
13. 14.
15.
between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. BMJ Qual Saf 2011; 20: 268–74. Flin R, Patey R. Improving patient safety through training in non-technical skills. Br Med J 2009; 339: b3595. Flin R, Patey R. Non-technical skills for anaesthetists: developing and applying ANTS. Best Pract Res Clin Anaesthesiol 2011; 25: 215–27. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R. Anaesthetists’ Non-Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth 2003; 90: 580–8. Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D. Development of a rating system for surgeons’ non-technical skills. Med Educ 2006; 40: 1098–104. Mitchell L, Flin R, Yule S, Mitchell J, Coutts K, Youngson G. Development of a behavioural marker system for scrub practitioners’ non-technical skills (SPLINTS system). J Eval Clin Pract 2013; 19: 317–23. Rutherford JS, Flin R, Mitchell L. Teamwork, communication, and anaesthetic assistance in Scotland. Br J Anaesth 2012; 109: 21–6. Ringsted C, Østergaard D, Scherpbier A. Embracing the new paradigm of assessment in residency training. An assessment programme for 1st year residency training in anaesthesiology. Med Teach 2003; 25: 54–62. Ringsted C, Østergaard D, Van der Vleuten CPM. Implementation of a formal in-training assessment programme in anaesthesiology and preliminary results of acceptability. Acta Anaesthesiol Scand 2003; 47: 1196–203. Cosby KS, Croskerry P. Profiles in patient safety: authority gradients in medical error. Acad Emerg Med 2004; 11: 1341–5. Spanager L, Lyk-Jensen HT, Dieckmann P, Wettergren A, Rosenberg J, Østergaard D. Customization of a tool to assess Danish surgeons’ non-technical skills in the operating room. Dan Med J 2012; 11: A4526. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005; 15: 1277–88.
16. Gaba DM, Howard SK, Small SD. Situation awareness in anesthesiology. Hum Factors 1995; 37: 20–31. 17. Rabøl LI, McPhail MA, Østergaard D, Andersen HB, Mogensen T. Promoters and barriers in hospital team communication. A focus group study. J Commun Healthc 2012; 5: 129–39. 18. Hofstede G. Culture’s consequences, comparing values, behaviors, institutions and organization across nations. Thousand Oaks, CA: Sage Publications, 2001. 19. Nisbett RE, Wilson TD. Telling more than we know. Verbal reports on mental processes. Psychol Rev 1977; 84: 231–59. 20. Kahneman D. Thinking, fast and slow. Toronto, Ontario: Doubleday, 2011. 21. Schaefer HG, Helmreich RL, Scheidegger D. Safety in the operating theatre – Part 1: interpersonal relationships and team performance. Cur Anaesth Critic Care 1995; 6: 48–53. 22. Reader TW, Flin R, Mearns K, Cuthbertson BH. Interdisciplinary communication in the intensive care unit. Br J Anaesth 2007; 98: 347–52. 23. Hollnagel E. The ETTO principle: efficiency-thoroughness trade-off: why things that go right sometimes go wrong. Aldershot: Ashgate Publishing, Ltd., 2009. 24. Hull L, Arora S, Symons NR, Jalil R, Darzi A, Vincent C, Sevdalis N. Training faculty in nontechnical skill assessment. National guidelines on program requirements. Ann Surg 2013; 258: 370–5.
Address: Helle Teglgaard Lyk-Jensen Danish Institute for Medical Simulation Centre for Human Resources Herlev Hospital 75 Herlev Ringvej, Herlev, Denmark. e-mail: [email protected]
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© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/aas.12315
Assessing Nurse Anaesthetists’ Non-Technical Skills in the operating room H. T. Lyk-Jensen, R. M. H. G. Jepsen, L. Spanager, P. Dieckmann and D. Østergaard Danish Institute for Medical Simulation, Centre for Human Resources, Capital Region of Denmark and University of Copenhagen
Background: Incident reporting and fieldwork in operating rooms have shown that some of the errors that arise in anaesthesia relate to inadequate use of non-technical skills. To provide a tool for training and feedback on nurse anaesthetists’ nontechnical skills, this study aimed to adapt the Anaesthetists’ Non-Technical Skills (ANTS) as a behavioural marker system for the formative assessment of nurse anaesthetists’ non-technical skills in the operating room. Methods: A qualitative approach with focus group interviews was used to identify the non-technical skills of nurse anaesthetists in the operating room. The interview data were transcribed verbatim. Directed content analysis was used to code and sort data deductively into the ANTS categories: task management, team working, situation awareness and decision making. The prototype named Nurse Anaesthetists’ Non-Technical Skills (N-ANTS) was presented and discussed in a group of subject matter experts to ensure face validity.
