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Basic concepts for crew resource management and non-technical skills

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In this paper, we explain the conceptual background to non-technical skills and show how they can influence job performance in anaesthesia. We then describe the taxonomy of anaesthetists' non-technical skills (ANTS) and related systems, such as ANTS-AP for anaesthetic practitioners. We discuss the training courses that have been designed to teach these non-technical skills, which are called crew resource management (CRM), crisis resource management (CRM) or crisis avoidance resource management (CARMA). Finally, we discuss the application of non-technical skills assessment systems.

Introduction

Notwithstanding clinical and technical advances in anaesthesia, there are still risks for patients. One notable example is the English case of Mrs Elaine Bromiley, a 37-year-old mother of two young children, who died in April 2005 as a result of a problem in maintaining her airway during elective endoscopic sinus surgery, in a private clinic. Analyses in industry have indicated that human error can be a significant component of accident causation [1], and sometimes a key component is a deficiency in the non-technical skill (NTS) of operational staff. What is relevant about Elaine Bromiley's case is what occurred in the UK as a result of her death. Martin Bromiley, who was her husband, is an airline pilot. In his world of aviation, accidents are taken very seriously and that means they are carefully and systematically investigated by experts to discover not only the technical but also the non-technical causes. He assumed that his wife's unexpected and tragic death would be subjected to this level of scrutiny but he was told unless he pursued a legal case, that would not normally occur. He managed to instigate an independent inquiry by a senior anaesthetist, which revealed a number of deficiencies in NTS during the accident trajectory [2]. He then asked if there was a national clinical human factors group that can advise health-care organisations on the latest developments for NTS training and other human factors interventions. However, in the world of health care, no such group existed. Moreover, very little training in human factors or NTS was provided to health-care staff, unlike the other safety-critical industries.

Therefore, Martin Bromiley set about addressing these deficiencies, by establishing in 2007 the first Clinical Human Factors Group for clinicians and human factors specialists (www.chfg.org). His efforts are now leading to an enhanced awareness of the importance of the role of human factors in health care and patient safety. Human factors science essentially studies the variables that can influence human behaviour in relation to task execution. In a work context, this means the environmental, organisational and job factors, as well as the physiological and psychological characteristics that influence behaviour at work. The largest of the professional organisations is the Human Factors and Ergonomics Society, based in the USA (www.hfes.org), and its members come from various disciplines, such as ergonomics, psychology and engineering, and it hosts specialist meetings on health care. There are similar organisations in other countries.

There are many important applications of human factors science in anaesthesia [3]. One important relevant area concerns the behaviour of anaesthetists in relation to their NTS. In this paper, we explain the conceptual background to non-technical skills and show how they can influence job performance in anaesthesia. We describe the taxonomy of anaesthetists' non-technical skills (ANTS) and ANTS-AP for anaesthetic practitioners, as well as the training courses that have been designed to teach these skills. This type of course can be labelled crew resource management (CRM), crisis resource management (CRM) or crisis avoidance resource management (CARMA). Finally, we discuss the development and application of NTS assessment systems.

The term ‘non-technical skills’ was first used by the European civil aviation regulator in relation to airline pilots' behaviour on the flight deck. NTS can be defined as “the cognitive, social and personal resource skills that complement technical skills, and contribute to safe and efficient task performance” (p. 1) [4]. In essence, they enhance workers' technical skills. Poor NTS can increase the chance of error, which in turn can increase the chance of an adverse event. Good NTS (e.g., high vigilance, clear communication and team coordination) can reduce the likelihood of error and consequently of accidents. Analysis of incidents, as well as studies of behaviour during routine work (task analysis), can reveal which workplace behaviours positively or negatively influence job performance and adverse events. A recent study of difficult airway management cases showed how a human factors interview protocol can help to extract additional information from anaesthetists who have experienced these cases [5]. The findings underline the importance of situation awareness, as well as some of the social factors that can impede effective performance. This type of knowledge can help to inform the design of NTS training and competence assessment systems.

The aviation industry had realised by 1980, from a series of accidents with no primary technical failure, that maintaining high standards of safety was going to require attention to the pilots' NTS and their relation to safe and unsafe behaviours during flight operations [6]. Experienced pilots were interviewed to discover which behaviours constituted ‘good airmanship’. The aviation psychologists conducted experiments in flight deck simulators and reanalysed accident reports, in order to determine which skill components either contributed to accidents or were effective in preventing adverse events. Having identified these skills, crew resource management (CRM) training courses were designed for pilots to increase understanding of the importance of particular behaviours for safety and to provide opportunities to practise the skills in exercises and simulated flights. In 1989, a British Midland plane crashed at Kegworth after the pilots mistakenly shut off the working engine when the other was on fire. This was such a strong demonstration that human error and teamwork failures were contributing to fatal accidents that the UK Civil Aviation Authority took the view that CRM had to be introduced, even though at the time there were only a few scientific studies on its effectiveness. By the 1990s, CRM training for pilots had been widely introduced in aviation, driven by national regulators and the influence of the International Civil Aviation Organisation.

