Could physical therapy learn from air disasters? Photo credit: Valley Guy / Foter / CC BY-NC

Safe in your hands: do we have the non-technical skills to keep patients safe?

Professor Rhona Flin, Chair in Applied Psychology at the University of Aberdeen, asks whether health professionals need to pay more attention to communication and decision-making skills

All health care jobs have patient safety at their core. If those working in health are to take safety issues seriously, they need to look beyond clinical skills and towards understanding the types of expertise that make adverse events less likely. I’m talking about “non-technical skills”, which complement technical skills, and embrace cognitive and interpersonal abilities. 

The importance of these non-technical skills has long been recognised in industries classified as potentially “high risk” such as civil aviation or nuclear power. They are not new or mysterious skills, but are what the best practitioners exhibit.  The skills include situation awareness, good decision-making, good communication, good team work and strong leadership – and having them helps workers achieve consistently high performance.

The example of civil aviation has much to teach any occupation which involves risk. Those working in the aviation industry are formally trained and assessed in non-technical skills, and the Civil Aviation Authority assesses both technical and non-technical skills as part of its system of regulating pilots, airport staff and commercial air operators. Skills at decision making, situation awareness, teamwork and leadership are known to reduce error and enhance safety. 

This emphasis in the aviation industry began to take shape after a major accident in Tenerife in 1977 when two Boeing 747s crashed into each other on the runway, killing 583 people – making it the deadliest accident in aviation history. Investigation revealed that the main causes were poor communication, lack of situation awareness, stress, assertiveness – the human factors. These non-technical aspects rather than technical failings were at the heart of the disaster. 

The analysis of this aviation accident and others revolved largely around the conversations recorded on the “black box”, which contains the cockpit voice recorder.  I wonder what we’d find on voice recorders if they were put into clinical units? I can imagine some snippets: “My way is much quicker...”; “Did she say four?”; “No-one follows that procedure…”; “I’ve done this hundreds of times...”; “We need to get this case done…”; “I knew that was going to happen…”

There are obviously significant differences between industry and healthcare, and industry procedures cannot be simply transferred to health services. However it is clear that health services and their patients could benefit from a greater focus on the issues around communication, conflict, misunderstanding, assertiveness, frustration which such conversations illustrate, and on the non-technical skills that can be measured and adopted to reduce their risk.

Research has shown adverse events in surgery can often be traced to failures of teamwork and judgement. A 1999 study showed there was communication breakdown in 43% of surgical errors. Balancing that, studies have shown that effective leadership and teamwork leads to positive outcomes for patients.

At the University of Aberdeen, we have developed methods for observing and rating the non-technical skills of surgeons and anaesthetists. We have published system handbooks on how to do this. 

Our SPLINTS project (Scrub Practitioners' List of Intra-operative Non-Technical Skills) aims to identify the cognitive and social skills necessary for the safe and effective performance of scrub practitioners (nurses and technicians). The SPLINTS taxonomy we developed is being used to design non-technical skills training programmes for scrub practitioners. 

Similar resources are being developed for other clinical specialists, such as emergency physicians and anaesthetic nurses. As physical therapists also strive to provide safe and efficient care, then perhaps they too will begin to identify the non-technical skills of their best practitioners.

This article is based on a presentation made at the World Health Professions Regulation Conference, held in Geneva in May 2014. It was organised by the World Health Professions Alliance, of which WCPT is a member. 

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