We all are aware about the importance of technical knowledge and skills, that are required for effective delivery of the MCH services. Very less is said, taught and discussed about “Non technical skills”, which have their own place in improving the effectiveness, quality of services and clientele satisfaction.
It is said that “Non-technical skills (NTS)” are important and underpin technical ability. They include the social skills of communication, team-working and leadership and the cognitive skills of situational awareness and decision- making, as well as the important inﬂuences of managing stress and coping with fatigue. Such skills are of particular relevance in MCH care, where multiple tasks are often required simultaneously, the woman is usually awake, and the clinical circumstances may be stressful.
The concept of these skills is not new, but interest in them is growing as increasing evidence suggests that NTS failures are likely to lead to adverse events. In the conﬁdential enquiries conducted to review maternal deaths, it is observed that in large number of cases there is an element of substandard care. The inquiry reports do not detail these deﬁciencies speciﬁcally, but identiﬁes failures in teamwork, communication and interpersonal skills as areas of particular concern. Lack of adequate skills often result not just in increased morbidity and mortality, but also is a ground for medico-legal litigations and incidences of violence against the health care workers and physical damage to the health care facilities.
Key non-technical skills
1-Situational (or situation) awareness
Situational awareness is essentially perception or attention to the surroundings and the detection of any changes. This concept is familiar on the delivery suite, where multiple tasks may present simultaneously, task interruption is common and delegation is often required. It is also essential as part of good surgical decision making in the operating theatre. Situational awareness may be inﬂuenced by factors such as experience, preconceptions, expectations and task workload. Of use in building situation awareness are quick updates, team huddles and planning meetings in order to maintain a shared mental model and ensure that team members are able to anticipate future events.
The process of reaching a judgement or choosing an option to meet the needs of a given situation or task is required in almost every patient encounter in maternity ward especially in labour room. Conditions for decision making can vary in relation to time pressures, feasibility of options, task demands and levels of support for the decision maker. Broadly speaking, the ﬁrst stage in decision making requires situation assessment – i.e. observation and identiﬁcation of the problem. In the second stage of decision making, there is a process of choosing a course of action to meet the needs of the situation assessment. The effectiveness of the response chosen will depend on the accuracy of the initial assessment and the experience of the individual making the decision. Decision making may be degraded by fatigue, as it erodes working (short-term) memory, thereby reducing one’s ability to retrieve problem solving information from the long-term memory.
Poor teamwork and risk to women is well known observation of confidential maternal death inquiries. Key elements of team working include support for other team members through sharing workload, accepting individual responsibility, conﬂict resolution and exchange of information. We work in teams that are constantly changing, with different health professionals and different levels of expertise coming together on each shift, and there is increasing demand for ﬂexibility and responsiveness within the team. The focus must be on the individual to be as effective as possible and to have a clear understanding of their individual role.
Communication is an important element of effective teamwork (i.e. a co-skill) and is the exchange of information, ideas, feelings or feedback. The ability to communicate effectively with the mother and her relatives is also essential in order to gain their conﬁdence and provide reassurance in a stressful life-situation. Communication issues are particularly relevant in maternity services where there may be multiple handovers, transfers between home settings and hospital and referrals between professional groups. Poor communication between primary care and hospital or within hospital has frequently been cited as a contributor to adverse events. In an emergency, more efficient teams are likely to recognise and verbalise the crisis and use closed-loop communication (i.e. task clearly and loudly delegated to speciﬁc individuals, accepted, executed and completion acknowledged) to protect the ﬂow of information. The SBAR format (situation, background, assessment, response) is also of use in transmitting critical information and is now common place on many delivery suites.
Effective leadership is essential for maintaining safe performance in the workplace and maintaining morale. Leadership requires motivating, directing and organising the team, encouraging individuals to work together, assessing performance, task assignment and generating a positive environment. Leadership skills may also be needed by other members of the team when necessary to plan, prioritise and manage workload.
6-Other non-technical skills
In labour room and operation theatre, maintaining dignity and a professional relationship with the woman when she is awake and vulnerable should be considered as an additional key NTS. Partner (relative or accompanying person) management and dealing with disruptive behaviour are also essential and can be classed as separate, but related, entities to communication skills. In addition, professional behaviour (i.e. remaining calm under pressure, coping with distractions and interruptions) and cross-monitoring of performance are also skills required.
Non-technical skills are the cognitive, social and personal resource skills that complement clinical and technical skills. They are a vital part of the skill set required to become a competent obstetrician or a nurse. Non-technical skills are currently not adequately integrated within, or assessed as part of the curriculum, although the interest in this area is growing. NTS concepts should be incorporated into training, including both simulation and real-life operating room/ delivery suite settings in order to provide formative evaluation and feedback with the aim of improving quality of care.