The Utility of Non-Technical Skills for Surgeons (NOTSS) as an Assessment Tool in Surgical Training

Research indicates that poor communication accounts for almost half of errors made during surgery. Despite this, formal training in the cognitive and interpersonal aspects of operating is lacking in the surgical curriculum. Non-Technical Skills for Surgeons (NOTSS) is a behaviour rating system designed to evaluate surgeons on their non-technical skills in the operating room. This rating system splits intraoperative non-technical skills into four domains: situation awareness, decision-making, communication and teamwork, and leadership. Assessors score surgical trainees on each of these domains, using these ratings to inform a structured debrief. NOTSS has been shown to have a robust construct, content and concurrent validity, accurately predicting the risk of adverse events in surgery. Its reliability is threatened by considerable inter-rater variance, particularly in the cognitive domains of the taxonomy, which makes it difficult to defend its use as a summative assessment, but it is relatively procedure-independent as an assessment tool. The feasibility of incorporating NOTSS into the surgical curriculum depends on the viability and financial cost of training assessors across the United Kingdom (UK) in its use, which is currently unknown. It has been received positively by assessors and trainees alike as a formative tool to facilitate a deeper understanding of non-technical skills in theatre, but its acceptability as a barrier to progression has not been examined. Promisingly, a small study has demonstrated NOTSS assessments to have a positive impact on trainees' non-technical proficiency in surgery, but further research is warranted before any definitive conclusions can be drawn about its educational value.