A framework of essential non-‐technical skills (NOTECHS) for healthcare professionals

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A framework of essential non-‐technical skills

(NOTECHS) for healthcare professionals

Abstract

★★★

Student Sandra Esmé Zoetelief

Student number 6037615

Phone number + 31 (0) 6 50 85 60 59 Email address s.e.zoetelief@amc.uva.nl

Supervisors L.H. Christoph (daily supervisor) & Dr. R. de Vos (PI) Division Center for Evidence-‐Based Education (CEBE)

Phone number + 31 (0) 20 56 63 287

Email address l.h.christoph@amc.uva.nl r.vos@amc.uva.nl

Background. Patient care has to be provided by a specialized medical team (MT) that has to

function in a very complex work environment. Given the complex work environment of an MT, medical errors can occur, due to human factors. The hypothesis is that training on non-technical skills (NOTECHS) in healthcare could help to reduce the number of errors and consequently result in a better patient safety. The aim of the present paper is to provide a framework of essential NOTECHS for healthcare professionals that can be used for the development of training of NOTECHS for healthcare professionals.

Method. A literature review was done. Online database PubMed was consulted following the

guidelines of a systematic review. The search has led to the selection of 15 articles to be included in this review.

Results. Situational awareness, communication, task management and leadership &

coordination are found to be most essential NOTECHS for health care professionals.

Conclusion. Training of NOTECHS could reduce errors due to human factors. The results of

this review could serve as a broad-based framework for the development of training of NOTECHS for healthcare professionals in the future.

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Introduction

An eighteen-‐year-‐old boy arrives in the emergency room, accompanied by his parents. His mum is sure that her son took an overdose of acetaminophen, since she found an empty acetaminophen bottle in the bathroom. The boy has been under psychiatric treat for a while, but he denies that he took an overdose. The doctor asks for a blood check to determine the acetaminophen value. When the results are known, the lab calls to the emergency unit, a nurse answers the phone call from the lab, takes wrong results (so that it seems that there is no overdose) and the patient dies (based upon Schraagen, 2013).

An acutely ill patient has to trust his or her life to the care of a usually multidisciplinary team of medical experts. In an acute situation the medical team (MT) has the primary responsibility to ensure that the patient is getting the best care possible and maybe even more important, that the patient survives and/or revives in the best way possible. Working in teams is a common situation when complex and difficult tasks have to be performed, as is in healthcare (Salas et al., 2008). Since it may often be a matter of life or death, the members of an MT have to make high stake decisions. Such decisions have to be made under time

pressure by the MT. The composition of the MT may also be differing. The latter named circumstances make it a challenge to create a good functioning medical team (especially in an acute situation) (Eppich & Hunt, 2008), capable to function in a very complex work environment.

As stated above, the patient has to rely on the expertise of the MT. Therefore the health of the patient must be the matter of concern in the

provision of medical care. Observing the complex work environment of the MT, it’s a challenge for the MT to keep patient safety at a high level. It may also not be surprising that many errors are made in providing healthcare (IOM Committee, 1999). Most of these medical errors (60% -‐80%) are due to human factors1_,

1_{"Human
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individual characteristics which influence behavior at work in a way which can affect health and safety. A simple way to view human factors is to think about three aspects: the job, the individual and the organization and how they impact people’s health and safety-‐related behavior” (WHO,

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despite the best intentions of medical professionals (Eppich & Hunt, 2008). In a situation as described above, a fault in communication (by hearing and taking the wrong lab results) has led to the death of a patient. This is in line with a statement in the article of Eppich and Hunt (2008) that “most medical errors occur because of poor teamwork and poor communication rather than due to individual mistakes.” As an addition, Schraagen et al. (2011) state that: “in cases teams infrequently display team behaviors, patients are more likely to

experience death or major complications.” Given the complex work environment of an MT, medical errors occur, most often due to human factors.

