Introduction
“Engine fire,” announced the first officer during the take-off roll. The captain rotated the aircraft and confirmed that the aircraft was climbing away and commanded the landing gear to be retracted. Then the flight deck was silent with no one saying anything until 400 feet above the ground when a carefully choreographed sequence was commenced, identifying the engine that was on fire and shutting it down. This is a typical simulator scenario that every airline crew around the world will practice. An observer in the simulator watching a good crew would be surprised at the unhurried performance, a notable absence of talking, and the seemingly low workload that was displayed. However, there is a huge hierarchy of skills that the pilots will draw upon to achieve this performance which is not immediately obvious to the casual observer.
Aviation is an industry where training is at the core of an airline’s Safety Management System (SMS) and every pilot undergoes regular recurrent training in the simulator up to four times per year to maintain and enhance technical and nontechnical skills. Advances in aircraft design, engineering and flight training have been responsible for the safety record that aviation enjoys today with an accident rate of 2.6 accidents per million departures. Medicine, and in particular surgery, has an interest in aviation as pilots and surgeons do share some common ground in the cognitively complex and technically and nontechnically challenging environment of the flight and deck and the operating theater. However, not everything in aviation can be seamlessly transferred as both domains have unique differences. Aviation is less variable, highly regulated and the current fourth generation of aircraft are very reliable and do not show the nuanced problems of human beings such as comorbidities or difficult anatomies. Despite these differences, some aspects of aviation are very transferable such as nontechnical behaviors and training methods, and this chapter will focus on these nontechnical skills and allied subjects that are so critical to the high performance of airline crews as there is increasing realization of the potential benefit of the transferability of these skills into surgery to improve surgical outcomes.
Humans are subject to error
Flying an aircraft is a complex and challenging task and it was often said that good pilots had a “great set of hands.” This focused on the technical aspects of flying, but in a survey conducted by the author among experienced instructors, the general opinion is that this has shifted to an emphasis on nontechnical expertise with up to 70% of skilled flying attributed to nontechnical ability. However, humans, despite being well trained, are subject to error and we are all fallible. , Errors are a fact of life and they can be small and inconsequential or catastrophic in high-risk industries such as aviation. In surgery, an error committed by a well-trained surgeon can have similar tragic outcomes. Human error cannot be eliminated but can be mitigated by nontechnical training.
Over many years, aviation and a number of other high-risk industries were forced to investigate a number of accidents where human error was a causal factor. During the 1970s several major accidents were very puzzling: the aircraft were serviceable and flown by well-trained crews but were involved in accidents that resulted in the loss of life. The major event was the 1977 Tenerife crash between two Boeing 747 aircraft, one operated by KLM and the other by Pan American where the aircraft collided in reduced visibility on the ground, resulting in the loss of 569 lives. The subsequent investigation revealed failures in communication, teamwork, decision making and leadership. , Other nonaviation accidents had similar factors present, such as the Chernobyl and Challenger disasters of 1986 and the Piper Alpha oil platform explosion of 1988.
Investigations and the findings into aviation accidents made it clear that technical skills were not enough to ensure safe flight and that nontechnical behaviors were influencing pilot’s decisions and behaviors. , Surgeons are similarly affected, where the mastery of technical skills is insufficient in preventing error. An estimated 50% of all surgical errors occur in the operating theater, and of these, 40% to 50% are deemed entirely preventable. In more sobering statistics, in the United States, the US Institute of Medicine estimated that each year between 44,000 and 98,000 people die as a result of medical errors—which puts doctors at 7500 times more likely to cause harm than a gun owner.
Although technical errors do occur in surgery, there has perhaps been an overemphasis in the past on the teaching of technical skills in surgery, despite the most influential contributions to error being a lack of application or the poor use of nontechnical skills. The nontechnical skills taught in aviation apply equally to surgery, as in both of these domains the work requires high levels of interpersonal collaboration, communication, and coordination, and teamwork is essential. ,
Nontechnical skills
Nontechnical skills are the cognitive and social skills that complement a worker’s technical skills and are defined in this chapter as “the cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance.” These are not new or mysterious and are in essence what the best performing surgeons or pilots do every day. The “surgeon’s surgeon” will display these every day with skill, diligence, judgment and demeanor all contributing to positive patient care. ,
There are five main nontechnical skills that are taught and assessed that will be discussed in this chapter:
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Situation awareness (SA)
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Decision making
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Communication
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Teamwork
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Leadership
It should be noted that nontechnical behaviors are usually displayed concurrently and not necessarily as discrete units of behavior. At times, however, more emphasis and importance will be needed on individual skills depending on the task’s demands.
