Interventions to Improve Nontechnical Skills in Surgery: A Systematic Review And Meta-Analysis

Many surgical adverse events are due to failures in nontechnical skills. Improving nontechnical skills has become a priority for surgical training organizations, yet there is little evidence to guide improvement activities. aim of this review was to investigate the effectiveness of interventions to improve surgeon nontechnical skills overall and by individual domains.

A systematic search of Embase, Med-line (including PubMed), and PsycINFO were conducted using a predefined search strategy. Randomized controlled trials (RCTs), non-RCTs, and pre vs post intervention cohort studies from data-base inception to February 3, 2025, reporting change in surgeon nontechnical skills in the context of an improvement intervention were included. Two independent reviewers screened all articles first by title and abstract, then by full text. All disagreements were resolved by a third independent reviewer. Data was extracted by 2 independent reviewers in accordance with a predefined data extraction template in accordance with both PRISMA and MOOSE guidelines. Any disagreements were resolved by a third reviewer. Data was pooled using a random-effects model. Main outcome for meta-analysis was change in overall nontechnical skills measured either pre vs post intervention or control vs intervention. Secondary outcomes included change in nontechnical skill domains explored through narrative review.

About 2682 studies were identified, after screening 65 were included comprised of 20 RCT's and 45 non-RCT's. Meta analysis demonstrated statistically significant association between nontechnical skill improvement and 4 intervention types: practice with debrief/feedback (SMD:1.80, 95%CI: 1.18,2.41), coaching (SMD:0.82, 95%CI: 0.25,1.40), checklists/standardized procedures (SMD:0.53, 95%CI: 0.12, 0.94), and didactic/workshop (SMD:1.26, 95%CI:0.49,2.04). Practice with debrief/feedback, coaching, and curriculum interventions demonstrated a trend towards improving individual NTS domains.

The results of this meta-analysis provide evidence of the effectiveness of several intervention types to improve surgical nontechnical skill both overall and by individual domain. These effective interventions can be used to guide future non- technical skill improvement activities in real-world surgical settings.