The latter two observations illustrate that besides well-‐developed

medical skills of each individual team-‐member, the members of an MT also need to possess skills in teamwork and communication to assure patient safety at a high level within an MT. In this way, the required skills for an MD can be

subdivided in two types, namely technical and non-‐technical skills. To elucidate the distinction between the two types of skills, some examples will be provided. Technical or medical skills include medical treatment and clinical assessment. More specific technical skills in emergency situations are monitoring of airway, breathing and the cardiovascular status of a patient and to act upon changes. The induction of drugs (correct selection and dosage) is also an important technical skill (Lambden et al., 2013). Non-‐medical skills, in this paper defined as non-‐ technical skills (NOTECHS) are mostly related to teamwork. Categories of NOTECHS are effective communication, teamwork, coordination and leadership within the team (Schraagen, 2013; Cheng, Donoghue, Gilfoyle & Eppich 2012; Fernandez et al., 2008; Fletcher, Flin, McGearoge, Glavin, Maran & Patey, 2003; Flin, Patey, Glavin & Maran, 2010; Lambden, 2013; Schmutz & Mantser, 2013). As mentioned before, teamwork is prone to errors due to human factors. Accident analysis within aviation revealed that unsafe flight conditions often were related to pilots’ cognitive and social skills instead of their technical

abilities (Flin et al., 2010). Training of NOTECHS in aviation and Navy teams with the aim to perform better in stressful scenarios has proven to be successful, i.e. fewer accents occurred after training of NOTECHS (Zsambok & Klein, 1997). The

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work in a complex environment (high-‐stakes decisions, e.g. a matter of life and death) and under high pressure. As there are many similarities in work

circumstances in healthcare and aviation, the proven importance of NOTECHS in aviation could imply that NOTECHS play an important role in healthcare too. In the recent past, more attention is given to the importance of NOTECHS in healthcare. This is not surprising, taking into account the success of training of NOTECHS in aviation and Navy teams. Training of NOTECHS in the medical world could help to reduce the number of errors and consequently providing a better patient safety (Carne, Kennedy & Grey, 2012; Eppich & Hunt, 2008). The first (and only) published NOTECHS framework in health care is the anesthetists’ non-‐technical skills (ANTS) taxonomy and behavior rating tool (Flin et al, 2010). To be able to create NOTECHS trainings for healthcare professionals in general, not only focusing on anesthetists (ANTS), there should be insight in which NOTECHS are essential for healthcare professionals in general. By essential NOTECHS is meant that, if these are in absence, this could lead to major complications or even death of patients. This led to the following research question: What are the, as in the medical literature identified, essential NOTECHS that healthcare professionals should possess to function well in a medical team (MT) and to provide safe healthcare?

By answering the research question, this paper will provide an overview of essential NOTECHS for health care professionals, which can be used as a framework for the development of trainings of NOTECHS for healthcare professionals. Abstract and more specific NOTECHS will be explained.

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Methods

The objective of this paper is to discuss the essential NOTECHS for

healthcare professionals. To find relevant articles about NOTECHS for healthcare professionals a literature review was done. The articles used for this paper resulted from a systematic search of the online database PubMed.

Search strategy

With help of a medical information specialist of the AMC Medical Library, PubMed skills developed during a working group and acquired knowledge from lectures about the use of database PubMed, search terms were identified that matched the research question of this article. These terms, both MeSH and non-‐ MeSH terms for teamwork and healthcare were combined during our search. To get an impression of the existing literature about NOTECHS in health care, a broad search was done, with the following search strategy:

(team management[tiab] OR team training[tiab] OR teamwork*[tiab] OR team work*[tiab] OR team performance*[tiab] OR team effect*[tiab] OR team skills[tiab] OR non-‐technical skills[tiab] OR patient safety training[tiab] OR human

factors[tiab]) AND ("Medicine"[Majr] OR "Pediatrics"[MAJR] OR "Health Personnel"[MAJR] OR "Patient Care Team"[MAJR] OR healthcare[ti] OR physician*[tiab] OR pediatric*[ti] OR paediatric*[ti] OR (team*[tiab] AND organization*[tiab])) AND ("Clinical Competence"[Mesh] OR "Cooperative Behavior"[Majr] OR expertise[tiab] OR "Communication"[MeSH Terms]) AND ("Medical Errors/prevention and control"[MeSH] OR "Educational

Measurement/methods"[MeSH Terms] OR quality improvement OR "Quality of Health Care/organization and administration"[MAJR] OR effective*[tiab]).