S
ome errors that arise in anaesthesia relate to inadequate use of non-technical skills (NTS).1,2 NTS are social, cognitive, and emotional capabilities that complement technical skills and comprise skills such as decision making, teamwork, situation awareness, and task management.3 Studies show that staff members have difficulty in applying NTS in clinical practice.1,4,5 This has consequences for clinical performance.4 To reduce iatrogenic injury, healthcare organizations have adopted approaches from high-risk industries, most notably aviation, where for many years individuals and organizations have been trained to understand the importance of nontechnical skills.6 Also, methods for assessing NTS in aviation have inspired researchers to develop behavioural marker systems for health care. One example is the Anaesthetists’ Non-Technical Skills (ANTS).6 ANTS is a behavioural marker system for individual workplace-based assessment that has provided reliable and valid ratings of NTS.7 It is based on four categories: task management, team working, situation awareness, and decision making. Fifteen
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Results: The N-ANTS system consists of the same four categories as ANTS and 15 underlying elements. Three to five good and poor behavioural markers for each element were identified. The headings and definitions of the categories and elements were adjusted to encompass the behavioural markers in N-ANTS. The differences that emerged mainly reflected statements regarding the establishment of role, competence, and task delegation. Conclusion: A behavioural marker system, N-ANTS, for nurse anaesthetists was adapted from a behavioural marker system, ANTS, for anaesthesiologists. Accepted for publication 24 February 2014 © 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
underlying elements further describe the categories in more detail, and numerous behavioural markers illustrate positive and negative behaviours relating to safety in the operating room (OR). Behavioural marker systems have also been developed for surgeons8 (NOTSS), scrub practitioners9 (SPLINTS), and are being developed for anaesthetic assistants.10 Nurse anaesthetists administer general anaesthesia in collaboration with the anaesthesiologist during induction, and may work independently during anaesthesia of ASA I and II patients. They work according to standardized processes and provide standardized medications for general anaesthesia. They are not responsible for medical assessments and diagnosis. Nurse anaesthetists work in several countries, including Sweden, Norway, Denmark, the United States, and Switzerland. In these countries, specialist-training programmes have been developed.*
*http://www.ifna-int.org/ifna/news.php [Accessed 6 November 2013]
Nurse Anaesthetists’ Non-Technical Skills
In Denmark, the specialty-training curriculum for nurse anaesthetists includes learning objectives for both technical skills and NTS. Today, mainly technical skills are assessed. The assessments take place in the clinical workplace using workplace-based assessment tools such as competence cards.11,12 The assessments are formative throughout the education, which means that feedback and guidance from educators are provided in order to facilitate the learning of the trainees. At the end of the education, the trainees need to have passed all assessments (summative part). Developing a behavioural marker system of NTS specifically for the nurse anaesthetist would allow assessment and feedback on important individual skills. Such a system is lacking at present. This system would also foster the use of a common terminology for NTS in the anaesthesia team and thus might enhance collaboration among OR team members.13 However, the behavioural marker system for anaesthesiologists, ANTS, may not adequately describe nurse anaesthetists’ NTS as tasks and working conditions differ between the two professions. This study aimed to adapt ANTS into a behavioural marker system for nurse anaesthetists’ NTS in the OR.
Methods Participants A qualitative approach with focus group interviews was used for the study. Nurse anaesthetists, anaesthesiologists covering anaesthesia for all specialties in the hospital, surgeons, and scrub nurses from three specialties (orthopaedic, gynaecological/ obstetric, general surgery) took part in the interviews. The surgeons and scrub nurses were included to broaden the view on nurse anaesthetists’ NTS – a procedure successfully used previously.14 We deliberately composed four monodisciplinary focus groups to avoid dominance of some professions over others, e.g. doctors over nurses. The criterion for inclusion was that all participants were experienced OR team members. Interviews were conducted in 2011 in a Danish University-affiliated hospital. The sampling was based on convenience principles. Participants were invited by email. They received written and verbal information about the study and gave oral consent. We aimed at including four to six participants in each group to give room for intense discussions. Danish law exempts this kind of research from ethical board approval. Data were handled in
conformity with the regulations of the Danish Data Protection Agency.
