- •The developed skills taxonomy comprised six categories and 18 elements.
- •Each category comprised one to six elements, which is a list of observable behaviors.
- •The taxonomy contains contextual information with commonly used terminologies for nontechnical skills in nursing crisis management.
Effective crisis management requires nurses to demonstrate proper nontechnical skills as first responders to intervene early in handling crisis situations. Currently, a behavioral marker system with structured taxonomy of nontechnical skills in crisis management is lacking in the nursing literature. This article outlines the development of a skills taxonomy, which will form the basis of the behavioral marker system that we aim to develop in our next phase of study.
We audio-recorded 50 registered nurses and enrolled nurses over five simulation debriefing sessions. We analyzed the data using a thematic analysis approach and developed a skills taxonomy. To ensure face validation, we invited four experts to review the skills taxonomy and to comment on each behavior's observability.
We developed a skills taxonomy comprising six categories and 18 underlying observable behaviors (elements). The developed categories are task and resource management, situational awareness, teamwork, communication, control of emotions, and leadership.
We have developed a skills taxonomy fostering the use of a common terminology for nontechnical skills in nursing crisis-management teams. Further work to develop a rating system and to test its reliability will be conducted.
Human factors and poor teamwork contribute to poor performance in high-risk industries (
Flin et al., 2008). This leads to the introduction of team-oriented training, called crew resource management (CRM) in the aviation industry, for pilots in the late 1970s. The aim of the training is to promote safety through optimum use of equipment, procedures, and people (
- Flin R.H.
- O'Connor P.
- Crichton M.
Safety at the Sharp End: A Guide to Non-technical Skills.
Ashgate Publishing, Ltd, Hampshire, England2008
Lauber, 1984) with focus on nontechnical skills which complement technical or psychomotor proficiency (
- Lauber J.K.
Resource management in the cockpit.
Air line pilot. 1984; 53: 20-23
van Avermaete and Krujisen, 1998). Similarly, in health care, breakdowns in communication, poor teamwork, lack of leadership, poor decision-making, and failure in collaboration between individuals and teams have strong linkages to incidence of error and adverse events in hospitals (
- van Avermaete J.A.G.
- Krujisen E.
The evaluation of non-technical skills of multi-pilot aircrew in relation to the JAR-FCL requirements.
National Aerospace Laboratory (NLR), Amsterdam1998
Greenberg et al., 2007,
- Greenberg C.C.
- Regenbogen S.E.
- Studdert D.M.
- Lipsitz S.R.
- Rogers S.O.
- Zinner M.J.
- Gawande A.A.
Patterns of communication breakdowns resulting in injury to surgical patients.
Journal of the American College of Surgeons. 2007; 204: 533-540
Kennedy et al., 2009,
- Kennedy T.J.
- Regehr G.
- Baker G.R.
- Lingard L.
Preserving professional credibility: Grounded theory study of medical trainees’ requests for clinical support.
BMJ. 2009; 338: b128
Kohn et al., 2000,
- Kohn L.T.
- Corrigan J.
- Donaldson M.S.
To err is human: Building a safer health system.
National Academy Press, Washington, DC2000
Manser, 2009). In recent years, there has been an upsurge in the application of CRM-type training within hospitals; such training provides a systematic teaching and learning approach for improving nontechnical skills.
- Manser T.
Teamwork and patient safety in dynamic domains of healthcare: A review of the literature.
Acta Anaesthesiologica Scandinavica. 2009; 53: 143-151
Crisis situations are situations with life-threatening emergencies, for which urgent and coordinated actions between different professions are needed to ensure safe patient care. Nurses, working as front-line health care professionals are required to respond early and in a timely manner in managing crisis situations in the clinical setting. Hence, it is critical for nurses to demonstrate not only clinical competence but also effective nontechnical skills. Nurses need to develop, learn, and improve their nontechnical skills to solve a myriad of problems and issues during their daily routine work to ensure safe and efficient task performance.
To facilitate trainings and assessments, nontechnical skills taxonomies have been developed in health care based on the CRM principles (e.g., situation awareness, teamwork). For example, the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) system (
King et al., 2008) aims to improve team training initiatives and outcomes. It comprises training programs and standardization and validation measures that allow health care providers to improve performance through training. In more specific health care contexts, assessment tools for nontechnical skills with tested reliability and validity in medical or in multidisciplinary team settings were developed: (1) Observational Teamwork Assessment for Surgery (
- King H.B.
- Battles J.
- Baker D.P.
- Alonso A.
- Salas E.
- Webster J.
- Salisbury M.