In the broad search, the observation was that there were multifarious articles about the same topic. Although the selection of articles seemed useful, the question was if a combination of search terms (narrow search) would lead to

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Therefore, combined search terms were used in a ‘narrow search’:

(team management[tiab] OR team training[tiab] OR teamwork*[tiab] OR team work*[tiab] OR team performance*[tiab] OR team effect*[tiab] OR team skill*[tiab] OR non-‐technical skill*[tiab] OR patient safety training[tiab] OR human

factor*[tiab]) AND ("Pediatrics"[Mesh] OR pediatric*[tiab] OR paediatric*[tiab]) AND ("Clinical Competence"[Mesh] OR "Cooperative Behavior"[Majr] OR

expertise[tiab] OR "Communication"[MeSH Terms]) AND ("Medical Errors/prevention and control"[MeSH] OR "Educational

Measurement/methods"[MeSH Terms] OR quality improvement OR "Quality of Health Care/organization and administration"[MAJR] OR effective*[tiab]).

Selection of studies

The ‘broad search’ led to 705 hits. The limits used were ‘English’,

‘abstract’, and ‘publication since 2003’. Clinical Queries were used to find out the number of systematic reviews. Out of the 705 hits, 56 were systematic reviews. In this search the focus was on systematic reviews, because systematic reviews are most often found to be reliable. All systematic reviews were selected for further analysis.

The ‘narrow search’ resulted in 55 hits of which five were systematic reviews. The systematic reviews resulting from the broad search (n = 56) were put together with the 55 hits resulted from the narrow search. This meant that 111 articles remained for further analysis.

The 111 resulted articles were assessed on their eligibility and quality based on title and abstract. The titles and abstracts were read carefully and the usefulness of the articles was thereby evaluated. Inclusion criteria were a (seemingly) clear description of NOTECHS, a description of the (complex) work environment of health care professionals and/or other information concerning teamwork that was found to be relevant (e.g. evaluation of an existing marker system). This resulted in 27 articles for further analysis. Excluded were duplicates, articles that didn’t give NOTECH descriptions and articles with publication date after 2003.

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The 27 articles remained were divided into subcategories (NOTECHS description; training related articles; work circumstances of MT’s etc.) to find out which articles were really relevant for the research question of this paper. The full texts of each of these 27 articles were read carefully. Twelve articles were excluded after reading full text, because there was no NOTECHS description and/or there was no description of complex work circumstances of health care professionals in relation to NOTECHS. The fifteen articles that were remained gave a description of NOTECHS for health care professionals and were included in the review. An overview of the search strategy is found in the search tree on the next page.

Data extraction

The PubMed search resulted in 15 articles that are included in the literature review. The full text of each of these articles was read carefully. The articles were screened both on quality and content. First the articles were screened on kind and quality. Ten of the 15 articles were conceptual. Five of the 10 articles were descriptive based on theory. Four of the ten were

descriptive based on a combination of theory and practice and the one left only descriptive based on practice. The remaining five articles described empirical studies. These five were divided in one randomized control trial, three quasi experiments and one observational study.

As explained before, next to the broad search, a narrow search was done to find out if the conclusions would be similar if more specific search terms would be used. A big overlap was seen between the selected articles from the narrow search and the broad search. Nine out of 15 selected articles used for the review were found in both the broad and narrow search. Besides, the content of the articles that differed didn’t significantly influence the final conclusions. Consequently, the results of this paper aren’t much different when using

combined or narrower search terms. In the following section, the content of the articles will be discussed.

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Narrow search in PubMed

n = 55 Broad search in

PubMed

n = 705

Potential relevant papers identified and screened for retrieval on title and abstract: n = 27 Excluded papers (n=649) because of: > No systematic review (n=649) Excluded papers (n = 84) because of: > duplicates (n = 32) > no NOTECHS description (n = 43) > publication date (n = 9) Excluded papers (n = 12) because of: > no NOTECHS description (10), or > no description of work circumstances (2)

27 papers retrieved and screened on full text

15 papers included in the review (and used for the table)

Search tree

Number of hits in database PubMed n = 760 Selection of systematic reviews n = 56

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Results

The articles acquired from the literature search were also studied on content. Various articles came from various journals and presented results from research in different disciplines. However the points of view (associated with the discipline in which research was done) of different authors varied, the articles all had in common that they described NOTECHS in relation to teamwork and/or a complex work environment. Different articles highlighted different relevant aspects. This is why the results from this search could serve as a broad-‐based framework of NOTECHS for healthcare professionals.

