Operating Room Team Training with Simulation: A Systematic Review

Abstract

Introduction:

Nontechnical skills (NTS) such as teamwork and communication play an important role in preventing adverse outcomes in the operating room (OR). Simulation-based OR team training focused on these skills provides an environment where team members can learn with and from one another. We sought to conduct a systematic review to identify simulation-based approaches to NTS training for surgical teams.

Materials and Methods:

We conducted a systematic search of PubMed, ERIC, and the Cochrane Database using keywords and MeSH terms for studies describing simulation-based training for OR teams, including members from surgery, anesthesia, and nursing in September 2016. Information on the simulations, participants, and NTS assessments were abstracted from the articles meeting our search criteria.

Results:

We identified 10 published articles describing simulation-based OR team-training programs focused on NTS. The primary focus of these programs was on communication, teamwork, leadership, and situation awareness. Only four of the programs used a validated instrument to assess the NTS of the individuals or teams participating in the simulations.

Discussion:

Simulation-based OR team-training programs provide opportunities for NTS development and reflection by participants. Future programs could benefit from involving the full range of disciplines and professions that compose an OR team, as well as increased use of validated assessment instruments.

Introduction

Nontechnical skills (NTS) are important factors for improving the safety of medical and surgical care.¹ Specifically, teamwork² and communication³ play an important role in preventing adverse events and ensuring patient safety in the operating room (OR). While these skills are considered essential, most formal curricula focus on the knowledge and technical skills necessary for the profession.¹ Few curricula are dedicated to specific improvement in NTS.

Simulation-based training has been widely adopted by medical and health professional programs for teaching technical skills.⁴ By providing an environment that can be used for training NTS, it provides a safe place where clinicians are able to receive instruction and develop their skills without risk to patients. Many disciplines, including anesthesia⁵ and obstetrics,⁶ have used simulation-based training programs to teach communication and teamwork skills to create safer care and reduce malpractice claims. Participants in these programs frequently come from a single discipline or profession, with the other roles being played by actors in confederate roles.

Teams that work together have been called upon by the US Institute of Medicine to train together to fully understand the strengths and weakness of each member's discipline and training.⁷ While simulation-based training for a single discipline may provide opportunities for education and development, interprofessional simulation-based team training allows learners from all involved disciplines to engage in the deliberate practice of team and communication skills with individuals from the professions that they work with on a day-to-day basis in the OR.⁸

Previous reviews of OR team-training programs have focused either on the acceptability of such programs⁸ or have included studies that did not include all three major disciplines involved in surgery.⁹ To determine the current state of surgical team training in NTS, we conducted a systematic review of the literature regarding interprofessional OR team simulation training programs that include members of all three major professional groups (surgeons, anesthesiologists, and nurses). We also sought to identify the assessment tools used in these programs.

Materials and Methods

Search strategy

We searched PubMed, ERIC, and Cochrane for all original research studies describing simulation-based NTS team training for OR teams published between January 1, 2000 and September 1, 2016. The search was performed using the following relevant keywords and MeSH terms: interprofessional, interdisciplinary, NTS, communication, surgery, OR, surgical team, teamwork, and simulation. The reference lists of identified articles were hand-searched for additional publications that might have been missed in the search.

Titles and abstracts of all identified articles were read to determine whether the article fit the objectives of the review. Full text of articles that appeared to be relevant was reviewed to determine whether the articles met the inclusion criteria.

Inclusion and exclusion criteria

Articles were included if they were written or translated into English, published in a peer-reviewed journal or other peer-reviewed periodical, contained a simulation component, had activities or assessments related to NTS, and included at least one team member from surgery, anesthesia, and nursing as part of the training team. Surgery participants could include students, residents, fellows, or attending surgeons. Anesthesia participants could include either physician anesthesiologists or nurse anesthetists at the student, trainee, or practitioner level. Nursing participants could include circulating nurses or scrub technician at either the student or practitioner level.

Articles were excluded if they did not include a member from each of the disciplines, if a discipline was only included in a planned confederate (actor) role, or if the training focused solely on technical skills.

Data extraction

Two independent reviewers assessed and abstracted information from each of the articles using a predefined data abstraction form. Data regarding the following factors were obtained from each of the articles: first author, publication date, study method, participant characteristic, assessment methods, and major findings. Any points of disagreement were discussed until a consensus was reached. A third reviewer was available if any discrepancies in data extraction could not be reconciled.

