Ed Mellanby , June 2013

2. “There was a 6% higher odds of death for all patients admitted in the week following the first Wednesday in August than in the week before"

3. Non-Technical Skills for Junior Doctors in Acute Care Ed Mellanby, June 2013 Supervisors: Janet Skinner, Nikki Maran Advisor: Ronnie Glavin Co-researcher: Megan Hume

4. The next 30 minutes • Introduction • Why this project? • Non Technical Skills • Project Aims • Method • Results (so far) • Conclusions

5. Introduction • Why this project?

6. Introduction • 14,000 preventable deaths a year Hogan H et al. Preventable deaths due to problems in care in English acute hospitals. BMJ QualSaf 2012.

7. Introduction • 14,000 preventable deaths a year • 70-80% attributed to ‘human factors’ Hogan H et al. Preventable deaths due to problems in care in English acute hospitals. BMJ QualSaf 2012.

8. Introduction • 70-80% of errors due to ‘human factors’ • Same in: • Aviation • Nuclear power industry • Oil industry • Military Wiener E et al. Cockpit resource management: Academic Press, 1993:3-45

9. Introduction “If you were to take a flight every day, odds are you would fly 14,000 years without being in an accident,” IATA Source: http://www.economist.com/blogs/gulliver/2011/01/air_accidents

10. Introduction • What are Non-Technical Skills? • ‘Cognitive, social and personal resource skills that complement technical skills, and contribute to safe and efficient task performance’ Flin et al. Safety at the sharp end. 2008

11. VIDEO

12. Introduction • What are Non-Technical Skills? • ‘Cognitive, social and personal resource skills that complement technical skills, and contribute to safe and efficient task performance’ • What is a behavioural marker system?

13. Structure • 3-Level Hierarchy

17. Improved Non-technical Skills • Increased Teamwork • Reduced Operative Errors • Reduced Non Operative Errors

18. Project Aims: • Develop a behavioural marker system for junior doctors • What are the critical NTS and behaviours that are associated with safe and effective performance?

19. Method

20. Method Identification of NTS • Literature review • 27 Interviews with junior doctors • Critical Incident Technique

21. Critical Incident Technique • Sweep 1- Uninterrupted description • Sweep 2- Filling in the gaps • Sweep 3- Expanding • Sweep 4- ‘What if’ queries Flanagan J. The critical incident technique. Psychological Bulletin 1954

22. Analysis: King N. Using templates in the thematic analysis of texts. 2004

23. Results 27 Semi-structured interviews completed 17 female, 10 male working in SE Scotland Graduating from 9 different Universities Working in 5 different hospitals across SE Scotland 1 to 1¾ hours long

24. Critical Incident Technique Interviews “It was in my first two weeks of the job and I got called to see this lady who was extremely breathless and I remember her saying to me “I can’t breathe, I can’t breathe” and it was horrible because I remember thinking there’s nobody here, it’s just me and a nurse and I just thought…..”

25. Prototype Framework

26. Prototype Framework

27. Situation Awareness • Knowing what is going on around you • What? • So What? • Now What?

28. Whodunnit?!

29. Situation Awareness Uses a structured approach to assessment

30. Situation Awareness Uses a structured approach to assessment “I think because there were so many other things going on, making it difficult to go through it how I’d have liked to have gone through it, so….at the same time there were two nurses in the room as well, who were speaking at me, at the same time and you know trying to add in, they were trying to add extra information but perhaps that was distracting me a bit from maintaining the structure as much as I would have liked. I mean that skeleton is there, and I did eventually get enough information to fill that out perhaps, although perhaps just not in the ordered manner that I would have liked to.” (FYDr2)

31. Situation Awareness Uses a structured approach to assessment “And now when I go into the room independent of what the problem is, with a much more structured way in my head, and I do those things almost in the classical structured way….and do those first, and I don’t let myself get sideways by my own panic, or even the patient’s panic, and then I re-evaluate so it kind of prevents the panic from happening.” (FYDr4)

32. Situation Awareness Pauses activities to put together findings

33. Situation Awareness Pauses activities to put together findings “then take another quick breath and have a think about what you’ve found cause it’s easy sometimes to just forget, like you listen to someone’s chest and then you forget what you’ve heard or, especially if you’re tired or….so yeah take a breath and think about things” (FYDr18)

34. Long Term Memory Working Memory INPUT • Knowledge • Skills • Experience Distractions Practical Procedures Info. from nurse Patient Condition Flin et al. Safety at the sharp end. 2008

35. Novice Long Term Memory INPUT • Knowledge • Skills • Experience Working Memory Distractions Practical Procedures Info. from nurse Patient Condition Limited time Stress Fatigue Technical tasks Flin et al. Safety at the sharp end. 2008

36. Prototype Framework

37. Decision making Weighs up factors with respect to patient’s condition

38. Decision making Weighs up factors with respect to patient’s condition “think “can I manage this on my own?”, and if you think at any point “I’m not quite sure” , as soon as you think that get someone else. You are only thinking of the best interests of the patient, and so do it.” (FYDr19)

39. Decision making Weighs up factors with respect to patient’s condition “it’s that whole thing that you think you should be able to deal with things but you realise you don’t….you can’t, whereas now I don’t mind if I can’t deal with something, better just to ask, whereas before I was worried about my pride” (FYDr14)

40. “Organisational Factors” The Behaviour of Junior Doctors “Identity Issues”

41. “I was really, really scared to ring erm for peri arrest cause even though everyone always says (whispers) “Oh no one will ever get cross” - I’ve kind of seen a couple of situations where people have been made to feel and look stupid” (FYDr2) “Identity Issues”

42. “Organisational Factors” “If I’d had someone to talk to, phone right away I probably would have phoned them quicker, but phoning the medical registrar is a real big hurdle as that is kind of the top person in the hospital at night” (FYDr4)

43. Escalating Care Uses concise structured communication “waffling is quite an easy habit, especially as a medical student as waffling as a medical student can get you quite far, but not in an emergency, as waffle doesn’t sound like it’s urgent.” (FYDr26)

44. On-going Work • Scenario and teaching developments • Attaching exemplar behaviours • Evaluation of prototype

45. Conclusions • Non-Technical Skills • Challenging for junior doctors • Important for patients • Prototype framework can be used to: • Guide educational interventions • Guide performance feedback • Encourage safe and effective behaviours

46. Thank you PTAS! Questions?