Four essential NOTECHS will be presented as they have been identified in the literature of various medical disciplines. The literature search resulted to the statement that the most essential NOTECHS relevant for healthcare professionals are, in random order, situational awareness (1), communication (2), task

management (3) and leadership & coordination (4) (Cheng et al., 2012; Fernandez et al., 2008; Fletcher et al., 2003; Flin et al., 2010; Lambden et al., 2013; Schmutz & Mantser, 2013). These NOTECHS are considered as most essential, because they were described most often or in most detail in the relevant articles, consulted after the literature search.

First, a broad definition of each of the NOTECHS will be given. In general terms, situational awareness is described as awareness of the environment and the available resources. Communication, in general terms, is to share or to exchange relevant information effectively. Task management is a broad term concerning multiple elements such as forward planning, the distribution of workload amongst team members, shared understanding and prioritizing. The last named NOTECH leadership & coordination in the context of healthcare is to lead the medical team and to coordinate patient care.

To provide an overview of the NOTECHS descriptions, they are put together in table 1, which is attached to this article. In the next paragraphs these NOTECHS will be discussed in more detail.

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Situational awareness

The first NOTECH that will be discussed in more detail is situational awareness. Different authors give their definition of ‘situational awareness’. Although situational awareness is seen as one of the four most essential

NOTECHS for healthcare professionals, in only five of the fifteen selected articles situational awareness is defined specifically. Below, you find a clear definition that is the result of the combination of the five articles.

Box 1

As can be seen in box 1, one of the elements of situational awareness is awareness of the physical environment. This is awareness of all the available resources, e.g. the location and function of the available equipment (Carne et al., 2012; Fernandez et al., 2008; Flin et al., 2010). The importance of knowing the meaning of the elements in the environment is to make sure that the chance to success is maximized in an acute situation (Eppich & Hunt, 2008). For example, it would be too time-‐consuming if one still has to search for the AED just before resuscitation instead of knowing the exact location so that there is no delay while searching for it.

Besides awareness of the physical environment, it’s important to know the cultural environment (Carne et al., 2012; Fernandez et al., 2008; Flin et al., 2010). Culture can be the way people interact, how they talk to each other and

Situational awareness in bullet points:

-‐ To be aware of the environment (Carne et al., 2012; Fernandez et al., 2008; Flin et al., 2010)

o Physical environment o Cultural environment

-‐ To be aware of the available resources and to make use of them (Eppich & Hunt, 2008)

o The location and function of equipment (Carne et al., 2012)

o The meaning (in future events) of elements in the environment (Cheng et al., 2012)

-‐ To anticipate to the environment (Flin et al., 2010)

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who takes the lead in emergency situations. This is important to make sure there is mutual understanding and good communication.

In the following paragraph, (good) communication will be explained further.

Communication

The anecdote at the beginning of this article serves as an illustration of the importance of good communication. Poor communication can lead to terrible outcomes and therefore good communication is a must in healthcare. In the anecdote, the terrible outcome could have been avoided if communication would have been better. In this specific example, this could have been the case if the nurse in the emergency care unit had repeated the lab results before hanging the phone. If the employee from the lab would pay attention, he/she would have noticed that the results were interpreted erroneously. The lab employee could have corrected this. If this had been the case, the MT in the emergency care unit would have known that the boy was overdosed. This way of communication is called closed loop communication and will later be explained further.

In 13 out of 15 articles, a description of communication is given. Although, the importance of good communication is made clear in these articles, the

descriptions are quite general. Even so, there is tried to give a useful definition. As can be seen in Box 2 by communication is meant to share needed or relevant information effectively (Carne et al., 2012; Haftel et al., 2011; Eppich & Hunt, 2008; Schraagen et al., 2013). It’s important to exchange information in the (whole) team, so that every team member knows what to do. While sharing, the messenger should use clear and precise instructions for colleagues, so that everything is clear to everyone (Eppich & Hunt, 2008). To make sure no

misunderstandings through communication occur in emergency situations it’s a good option to adopt a critical language (a chosen sentence) that can be used to give the message: ‘I’m concerned’ or ‘I’m uncomfortable’ (d’Angincourt-‐Canning Kissoon, Singal & Pitfield, 2011).

