“There was a 6% higher odds of death for all patients admitted in the week
following the first Wednesday in August than in the week before"
Non-Technical Skills for Junior
Doctors in Acute Care
Ed Mellanby, June 2013
Supervisors: Janet Skinner, Nikki Maran
Advisor: Ronnie Glavin
Co-researcher: Megan Hume
The next 30 minutes
• Introduction
• Why this project?
• Non Technical Skills
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Project Aims
Method
Results (so far)
Conclusions
Introduction
• Why this project?
Introduction
• 14,000 preventable deaths a year
Hogan H et al. Preventable deaths due to problems in care in English acute
hospitals. BMJ Qual Saf 2012.
Introduction
• 14,000 preventable deaths a year
• 70-80% attributed to ‘human factors’
Hogan H et al. Preventable deaths due to problems in care in English acute
hospitals. BMJ Qual Saf 2012.
Introduction
• 70-80% of errors due to ‘human factors’
• Same in:
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Aviation
Nuclear power industry
Oil industry
Military
Wiener E et al. Cockpit resource management: Academic Press, 1993:3-45
Introduction
Source:
http://www.economist.com/blogs/gulliver/2011/01/air_accidents
“If you were to take a flight every day, odds are
you would fly 14,000 years without being in an
accident,” IATA
Introduction
• What are Non-Technical Skills?
• ‘Cognitive, social and personal resource
skills that complement technical skills, and
contribute to safe and efficient task
performance’
Flin et al. Safety at the sharp end. 2008
VIDEO
Introduction
• What are Non-Technical Skills?
• ‘Cognitive, social and personal resource skills that
complement technical skills, and contribute to
safe and efficient task performance’
• What is a behavioural marker system?
Structure
3-Level Hierarchy
•Improved Non-technical Skills
•Increased Teamwork
•Reduced Operative Errors
•Reduced Non Operative Errors
Project Aims:
• Develop a behavioural marker system for
junior doctors
• What are the critical NTS and behaviours that are
associated with safe and effective performance?
Method
Identification of NTS
Develop prototype
marker
Evaluation of
prototype
Method
Identification of NTS
• Literature review
• 27 Interviews with junior doctors
• Critical Incident Technique
Critical Incident Technique
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Sweep 1- Uninterrupted description
Sweep 2- Filling in the gaps
Sweep 3- Expanding
Sweep 4- ‘What if’ queries
Flanagan J. The critical incident technique. Psychological Bulletin 1954
Analysis:
Transcribed Interviews (n=27)
Template Analysis of all interviews by 2 researchers using a priori themes
(included discussion of coding differences and any template additions)
Workshop of 6 'subject matter experts' refining template structure
Analysis of 6 interviews using refined template by 2 researchers
(included discussions of coding differences)
Analysis of all 26 interviews with refined template by 1 researcher
King N. Using templates in the thematic analysis of texts. 2004
Results
• 27 Semi-structured interviews completed
– 17 female, 10 male working in SE Scotland
– Graduating from 9 different Universities
– Working in 5 different hospitals across SE Scotland
– 1 to 1¾ hours long
Critical Incident Technique Interviews
“It was in my first two weeks of the job
and I got called to see this lady who
was extremely breathless and I
remember her saying to me “I can’t
breathe, I can’t breathe” and it was
horrible because I remember thinking
there’s nobody here, it’s just me and a
nurse and I just thought…..”
Prototype Framework
Category
Situation Awareness
Elements
Gathering Information
Pause to interpret information
Projection to future states
Decision Making
Generating Options
Balancing Options
Reviewing of Decisions
Getting the Job Done Prioritising (tasks and patients)
Applying Rules
Planning and Preparing
Teamwork
Speaking up
Establishing shared understanding
Establishing a team
Escalating Care
Communicating Seriousness of Situation
Identifying and utilising resources
Prototype Framework
Category
Situation Awareness
Elements
Gathering Information
Pause to interpret information
Projection to future states
Decision Making
Generating Options
Balancing Options
Reviewing of Decisions
Getting the Job Done Prioritising (tasks and patients)
Applying Rules
Planning and Preparing
Teamwork
Speaking up
Establishing shared understanding
Establishing a team
Escalating Care
Communicating Seriousness of Situation
Identifying and utilising resources
Situation Awareness
• Knowing what is going
on around you
• What?
• So What?
• Now What?
Whodunnit?!