Design and procedure The original English version of ANTS was translated into Danish by a native Danish consultant in anaesthesiology, bilingual in Danish and English. The research group refined the translation. A semi-structured approach was used in the focus groups. This approach enabled the facilitators to ask pre-determined questions while still remaining flexible within the present topic areas. Focus groups participants were allowed to elaborate on topics that emerged. Only the name and the translated definition of the four ANTS categories3 were presented to the participants as a starting point for discussions about each category. Neither the elements nor the behavioural markers were shown to the participants. Thus, the research group’s pre-understanding was balanced against the openness needed for an adaptation. The interviews lasted between 1 h and 1.5 h, and were conducted in a quiet setting. The interviews were audio recorded and guided by two interviewers from the research group (one registered nurse anaesthetist accompanied by either one trainee anaesthesiologist, one trainee surgeon, or one consultant anaesthesiologist). The research group further included a work and organizational psychologist.
Data analysis Table 1 illustrates the analysis process from quotations to behavioural markers. Three steps were taken during the analysis. Step 1: The interview data were transcribed verbatim and anonymized. Directed content analysis15 was used to code and sort data. Two researchers (H. T. Lyk-Jensen and R. M. H. G. Jepsen) independently coded each transcript using the categories of ANTS and discussed the coding until consensus. Approximately 30% of the transcribed text was excluded, because it was irrelevant to discussions of NTS (e.g. material on organizational issues pertaining to the participants’ work settings). The quotations that did not fit into the ANTS elements were analyzed separately using an inductive approach. During this process, it became clear that category and element definitions needed adjustment to accurately describe the behavioural markers for nurse anaesthetists. Throughout the analysis process, sortings were discussed within the research group to ensure adequate analysis. The analysis
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796 Team working
Task management
A, anaesthesiologists; NA, nurse anaesthetists; S, surgeons; SN, scrub nurses.
SN: ‘It’s important to break members down by tasks and responsibilities’
S: ‘They have to be helping out where it’s needed, knowing what task they have right now, doing what we didn’t have the time to do’ NA: ‘Knowing my team members is first and all about knowing my own duties and qualifications in relation to team members’
S: ‘That they’re good at sorting out all the unimportant details’ NA: ‘Maybe someone can help me with some of it, but there are certain things that I have to have in my hands’ A: ‘Basis for successful and respectful teamwork is when you shortly clarify your qualifications’
NA: ‘I call for help when I can’t figure out what’s the problem and when the patient doesn’t react as I expected’ A: ‘If it’s critical and the nurse thinks it’s relevant, she should calm people down’
S: ‘I cannot dislike someone who in time recognises own limitations. That the most beautiful skill to have’
Decision making
Judging own and others’ skills and abilities. Being alert to contributors to workload or factors that may limit performance
Using ongoing evaluation whether there’s a need to change priorities
Considering and understanding consequences of various options
Knowing how to use gathered information to act accordingly
Situation awareness
S: ‘A fine almost musical feeling of what is going on in the theatre. Catches when the surgeon turns silent, giving short answers or shows signs of being in trouble’
NA: ‘Saying “when you are ready, let me know and we’ll send for the patient”. I think that is part of team work, but also something about having the feeling and understanding of other team members’ work’ SN: ‘If there is someone who recognizes and sees it, and shows “yes I can see you’re busy, but as soon as you’re ready, let me know”, then you get the feeling that somebody sees and understands you’ A: ‘It’s not that they become sloppy but when they’re tired and cannot concentrate’, they send each other out’ (offers colleagues a break)
Paraphrases
Category
Quotations from focus groups
Good performance Declines tasks that exceed own competences
Assessing and weighing up options
Assessing roles and competences
Setting priorities
Good performance Adapts behaviour to the situation and creates a good atmosphere around the task to be carried out Poor performance Fails to register own and other team members’ critical periods
Recognising and understanding contexts
Poor performance Does not seek a professional dialogue or is not willing to have own decisions challenged concerning execution of tasks
Poor performance Does not solve important tasks Good performance Exhibits awareness of own role in relation to the rest of the team
Good performance Distinguishes between important and less important tasks
Poor performance Does not exhibit awareness of own limitations
Behavioural markers
Elements
The table shows the analytical process, how quotations are summed, and condensed and written as observable behavioural examples.
