Do surgeon non-technical skills correlate with teamwork-related outcomes during robot-assisted surgery?

Abstract

IntroductionTo evaluate the impact of non-technical skills (NTS) on team performance, workload and clinical outcomes.MethodsThe operating room (OR) environment of 20 robot-assisted radical prostatectomies performed by three different surgeons was recorded. Trained observers assessed NTS utilising the Non-Technical Skills for Surgeons (NOTSS) questionnaire. Associations between NOTSS scores, teamwork attributes (anticipation and inconveniences), workload (measured by National Aeronautics and Space Administration-Task Load Index (NASA-TLX)) and clinical outcomes (operative time, blood loss and surgical complexity) were determined using logistic regression and Pearson correlation.Results1780 requests were observed, 703 (39%) were non-verbal. Utilisation of non-verbal requests differed significantly among surgeons (26%, 36% and 44%, p<0.001). Anticipation was significantly associated with ‘Situational Awareness’ (OR 2.59, 95% CI 1.52 to 4.38, p<0.001), ‘Decision Making’ (OR 0.42, 95% CI 0.33 to 0.55, p<0.001) and ‘Communication and Teamwork’ (OR 0.43, 95% CI 0.25 to 0.74, p=0.002) domains. Inconveniences were significantly associated with ‘Situational Awareness’ (OR 0.21, 95% CI 0.08 to 0.59, p=0.003), ‘Decision Making’ (OR 2.73, 95% CI 1.53 to 4.86, p<0.001), and ‘Leadership’ (OR 0.62, 95% CI 0.41 to 0.94, p=0.03). There was a significant positive correlation between NOTSS scores and perceived physical and mental workload measures of NASA-TLX, as well as self-perceived performance. There was no significant association between NOTSS scores and any of the investigated clinical outcomes.ConclusionNTS in the OR were associated with team efficiency, fewer surgical flow disruptions and an improved self-perceived performance.

Non-Technical Skill Assessment and Mental Load Evaluation in Robot-Assisted Minimally Invasive Surgery

“…Workload can be defined with self-rating techniques, where a subject fills a questionnaire about his/her personal experience about the task workload. It is naturally a subjective technique, however, there are works in the literature which studied both subjective workload measurements and objective non-technical skill assessment metrics [ 32 , 40 ], or objective physiological parameters [ 30 , 34 , 41 , 42 , 43 , 44 , 45 , 46 ]. Workload measurements do not only help to assess the personal workload index, but also to define the main stressors and disturbing factors in surgery in general, furthermore, to provide personal training for novices as well.…”

“…NASA-TLX is a widely used technique for workload measurement in aviation, military and healthcare. NASA-TLX can be found in traditional MIS mental workload estimation [ 48 , 49 , 50 , 51 , 52 ], and employed in the case of surgical robotics workload assessment as well [ 8 , 32 , 34 , 40 , 41 , 43 , 45 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 ]. There are additional mental workload assessment techniques that are not originally created for surgery, and used in workload assessment for RAMIS.…”

“…With self-rating tools, the real stressors of the surgery can be observed, and other approaches have to fit to the clinical relevance. Self-rating studies can be found in Table 5 under the following references: [ 30 , 31 , 32 , 34 , 40 , 41 , 42 , 43 , 44 , 50 , 56 , 57 , 59 , 60 , 61 , 62 , 63 , 64 , 66 , 68 , 69 , 70 , 71 , 72 , 75 , 76 , 81 , 85 , 93 , 94 , 95 ].…”

“…In the case of non-technical skill assessment, there are several different expert-rating metrics for traditional MIS, such as NOTECHS, OTAS and NOTSS ( Table 3 ). A few publications were identified which studied NOTSS in the case of RAMIS [ 32 , 33 , 96 ]. For surgical robotics, there is one metric which specifically measures the non-technical skills of robotic surgeons [ 22 ]; the Interpersonal and Cognitive Assessment for Robotic Surgery (ICARS), developed by Raison et al in 2017.…”

“…However, in these studies questionnaires created for traditional MIS were used, the main workload parameters in RAMIS are not yet defined. For RAMIS, non-technical skill assessment expert-rating methods originally created for traditional MIS can be found [ 32 , 33 ]. There is one metric specifically created for RAMIS non-technical expert-rating assessment (ICARS, [ 22 ]), which describes the most important non-technical skills in RAMIS ( Figure 2 ).…”