Situation awareness
According to the US Air Force, SA is the most important factor in improving mission effectiveness but, despite this importance, the definition of SA is not commonly accepted. Mica Endsley, a researcher into SA and flight deck automation, defines SA as “the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future.” Basically, SA is knowing where you are and where you are going to be and is the crucial first step to decision making and one of the most challenging portions of many people’s jobs. , , In 175 aviation accidents, poor SA was found to be the leading causal factor ( Box 7.1 ).
- 1.
In 1972, an Eastern Airlines L1011 aircraft descended into the Everglades and crashed, killing all on board. The crew failed to maintain SA while becoming fixated with an inconsequential light and nobody noticed the autopilot was disengaged and the aircraft lost height.
- 2.
An orthopedic resident was observing spinal surgery with a very senior surgeon. The resident noticed that the surgeon was about to cut a nerve root by mistake and spoke up.
The human brain functions as an information-processing machine, but the brain is limited in the amount of information it can process at any one time and therefore attends to the environment selectively. Humans will select environmental cues and information in the memory, and it is this selective attention process that forms the basis of SA. Memory is very important in SA. There are three linked memory systems: sensory, working, and long-term memory. Sensory memory holds information for a very short time and is of less importance to SA than working memory and long-term memory.
Working memory is the contemporary label for short-term memory and contains conscious awareness. It is of limited capacity, fragile and subject to distractions and interference. When the capacity of an individual is reaching the limit, reducing the attention on extraneous information such as background music or asking team members for silence is a technique to preserve working memory. To assist in maintaining SA, pilots will often verbalize what they are seeing, and their understanding, to the other crew members and use a “mini summary” of an event or a task.
The main memory store is the long-term memory store. This memory store is a huge warehouse of masses of information which increases with experience and can be drawn out and transferred to working memory. SA involves a cyclic interplay of information, with perception interacting with working memory and knowledge being drawn from long-term memory, and involves three stages—gathering information and perception, understanding, and projection. , Accurate mental models are critical to accurate SA.
Mental models
Humans are very skilled at pattern matching. Streams of information can be categorized and recognized quickly, especially by an expert, with little conscious effort. This process of categorization and comprehension is facilitated by “mental models,” sometimes called “schema,” that are stored in the memory. These are combinations of cues and meaning. An aviation example is a complex taxiway procedure used by a pilot or a sequence of surgical activities—for example, the initial insertion of robotic ports and docking of a robot, where novel cues may result in subtle intraoperative modification of a very standardized procedure. Experts have a vast store of mental models in comparison to a novice who has to spend more time and mental effort trying to comprehend patterns using a more systematic analysis. The mental model does not need to be an exact match to the current situation but does need sufficient similarities to be able to categorize.
Mental models provide direction to critical cues, an expectation of the future state helping to project forward, and a link between the situation and appropriate actions. Experience forms the creation of mental models, but briefings are a very effective way of mental model creation. This is particularly helpful in team environments so that all team members have a shared understanding of a task, their role and any risks that may be involved. However, if the briefing is not accurate, then the wrong mental model may be created, facilitating the risk of poor decision making. This heightens the risk of bias influencing the decision, such as confirmation bias, discussed further in the chapter, where facts are “bent” to fit the model.
Three stages of situation awareness
Gathering information can come from an array of sources such as visual, auditory, or other team members to build up the picture of the environment. The second stage is the cue interpretation or understanding phase, using long-term stored knowledge and recognizing patterns. An expert will do this quickly with limited use of the working memory; a novice however, will find this stage more cognitively challenging. The final stage is projecting the information forward to a future state and anticipating what might happen at a later stage. SA is an essential first step in the next nontechnical skill of decision making.
Decision making
Decision making is the process of reaching a judgment or choosing an option depending on the situation. In operational settings, decision making is a continuous cycle of monitoring and evaluating the environment and may involve more than one method depending on the circumstances, such as time pressure and task demands. Decision making is important in all work settings, but in high-risk settings, decision making becomes critical. In the United States between 1983 and 1987, poor crew judgment and decision making were contributory causes to 47% of cases. Poor decision making is not unique to pilots; all high-risk industries have examples of the importance of the decision-making skill in safe task performance ( Box 7.2 ).
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Poor decision making by two US fighter pilots to shoot down two enemy helicopters resulted in multiple deaths. The enemy helicopters were US helicopters carrying UN peacekeepers. They expected to see two Hind helicopters, and this influenced what they saw.
- 2.
