key: cord-0904360-y0r8iqmb
authors: Yule, Steven; Smink, Douglas S.
title: Nontechnical Skill Countermeasures for Pandemic Response
date: 2020-05-22
journal: Ann Surg
DOI: 10.1097/sla.0000000000004107
sha: 5f62c20a2d0641f135dd95ac0bc26df1d8b57c32
doc_id: 904360
cord_uid: y0r8iqmb

nan

potential risks to both staff and patients, and has the potential to compromise healthcare systems. During a pandemic response, surgeons are likely to work in large and dynamic teams, often with people they have never met before and in high demand, variableresource settings. Optimizing team performance via enhanced nontechnical skills can result in improved decision making, increased efficiency, higher adherence to safety standards, greater resilience, and better outcomes. 1 In this Surgical Perspective, we describe the specific behavioral and nontechnical skills for medical event management that have been shown to reduce performance errors and save lives in healthcare settings, and suggest best practices for surgeons with specific reference to a pandemic response. Nontechnical skills are important both during a pandemic response and in rebuilding capacity for surgical care after the acute phase has passed.

Nontechnical skills are the cognitive and social skills that characterize high performing individuals and teams. They enable team members to exchange information about their perceptions of ongoing situations (mental models) to support error detection, share critical information, and generate a team-level, shared mental model of understanding. Specific frameworks for crisis management 2 and nontechnical skills 3 exist in the literature. Arguably, the greatest magnitude of impact that is available to surgeons during a pandemic is due to their nontechnical skills; how they gather and use information, leverage shared experience at critical moments, galvanize team members to act, and inspire others to question and speak up when they feel something is not safe. In surgery, the nontechnical skills for surgeons system delineates the essential nontechnical competencies for effective team dynamics to handle medical scenarios that present danger to patients and staff. 4 These skills are broadly defined as situation awareness, decision making, team communication, and leadership.

Arguably the most critical nontechnical skill, situation awareness, is required for accurate decision-making, timely communication, and appropriate leadership. For the operative environment, situation awareness is defined as: ''Developing and maintaining a dynamic awareness of the situation in the operating room (OR), based on assembling data from the environment (patient, team, time, displays, equipment); understanding what they mean, and thinking ahead about what may happen next.'' 5 Situation awareness comprises three distinct levels:

1. Gathering information 2. Interpreting the information (based on experience); and 3. Projecting and anticipating future states During the COVID-19 crisis, a surgeon may be asked to evaluate a patient with an acute abdomen, and a fever and cough. In addition to diagnosing the patient's surgical disease, the surgeon will need to be aware of the incidence of disease in their region and the COVID-19 testing available at their hospital. They will need to work with emergency physicians and surgical team members to gather the relevant clinical information, interpret the test results and symptoms, and project how the patient will tolerate operative or nonoperative management.

Check back important information Provide periodic status updates Share what will likely happen in the near future so others can plan Engage the team in ''mental simulations'' regarding what may happen in the future

Surgical decision making can be defined as ''Skills for diagnosing a situation and reaching a judgement to choose an appropriate course of action.'' Classical models of decision-making propose that this is an analytical process: the relative features of options are compared in turn and an optimal course of action is selected; however, this is an effortful process, requiring both experience and time to come to an acceptable solution. Rule-based decision making may be helpful during pandemic response and used effectively by novices and experts alike; once a situation has been detected, a relevant rule can be applied, either by following national guidelines or local protocols. Deciding what personal protective equipment (PPE) to wear during an aerosol-generating procedure to reduce the risk of staff exposure is one example, in which the surgeon follows the rules developed at their institution. Experts however, tend to use a more heuristic-based style called recognition-primed decision-making 6 ; a type of pattern matching used to make satisfactory decisions under times of high stress or timepressure. As pandemic situations are rapidly changing and uncertain, there are not always prior experiences to work from so surgeons may use creative decision making when a totally novel solution is required to treat patients, protect staff, or develop new processes of care.

Gather sufficient data to make decisions Do not delay to have the complete picture Offer potential solutions Apply rule-based decision making where appropriate. When not practical, recognition-primed decision-making works well for experts

Introduce yourself and role to other team members Be clear and concise Express authentic curiosity Use names if you can and eye contact if culturally acceptable LEADERSHIP In organizations exposed to hazards, there is widespread recognition that leadership is essential for efficient and safe team performance. During a pandemic response, surgeons who are usually leaders may need to work in teams alongside or under direction of their critical care colleagues. Those who would normally be used to autonomous practice can contribute by demonstrating shared leadership or assuming followership 8 in certain situations, skills that are also explicit in astronaut training. A core function of leadership is demonstrating the standards that are expected from other team members. A key failing of leaders is to emphasize the importance of safety but then implicitly undermine those sentiments by breaking rules and not adhering to high standards of ethical and professional conduct themselves. For surgeons, examples of this are adhering to guidelines regarding antibiotic use, respecting sterility protocols, and being transparent regarding errors, even during non-normal situations such as pandemic response. Advocating for PPE and vital equipment for team members and adhering to local guidelines are essential. In addition, surgeons exert leadership by coping with pressure and by keeping composure even in the most difficult of times.

Set expectations on roles, culture, and norms of team behavior to unite the team Listen to concerns of others and validate them Be aware of nonverbal communication Actively engage in conflict resolution

Resource limitations may affect team dynamics and complicate medical management in a pandemic. Teams will need to operate autonomously and make effective medical decisions based on ambiguous information, variable medical knowledge, and limited resources. Typically, most surgeons are accustomed to practicing with ample resources. In a pandemic response, however, resources such as PPE, ventilators, hospital staff, ORs, and inpatient beds may be restricted. Supplies of these resources may fluctuate by day or within hospitals in the same system or region. Surgeons can benefit from work in limited-resource settings to understand how to deliver safe and effective care in those situations. 9 In Rwanda, a number of contextual challenges to safe surgery have been identified that surgeons and OR teams have developed adaptive responses to, including variability of resources, staff, communications, and systems. Table 1 shows these challenges and the nontechnical skill countermeasures that may be useful to deploy during a pandemic response.

COVID-19 has presented as an acute global health emergency, with an unimaginable toll of human suffering and downstream economic and social impact that will likely last for many years. Behavioral and psychological science plays an important role in supporting the performance, health, and safety of healthcare teams. 10 The contextual challenges that pandemics bring, including constraints on resource, staff, communications, and systems at a time of most acute need highlights the importance of effective team dynamics and nontechnical skills. In this perspective, we offered specific behaviors and best practices that could be useful countermeasures for surgeons and all frontline workers both during a Refers to occasional deficiency in both number of available staff and sufficiency of provider training and skill mix

Knowing your team and their skill mix Predicting staff availability and potential changes during a case Being flexible Communication variability

Refers to multiple languages spoken in the operating room, variation in degrees of proficiency, and communication styles of different providers

Association between implementation of a medical team training program and surgical mortality

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Training tools for nontechnical skills for surgeons-a systematic review

Construct and criterion validity testing of the non-technical skills for surgeons (NOTSS) behaviour assessment tool using videos of simulated operations

Toward a theory of situation awareness in dynamic systems

Naturalistic decision making

Communication in interdisciplinary teams: exploring closed-loop communication during in situ trauma team training

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Contextual challenges to safe surgery in a resource-limited setting: a multicenter, multiprofessional qualitative study

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