Results

A total of 232 studies were identified during the initial search. After abstract review, 19 studies were included as potentially being relevant to the questions. After final review, abstraction, and consensus, nine articles met the inclusion criteria. One additional article was found by hand-searching the reference lists of full-text articles. Thus, a total of 10 studies were identified for inclusion in the review (Fig. 1).^10–19

FIG. 1.

Review process flow and article inclusion and exclusion.

Setting

Single-institutional programs comprised nine^10–18 of the ten included studies, with the other¹⁹ conducted at four different sites. Four studies utilized simulation centers for the training,^13–15,18 three studies used in situ simulation^10,12,16 and one study used a combination of both in situ and simulation center-based training.¹⁷ The study¹⁹ that occurred at multiple sites had three sites that utilized simulation centers and one that utilized in situ simulation. In one¹¹ study, the location of the training was unclear (Table 1).

Table 1.

Participant and Scenario Characteristics

Refs.	Setting	Surgical specialty	Surgery participants	Anesthesia participants	Nursing participants	Other participants
Paige et al.¹⁵	Simulation Center	General	3 PGY4 surgical residents	2 CRNAs; 2 CRNA students	3 circulating registered nurses	None
Undre et al.¹⁴	Simulation Center	General	20 senior surgery residents	20 senior anesthesia residents	20 scrub nurses	20 newly qualified or student ODPs
Paige et al.¹⁶	In situ	General	3 attending level surgeons; 6 senior level (PGY3–5) surgical residents	10 CRNAs	11 circulating nurses	None
					8 scrub technicians
Volk et al.¹⁰	In situ	Otolaryngology	18 PGY3 otolaryngology residents	5 anesthesia residents; 5 anesthesia fellows; 4 CRNAs	20 OR nurses	None
			7 PGY6 otolaryngology fellows
Stevens et al.¹³	Simulation center	Cardiac	5 attending cardiac surgeons	5 attending cardiac anesthesiologists	5 cardiac operating room nurses; 5 cardiac anesthesia nurses	5 perfusionists
Arriaga et al.¹⁹	Simulation Centers and in situ	General	58 attending surgeons	38 attending anesthesiologists	53 OR nurses	5 surgical PAs
						8 biomedical engineers
			7 surgery residents	7 CRNAs	16 surgical technologists	29 other members
Kjellin et al.¹⁸	Simulation Center	General	2 surgery residents	2 anesthesia residents	3 anesthesia nurses	None
					6 scrub nurses
Nicksa et al.¹⁷	Simulation Center and in situ	General surgery with emergency medicine and critical care components	23 PGY1 surgical residents; 20 PGY2 surgical residents	Anesthesia residents and fellows (no n provided)	Full time and student nurses (no n provided)	Members from critical care, medicine, respiratory therapy and pharmacy
Phitayakorn et al.¹²	In situ	General	5 surgery residents	10 anesthesia residents	10 OR nurses and scrub nurses	None
Stewart-Parker et al.¹¹		General	26 surgical residents	3 anesthesia residents	25 scrub nurses	4 HCAs; 10 ODPs

CRNAs, certified registered nurse anesthetists; HCA, healthcare assistant; ODP, operating department practitioner; OR, operating room.

Eight studies were in general surgery.¹⁹ Two studies were in surgical subspecialties, one each in cardiac surgery¹³ and otolaryngology.¹⁰

Participant characteristics

Surgery

Of the 10 programs included in this review, seven^{10–12,14,15,17,18} were designed specifically for surgical trainees. Two described programs that involved both surgical trainees and attending surgeons.^16,19 A single study included only attending surgeons.¹³

Surgical trainees were described as being senior level residents and fellows in four programs.^10,14–16 One study focused on junior surgical residents.¹⁷ In three of the studies, the level of the participating residents was not noted.^11,12,18

Anesthesia

Participants from anesthesiology varied among physician anesthesiologists at the resident, fellow, and attending level and certified registered nurse anesthetists (CRNAs) at the practitioner and student level. Five studies^{11,12,14,17,18} involved physician anesthesia trainees at the resident and/or fellow level. A single study¹⁰ used both physician anesthesia trainees and CRNAs as the participants. One study^15,16 used only practicing CRNAs, and another study¹⁵ used both practicing and student CRNAs. Attending anesthesiologists were the sole participants in a single study.¹³ A final study involved both attending anesthesiologists and practicing CRNAs.¹⁹ Two studies involved attending physician anesthesiologists, one in conjunction with CRNAs. In addition to the main anesthesia role, two studies^13,18 also included specific anesthesia nurses as participants.

