Development of a rating system for surgeons' non-technical skills

Analyses of adverse events in surgery reveal that many underlying causes are behavioural, such as communication failure, rather than technical. Non-technical (i.e. cognitive and interpersonal) skills are not addressed explicitly in surgical training. However, surgeons need to demonstrate these skills, which underpin their technical excellence, to maximise patient safety in the operating theatre. This paper describes the method used to identify surgeons' non-technical skills, and the development of a skills taxonomy and behavioural rating system to structure observation and feedback in surgical training.

Cognitive task analyses (critical incident interviews) were conducted with 27 consultant surgeons in general, cardiac and orthopaedic surgery. The interviews were coded and a multidisciplinary group of surgeons and psychologists used an iterative process to develop a skills taxonomy. This was supported by data gathered from an attitude survey, literature review, analysis of surgical mortality reports and observations in theatre.

Five categories of non-technical skills were identified, including situation awareness, decision making, task management, leadership and communication and teamwork. This provided a structure for a prototype skill taxonomy (v1.1), which comprised 14 non-technical skill elements. Observable behaviours (markers) indicative of good and poor performance were developed for each element by 16 consultant surgeons to form a prototype behaviour rating system.

The prototype skills taxonomy and behaviour rating system are grounded empirically in surgery. The reliability of the system is currently being tested using standardised scenarios. If this evaluation proves successful, the system could be used to structure feedback and guide non-technical skills training.