Identification of Critical Non-Technical Skills to Optimize Austere Resuscitative Surgical Team Training

Many adverse events in health care can be attributed to lapses in communication, situational awareness, or decision-making, collectively known as non-technical skills (NTS). Research on military interprofessional health care team (MIHT) research and care in low- and middle-income countries (LMICs) demonstrates that teams in these environments with limited or variable resources demonstrate specific non-technical behaviors to overcome challenges unique to these clinical contexts. However, behaviors specific to austere and resuscitative and surgical care (ARSC) teams are not well-described in the literature to guide curriculum development or team training. We sought to identify role-specific non-technical behaviors observed during high-fidelity ARSC simulations and anchor these to validated NTS assessment rubrics, with the ultimate goal of creating a conceptual framework for both instructors and students and a shared understanding of role-specific optimal non-technical performance.

The ground surgical team (GST) is the Air Force's conventional 6-person ARSC. Students attending GST training complete a total of 6 high-fidelity simulations which closely replicate the austere environment. The non-technical performance for each team member was evaluated during 4 of these simulations utilizing validated rubrics including non-technical skills for surgeons (NOTSS), anesthetists' non-technical skills (ANTS), and scrub practitioners' non-technical skills (SPLINTS). Instructors kept field notes including descriptions of student behaviors justifying each score. After 17 months of evaluation, field notes were collated and role- and ARSC-specific examples of optimal and poor performance were identified and mapped onto subcategories of assessment rubrics.

A total of 360 individual NTS evaluations were completed for 15 teams (6 individuals per team) across 60 simulations. Themes of effective and ineffective behaviors were identified for each team role and categorized within the framework of the role-specific rubric.

Austere surgical environments are substantially different than non-deployed clinical spaces. Although important in all clinical contexts, optimal non-technical performance is even more crucial for ARSC personnel. Mapping ARSC- and role-specific behaviors onto validated non-technical performance rubrics creates a scaffold for curriculum development and consistent performance assessment by cadre. The behaviors identified can serve as an important educational tool while preparing teams for this environment. Further research will evaluate the impact of non-technical skills training on team behavior and determine the extent to which these findings are applicable to other ARSC teams across the military.