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Box 2

As also shown in Box 2, there are different forms of communication. As mentioned before, closed loop communication can help to prevent mistakes in communication (d’Angincourt-‐Canning et al, 2011). The key is for the sender of a message to wait for acknowledgements from the information receiver (team member) if information is received right. This helps to make sure the message is received as intended (Lambden et al., 2013). Other forms of communication are defined sufficiently in Box 2.

In the following paragraph the NOTECH task management will be discussed.

Communication in bullet points:

-‐ To share needed or relevant information effectively (Carne et al., 2012; Haftel & Hicks, 2011; Eppich et al., 2008; Schraagen et al., 2013)

-‐ To exchange information in the (whole) team (Flin et al., 2010; Schraagen et al., 2013; Sutton, Liao, Jimmieson & Restubog, 2011)

o With effective team member interaction (Eppich et al., 2008) o Verbalizing relevant information directed to other team

members (Thomas et al., 2010) -‐ Different forms of communication

o Closed loop communication (d’Angincourt-‐Canning et al., 2011; Cheng et al., 2012; Fernandez et al., 2008)

§ A team member gives a command (sender)

§ Ask team member to repeat the command back to the sender to verify if message was correctly received § Clarify with sender if the message was received,

understood and interpreted as intended by receiver § Report if the order is completed

o Organizational communication (Ohlinger, Brown, Laudert, Swanson & Fofah, 2003)

§ Use multiple methods of communicating the same information

§ Share information openly and often with all team members

o Interpersonal communication (Ohlinger et al., 2003)

§ Listen attentive to understand the message as good as possible

o Assertive communication (Cheng et al., 2012) § Pay necessary attention

§ Deliver messages in clear, but nonthreatening, respectful manner

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Task management

Task management is a very broad concept. However, task management is a very broad concept, some elements are named very often and are, therefore, seen as the most relevant elements of task management. In 13 out of 15 selected articles elements of task management are described. An overview of these elements is given in Box 3.

Task management in bullet points:

-‐ To plan forward (d’Angincourt-‐Canning et al., 2011; Carne et al., 2012; Eppich et al., 2008; Fernandez et al., 2008; Flin et al., 2010; Haftel et al., 2011; Schraagen et al., 2013; Sutton et al., 2011)

o Clinically o Practically

-‐ To distribute tasks based on expertise (Carne et al., 2012; Eppich et al., 2008; Fernandez et al., 2008; Flin et al., 2010; Haftel et al., 2011; Salas et al., 2008; Schraagen, 2013; Sutton et al., 2011)

o To distribute workload

o To assign specific tasks to individuals

o To detect and identify inability of team members for certain tasks by knowing capabilities of team members

o To acknowledge the capacity and contributions of other team members

-‐ To avoid impairment due to (Carne et al., 2012; Eppich et al., 2008; McKeon, Oswaks & Cunningham, 2006; Salas, Rosen & Hing, 2007; Schraagen et al., 2013):

o Maximum working capacity; o Distractions;

o Lack of attention; o Fatigue;

o Personality; o Level of expertise;

§ Recognize own limitations

§ Recognize limitations of team members o Decision making skills;

o Fixed mind-‐set; o Stress

-‐ To have shared understanding (Cheng et al., 2012; Fernandez et al, 2008; Flin et al., 2010; Salas et al., 2007; Schraagen et al., 2013)

o To be on the same page with all team members regarding: § Team goals

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Box 3

As mentioned before, task management is a collective noun for different elements together. Concerning task management, planning forward is one of the most important elements. Both clinical planning (what medical procedures have to be performed) and practical planning (e.g. if there’s sufficient room for

surgery if necessary) are important (d’Angincourt-‐Canning et al., 2011; Carne et al., 2012; Eppich & Hunt, 2008; Fernandez et al., 2008; Flin et al., 2010; Haftel et

o To have mutual understanding and support

§ To feel safe and empowered to share thoughts o To recognize and understand each other and the situation o To have shared believe in the group’s ability