Situation Awareness
Situation
Awareness
Gathering Information
Pause to interpret information
Projection to future states
Uses a structured
approach to assessment
Situation Awareness
Situation
Awareness
Gathering Information
Pause to interpret information
Projection to future states
Uses a structured
approach to assessment
“I think because there were so many other things going on,
making it difficult to go through it how I’d have liked to have
gone through it, so….at the same time there were two nurses
in the room as well, who were speaking at me, at the same
time and you know trying to add in, they were trying to add
extra information but perhaps that was distracting me a bit
from maintaining the structure as much as I would have liked. I
mean that skeleton is there, and I did eventually get enough
information to fill that out perhaps, although perhaps just not
in the ordered manner that I would have liked to.”
(FYDr2)
Situation Awareness
Situation
Awareness
Gathering Information
Pause to interpret information
Projection to future states
Uses a structured
approach to assessment
“And now when I go into the room independent of what the
problem is, with a much more structured way in my head, and I do
those things almost in the classical structured way….and do those
first, and I don’t let myself get sideways by my own panic, or even
the patient’s panic, and then I re-evaluate so it kind of prevents
the panic from happening.”
(FYDr4)
Situation Awareness
Situation
Awareness
Gathering Information
Pause to interpret information
Projection to future states
Pauses activities to put
together findings
Situation Awareness
Situation
Awareness
Gathering Information
Pause to interpret information
Projection to future states
Pauses activities to put
together findings
“then take another quick breath and have a think about
what you’ve found cause it’s easy sometimes to just forget,
like you listen to someone’s chest and then you forget what
you’ve heard or, especially if you’re tired or….so yeah take a
breath and think about things”
(FYDr18)
INPUT
Working Memory
Long Term Memory
• Knowledge
• Skills
• Experience
Distractions
Practical Procedures
Info. from nurse
Patient Condition
Flin et al. Safety at the sharp end. 200
Novice
Long Term Memory
INPUT
Working Memory
Distractions
Practical Procedures
• Knowledge
• Skills
• Experience
Info. from nurse
Patient Condition
Limited time
Stress
Fatigue
Technical tasks
Flin et al. Safety at the sharp end. 200
Prototype Framework
Category
Situation Awareness
Elements
Gathering Information
Pause to interpret information
Projection to future states
Decision Making
Generating Options
Balancing Options
Reviewing of Decisions
Getting the Job Done Prioritising (tasks and patients)
Applying Rules
Planning and Preparing
Teamwork
Speaking up
Establishing shared understanding
Establishing a team
Escalating Care
Communicating Seriousness of Situation
Identifying and utilising resources
Decision making
Decision Making
Generating Options
Balancing Options
Reviewing of Decisions
Weighs up factors with respect
to patient’s condition
Decision making
Decision Making
Generating Options
Balancing Options
Reviewing of Decisions
Weighs up factors with respect
to patient’s condition
“think “can I manage this on my own?”, and if you think at
any point “I’m not quite sure” , as soon as you think that
get someone else. You are only thinking of the best
interests of the patient, and so do it.”
(FYDr19)
Decision making
Decision Making
Generating Options
Balancing Options
Reviewing of Decisions
Weighs up factors with respect
to patient’s condition
“it’s that whole thing that you think you should be able to
deal with things but you realise you don’t….you can’t,
whereas now I don’t mind if I can’t deal with something,
better just to ask, whereas before I was worried about my
pride”
(FYDr14)
“Organisational
Factors”
The Behaviour of
Junior Doctors
“Identity Issues”
“I was really, really scared to ring erm for peri arrest
cause even though everyone always says (whispers)
“Oh no one will ever get cross” - I’ve kind of seen a
couple of situations where people have been made to
feel and look stupid”
(FYDr2)
“Identity Issues”
“Organisational
Factors”
“If I’d had someone to talk to, phone right away I probably
would have phoned them quicker, but phoning the medical
registrar is a real big hurdle as that is kind of the top person
in the hospital at night”
(FYDr4)
Escalating Care
Escalating Care
Communicating Seriousness of Situation
Identifying and utilising resources
Uses concise structured
communication
“waffling is quite an easy habit, especially as a medical
student as waffling as a medical student can get you quite far,
but not in an emergency, as waffle doesn’t sound like it’s
urgent.”
(FYDr26)
On-going Work
• Scenario and teaching
developments
• Attaching exemplar
behaviours
• Evaluation of prototype
Conclusions
• Non-Technical Skills
• Challenging for junior doctors
• Important for patients
• Prototype framework can be used to:
• Guide educational interventions
• Guide performance feedback
• Encourage safe and effective behaviours
Thank you PTAS!
Questions?