“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"

Ed Mellanby, June 2013 Non-Technical Skills for Junior Doctors in Acute Care Supervisors: Janet Skinner, Nikki Maran Co-researcher: Megan Hume Advisor: Ronnie Glavin

The next 30 minutes Introduction Why this project? Non Technical Skills 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: Aviation Nuclear power industry Oil industry Military Wiener E et al. Cockpit resource management: Academic Press, 1993:3-45

Introduction Source: “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 Improved Non-technical Skills Increased Teamwork Increased Teamwork Reduced Operative Errors Reduced Operative Errors Reduced Non 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

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

Situation Awareness Knowing what is going on around you What? So What? Now What?

Whodunnit?!

Situation Awareness Gathering Information Pause to interpret information Projection to future states Uses a structured approach to assessment

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 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 Gathering Information Pause to interpret information Projection to future states Pauses activities to put together findings

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)

Knowledge Skills Experience Knowledge Skills Experience Patient Condition Info. from nurse Practical Procedures Distractions Working Memory INPUT Long Term Memory Flin et al. Safety at the sharp end. 2008

Patient Condition Info. from nurse Practical Procedures Distractions Working Memory INPUT Limited time Stress Fatigue Technical tasks Novice Long Term Memory Knowledge Skills Experience Knowledge Skills Experience Flin et al. Safety at the sharp end. 2008

Prototype Framework

Decision making Decision MakingGenerating Options Balancing Options Reviewing of Decisions Weighs up factors with respect to patient’s condition

Decision making Decision MakingGenerating 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 MakingGenerating 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)

“Identity Issues” “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)

“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 CareCommunicating Seriousness of Situation Identifying and utilising resources Escalating Care 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?