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It is well recognised that a significant proportion of errors involving trainee doctors result from failures of non-technical skills (NTS),1 which occur at least as frequently as knowledge and technical errors.2 Regardless of background, all trainees need generic skills of leadership, decision-making, team-working and resource management.3 It might, therefore, be expected that curricula for different specialties would use similar definitions and teaching methods to specify NTS standards. We have performed an analysis of medical training curricula to determine the extent to which different medical specialties set training objectives in NTS, and to seek trends in the prominence with which these skills feature.
All hospital-based medical, surgical and critical-care specialties were obtained in mid-2013, along with each curriculum's immediate predecessor (where available). The curricula were initially searched for the core keywords ‘non-technical skills’, ‘situational awareness’ and ‘human factors’, as well as a list of secondary keywords (generated by a modified Delphi process) grouped under headings ‘task management’, ‘team working’, ‘situational awareness’ and ‘decision making’. The list was refined over two generations before consensus was reached. Each curriculum was analysed using NVivo V.10 (QSR International, Warrington, UK).
Curricula of 31 medical, 3 critical-care and 12 surgical specialties were reviewed comprising approximately two million words of text over 88 documents (see online supplementary appendix tables A1 and A2). NTS terms occurred infrequently across most of the examined texts, with most occurrences in anaesthesia, emergency medicine (EM) or intensive care medicine (table 1).
Only these critical-care specialties specify requirements for formal training in NTS, using methods including self-study, tutorials and simulation. NTS are generally described as both knowledge and behaviours requiring observation and assessment, including at professional examinations.4 The availability of a validated assessment tool in anaesthesia5 facilitates the delivery of such training.
No comparable training or assessment requirements exist in the curricula of medical and surgical specialties. Although well placed to train and assess NTS, simulation is seldom mentioned outside critical-care specialties, and almost exclusively recommended only for procedural skills training or resuscitation. NTS-related objectives, where specified, are generally considered knowledge skills and assessed accordingly.
Several medical curricula contained no relevant instances of any keywords. These curricula touched on aspects of NTS, but lacked in specific detail on learning objectives or assessment recommendations. For example, communication was considered only in the context of doctor–patient relationships, language skills or record-keeping. Safety was considered in terms of adherence to guidelines, evidence-based practice and continuing professional development. Understanding components of team-working is expected by many of these curricula, but it was generally unclear what the curriculum authors consider these components to be, or how they should be taught.
There is evidence that NTS training impacts patient safety in a wide range of clinical areas,6–8 but NTS learning objectives feature rarely outside critical-care specialties. Although, at first glance, human factors seem primarily of interest to practitioners dealing with the most acute situations, the principles are widely applicable, and have value in less urgent settings. Industrial data clearly show that human errors contribute to critical incidents in a breadth of circumstances,9 and although error frequency is higher when time and workload pressures increase,10 significant incidents still occur at lower operating tempos.11
It seems likely that most curricula are drafted assuming NTS can be acquired implicitly, for example, through the observation of suitable role models, rather than recognising a need for formalised training and assessment. This may be less desirable as self-assessment of NTS quality is unreliable,12 and the way objectives and assessments are set and measured has a motivational impact on learners.13 We suggest a need to move to explicit NTS teaching and assessment in all curricula.
There is a need for assessment tools to enable both trainee and assessor to objectively define acceptable standards. Validated systems exist in anaesthesia for NTS assessment, and comparable tools exist in surgery and EM, but there is a need to develop such taxonomies in other specialties. NTS are a behavioural system, and assessments must include an observational component: although retrospective assessments such as case-based discussions are often cited as assessment tools, it is unlikely that instruments designed to assess knowledge are appropriate for measuring NTS.
Many specialty programmes are recognising these needs at a local level; however, teaching and assessment can vary within and between institutions. A fundamental feature of multidisciplinary teams working in high-reliability organisations is that team members observe each other's practice and offer feedback on it. This requires each member of the team, regardless of professional background, to have a shared understanding of NTS.4 With such variability in training methods, the body of literature and educational materials generated by one specialty would at best be opaque, and at worst inaccessible, to another. This presents significant barriers to delivering multidisciplinary team-training.
We hope that this paper will spark a debate about the role perceived for NTS training within individual specialties, and how we can find commonalities around which to build quality training to enhance patient safety.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
- Data supplement 1 - Online tables
Contributors PRG was responsible for the design of the experiment, data collection and drafting of the manuscript. HH and EV have made important contributions and amendments to the drafting of the manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
Data sharing statement No additional unpublished data is available from this study.