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Teamwork is not always obvious or apparent and the impact that it has is often invisible. Take this astronaut on a spacewalk – we are astounded by the courage and skill that this requires, the physical and mental effort to remain calm, move within a space suite, analyse, understand and resolve a problem that is only partially understood prior to leaving the spacecraft. Yet despite all of their individual skill this endeavour is not possible without a team- a team of trainers and educators, engineers and designers, fellow astronauts to monitor progress and physical wellbeing.  Once outside the astronaut appears to be on their own, but they are figuratively “standing on the shoulders” of the team, those supporting them to do the job.

Contrast this with sport, the team effort, success or failure is apparent throughout we can see the players move in a coordinated effort, each aware of the other, creating spaces, passing to fellow players, keep  possession, preventing the other team from scoring, all equally striving to win the game.

So how does this relate to us in healthcare, how do we view the team are we an “astronaut” working alone on a foundation of support or are we a “sportsman”, optimising the performance of fellow team players to achieve the optimal outcome?

I believe that both are true, as highly trained professionals we have to make decisions and judgements that are directly attributable to us as individuals and will effect patient outcome. We do this through our training, gaining information from other departments, using technology, discussing cases with colleagues & monitoring patient progress.  But, there are also times when we work with others in a co-ordinated effort, each contributing particular skills, each with the potential to effect the performance of another, dependent upon one-another, communicating & updating.  This is true of the operating team, even though the outcome may be directly attributed to a particular surgeon, there is evidence to suggest that the team & teamwork impact patient outcome.


A trust in London was found to have a higher than average death rate following cardiac surgery.  The independent review is quoted as saying “the surgical team was viewed as dysfunctional both internally and externally”.  It commented upon a “toxic atmosphere”. “Staff felt poor performance was inevitable due to the pervading atmosphere”

This is the first time (in my memory) that non-technical skills have been specifically mentioned and linked to poor outcome in the national press.

There is evidence that team training interventions in non-technical skills help in reducing communication failure and decrease surgical morbidity & mortality.  This has been recognised and non-technical skills training instigated by the Royal College of surgeons in Ireland, the Royal Australasian College of Surgeons, the Royal College of Surgeons Edinburgh and many of the regulatory bodies in the USA

So what are these non-technical skills and how do we train them?

Human Factors (HF) specialists have been involved in developing behavioural assessment tools for non-technical skills.  Skills such as situational awareness, communication, workload management, team co-ordination etc. In addition, HF provides an understanding and vocabulary to describe the quality of these skills. It also helps us identify potential sources of error and address them.  Some of the preventative strategies depend upon good teamwork- using the team to provide multiple checks of surgical site, cross checking critical steps e.g. blood transfusion, monitoring one another for signs of fatigue, updating one another regarding patient progress-  5 pairs of eyes all watching the same procedure from different perspectives are more likely to identify an anomaly than 2 engaged in operating

I think that one barrier to optimal team work is the failure to recognise the potential of the team, the skills and support available, the opportunities for shared vigilance.

Professor Rhona Flin was instrumental in developing the Non-Technical Skills Assessment tool for pilots, more recently she has been involved in developing non-technical skills assessment for healthcare.  We will have the opportunity to hear her speak on Non-technical skills at HFC19- the second inter-agency human factors conference for healthcare, fire service and airport operators.

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