Table 1
H. T. Lyk-Jensen et al.
Nurse Anaesthetists’ Non-Technical Skills Table 2 Demographic data on the participants from the four focus groups shown by profession. Interview participants
Number
Gender female/male
Experience in specialty (years)
Nurse anaesthetists Anaesthesiologists Scrub nurses Surgeons
4 4 4 4
3/1 2/2 4/0 1/3
3–17 5–21 5–10 4–8
resulted in the prototype of the Danish version of ANTS for nurse anaesthetists and was given the title Nurse Anaesthetists’ Non-Technical Skills (N-ANTS). Step 2: To ensure face validity, the N-ANTS prototype was presented to a group of 12 clinical supervisors and nurse anaesthetists responsible for education from one out of the four educational regions in Denmark during a workshop. This region educates more than half of the nurse anaesthetists as they take in trainees twice a year, contrasted by once a year in the other regions. Participants discussed the wording, whether the framework was easy to understand and if the language was specific for the profession and illustrated observable behaviour.† Behavioural markers that were judged to be too similar to each other were removed, and seven new markers were formulated by the workshop participants to supplement the results from the focus groups. Further, workshop participants suggested changing the wording in two of the element headings and in 12 of the markers. Overall, the workshop participants found the tool comprehensive, representative and relevant for assessing and providing feedback on nurse anaesthetists’ NTS. Step 3: On the basis of the input from the workshop (Step 2), the research group adjusted the N-ANTS prototype. The final N-ANTS was then returned to the original focus group and the workshop participants by mail. No further suggestions for change were made during this step.
Translation and back-translation of N-ANTS To be able to use the tool for nurse anaesthetists outside Scandinavia a translation from Danish to English was carried out by a professional translator. A second professional translator carried out backtranslation from English to Danish to ensure that the English version of the N-ANTS tool was correct. A Danish speaker and a subject matter expert (HTLJ) †http://www.abdn.ac.uk/iprc/papers [Accessed 4 July 2013]
reviewed the back-translation and revised the English version accordingly.
Results Eight physicians and eight nurses participated in four focus group interviews. The scheduled time proved adequate to cover the material. Table 2 shows the demographic data of the participants. All quotations could be placed into one of the categories in ANTS. The majority of quotations also fitted into one of the elements of ANTS. Approximately, 30% of the quotations did not fit into any of the elements. In the analysis process, it became clear that the wording of some of the elements needed adjustment after sorting the matching quotations into them. The definitions of elements and categories were also revised. These adjustments were necessary to describe the nurse’s role, competence, and task. In the following sections, an overall summary of the changes made in the heading of the elements is provided. The N-ANTS heading of the elements ‘recognising and understanding contexts’ and ‘anticipating and thinking ahead’ in the category of situation awareness were extended with the words ‘contexts’ and ‘thinking ahead’. This was to emphasize that good situation awareness is the ability to adapt behaviour to dynamically changing contexts,9 and to maintain awareness of information that might be associated with potential problems. The wording in the heading of the elements ‘assessing and weighing up options’ and ‘reassessing decisions’ in the decision-making category were adjusted to address the circumstance that decisionmaking processes of nurse anaesthetists not only depend on the competence and task delegation of this profession but also depend on the fact that decisions made by anaesthesiologists must be considered and understood.
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H. T. Lyk-Jensen et al. Table 3 Shows the N-ANTS categories and elements as well as one good and one poor example of each element. Category
Element
Examples of good behavioural markers
Examples of poor behavioural markers
Situation awareness
Gathering information
Intensifies awareness when the situation requires it
Recognizing and understanding contexts
Aware of how to integrate the information from surgery and anaesthesia in handling the situation Thinks ahead during the operation and plans the solution of potential problems Exhibits knowledge of when it is necessary to call for help or seek a professional dialogue Declines tasks that exceed own competences Exhibits knowledge about when it is necessary to switch from Plan A to Plan B Departs follow a structured procedure when it is necessary to act differently Uses a systematic approach in prioritizing tasks Works on more than one task at a time when required Knows guidelines for hygiene, treatment regimes, documentation requirements, etc Communicates assessments and observations that are relevant for team members
Is inattentive and not concentrated when updating information about anaesthesia and surgery Does not adapt the anaesthesia if changes are introduced in the surgical plan
Anticipating and thinking ahead Decision making
Identifying options Assessing and weighing up options Reassessing decisions
Task management
Planning Setting priorities Making use of resources Maintaining standards
Team working
Exchanging information
Assessing roles and competences Coordinating activities Displaying authority and strength Exhibiting team behaviour and support for members of the team
Clarifies what the anaesthesia and operation teams expect of each other in carrying out the task Is flexible and helpful across specialization boundaries when the situation permits Clearly expresses disapproval to the team if safety is threatened Is accommodating and responsive
The wording in the heading of the elements ‘planning’, ‘setting priorities’, ‘making use of resources’, and ‘maintaining standards’ in the task management category were changed to emphasize a nonleading role in the overall task management. Finally, the wording in the heading of the elements ‘assessing roles and competences’, ‘coordinating activities’, displaying authority and strength’, and ‘exhibiting team behaviour and support for members of the team’ in the category of team working describes the role of nurse anaesthetists as a subordinate member of the team, not the leader.
