Surgery has undergone extraordinary advancements in recent decades, primarily due to technical innovations and the increasing subspecialisation of surgeons. Despite these advancements, surgeons have not devoted sufficient attention to the learning and implementation of another crucial set of skills known as Non-Technical Skills (NTS). These can be categorized into cognitive skills (such as decision-making and situation awareness) and social skills (such as leadership, communication and teamwork. These competencies play a critical role in patient safety and the performance of the surgical team.1,2
Analysis of adverse events in healthcare has shown that many errors stem from failures in communication and other cognitive and social skills, rather than deficiencies in technical skills.3–5 The link between NTS and patient safety is clear. One study demonstrated that improvements in decision-making and situation awareness significantly reduce the incidence of adverse events in surgery.6
The understanding of Non-Technical Skills (NTS) began first in other high-risk / high-reliability industries, for example offshore oil exploration, nuclear power and civil aviation, where it is called Crew Resource Management (CRM). The Industrial Psychology Unit of the University of Aberdeen then collaborated with the Royal College of Surgeons of Edinburgh to undertake studies in the surgical environment. This resulted in taxonomies and tools – first Anaesthesia Non-Technical Skills (ANTS),7 then Non-Technical Skills for Surgeons (NOTSS). These categorise into four domains: situation awareness, decision-making, communication and teamwork, and leadership.1 They identify the critical behaviors that influence the safety and efficiency of surgical procedures.8
In addition to NOTSS, other NTS assessment systems exist in surgery. The Oxford NOTECHS II system, for example, focuses on evaluating the non-technical skills of surgical teams and has been proven to be a reliable tool in multiple studies.9 Similarly, the Observational Teamwork Assessment for Surgery (OTAS) has been used to assess team performance in the operating theatre.10 Although the NOTSS system was originally developed for evaluating individual surgeons, it is also a valuable tool for observing and assessing surgical teams.11
The learning of Non-Technical Skills (NTS) should begin during medical education and be consolidated throughout surgical residency. Traditionally, surgical curricula in medical schools have focused on the acquisition of theoretical knowledge and technical skills,12 with the learning of NTS accounting for less than 10% of the total competencies in surgical subjects in Spanish medical faculties.13 The integration of these concepts into the surgical curriculum has been shown to improve patient safety and team efficiency,14 and in many countries, NTS training is a mandatory component of surgical residency.15
Several studies conducted in simulated environments have used the NOTSS system to distinguish between high- and low-performing individuals, with the constructive aim of then improving their non-technical skills through educational interventions. The NOTSS system has been adopted by many surgical communities worldwide to structure training and assessment, with accumulating evidence supporting its use in providing structured observation and feedback on surgeons' non-technical skills.17
Surgical competence requires more than just technical experience to ensure patient safety and maintain quality standards.4,16 Thus, it has been shown that higher scores in surgeons' non-technical skills (NTS) are associated with a lower risk of postoperative complications, mortality, and reinterventions.18 Therefore, strategies to improve postoperative patient outcomes should include enhancing surgeons' non-technical skills.17 It is, therefore, important to assess surgeons' non-technical skills and provide structured interventions to improve patient safety.
Methods such as simulation have proven effective in developing these skills, allowing trainees to confront critical scenarios in a safe environment [11]. Additionally, postoperative debriefing is a key tool for reflection and continuous improvement of NTS [12].
Effective leadership in the operating theatre is essential for coordinating the team and managing crisis situations. Leading surgeons must define and maintain quality standards, motivate other team members, and appropriately manage stressful and high-pressure situations.18
Teamwork is another fundamental pillar of NTS. Clear communication and effective collaboration between surgical team members reduces errors and improve clinical outcomes [15]. It has been shown that greater cohesion within the surgical team is associated with a lower rate of postoperative complications [16]. A key concept here is that of “Shared Mental Models”.
Summarizing, interest in NTS is on the rise, demonstrating the growing awareness that surgical practice requires more than just clinical knowledge and technical skills. Thanks to experience gained in the aviation industry and other high-risk sectors, we now have clear definitions of these skills, applicable to the surgical environment, and validated NTS assessment tools that can support training.
The development of non-technical skills should be a priority in surgical training and daily practice. Their implementation not only enhances patient safety but also optimizes the performance of the surgical team and strengthens leadership in the operating theatre.
Tools such as the NOTSS system, along with other evaluation systems like Oxford NOTECHS II, OTAS, and GANTS, provide a structured framework for their teaching and assessment, contributing to safer and more efficient surgery.
Training in NTS should be included in the training curriculum for surgeons in our country, although the best modality and most appropriate means for its teaching still need to be designed.