TeamSTEPPS™: Team strategies and tools to enhance performance and patient safety.
in: Advances in patient safety: New directions and alternative approaches. Vol. 3. Agency for Healthcare Research and Quality, Rockville, MD2008: 5-20
Undre et al., 2007), Oxford Non-Technical Skills (
- Undre S.
- Sevdalis N.
- Healey A.N.
- Darzi A.
- Vincent C.A.
Observational teamwork assessment for surgery (OTAS): Refinement and application in urological surgery.
World Journal of Surgery. 2007; 31: 1373-1381
Mishra et al., 2009), Non-Technical Skills for Surgeons (
- Mishra A.
- Catchpole K.
- McCulloch P.
The Oxford NOTECHS System: Reliability and validity of a tool for measuring teamwork behaviour in the operating theatre.
BMJ Quality & Safety. 2009; 18: 104-108
Yule et al., 2006), and Scrub Practitioners' List of Intra-operative Non-Technical Skills (
- Yule S.
- Flin R.
- Paterson-Brown S.
- Maran N.
- Rowley D.
Development of a rating system for surgeons' non-technical skills.
Medical Education. 2006; 40: 1098-1104
Mitchell et al., 2013) in the context of surgery; (2) Trauma Non-Technical Skills (
- Mitchell L.
- Flin R.
- Yule S.
- Mitchell J.
- Coutts K.
- Youngson G.
Development of a behavioural marker system for scrub practitioners' non-technical skills (SPLINTS system).
Journal of Evaluation in Clinical Practice. 2013; 19: 317-323
Steinemann et al., 2012) for teams that attend trauma calls; (3) Anesthesiologists’ Non-Technical Skills (
- Steinemann S.
- Berg B.
- DiTullio A.
- Skinner A.
- Terada K.
- Anzelon K.
- Ho H.C.
Assessing teamwork in the trauma bay: Introduction of a modified “NOTECHS” scale for trauma.
The American Journal of Surgery. 2012; 203: 69-75
Fletcher et al., 2004) for anesthetic personnel; (4) Ottawa Crisis Resource Management Global Rating Scale (
- Fletcher G.
- Flin R.
- McGeorge P.
- Glavin R.
- Maran N.
- Patey R.
Rating non-technical skills: Developing a behavioural marker system for use in anaesthesia.
Cognition Technology and Work. 2004; 6: 165-171
Kim et al., 2006) and Mayo High Performance Teamwork Scale (
- Kim J.
- Neilipovitz D.
- Cardinal P.
- Chiu M.
- Clinch J.
A pilot study using high-fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Critical Care Medicine, High-Fidelity Simulation, and Crisis Resource Management I Study.
Critical Care Medicine. 2006; 34: 2167-2174
Malec et al., 2007) for teams in acute settings; and (5) Observational Skill-based Clinical Assessment Tool for Resuscitation (
- Malec J.F.
- Torsher L.C.
- Dunn W.F.
- Wiegmann D.A.
- Arnold J.J.
- Brown D.A.
- Phatak V.
The mayo high performance teamwork scale: Reliability and validity for evaluating key crew resource management skills.
Simulation in Healthcare. 2007; 2: 4-10
Walker et al., 2011) for resuscitation teams. Some tools are developed in the form of behavioral marker, which comprise a skills taxanomy and a rating system. Behavioral marker system consists of a stipulated set of behaviors indicative of performance of an individual. It can be used as a standardized lexicon to structure assessments and feedback (
- Walker S.
- Brett S.
- McKay A.
- Lambden S.
- Vincent C.
- Sevdalis N.
Observational Skill-based clinical assessment tool for resuscitation (OSCAR): Development and validation.
Resuscitation. 2011; 82: 835-844
Dietz et al., 2014) of different skill sets including communication, leadership, situation awareness, decision-making, teamwork, task management, problem solving, and resource utilization.
- Dietz A.S.
- Pronovost P.J.
- Benson K.N.
- Mendez-Tellez P.A.
- Dwyer C.
- Wyskiel R.
- Rosen M.A.
A systematic review of behavioural marker systems in healthcare: What do we know about their attributes, validity and application?.
BMJ quality & safety. 2014; 23: 1031-1039
To date, tools to assess nurse anesthetists (
Lyk-Jensen et al., 2014) and scrub nurses (
- Lyk-Jensen H.T.
- Jepsen R.M.H.G.
- Spanager L.
- Dieckmann P.
- Østergaard D.
Assessing nurse Anaesthetists' non-technical skills in the operating room.