Nursing

Three studies^12,16,19 included both circulating nurses and scrub practitioners in the scenarios. Four studies included^11,13,14,18 had scrub practitioners as the only nursing participants in the scenario, and three studies^10,15,17 had circulating nurses as the only nurse participants in the scenario. A single study¹⁷ utilized both practicing and student nurses as participants in the scenarios.

Other OR team members

Five^{11,13,14,17,19} of the identified studies included additional members of the OR team. One study¹³ included perfusionists as additional members of the surgical team during the scenarios. Another study¹⁷ included team members from pharmacy, critical care, emergency medicine, respiratory therapy, and cardiology as part of a larger simulation with surgical residents that took place across several simulated locations, including the OR. Two studies^11,14 included operating department practitioners (ODPs), and one study¹¹ also included healthcare assistants (HCAs) in the simulation. One study¹⁹ included surgical physician assistants, biomedical engineers, and other nonidentified team members.

Curricula

The described programs included between one and four scenarios for each of the OR teams. Four of the programs^12,14,15,17 used one training scenario, one program¹³ used two training scenarios, three programs^10,11,19 used three training scenarios, and one program¹⁸ used four training scenarios. In one program,¹⁶ the number of training scenarios varied by OR team. In addition to the scenarios and debriefing, four of the team-training programs^10,11,13,19 also included a didactic teaching component.

Nine^10–17,19 of the included articles described the focus of the postscenario debriefing. Communication,^{10,11,15,17,19} teamwork,^{11,13,15–17} leadership,^10,11 and situational awareness^11,15,17 were most common themes among the targeted behaviors for debriefing. Fixation,¹⁰ reflective practice,¹⁶ speaking up,^10,19 problem solving,¹⁷ decision-making,¹¹ use of the surgical checklist,¹⁹ and transfer of knowledge to clinical practice¹⁶ were also mentioned as the focus of the debriefing sessions, although less frequently.

The OR team-training programs ranged from a 3-hour course to a full-day training session. Four^10,13,14,19 were half-day training programs, and two^11,18 were full-day courses. Another two programs^15,16 were 3 hours in length. In two programs,^12,17 the description did not include the length of the training.

Evaluation and assessment

NTS assessment

Six^{10,13,15,16,18,19} of the ten included programs did not use any NTS assessment for the teams or participants. Four^11,12,14,17 studies used a validated instrument for assessing the NTS of participants. In three^11,14,17 of these studies the programs used a modified version of NOTECHS²⁰ (Table 2). A single study¹² used separate rating scales for the participating scrub practitioners (SPLINTS),²¹ anesthesiologists, (ANTS)²² and surgeons (NOTSS)²³ as well as an overall teamwork assessment scale (OTAS).²⁴

Table 2.

Formal and Informal Assessments of Participant Nontechnical Skills

Refs.	Validated NTS tools assessment	Other assessments/evaluations	Focus of debriefing
Paige et al.¹⁵	None	Post-training questionnaire on the effectiveness of the training,	Debriefed on teamwork, communication and situational awareness
Undre et al.¹⁴	Modified NOTECHS	OSATS	Debriefed on team performance, teamwork in surgery, and teamwork skills.
		ICATS-N
		Detailed notes on the technical performance of anesthesiologists and ODPs
		PETQ
Paige et al.¹⁶	None	Pre- and post-training questionnaire on self efficacy for performing teamwork competencies in the OR	Debriefed on reflective practice, specific teaching of teamwork competencies, and strategies for transferring learning to everyday practice.
Volk et al.¹⁰	None	Course evaluation focused on course organization, realism, debriefing, and relevance to future practice	Debriefing focused on leadership, speaking up, fixation, and communication
Stevens et al.¹³	None	Operating room teamwork climate survey done presimulation and 6 months postsimulation.	Debriefing focused on team and individual performances related to CRM
		Postsession questionnaire on the experience and teamwork effectiveness
Arriaga et al.¹⁹	None	Postcourse survey on perceptions of the scenarios and quality of debriefing sessions	Debriefed on closed-loop communication, use of the WHO Surgical Safety Checklist and speaking up/assertiveness.
Kjellin et al.¹⁸	None	Situational Motivational Scale	Not described
		Self-determination continuum
		Pre- and post-training self-efficacy
		Course exit questionnaire
Nicksa et al.¹⁷	Modified NOTECHS	Postcourse surveys on perceptions of the simulation sessions and improvement in communication skills, problem diagnosis, and procedural skills.	Debriefed on communication and interaction, leadership and managerial skills, teamwork and cooperation, problem solving and decision-making, and situational awareness and vigilance.
Phitayakorn et al.¹²	SPLINTS, ANTS, NOTSS, OTAS	Adherence to malignant hyperthermia checklist	Debriefing focused on behaviors during the session
Stewart-Parker et al.¹¹	Modified NOTECHS	Course evaluation at end of session and 6 months after course to gauge attitudes and measure learning	Debriefing on individual pieces of NOTECHS scale