In aviation, pilots are taught and examined in the psychological and physiological factors influencing task performance from the start of their training (human performance limitations courses). They then undertake crew resource management training provided by their employing airline on a regular basis. Consequently, they are very familiar with the cognitive and social skills required for safe and efficient flight operations, as well as how these skills can be influenced by stress and fatigue.

It was not only in aviation where cognitive and social skills were found to contribute to workplace safety; studies of accidents in many other sectors of industry began to reveal the same patterns [4]. Today, CRM (i.e., NTS) training is now widely used for different occupations as a form of safety management and skills development, as a recent report by the Energy Institute (2014) describes [7]. Ab initio courses in medical schools are beginning to introduce the concept of NTS and explain their importance for patient safety. At a number of Scottish medical schools, there are now psychologists employed to lecture on human factors and patient safety and these topics are being embedded throughout the 5-year curriculum [8].

The main categories of NTS are as follows:

  • Situation awareness

  • Decision-making

  • Teamwork

  • Leadership

  • Coping with stress

  • Managing fatigue

These skills are not unfamiliar to anaesthetists but they have not traditionally been taught as part of clinical training. An increasing body of evidence suggests that they are required by anaesthetists to maintain safe performance [9]. Human error cannot be eliminated, but efforts can be made to minimise, catch and mitigate errors by ensuring that people have appropriate NTS to cope with the risks and demands of their work. In the next section, the main categories of NTS and their application to anaesthesia are briefly described.

Section snippets

Situation awareness

Situation awareness is essentially a continuous monitoring of the task, noticing what is going on and detecting any changes in the environment. Almost all aspects of the anaesthetists' intraoperative tasks rely heavily on their vigilance and situation awareness skills. The critical role of situation awareness for anaesthetists has recently been reviewed with implications examined for practice, training, measurement and equipment design [10]. Fioratou et al. [11] pointed out that the

Identifying ANTS

The specific NTS required for a particular occupation need to be determined by a systematic process of identification based on task analysis. While the main skill categories (e.g., decision-making or leadership) are similar across professions, the component elements and examples of good and poor behaviours need to be carefully specified for a given profession and task set. These can be distinctive and clearly vary from one technical setting to another. This is why it is inadvisable to use an

Anaesthetists' non-technical skills

Having identified the basic set of NTS for the practice of safe delivery of anaesthesia (ANTS) and having structured these into a taxonomy, the next stage was to design and test a behavioural rating tool. A four-point scale for ANTS was devised for rating observed behaviours with regard to the elements and categories. The descriptors on the rating scale not only reflect performance levels but also emphasise their relevance for patient safety. The ANTS ratings can be made where anaesthesia is

Training ANTS

Anaesthesia has been at the forefront of developments to train NTS in medicine with Gaba and colleagues designing the first anaesthesia crisis resource management (ACRM) courses based on aviation crew resource management [42]; see Lighthall for recent review [43]. In addition to introducing basic theories of human performance limitation, the original course focused on some ‘key principles’ including the following:

  • Anticipate and plan

  • Demonstrate leadership

  • Utilise all available resources

  • Use

Assessing anaesthetists' NTS with ANTS

With regard to assessment, ANTS has been used in practice in hospital anaesthetic departments, as well as in simulation centres, which is typically for formative purposes [51]. Rall and Gaba [54, p3088] considered the ANTS system and concluded, “On the whole, the ANTS system appears to be a useful tool to further enhance assessment of nontechnical skills in anaesthesia, and its careful derivation from a current system of nontechnical assessment in aviation (NOTECHS) may allow for some

Practical application of ANTS

Training in identification and use of NTS behavioural marker systems is key to effective utilisation. Regular use, training and calibration are necessary to ensure high inter-rater reliability where the tool might be used for summative assessment. However, the introduction of NTS rating systems in clinical practice may be assisted by concentrating on an individual category (such as situation awareness or task management) for the duration of a case. Alternatively, breaking the task down into

Summary/future developments

NTS are the cognitive and social skills set that support the application of knowledge and practical skills to safe anaesthetic practice. These skills are not new and are observable in expert practitioners; however, until recently, such skills were not explicitly described or discussed. Investigation of adverse events often highlights the important part played by failures in NTS of individuals and within teams.

Over the last decade, the explicit description of NTS through taxonomies such as ANTS,

Conflict of interest

The authors have no conflicts of interest to declare.

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