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Fails to consider potential problems associated with small details that may herald problems Is not open to input for decisions Does not exhibit awareness of own limitations Does not assess whether the plan is proceeding as anticipated Departs from a systematic procedure without giving reasons for this Allows him/herself to be distracted when prioritizing tasks Does not work parallel with the team on carrying out tasks Fails to follow guidelines, and does not explain departures from them Does not communicate or warn about problems and thus fails to make the seriousness of the situation clear for team members Does not attune to what the others do and will do Does not coordinate own or others’ tasks Communicates or argues unprofessionally when facing problems in carrying out tasks Does not respect the fields of work and responsibility of other team members
In the discussion section, the basis for these changes will be presented in more detail. Table 3 shows the N-ANTS system, consisting of four categories, 15 underlying elements, for which one good and one poor example are given – the full version of N-ANTS is available as a user guide.‡ The two cognitive categories – situation awareness and decision making – are presented before the social categories of task management and team working to ‡http://www.regionh.dk/dims/menu/Forskning/NonTechnical+Skills/N-ANTS.htm [Accessed 15 January 2014]
Nurse Anaesthetists’ Non-Technical Skills
emphasize that social aspects of performance feed on essential cognitive skills.
Discussion The adaptation of ANTS to describe the NTS required for the nurse anaesthetists resulted in a behavioural marker system for nurse anaesthetists’ NTS in the OR, called N-ANTS. To the best of our knowledge, this is the first tool thoroughly describing the non-technical skills of nurse anaesthetists. The N-ANTS system comprises a three-level hierarchy of categories, elements, and behavioural markers. At the highest level, the tool has four main skill categories: situation awareness, decision making, task management, and team working. The categories overlap to a certain degree. One example is the marker ‘assesses and communicates decisions on the basis of knowledge of advantages and disadvantages’, which could be placed in the teamworking category, as well as in the decision-making category. Overall, N-ANTS address many of the same key NTS required for anaesthesiologists as represented in ANTS. Those similarities are plausible given the overlap in tasks of nurse anaesthetists and anaesthesiologists: providing anaesthesia. The differences in the behavioural markers may reflect the roles, tasks, and competence of the nurse anaesthetists that do differ compared to anaesthesiologists. These are discussed in more detail in the following: The nurse anaesthetists are not allowed to diagnose the patient. They use only medication needed to induce and maintain anaesthesia. The nurse anaesthetist always needs to monitor when her or his competence is not sufficient for the task at hand and call the anaesthesiologist if needed. Several of the behavioural markers in N-ANTS in the category of decision making reflect this: ‘asks for help when in doubt or uncertain about decisions’ and ‘declines tasks that exceed own competence’. Furthermore, nurse anaesthetists have less leadership responsibility than anaesthesiologists. This is reflected in N-ANTS with behavioural markers such as ‘identifies own and team members’ resources, so the task is carried out optimally’ under the element ‘making use of resources’ in the task management category and ‘gets team members to be receptive for input’, under the element ‘displaying authority and strength’ in the team-working category. The behavioural markers in the decision-making category indicate the specific role of the nurse anaesthetist in the anaesthesia team. Under the element
‘assessing and weighing up options’, the marker ‘assesses and communicates decisions on the basis of knowledge of advantages and disadvantages’ indicates that the nurse anaesthetist participates in the decision-making process. The anaesthesiologist has the overall responsibility for case planning and medical assessments of the patient, and might oversee several ORs at the same time. Therefore, he or she is dependent on the nurse anaesthetist’s ability to stay focused and to allocate attention to cues that might evolve subtly.16 Bringing this continuous situation awareness into the decision making makes the nurse anaesthetist a co-decision maker. The differences between N-ANTS and ANTS may also be related to differences in professional and/or national culture. In Denmark the power distance is low.17,18 Consequently, nurses may find it relatively easy to speak up to the team when in doubt or having concerns.17 The behavioural marker ‘clearly expresses approval or disapproval to the team if safety is threatened’ within the team-working category is one example of this. This finding is in agreement with Rabøl et al,17 who also identified the perception of a flat hierarchy, which allows everyone to speak up in Denmark. Several studies have concluded that hierarchy influences values in the workplace and that this varies across national cultures.13,18 The differences over time in patient safety culture may also provide an explanation of the differences between the systems. N-ANTS was developed 10 years later than ANTS and the organizational and professional culture may have changed during this period, reflecting new standards for acceptable behaviours.