§ To execute tasks to achieve team goals o To know tasks of individual team members o To openly share information about observations,

interpretations and interventions to achieve shared understanding

-‐ To prioritize team’s tasks dynamically (Eppich et al., 2008; Fernandez et al., 2008)

o Use all the available information and make sure certain team activities happen at the right time

-‐ Cooperation (d’Angincourt-‐Canning et al., 2011; Fernandez et al., 2008; Haftel et al., 2011; Lambden et al., 2013; Sutton et al., 2011)

o To identify team’s tasks

§ To maintain the ‘big picture’ within the team § To be on the same page and starting point

• Use checklists • Briefings o To monitor each others tasks o To support each other

§ To review and back up other team members’ performance

o To be aware of potential challenges § And to identify problems

o To be proactive and reactive in managing conflicts § To be open to opinions of other team members § Focus on what is right instead of who is right o To be competent with role assignment

o To reflect on team performance § To evaluate

o To maintain interpersonal relations

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A lot of different tasks have to be performed by the team. If the capabilities of team members are known within the team (and openly

discussed), these tasks can be distributed based on expertise (Carne et al., 2012; Eppich & Hunt, 2008; Fernandez et al., 2008; Flin et al., 2010; Haftel et al., 2011; Salas et al., 2008; Schraagen et al., 2013; Sutton et al., 2011). This workload distribution based on expertise could lead to less mistakes and more efficient working.

For teamwork and associated task work, it’s also important to achieve good cooperation. There are many important components in cooperation. First, team members have to understand each other. They have to be on the same page concerning team goals, individual tasks and – as named before – each other’s capacities and qualities (Cheng et al., 2012; Fernandez et al, 2008; Flin et al., 2010; Salas et al., 2007; Schraagen et al., 2013). This shared understanding also includes trust. A team is in need of a safe environment in which team members recognize and understand each other and the situation (Cheng et al., 2012; Fernandez et al, 2008; Flin et al., 2010; Salas et al., 2007; Schraagen et al., 2013). If team members feel safe within the team, this provides room for discussion of inabilities of team members, without insulting each other.

In short, problems and mistakes due to human factors can be reduced if the medical team plans forward and prepares complex tasks. If the team is seen as a safe environment, in which team members trust each other, tasks can be monitored, capabilities or just inabilities of team members can be identified and feedback can be given. To get to know the capabilities and mind-‐set of staff and other team members can also contribute to effective distribution of workload (Carne et al., 2012).

To make sure task management in a medical team is done properly, it can be helpful if a good leader supervises the team. Therefore, in the following

paragraph, leadership/coordination is the next NOTECH that will be discussed in more detail.

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Leadership & coordination

Coordination was first seen as a self-‐contained NOTECH. After further analysis of the table, coordination and leadership are put together in one column in the table. The columns of coordination and leadership contained the same elements. This can be explained by taking in account the definitions of coordination and leadership. Coordination is (following dictionary Merriam-‐ Webster, 2015) “the process of organizing people or groups so that they work together properly and well”. The definition of leadership is (following dictionary Merriam-‐Webster, 2015): “a position as a leader of a group, organization, etc.”. So actually, coordination is what the leader should do to be able to lead the team properly. That’s why leadership and coordination are merged in the table and in this article.

Box 4

As you can see in Box 4, leadership in healthcare is to lead and coordinate patient care (Carne et al., 2012; Cheng et al., 2012; Fernandez et al., 2008; Flin et al., 2010; Lambden et al., 2013; Schraagen et al., 2013). A leader coordinates the team to accomplish its goals; both on the level of individuals as on team level. If necessary, the leader can use authority and assertiveness to achieve this (Carne et al., 2012; Cheng et al., 2012; Fernandez et al., 2008; Flin et al., 2010; Lambden et al., 2013; Schraagen et al., 2013).

Leadership also includes the responsibility for a leader to outline strategy and to develop a plan of action (Carne et al., 2012; Cheng et al., 2012; Fernandez et al., 2008; Flin et al., 2010; Lambden et al., 2013; Schraagen et al., 2013).

