Elsevier

Journal of Surgical Education

Volume 78, Issue 5, September–October 2021, Pages 1618-1628
Journal of Surgical Education

Original Reports
Understanding Barriers and Facilitators to Behavior Change After Implementation of an Interdisciplinary Surgical Non-Technical Skills Training Program in Rwanda

https://doi.org/10.1016/j.jsurg.2021.01.011Get rights and content

Objective

Nontechnical skills, such as situation awareness, decision making, leadership, communication, and teamwork play a crucial role on the quality of care and patient safety in the operating room (OR). In our previous work, we developed an interdisciplinary training program, based on the NOTSS (Non-Technical Skills for Surgeons) taxonomy. The aim of this study was to understand the challenges faced by Rwandan surgical providers, who had undergone NOTSS training, to apply these nontechnical skills during subsequent operative surgery.

Setting Design

A sequential exploratory mixed method study design was used to assess how participants who took the NOTSS in Rwanda applied nontechnical skills in surgical care delivery. The qualitative phase of this study deployed a constructivist grounded theory approach. Findings from the qualitative phase were used to build a quantitative survey tool that explored themes that emerged from the first phase.

Participants

Participants were nurses and resident from the departments of Surgery, Anesthesia, Obstetric, and Gynecology, from the University of Rwanda who attended the NOTSS course in March 2018.

Results

A total of 25 participants and 49 participants were respectively enrolled in the qualitative phase and quantitative phase. Participants noted that nontechnical skills implementation in clinical practice was facilitated by working with other personnel also trained in NOTSS, anticipation, and preparation ahead of the time; while lack of interdisciplinary communication, hierarchy, work overload, and an inconsistently changing environment compromised nontechnical skills implementation. Nontechnical skills were useful both inside and outside the operating. Participants reported that nontechnical skills implementation resulted in improved team dynamics, safer patient care, and empowerment.

Conclusion

Surgical care providers who took the NOTSS course subsequently implemented nontechnical skills both inside and outside of the OR. Human and system-based factors affected the implementation of nontechnical skills in the clinical setting.

Introduction

Surgical teams require effective technical and nontechnical skills to provide safe and high quality care to patients in the operating room (OR). In low- and middle-income countries (LMICs), the resource-variable environment in which surgery is performed makes nontechnical skills even more relevant.1 Previous studies have identified nontechnical skills training as an essential method of mitigating medical errors in the OR.2 The Non-Technical Skills for Surgeons (NOTSS) training course and assessment tool defines the cognitive and social behaviors for surgeons and OR team members, which underpin medical expertise and appropriate use of resources. These behaviors comprise 4 categories: Situation awareness, decision making, communication and teamwork, and leadership.3,4 To improve the intraoperative safety of patients in LMICs, nontechnical skills for surgery course addressing the variable-resource context (NOTSS-VRC) of developing countries was developed and implemented in Rwanda. This course consists of short lectures, simulated surgical videos, nontechnical skills rating, and small group discussions.1,5,6

Studies that have assessed the impact of nontechnical skills training on patient outcomes revealed variable results. A study demonstrated decreased complication rates on patients who are managed by teams that participated in the nontechnical skills course,7 while other studies did not find any difference in patient outcomes and system-based care delivery.8, 9, 10 Transfer of knowledge and skills to the clinical setting is the main goal of surgical training, and nontechnical skills courses are no different in this regard. This translational aspect can be objectively assessed by direct observation of learners in the clinical environment or, subjectively, through self-report instruments (e.g., asking learners how they apply lessons in real life).11

Despite previous efforts to train Rwandan surgical providers in nontechnical skills, there is scarce data on if and how behaviors change after training and the common barriers encountered while implementing nontechnical skills in real life situations.1,5,12,13 The Theoretical Domain Framework,14 offers guidance for understanding the behavior change needed for implementing new practices. This framework recommends beginning with qualitative assessment when the implementation of the behaviors is not well understood. In our context, nothing is known about how healthcare providers implement nontechnical skills in clinical practice or the facilitators and barriers to its incorporation. Understanding these will help instructors to tailor the nontechnical skills course and facilitate trainees’ acquisition of important skills to address context-specific challenges while implementing nontechnical skills in clinical practice.

The aim of this study was to understand the barriers and facilitators faced by surgical providers who had participated in the NOTSS course in Rwanda when applying nontechnical skills to the delivery of surgical care in the OR.

Section snippets

Study Design

This study used a sequential exploratory mixed-method design. The mixed-method design is characterized by an initial qualitative phase to explore a phenomenon followed by a quantitative phase of data collection and analysis to further test insights from the first phase.15 The qualitative phase was used to identify and define the barriers and facilitators encountered by surgical care providers trained in NOTSS-VRC. Findings from the qualitative phase were used to build a survey tool that was

Themes

We identified 3 overarching themes that represent the process and impact of the NOTSS implementation in the OR: (1) Factors affecting the implementation of nontechnical skills (barriers and facilitators), (2) Implementation of nontechnical skills in clinical practice, and (3) Impact of nontechnical skills on systems of patient care. We describe each of these overarching themes and several subthemes in detail below.

Figure 1: Themes

Figure 1 illustrates relationships between themes

Theme 1: Factors

Discussion

This study intended to understand the barriers and facilitators to behavior change after implementation of the multi-disciplinary NOTSS-VRC training program in Rwanda. We described the factors influencing the implementation of nontechnical skills in clinical practice. Working with personnel trained in nontechnical skills, and anticipation and preparation ahead of the time were found to facilitate implementation of nontechnical skills in clinical practice, while poor interdisciplinary

Conclusion

Surgical care providers who took the nontechnical skills for surgery course implemented the newly acquired nontechnical skills both in the operating room and outside it. Human and system-based factors affected the implementation of nontechnical skills in clinical environment. By understanding these barriers and facilitators of nontechnical skills implementation we can help health professions educators effectively design and deliver courses that have a higher chance of achieving course goals and

Declaration of Competing Interest

We have nothing to disclose.

Acknowledgment

We would like to thank the following people for their tremendous support in reviewing the data collection tool and results of this study: Amanda Reich, and Deborah Navedo.

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