Strengths and limitations Focus groups were chosen to collect as much information as possible without potentially influencing how the task was performed.19 Focus groups were chosen because we hoped that participants would inspire each other and provide a broad coverage of NTS. One challenge in the cognitive categories of situation awareness and decision making is the assumption that mental processes are always analytical, purely rational, and can be described verbally.20 The total number of participants was small, and it can be questioned whether saturation was obtained. However, 12 clinical educators refined the prototype. The final feedback round (Step 3) did not result in changes.
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In this study, as opposed to the original ANTS study, we included the perspectives of the full OR team to broaden the perspective of nurse anaesthetists’ NTS since the NTS of one team member influence the task management of others.1 Various studies have documented differences of opinions regarding the perceived quality of teamwork in OR teams.21,22 By expanding the overall understanding of what safe anaesthetic behaviour is, there is a risk, however, that we have overemphasized the perspectives of the collaborating team members. It may be argued that composing mixed focus groups might have captured more inter-professional aspects such as different attitudes across professions. However, the scope of the study was to achieve a broad description of nurse anaesthetist behaviours rather than exploring differences of opinion – and we therefore consider the chosen group composition adequate for the purpose. Our decision to present the translated ANTS categories to the focus group may have generated a bias. Our method might have more readily resulted in data supportive of the initial framework rather than non-supportive. Given the similarities in the task (providing anaesthesia) however, it seemed reasonable to build on the previous extensive development work behind ANTS. Furthermore, using ANTS as a starting point may have blinded the research group to other aspects of nurse anaesthetists’ NTS. A thorough task analysis may have captured new or other aspects and concepts. Not all behavioural markers present the de facto standard for a mature safety culture. ‘Works on more than one task at a time when required’ and ‘does not follow a structured procedure when it is necessary to act differently’ are two such behaviours. Both markers mirror clinical reality in which a trade-off between efficiency and thoroughness is often required.23 Revisions of N-ANTS may become necessary at a later point in time to adjust for changes such as improved human factor’s knowledge. The interviews were conducted in a single university hospital in Denmark. However, we presented and discussed the first edition of N-ANTS with regional subject matter experts. It might not be fully representative, but we suggest that the N-ANTS system could be used initially for formative assessment in the clinical setting in all the regions of Denmark.
Perspectives The N-ANTS behavioural marker system has the potential to facilitate learning and assessment for
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nurse anaesthetists’ NTS during intra-operative cases. The system allows educators to provide feedback on the strengths and weaknesses of the participants’ NTS and in this way enable them to reflect on their own NTS. Complementary to Danish workplace-based assessment tools such as competence cards,11,12 N-ANTS has the potential to help trainees and educators structure training, assess competence, and provide feedback. Our study adds to existing scientific knowledge by providing a framework for the description of the behaviours of nurse anaesthetists in the OR. This is necessary in order to be able to make reliable and valid assessments of nurse anaesthetists’ NTS, and it provides a tool that can be used to evaluate potential training interventions. Training of educators in using the tool will be necessary to obtain the best result.†24 When adapting tools for other countries, cultural differences at the organizational, professional or national level should be taken into account.† Cultures similar to the Danish culture are found within Scandinavia, and N-ANTS may need only a few adjustments in order to be used in these countries. It will remain to be investigated further what differences in tasks, roles, responsibilities, and culture would require a further adaptation of N-ANTS.