NTS, nontechnical skills; PETQ, Participant Evaluation of Training Questionnaire.

Technical skill assessment

In addition to the NTS focus during the training sessions, two studies^12,14 also included assessments of technical skills. Specifically, one study¹² used a checklist with the steps for managing malignant hyperthermia, and another¹⁴ used several validated instruments for assessing the technical skills of the surgeons (OSATS) and nurses (ICATS-N), as well as detailed notes of the technical skills of anesthesiologists and ODPs for feedback and coaching.

Course evaluation

Nine^{10,11,13–19} of the ten included studies described the use of a course evaluation completed by participants on the content, structure, and overall impact of the material. In one of these studies,¹⁴ the program used a modified version of the validated Participant Evaluation of Training Questionnaire (PETQ)²⁵ at the end of the session. Several of the studies also included other measures of success as part of the training program. One course¹¹ measured attitudes and learning related to the course, both immediately following the training session at 6 months after training. Another course¹³ conducted an OR teamwork climate survey both before and 6 months after their team-training intervention to assess the impact of the program on the OR climate. Two studies^16,18 measured pre- and post-training self-efficacy related to used NTS in the OR.

Discussion

This systematic review identified 10 unique reports of simulation-based OR team-training programs focused on the NTS of surgeons, anesthesiologists, and nurses. Overall, the educational programs described in these articles focused heavily on the teamwork and communication between members of the different disciplines participating in the simulation trainings.

Given the popularity of simulation-based training, one might expect more reports of interdisciplinary surgical team training. There are many more reports in the literature of single disciplines or two disciplines working together. This is not an uncommon training model as there are fewer barriers to include only two of the disciplines, including cost, time, and departmental buy-in. While these programs provide an important training opportunity for individuals from different disciplines or professions to work together, they leave other essential team members. Whole-team communication failures can lead to errors and threats to patient safety; therefore, whole surgical team simulations targeting NTS, as well as change OR culture around communication and teamwork, may improve patient care and assist teams in creating shared mental models with the OR.

While several validated instruments exist for objectively measuring the NTS of individuals^21–23 as well as OR teams,²⁰ only four^11,12,14,17 of the programs included in this review made use of these instruments for assessment of participants. These tools can be helpful for guiding discussions and debriefing, coaching participants toward improvement, and tracking improvements of participants over time.

As reporting of outcomes from these studies is not standardized and is largely based on responses to postcourse evaluations or various assessments conducted by the facilitators, it was not possible to perform a meta-analysis. To gain a better understanding of the variability and extent of the simulation-based OR team-training programs being conducted, we chose to include all reports, regardless of the quality of the research or reporting. Possible future research into the development of standardized instruments for assessing OR team training would be beneficial to enable comparison of different educational programs. Presumably, a number of groups are running similar programs but have not published their educational program.

To our knowledge, this is the first review to look at NTSs in interprofessional OR team training where all three disciplines were represented. Given the continued rise of such programs, it is likely that other programs will continue to develop. While many similarities between the training programs exist, each of the developed programs has unique elements that may influence the resulting knowledge and ultimately behavior changes that occur as a result of the training. Standardized outcomes would allow for comparison between programs and identification of the hallmarks of a successful OR team-training program that can be shared and adopted by departments and centers looking to create a program to increase communication and teamwork among OR teams and improve patient safety.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Yule

, Paterson-Brown

. Surgeons' non-technical skills. Surg Clin North Am, 2012; 92:37–50.

Mazzocco

, Petitti

, Fong

, et al. Surgical team behaviors and patient outcomes. Am J Surg, 2009; 197:678–685.

Greenberg

, Regenbogen

, Studdert

, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg, 2007; 204:533–540.