Leadership/coordination in bullet points:

-‐ To lead and coordinate patient care*

-‐ To use authority and assertiveness to coordinate* -‐ To coordinate the team to accomplish its goals*

o To coordinate the performance of multiple individuals -‐ To outline strategy and to develop a plan of action*

*(Carne et al., 2012; Cheng et al., 2012; Fernandez et al., 2008; Flin et al., 2010; Lambden et al., 2013; Schraagen et al., 2013)

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A team leader has the main responsibility to support the team to function well. Therefore, it’s important that the leader has various skills to make sure this happens as good as possible. In Box 5, you find an overview of the associated behaviors that a good leader should comply, while leading a medical team.

Box 5

As can be seen in Box 5, a good leader coordinates the team to accomplish its goals. The leader should set expectations of performance. This must be

understood and interpreted in the same way by al the team members (shared cognition). It must be clear what each team member has to do, when and how. Therefore, the team leader should assign team roles.

In difficult situations, the team leader should take the lead to solve

problems and settle conflicts. In the latter point, the leader should have a neutral position and has to be open to the opinions of other team members and should focus on what is right instead of who is right, to prevent nepotism. To make problem solving in the team easier, the leader can try to maximize the adaptability of team members. This can help the team to be prepared for unexpected events.

A good leader in bullet points:

-‐ Coordinates the team to accomplish its goals**

-‐ Assigns team roles and sets expectations of performance of team members**

-‐ Makes sure the team has a shared cognition** -‐ Maximizes the adaptability of team members**

-‐ Helps the team to be prepared for unexpected events** -‐ Leads the team in difficult situations**

-‐ Solves problems** -‐ Settles conflicts**

o Neutral position in the team

-‐ Uses authority and assertiveness to coordinate if necessary** -‐ Is able to synthesize most important information from team

members**

-‐ Informs team members to do their jobs as effective as possible by facilitating al needed resources**

**(Carne et al., 2012; Cheng et al., 2012; Fernandez et al., 2008; Flin et al., 2010; Lambden et al., 2013; Schraagen et al., 2013)

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Discussion

The aim of this article was to provide a broad-‐based framework of essential NOTECHS for healthcare professionals. Based on the literature review, an overview of four essential NOTECHS (situational awareness, communication, task management and leadership & coordination) has been given. Healthcare professionals should be trained on these NOTECHS to make sure fewer errors occur and consequently better patient safety results. Here it will be discussed what the results of this article mean in the perspective of the existing

international literature.

In the past years, more attention is given to the importance of NOTECHS in the international literature. At this moment, the field of anesthesia is leading. The Anesthetics Non-‐Technical Skills (ANTS) system comprises four NOTECHS categories. Compared to the ANTS system, the taxonomies in this paper differ to the extent that they define a generic, domain independent competency or skill or much more concrete (measurable) behavioral elements or markers.

In the remainder-‐consulted literature about NOTECHS in healthcare, the description (and naming) of competences is very diverging. An explanation can be that most authors focus on one (or more) NOTECHS that they consider most important instead of providing a broad overview of NOTECHS for healthcare professionals. On the other hand, it could be that authors copy the NOTECHS present in the existing (leading) literature and thus a narrow view on the essential NOTECHS arises. In that case, it could be that essential NOTECHS are missing in the existing literature or that specific elements (or more out-‐of-‐the box definitions) of NOTECHS are missing. This paper differs from the consulted articles, because this article was intended to give a more complete and domain independent overview of essential NOTECHS.

Next, the currently known limitations of this review and implications for practice and future research will be discussed.

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Limitations of review

As is the case in every research, this review has limitations. At first, it was hard to find specific search terms, which might have led to an inadequate search of the literature. Besides, it has been a challenge to evaluate the quality of studies and especially to distinguish studies that are well or poorly designed. Sometimes an article was presented as a well-‐designed study, but seemed poor-‐designed after further analysis. This might have led to the unintended combination of results from well-‐ and poorly-‐designed studies. In addition, a lot of different (types) of articles are written about this topic and therefore it is also possible that the results of heterogeneous articles are combined in this study.

As mentioned before, there was a lack of articles that gave a complete overview of essential NOTECHS. Consequently, it has been a challenge to provide a complete overview of essential NOTECHTS based on the existing literature. For example, at first decision-‐making was added to the current four NOTECHS

described in this article. After the consultation of the selected articles, it seemed the column ‘decision-‐making’ remained conspicuously empty. This can be interpreted in two ways: decision-‐making is not one of the most essential NOTECHS for healthcare professionals or there is not enough attention paid to decision-‐making in the existing literature, because of the narrow view of some authors.

