We asked the experts: The evolving role of non‐technical skills for surgery in low‐ and middle‐income countries
Year: 2024
Type: editorial
Abstract: As the global burden of surgically treatable conditions continues to grow, a disparity in the quality and quantity of surgical care available across the world persists. Data suggest that the poorest third of the world's population receive less than 4% of major operations performed, and that there is a higher rate of perioperative morbidity and mortality within low- and middle-income countries (LMICs) compared to high-income countries (HICs).1-3 Some of the reasons cited for this include a lack of trained healthcare professionals, acceptable resources, and replenished consumables; the cost associated with treatment; follow-up and complications; and shortcomings in national policies, protocols, and procedures. Through training programs and capacity-building collaborations, surgical services are being developed to overcome these challenges. However, a rise in surgical capacity brings the concurrent risk of a rise in associated adverse events. To mitigate against this, it is critical that novel and evidence-based strategies are incorporated into surgical education, training, and quality improvement initiatives. Combining human factors with technical and non-technical skills training is one such promising paradigm shift. The importance of non-technical skills (NTS) and their relationship with technical performance in influencing operative outcomes is recognized widely. In HICs, systems such as Non-Technical Skills for Surgeons (NOTSS) and the Oxford Non-Technical Skills (NOTECHS) scale have been developed to assess surgeons' performance and inform feedback on NTS. Categories are centered on the cognitive skills of situation awareness and decision making, and the social skills themes of leadership, teamwork, and communication (Table 1).4 Although there is a paucity of data on NTS in LMICs, studies have described the presence of similar themes. Specifically, in emergency general surgery, the NTS categories of communication and leadership have been recognized as relevant, and in trauma and orthopedics, communication skills and NTS pertaining to patient safety and infection prevention have been highlighted as priorities. There is evidence that the major NTS categories appear reproducible across surgical settings, although it has been suggested that this may be context dependent. Factors that may alter NTS in the context of LMICs are: (i) overburdened health care systems, (ii) lack of provider empowerment, and (iii) deficiencies in provider training. Through interdisciplinary interviews and direct observations of surgical teams in four Rwandan hospitals (urban and rural academic hospitals, one military hospital, and one private hospital), Scott and colleagues identified representative effective and ineffective behaviors for NOTSS in a variable-resource context.5 They also identified unique contextual challenges in LMICs relating to resource, staff, communication, and systems.6 They described … surgeons acting as “bravos” (uncontrollable or aggressive), refusing to do surgeries when it does not suit them. This process led patients in the study to lose trust in the system and eventually avoid it altogether. Recognizing the potential impact of such contextual challenges on patient safety, a Non-Technical Skills for Surgeons for variable-resource context (NOTSS-VRC) curriculum was developed and has been successfully delivered in several sub-Saharan locations, including Kenya, Nigeria, and Rwanda.8 Follow-up studies have identified that, to achieve optimal delivery: participants require high-quality training in NTS and the ability to implement the skills in differing contexts; the course should be made multidisciplinary through the use of scenarios involving other theater roles, and access should be facilitated through online resources to reduce travel time away from work. As the surgical services in LMICs expand, patient safety must be protected. The importance of perioperative NTS is now well established. However, learning opportunities should target the multidisciplinary operative team, and NTS education must evolve as global surgical services modernize and scale up. Widening participation to include representatives from anesthesia, nursing, and nonphysician healthcare workers A hybrid delivery method incorporating video-conferencing from remote instructors with face-to-face teaching from local faculty Integration of the course into existing surgical skill workshops for operative teams in provincial and district hospitals. The principles of non-technical skills are consistent across all elective and emergency surgical settings. As well as being integral to intraoperative performance, NTS play a pivotal role in directing critical and culturally sensitive decisions such as goals of treatment and ceilings of care. This will become increasingly relevant globally when trying to balance the demands of population growth and greater treatment options with finite healthcare resources. In response to some of the barriers to safe and timely surgical care, there is a growing use of telemedicine in LMICs, which can assist in democratizing access to services, reducing unnecessary transfers, and facilitating patient and professional education.9 In a surgical context, this may translate to increased available appointments, easier follow-up, and more accessible public health messages. Similarly, mHealth has been shown to have a role in medical and surgical rehabilitation.10 These technologies rely on accurate communication and proficient decision-making, however under quite different conditions. It is therefore critical that NTS training develops in tandem to address the specific challenges that they pose. Future iterations of NTS training and assessment tools should complement the global capacity building of surgical teams by targeting the unique considerations present within different contexts. The integration of adapted and relevant NTS education into medical school and surgical residency curricula, alongside the development of local accredited trainers, will support the safe expansion of surgical services in LMICs. Future research priorities include: (i) further characterizing the technological, socioeconomic, and specialty-specific factors, which influence NTS in different LMIC settings; (ii) ensuring that NTS education programs are informed by those who use them; and (iii) involving all members of the multidisciplinary surgical team in the design and delivery of training. Fiona M. Kerray: Writing – original draft, writing – review & editing. Egide Abahuje: Writing – review & editing. Andrew L. Tambyraja: Conceptualization, supervision, writing – review & editing. Steven J. Yule: Conceptualization, supervision, writing – review & editing. SY reports research grants from the Johnson & Johnson Foundation, the National Institutes for Health, Canadian Department of National Defence, National Aeronautics and Space Association, Melville Trust for Care and Cure of Cancer, and the Royal College of Surgeons of Edinburgh. SY co-authored original research, which informed the design of ‘Non-technical Skills for Surgeons’ and ‘Non-technical Skills for Surgery-Variable Resource Contexts’ and is currently Director of Non-Technical Skills for The Royal College of Surgeons of Edinburgh. FK has received a research fellowship in human factors and digital education from The Circulation Foundation, The Royal College of Surgeons of Edinburgh and The Vascular Society for Great Britain and Ireland, and is involved in teaching NOTSS and NOTSS-VRC courses. EA has co-authored original research which informed the design and delivery of ‘Non-technical Skills for Surgery-Variable Resource Contexts’ and continues to be involved in course delivery. EA has received a research fellowship from the Robert Havey Institute of Global Health, Northwestern University. ALT is involved in the delivery of NOTSS courses. The author has provided further references that are included in the article or it could be made available on request.
Source: World Journal of Surgery
DOI: 10.1002/wjs.12046
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $4,000
OpenAlex ID: W4390840209