Motola

, Devine

, Chung

, Sullivan

, Issenberg

. Simulation in healthcare education: A best evidence practical guide. AMEE Guide No. 82. Med Teach, 2013; 35:e1511–e1530.

Lorello

, Cook

, Johnson

, Brydges

. Simulation-based training in anaesthesiology: A systematic review and meta-analysis. Br J Anaesth, 2014; 112:231–245.

Fransen

, Banga

, van de Ven

, Mol

BWJ

, Oei

. Multi-professional simulation-based team training in obstetric emergencies for improving patient outcomes and trainees' performance. Cochrane Database of Systematic Reviews, 2015, Issue 2. Art. No.: CD011545.

Kohn

, Corrigan

, Donaldson

. To Err Is Human: Building a Safer Health System. Vol. 6. Washington, DC: National Academies Press, 2000.

Cumin

, Boyd

, Webster

, Weller

. A systematic review of simulation for multidisciplinary team training in operating rooms. Simul Healthc, 2013; 8:171–179.

Tan

, Pena

, Altree

, Maddern

. Multidisciplinary team simulation for the operating theatre: A review of the literature. ANZ J Surg, 2014; 84:515–522.

10.

Volk

, Ward

, Irias

, Navedo

, Pollart

, Weinstock

. Using medical simulation to teach crisis resource management and decision-making skills to otolaryngology housestaff. Otolaryngol Head Neck Surg, 2011; 145:35–42.

11.

Stewart-Parker

, Galloway

, Vig

. S-TEAMS: A truly multiprofessional course focusing on nontechnical skills to improve patient safety in the operating theater. J Surg Educ, 2016; 74:137–144.

12.

Phitayakorn

, Minehart

, Hemingway

, Pian-Smith

, Petrusa

. The relationship between intraoperative teamwork and management skills in patient care. Surgery, 2015; 158:1434–1440.

13.

Stevens

, Cooper

, Raemer

, et al. Educational program in crisis management for cardiac surgery teams including high realism simulation. J Thorac Cardiovasc Surg, 2012; 144:17–24.

14.

Undre

, Koutantji

, Sevdalis

, et al. Multidisciplinary crisis simulations: The way forward for training surgical teams. World J Surg, 2007; 31:1843–1853.

15.

Paige

, Kozmenko

, Morgan

, et al. From the flight deck to the operating room: An initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation. J Surg Educ, 2007; 64:369–377.

16.

Paige

, Kozmenko

, Yang

, et al. High-fidelity, simulation-based, interdisciplinary operating room team training at the point of care. Surgery, 2009; 145:138–146.

17.

Nicksa

, Anderson

, Fidler

, Stewart

. Innovative approach using interprofessional simulation to educate surgical residents in technical and nontechnical skills in high-risk clinical scenarios. JAMA Surg, 2015; 150:201–207.

18.

Kjellin

, Hedman

, Escher

, Fellander-Tsai

. Hybrid simulation: Bringing motivation to the art of teamwork training in the operating room. Scand J Surg, 2014; 103:232–236.

19.

Arriaga

, Gawande

, Raemer

, et al. Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams. Ann Surg, 2014; 259:403–410.

20.

Mishra

, Catchpole

, McCulloch

. The Oxford NOTECHS System: Reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Qual Saf Health Care, 2009; 18:104–108.

21.

Mitchell

, Flin

, Yule

, Mitchell

, Coutts

, Youngson

. Development of a behavioural marker system for scrub practitioners' non-technical skills (SPLINTS system). J Eval Clin Pract, 2013; 19:317–323.

22.

Fletcher

, Flin

, McGeorge

, Glavin

, Maran

, Patey

. Anaesthetists' Non-Technical Skills (ANTS): Evaluation of a behavioural marker system. Br J Anaesth, 2003; 90:580–588.

23.

Yule

, Flin

, Maran

, Rowley

, Youngson

, Paterson-Brown

. Surgeons' non-technical skills in the operating room: Reliability testing of the NOTSS behavior rating system. World J Surg, 2008; 32:548–556.

24.

Hull

, Arora

, Kassab

, Kneebone

, Sevdalis

. Observational teamwork assessment for surgery: Content validation and tool refinement. J Am Coll Surg, 2011; 212:234–243.e231–e235.

25.

Moorthy

, Munz

, Forrest

, et al. Surgical crisis management skills training and assessment: A simulation[corrected]-based approach to enhancing operating room performance. Ann Surg, 2006; 244:139–147.