Acta Anaesthesiologica Scandinavica. 2014; 58: 794-801
Mitchell et al., 2011) have been developed, but a tool to identify strengths and weaknesses among nurses within a crisis management context is lacking. To facilitate structured observation and systematic feedback on observable nontechnical skills among nurses, a tool to identify strengths and weaknesses of nurses’ performances is required.
- Mitchell L.
- Flin R.
- Yule S.
- Mitchell J.
- Coutts K.
- Youngson G.
Thinking ahead of the surgeon. An interview study to identify scrub nurses’ non-technical skills.
International Journal of Nursing Studies. 2011; 48: 818-828
Aim of the Study
We aim to develop a skills taxonomy in the context of nursing for crisis management by fostering common nontechnical skills terminologies in the nursing profession. This would form the basis of the behavioral marker system which we will be developing further in our next phase of study.
Fifty registered nurses (RNs) and enrolled nurses (ENs) with at least six months of work experience in a clinical environment were recruited over five “Crisis Management for Nurses” half-day simulation sessions between August and December 2016. Each simulation session was attended by 10 to 14 RNs and ENs. The half-day simulation sessions comprised an instructional simulation component that provided interactive and immersive simulated scenarios. The primary aim of the sessions was to assist RNs and ENs recognize their gaps in nontechnical skills through work coordination with team members; the secondary aim was to allow RNs and ENs to apply knowledge and skills in crisis management.
The simulation room was set up to mimic a clinical setting and with video- and audio-recording facilities. For each simulation, one EN and three RNs were randomly selected to form a team to role-play in a given scenario. A leader was nominated by the team members. The program facilitator clarified queries from the team members before role play. During the role-play, the program facilitator voiced over as a medical doctor and the patient (manikin). Here is an example of the scenario:
Mr. Goh was admitted for chest pain from ED two days ago. He has been complaining about chest discomfort for the past 3 weeks. ECG showed atrial fibrillation in ED. His vital signs at 12pm were BP-121/72 mmHg, PR – 99 bpm, RR-15 bpm and SPO2-97%. At 1.30 pm, while you approached him to serve his medication, he was found unconscious.
The RNs and ENs responded to and managed patients' conditions (e.g., breathlessness, chest pain, low blood pressure reading, and so forth) according to the given scenarios that are found common in clinical situations for patients with deteriorating health conditions. Each scenario took approximately 10 minutes. Nurses’ performances were video-recorded for debriefing purposes. A debrief session lasting for 30 to 45 minutes was conducted in a group setting immediately after the role play. During debriefings, the program facilitator helped RNs and ENs reflect on their behaviors and actions during role play by replaying the video and asking open-ended reflective questions rather than directed questions about nontechnical skills. For example, “There was a delay in preparing for the intubation. I am curious what were you thinking? Could you share with us?” The facilitator would then probe the RNs or ENs to elaborate on their responses whenever they mentioned about aspects related to nontechnical skills. The debriefing sessions were audio-recorded for data analysis.
Data collected during debriefings were audio-recorded over five simulation sessions and transcribed. Data on nontechnical skills were analyzed using thematic analysis approach. Similar codes were grouped together to form observable behaviors called elements; similar elements were grouped together to form categories. A brief description for each category was developed. To contextualize the use of each behavioral element, good and bad practice exemplars for each element were provided. The exemplars were either identified during the simulations or debriefing or developed by the study team members after reaching consensus. In view of the need for easy usage of the behavioral marker system as a tool of assessment and feedback for nurses, original terms and words used by the participants were retained as much as possible by the study team in the analysis process. All elements and categories were discussed and reviewed iteratively between study team members to minimize overlap between categories and to ensure the taxonomy was relevant to crisis management in nursing. Data were analyzed using ATLAS.ti 8.0.
The developed skills taxonomy was assessed further for face validation by nursing experts to better align with the nurses' role, competence, and task in crisis management. Four nursing experts (e.g., nurse clinicians, nurse educators) were invited based on their expertise as a life support trainer and experience in managing clinical crisis situations. They were asked to review the categories, descriptions, elements, and examples of good and bad practices. Specifically, they were asked to review the skills taxonomy by answering these questions: (1) Are the categories well defined? (2) Does each category consist of the right set of elements? (3) Is the wording common among nurses/Is the language used easy to understand? and (4) Are the good and bad practices of behavior related to the elements? Modifications to wording or deletions were made by the nursing experts as deemed appropriate. At the end of the reviews, nursing experts explained the rationales for changes made. This process is important for the study team members to decide whether recommended changes should be considered if nursing experts have contradicting views. Finally, the experts were asked to decide on each element's observability.