Conclusion A behavioural marker system, N-ANTS, for nurse anaesthetists was adapted from the behavioural marker system, ANTS, for anaesthesiologists. The necessity for the modification was explained by differences in tasks, roles, and responsibilities of Danish nurse anaesthetists as opposed to Scottish anaesthesiologists. National cultures may also have an influence on the needs for adaptation. Conflicts of interest: Authors declare no conflicts of interest. Funding: None.
References 1. Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, Bohnen J, Orser B, Doran D, Grober E. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care 2004; 13: 330–4. 2. Flin R, Maran N. Identifying and training non-technical skills for teams in acute medicine. Qual Saf Health Care 2004; 13: i80–4. 3. Flin R, Patey R, Glavin R, Maran N. Anaesthetists’ nontechnical skills. Br J Anaesth 2010; 105: 38–44. 4. Rabøl LI, Andersen ML, Østergaard D, Bjørn B, Lilja B, Mogensen T. Descriptions of verbal communication errors
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5. 6. 7. 8. 9.
10. 11.
12.
13. 14.
15.
between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. BMJ Qual Saf 2011; 20: 268–74. Flin R, Patey R. Improving patient safety through training in non-technical skills. Br Med J 2009; 339: b3595. Flin R, Patey R. Non-technical skills for anaesthetists: developing and applying ANTS. Best Pract Res Clin Anaesthesiol 2011; 25: 215–27. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R. Anaesthetists’ Non-Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth 2003; 90: 580–8. Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D. Development of a rating system for surgeons’ non-technical skills. Med Educ 2006; 40: 1098–104. Mitchell L, Flin R, Yule S, Mitchell J, Coutts K, Youngson G. Development of a behavioural marker system for scrub practitioners’ non-technical skills (SPLINTS system). J Eval Clin Pract 2013; 19: 317–23. Rutherford JS, Flin R, Mitchell L. Teamwork, communication, and anaesthetic assistance in Scotland. Br J Anaesth 2012; 109: 21–6. Ringsted C, Østergaard D, Scherpbier A. Embracing the new paradigm of assessment in residency training. An assessment programme for 1st year residency training in anaesthesiology. Med Teach 2003; 25: 54–62. Ringsted C, Østergaard D, Van der Vleuten CPM. Implementation of a formal in-training assessment programme in anaesthesiology and preliminary results of acceptability. Acta Anaesthesiol Scand 2003; 47: 1196–203. Cosby KS, Croskerry P. Profiles in patient safety: authority gradients in medical error. Acad Emerg Med 2004; 11: 1341–5. Spanager L, Lyk-Jensen HT, Dieckmann P, Wettergren A, Rosenberg J, Østergaard D. Customization of a tool to assess Danish surgeons’ non-technical skills in the operating room. Dan Med J 2012; 11: A4526. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005; 15: 1277–88.
16. Gaba DM, Howard SK, Small SD. Situation awareness in anesthesiology. Hum Factors 1995; 37: 20–31. 17. Rabøl LI, McPhail MA, Østergaard D, Andersen HB, Mogensen T. Promoters and barriers in hospital team communication. A focus group study. J Commun Healthc 2012; 5: 129–39. 18. Hofstede G. Culture’s consequences, comparing values, behaviors, institutions and organization across nations. Thousand Oaks, CA: Sage Publications, 2001. 19. Nisbett RE, Wilson TD. Telling more than we know. Verbal reports on mental processes. Psychol Rev 1977; 84: 231–59. 20. Kahneman D. Thinking, fast and slow. Toronto, Ontario: Doubleday, 2011. 21. Schaefer HG, Helmreich RL, Scheidegger D. Safety in the operating theatre – Part 1: interpersonal relationships and team performance. Cur Anaesth Critic Care 1995; 6: 48–53. 22. Reader TW, Flin R, Mearns K, Cuthbertson BH. Interdisciplinary communication in the intensive care unit. Br J Anaesth 2007; 98: 347–52. 23. Hollnagel E. The ETTO principle: efficiency-thoroughness trade-off: why things that go right sometimes go wrong. Aldershot: Ashgate Publishing, Ltd., 2009. 24. Hull L, Arora S, Symons NR, Jalil R, Darzi A, Vincent C, Sevdalis N. Training faculty in nontechnical skill assessment. National guidelines on program requirements. Ann Surg 2013; 258: 370–5.
Address: Helle Teglgaard Lyk-Jensen Danish Institute for Medical Simulation Centre for Human Resources Herlev Hospital 75 Herlev Ringvej, Herlev, Denmark. e-mail: [email protected]
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