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Studying Non-Technical Neurosurgical Skills


General purpose

Despite declarative knowledge acquired and perfectly mastered technical skills, a number of adverse events have been observed in the neurosurgical operating room (OR). These may have irreversible consequences and so cause serious functional impairment or vital complications. Surprisingly, these events were less often the result of a technical error than of a malfunction in the field of non technical skills (NTS). NTS are divided into interpersonal skills including communication, leadership, teamwork, briefing/planning/preparation, resource management, seeking advice and feedback, coping with pressure/stress/fatigue and cognitive skills including situation awareness, mental readiness, assessing risks, anticipating problems, decision making, adaptive strategies/flexibility and workload distribution (1). A growing number of publications on NTS and more generally human factors in surgery have been published in recent years. However, it is certain that NTS influence technical skills positively or negatively respectively by their presence or absence. The safety and quality of care in our modern society are a widespread and growing concern among the population. The surgical community understands this concern and, as in similar sensitive areas such as civil aviation or the nuclear industry, it is beginning to develop “firewall” tools such as checklists. These still incompletely described NTS are emerging with difficulty in the training objectives of surgeons and even more particularly in the confidential community of neurosurgery.


Quantitative assessment of NTS in neurosurgical OR

The objective of this section will be to define a quantitative assessment metric of NTS in neurosurgery. It will be built up from evaluation grids validated in the literature. The 3 main grids validated in the literature for the evaluation of NTS in surgery are the NOTSS, NOTECHS and OTAS (2). These scales are intended to explore all NTS (both interpersonal and cognitive). In fact, in practice they essentially analyse interpersonal skills, as they are based on analysis of behavioural markers and verbal communication. These are tested on Anterior Cervical Interbody Fusion (ACIF). This surgical procedure is standardized, homogenous and requires an operating microscope. Assessment is performed on data from video recordings. Analysis of videos is performed by both neurosurgeons and professionals from the field of “Human factors” (psychologists from the university of Social Psychology and member of the Centre for Research in Psychology, Cognition and Communication (CRPCC, EA 1285), University of Rennes 2 – France) using the three grids previously mentioned. The feasibility, validity, sensitivity, reliability and learning curve for the use of these grids are compared.

Qualitative assessment of NTS in neurosurgical OR: a focus on cognitive skills

NOTSS, NOTECHS and OTAS seem well adapted to assessing interpersonal skills but incomplete for full evaluation of cognitive skills. Cognitive skills are indeed often non-verbalized and lack behavioral markers to help decode them. So it seems essential, for a complete analysis of the NTS, to include a qualitative analysis of interviews with the surgeon after his operation. We would like to focus our work on cognitive skills and more precisely on assessing risks, anticipating problems and adaptative strategies . Semi-structured, 60-minute interviews seem to be appropriate (3). It would be a constructivist grounded theory study. Analysis of data would include thematic analysis of transcripts and field notes. Analysis would be made in an iterative manner up to thematic saturation. Data coding would be both inductive with a development of a new framework based on emergent themes, and deductive with creation of framework for assessing risks, anticipating problems and adaptive strategies for the specific ACIF surgical procedure.

Quantitative and qualitative assessment of NTS in neurosurgical OR with work domain variation

This part will consist of a quantitative and qualitative evaluation of NTS in neurosurgery with work domain variation (planned versus emergency situation). The evaluation will be at this time performed on various spinal surgeries with instrumentation (implant placement). We will also use in this part the methodology of quantitative analysis developed in the first part and the qualitative analysis developed in the second part.

  1. Yule S, Flin R, Paterson-Brown S, Maran N. Non-technical skills for surgeons in the operating room: a review of the literature. Surgery. 2006 Feb;139(2):140-9.
  2. Sharma B, Mishra A, Aggarwal R, Grantcharov TP. Non-technical skills assessment in surgery. Surgical oncology. 2011 Sep;20(3):169-77.
  3. Luu S1, Patel P, St-Martin L, Leung AS, Regehr G, Murnaghan ML, Gallinger S, Moulton CA. Waking up the next morning: surgeons' emotional reactions to adverse events. Med Educ. 2012 Dec;46(12):1179-88.

Main Collaborators

  • Estelle Michinov – Professor – Center for Research in Psychology, Cognition and Communication (CRPCC, EA 1285), University of Social Psychology – University of Rennes 2
  • Thierry Morineau - Professor – Center for Research in Psychology, Cognition and Communication – University of South Britanny
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