Based on the qualitative data collected during debriefings, the first version of the newly developed skills taxonomy comprised seven categories and 21 underlying elements. Modifications were made to the first version of the skills taxonomy in accordance with suggestions made by nursing experts and opinions of the study team. “Decision-making” and its elements were removed due to its low observability. Half of the nursing experts viewed that decision-making skills can be determined more accurately through verbal questioning and conversations rather than through observations. There were no other amendments made for the other six categories and their descriptions. All nursing experts deemed the categories to be appropriate and the descriptions as well defined and accurate.
When reviewing each category's element, half of the nursing experts commented that the element “anticipating and thinking ahead” should be removed from the category “situation awareness” due to its low observability in real settings. However, the study team reconsidered the suggestion and decided not to remove the element because this element reflects the importance of task planning. A simple task such as preparing emergency drugs for patients before doctors' arrival reflects the behavior of “anticipating”. Hence, the element has to be retained. In the process of language review, wordings for four out of eighteen elements were modified to better reflect accuracy and easy reading. Examples such as “anticipating and thinking ahead” was modified to “anticipating” and “identifying options and barriers” to “identifying risks”. Six out of eighteen good practices and eleven out of eighteen bad practices were revised. Table 1 shows the final version of skills taxonomy, consisting of six categories and 18 underlying elements with examples of good and poor behaviors.
Table 1Skills Taxonomy in Crisis Management for Nurses
|Category||Element||Examples of Good Behaviors||Examples of Poor Behaviors|
|Task and resource management: Skills for managing resources (e.g., people, equipment) and tasks by adhering to crisis management principles, protocols, and guidelines to accomplish team goals.||Applying knowledge and skills||Uses or applies learned crisis management nontechnical knowledge, nontechnical skills (e.g., leadership), crisis resource principles, protocols, and guidelines (e.g., using SBAR to communicate) to perform tasks appropriately.||Lack of crisis-management knowledge, skills, principles, protocols, and guidelines, which could risk patient safety.|
|Managing available resources||Uses one or multiple resources (e.g., seek help from seniors or experienced personnel, activate alarm devices) to complete tasks at hand.||Not using resources appropriately (e.g., not seeking help from seniors or experienced personnel, phone, code blue button) which causes delays in task completion.|
|Preventing and managing errors/lapses||Identifies potential risks and allocates attention to critical areas for error/lapse prevention (e.g., identifying presenting signs and symptoms of patients with deteriorating health condition that requires immediate attention and interventions).||Not performing appropriate measures to identify potential risk and/or avoid preventable errors/lapses.|
|Setting priorities||Sets priority for task completion using a systematic approach.||Not comparing the alternative possibilities in making decision or solving problem.|
|Situation awareness: Skills for developing and maintaining overall awareness of the crisis situations based on observations of the dynamically changing environment/situation/circumstances; thinking ahead on potential outcomes and responding with appropriate course of action.||Gathering information||Collects information about the situation by observing surroundings and cues and verifying information to confirm their reliability.||Is inattentive with details of the surroundings when managing crisis situations/events. Fails to collect accurate information.|
|Identifying risks||Performs risk assessment to determine appropriate follow-up actions.||Not performing appropriate measures to identify potential problems to determine appropriate follow-up actions.|
|Knowing the physical environment||Aware of the physical environment (e.g., space constraints).||Unaware of constantly changing situations of the environment and surrounding (e.g., working with cables dangling around).|
|Anticipating||Thinks ahead and prepares for upcoming tasks.||Fails to anticipate potential outcomes and consequences of actions.|
|Being aware of individual and team member roles and responsibilities||Fulfills own job responsibility and recognizes dynamic inrole switching and able to assume new role immediately.||Fails to carry out own role and responsibilities or unaware of role switching among team members.|
|Being responsive to changing situations||Aware of problems. Responds early and intervenes in a timely manner in managing crisis situations according to the hospital standard of care and practices.||Fails to carry out appropriate course of action according to needs of patients or instructions of team members/leader.|
|Teamwork: Skills for taking actions and initiatives in a group context; the focus is on the team rather than the task and individual.||Being present and involved||Takes initiative to help one another engaged in completing the tasks.||Is distracted and not focused on situations.|
|Employing assertiveness||Is assertive in addressing potential errors/challenging situations for the safety of team members.||Fails to address potential errors/challenging situations for the safety of team members.|
|Communication: Skills for effective communication with team members; ensuring that information is received and delivered accurately.||Exchanging information||Provides and receives information on critical events (e.g., using SBAR) required for team coordination and task completion.||Fails to clearly communicate potential/identified problems to highlight the seriousness of the situation.|
|Communicating loudly and clearly||Verifies orders in a loud and clear manner (e.g., task allocation) and has shared understanding with team members.||Communication is inaudible or incoherent.|
|Clarifying roles with each other||Communicates to clarify assumptions of roles.||Assumes team members' roles without clarifying. Not aware on the roles and responsibilities of team members.|
|Control of emotions: Skills for controlling own emotions without affecting task performance; demonstrating confidence in task performance.||Being calm and focused||Coordinates and organizes patient care activities in a calm manner.||Appears stressed or panicky, which affects task performance.|
|Demonstrating confidence||Has confidence in making decisions and performing tasks.||Is uncertain with decisions/steps required for task completion due to lack of confidence which might risk patient safety.|
|Leadership: Skills for leading teams and providing clear team goals; identifying strengths and weaknesses of team members and getting them to support each other.||Assuming a leadership role||Delegates tasks to team members with clear instructions and guidance during crisis situations.||Is disorganized when delegating tasks, and fails to identify issues and constraints that hinder team members from performing competently.|
SBAR = situation, background, assessment, recommendation.