The limitations as discussed might lead to incomplete conclusions in this article.

Implications for practice

As mentioned before, in medical training the focus should be on the development of NOTECHS besides the development of medical skills. The recommendation for implication of NOTECHS in practice is to develop training on NOTECHS for healthcare professionals.

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to have talent for) essential NOTECHS, this might makes it easier to train

NOTECHS later during the medical training. During medical training to become a general doctor (during the bachelor and clerkships) NOTECHS should be trained as well. This can be in theory to create awareness of the importance of NOTECHS (during the bachelor education) and in practice with specific exercises (during the clerkships).

When general medical training is completed, the recently graduated doctor can become member of a medical team. Team members of medical teams must be trained on NOTECHS as well. This training can, amongst others, be simulation-‐based training with simulated real life scenarios.

To make sure team members get the opportunity to develop themselves within the team and to develop and improve their NOTECHS, a safe working environment is necessary. It’s important to know the cultural environment, to be aware of the desired way to interact with each other in the team and the role(s) of each of the team members to make sure training is as effective as possible.

Implications for future research

During this review, it seemed that there was a lack of publications that gave a clear and complete overview of essential NOTECHS for healthcare

professionals. Consequently, the recommendation for future research is to focus on (a complete overview of) NOTECHS for each specific domain in healthcare. It would be helpful for implications in practice (e.g. development of training of NOTECHS for a specific domain) to find out what the behavioral markers are of the necessary NOTECHS in the specific field to investigate (e.g. observational research in a pediatric care unit). This could result in a framework that fits the requirements or needs for a specific domain in healthcare.

What is noticed as well is that some terms and or elements of NOTECHS were described vaguely. For example, the NOTECH communication is described in general terms in most of the articles, but the link to the importance (or behavioral markers) is sometimes missing in the existing literature. In future research, more attention should be given to specific skills (and behavioral

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markers) of NOTECHS, so that they are ready to be used for training development.

An addition, ‘out-‐of-‐the-‐box definitions’ of NOTECHS are lacking.

Surprisingly enough not mentioned in the consulted literature, leadership also plays an important role at the level of the team member. Besides a good team leader in the possession of good leadership skills and individual leadership skills (on the level of individual team members) are important as well. Personal

leadership skills are, e.g., to take the lead in difficult situations (for example in the absence of the team leader in an emergency situation); to stand up if one of the fellow team members or the team leader makes a mistake or is not

functioning well; to reflect on own skills and acting in the team; and to indicate own limits. The development of individual leadership skills in the team can contribute to better functioning of the team. In further research, these ‘out-‐of-‐ the-‐box definitions’ should be taken in mind, although not mentioned in the existing literature.

Conclusion

The research question of this article was: What are the, in the medical literature identified, essential NOTECHS that healthcare professionals should possess to function well in a medical team (MT) and to provide safe healthcare? By answering the research question, the aim of this article was to provide a framework of essential NOTECHS for healthcare professionals that could be used for the development of a training of these NOTECHS for healthcare professionals.

The literature review led to the conclusion that situational awareness; communication; task management; and leadership & coordination are the four essential NOTECHS for healthcare professionals. Training on these NOTECHS should help to make sure fewer errors occur and consequently patient safety improves.

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Acknowledgements

However the topic of this paper interested me a lot and I was very motivated to write the paper, it was a challenge for me. Without the support of the people around me, it would be even more challenging. Therefore, I would like to thank some people.

At first, I like to sincerely thank Noor Christoph for her professional support. I would like to thank for the insights and understanding you had when I was stuck at some point. I also want to thank Rien de Vos, who shared his

professional opinion on the first version, which helped me to learn more about research.

I would also like to thank my friends and family. Especially my former roommate Irene and my boyfriend Sebastian, who helped me to believe I could finish this paper.

If I wanted to share my thoughts about this topic, I could always call my dad. He therefore deserves special thanks as well.

At last I want to thank the medical information specialist F.S. van Etten-‐ Jamaludin who helped me with the search terms.

Finally, I learned a lot from this experience and I am happy with the achieved result.

A framework of essential non-­‐technical skills (NOTECHS) for healthcare professionals