The introduction of laparoscopic cholecystectomy resulted in an increased incidence of bile duct injuries as a result of a different perspective of the cystic duct for the surgeon. This remains a problem as sometimes the anatomy is interpreted as what the surgeon expects to find rather than what is actually present—for example, the bile duct being identified as a broad cystic duct, and ligated. In the situation where the anatomy is uncertain, introduction of additional cues such as an operative cholangiogram to clarify the biliary anatomy is invaluable.
In time-pressured, dynamic work environments, decision making has different dimensions. The classic decision theory of “normative” decision making was of limited value in the operational environment and led to a new approach to decision making called naturalistic decision making (NDM). NDM applies to aviation, the military, emergency services and acute medicine, which are all characteristic of environments that are uncertain, have inadequate information, are time pressured, are high risk, and usually involve working in teams.
There are a number of models of decision making, but the following model is used in airline settings and is applicable to all operational domains. The three stages of decision making are:
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What is the problem?
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What shall I do?
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Is this working?
Problem identification is fundamental and critical. If this is not done accurately, the decision will be flawed. This stage is the collection and assessment of clues to build the mental model of what is happening. This stage requires conscious effort to identify and understand the environment and is influenced by expertise, workload, and expectations. As expertise develops, more memories will be retained, and stored mental models will allow more rapid pattern matching and retrieval from memory to facilitate problem identification. At the completion of this step, the practitioner needs to decide what decision-making method to use. There are four methods:
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Intuitive: recognition-primed/fast and automatic selection of one option.
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Rule based : recalling the rule and actions.
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Analytical : slower and more considered choices.
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Creative : developing a new course.
Intuitive decision making is based on thinking fast and the rapid retrieval from memory of similar situations. The cues recognized in the current situation match those from a previous situation. This course of action is usually automatic, using minimal working memory, and should produce a solution that is workable and satisfactory for the current situation and is appropriate for events requiring immediate action. It requires experience and is less likely to produce an optimal solution, just one that works. An example in surgery would be management of a hemorrhage from the pelvis by “packing” the pelvis with packs to tamponade the bleeding. It is unlikely to be a definitive solution; however, it may be undertaken automatically with minimal thought processing or delay.
Rule-based decision making requires more conscious effort than the intuitive method and is the process of identifying a situation and extracting the rule to apply to it. Aviation is heavily ruled based with standard operating procedures (SOPs) and manuals covering most situations. This type of decision making is not used as often, for example, in intraoperative medical settings, due to the increased complexities of anatomy and other patient differences.
Analytical decision making is about choice. This method is slower and requires conscious effort to retrieve from memory a course of action or discuss options with a team. It is usually more appropriate when time is available and the options can be compared. A structured approach can assist in these situations, and one acronym, GRADE, has been found to be useful in aviation. GRADE is:
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Gather the information.
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Review the information.
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Analyze the information.
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Decide on a course of action.
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Evaluate .
The analytical method is very valuable before entering a complex environment where some of the options have been prethought and mentally rehearsed. This can help the decision making when the workload is high, such as in the flight deck or conducting a surgical procedure as all the heavy-duty thinking has been done before executing the task. In surgery this may necessitate stepping away from the side of the patient on the operating table, provided the patient is stable, to allow reflective consideration of the steps required to move forward with the operation if unexpected pathology should be identified intraoperatively.
The final method of decision making is creative decision making and is used when a new course of action is devised immediately. This is rarely used in aviation and also in settings of high risk and time criticality as it requires considerable conscious effort, and the result is untested.
Communication
Communication and teamwork are linked. Failure to communicate effectively in a team environment is one factor that differentiates the team that performs well to one that performs badly. Communication is the exchange of information, feedback and ideas and provides knowledge, builds relationships, establishes predictable behavior patterns and maintains attention on a task. It has four components:
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What information is to be communicated?
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How is the information communicated?
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Why is the information being communicated?
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Who is the audience?
When communication is done badly in an operational setting, the consequences can be tragic ( Box 7.3 ).
- 1.
Boeing 707 Avianca Flight 52 from Bogota to John F. Kennedy Airport, NY, crashed after running out of fuel. The National Transportation Safety Board determined that failure of the crew to communicate the emergency fuel state and lack of standardized terminology for minimum fuel states contributed to this accident, where eight of the nine crew and 65 of the 149 passengers were killed.
- 2.
A never event is the “kind of mistake (medical error) that should never happen” in the field of medical treatment. A 2012 study reported that there may be as many as 1500 instances of one “never event,” the retained foreign object, per year in the United States. An instrument and swab count at the end of every operation is considered an essential part of standard operating procedure at the end of surgery, with the confirmed count communicated by the scrub nurse to the operating surgeon at the end of the operation, and any deficit resulting in a cessation of closure and an exhaustive search for the missing item.
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