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