We have developed a skills taxonomy of nontechnical skills in the context of crisis management for nurses. The skills taxonomy contains contextual information for observable behaviors with examples of good and poor behaviors. In our next phase of study, we aim to develop a rating system and to test its reliability for practical use in assessment and feedback. We anticipate that this will lead to an overall improvement in nurses’ performances at crisis events, which will ultimately translate into a subsequent reduction in the rate of errors and adverse events.
- A systematic review of behavioural marker systems in healthcare: What do we know about their attributes, validity and application?.BMJ quality & safety. 2014; 23: 1031-1039
- Rating non-technical skills: Developing a behavioural marker system for use in anaesthesia.Cognition Technology and Work. 2004; 6: 165-171
- Safety at the Sharp End: A Guide to Non-technical Skills.Ashgate Publishing, Ltd, Hampshire, England2008
- Patterns of communication breakdowns resulting in injury to surgical patients.Journal of the American College of Surgeons. 2007; 204: 533-540
- Preserving professional credibility: Grounded theory study of medical trainees’ requests for clinical support.BMJ. 2009; 338: b128
- A pilot study using high-fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Critical Care Medicine, High-Fidelity Simulation, and Crisis Resource Management I Study.Critical Care Medicine. 2006; 34: 2167-2174
- TeamSTEPPS™: Team strategies and tools to enhance performance and patient safety.in: Advances in patient safety: New directions and alternative approaches. Vol. 3. Agency for Healthcare Research and Quality, Rockville, MD2008: 5-20
- To err is human: Building a safer health system.National Academy Press, Washington, DC2000
- Resource management in the cockpit.Air line pilot. 1984; 53: 20-23
- Assessing nurse Anaesthetists' non-technical skills in the operating room.Acta Anaesthesiologica Scandinavica. 2014; 58: 794-801
- The mayo high performance teamwork scale: Reliability and validity for evaluating key crew resource management skills.Simulation in Healthcare. 2007; 2: 4-10
- Teamwork and patient safety in dynamic domains of healthcare: A review of the literature.Acta Anaesthesiologica Scandinavica. 2009; 53: 143-151
- The Oxford NOTECHS System: Reliability and validity of a tool for measuring teamwork behaviour in the operating theatre.BMJ Quality & Safety. 2009; 18: 104-108
- Development of a behavioural marker system for scrub practitioners' non-technical skills (SPLINTS system).Journal of Evaluation in Clinical Practice. 2013; 19: 317-323
- Thinking ahead of the surgeon. An interview study to identify scrub nurses’ non-technical skills.International Journal of Nursing Studies. 2011; 48: 818-828
- Assessing teamwork in the trauma bay: Introduction of a modified “NOTECHS” scale for trauma.The American Journal of Surgery. 2012; 203: 69-75
- Observational teamwork assessment for surgery (OTAS): Refinement and application in urological surgery.World Journal of Surgery. 2007; 31: 1373-1381
- The evaluation of non-technical skills of multi-pilot aircrew in relation to the JAR-FCL requirements.National Aerospace Laboratory (NLR), Amsterdam1998
- Observational Skill-based clinical assessment tool for resuscitation (OSCAR): Development and validation.Resuscitation. 2011; 82: 835-844
- Development of a rating system for surgeons' non-technical skills.Medical Education. 2006; 40: 1098-1104
Published online: November 01, 2018
Funding: This project was supported by resources from the NHG-HOMER Grant (grant number: FY17/A02).
© 2018 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc.
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