When I say … non-technical skills

Non-technical skills can be defined as the ‘cognitive (situation awareness and decision making), social (teamworking, leadership, and communication) and personal resource (managing stress and fatigue) skills that complement technical skills, and contribute to safe and efficient task performance by individuals working in a team in high-risk work settings’.¹ The origin of the term non-technical skills can be found in a European aviation project from the early 2000s.² These skills are crucial to safe and effective team performance in health care, and there is a growing literature reporting the application and efficacy of training in these skills to improve performance in high-risk work settings. However, in recent years, there have been criticism of the term non-technical skills,^3-5 with alternative terms being suggested, and appearing, in the literature.^{6, 7} We would like to provide a justification as to why, despite the limitations of the term non-technical, we believe it is still the best adjective to describe these important skills.

Criticisms of the use of non-technical skills include that the term is ‘misleading, inaccurate, oversimplifies critical aspects of professional practice’,⁵ and it relies on the identification as something it is ‘not’.^{3, 4} The authors of these criticisms believe that a change in the term would help shift attitudes towards these undervalued skills.⁴ Alternative terms that have been suggested in place of non-technical skills are ‘behavioural’^{3, 4} or ‘human factors’^{5, 6} skills. However, we believe there are a number of fundamental problems with these alternative terms that makes them erroneous and may lead to confusion rather than elucidation.

A definition of behaviour provided by the American Psychology Association is ‘any action or function that can be objectively observed or measured in response to controlled stimuli’.⁸ Therefore, carrying out hand hygiene, suturing, or performing a cannulation can accurately be described as behavioural skills. Yet these tasks do not encompass the cognitive, social, or personal resource skills addressed by the term non-technical skills. Consequently, the term behavioural skills is too broad to be useful because it does not discriminate non-technical skills from the enormous range of behavioural skills that health care professionals must perform.

Another important objection to the term behavioural skills is that the skills of decision making and situation awareness are cognitive processes and not behaviours. While there may be disagreement among cognitive scientists about the features of cognitive processes, there is universal agreement that they are certainly not behaviours.⁹ Sometimes these processes can be inferred from observed behaviour (e.g. we can infer a junior's situation awareness through their communication in a phone call to a senior to request help), but sometimes they cannot (e.g. the decision making process used by an intensive care nurse to determine that a patient is deteriorating). That these skills can sometimes be inferred from behaviour is the premise behind behavioural marker systems (e.g. the Anaesthetists' Non-Technical Skills [ANTS] system). These systems support the observation, and assessment, of specific behaviours that are indicative of particular non-technical skills.¹

Human factors skills is another term that has been proposed, and used, as an alternative to non-technical skills.⁷ However, the use of this alternative term is detrimental to the discipline of human factors, and worse, could negatively impact patient safety improvement efforts. The International Human Factors and Ergonomics Association defines human factors as ‘the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and methods to design in order to optimise human well-being and overall system performance’.¹⁰ Therefore, human factors skills might be more accurately considered to be those skills required to evaluate and improve workplaces in order to support safety, quality, and efficiency (e.g. how to conduct a task analysis of a clinical procedure). The discipline of human factors has suffered from the misperception that it is only concerned with the behaviours of frontline health care workers. This misunderstanding promotes a person-centred view in which frontline health care workers are held responsible for failings that should actually be attributed to issues further back in the health care system. Ironically, a person-centred approach that is derived from the misuse of the term ‘human factors skills’ is diametrically opposite to the systems-focused view that human factors practitioners wish to encourage.

We appreciate the argument against defining something in terms of what it is ‘not’. However, this is common in the English language (e.g. non-fiction, non-verbal and non-dominant), in health care (e.g. non-cortisol steroids and non-ST-elevation myocardial infarction) and medical education (e.g. non-judgmental debriefing). Where the root-term is well understood (e.g. fiction), then the term is very useful in supporting an understanding of what it is not (i.e. non-fiction). In our experience of teaching and studying non-technical skills, we have found that frontline workers in health care, and other high-risk work domains, have a very clear understanding of the technical aspects of their jobs. As such, when confronted with the term non-technical skills, we find that they also understand the meaning of this term and the underlying skills it represents.

We refute the contention that the term non-technical skills is ‘misleading, inaccurate, and oversimplifies critical aspects of professional practice’.⁵ Rather, we argue that the terms behavioural or human factors skills may in fact be more misleading and a greater oversimplification of the nuanced and sometimes non-observable skills that are encompassed by the term non-technical skills. However, to aid clarity, we suggest that it may be useful to be more specific and identify the particular non-technical skill (e.g. decision making) or group of skills (e.g. cognitive skills) identified. We also disagree with the contention that these skills are undervalued.⁴ Over the last two decades, there has been an increasing recognition of the importance of non-technical skills for safe and effective performance in health care and the widespread application of interventions that provide training in these skills (e.g. TeamSTEPPS¹¹). Therefore, we are in agreement with Gaba that the term non-technical skills is well entrenched both in the literature and in common parlance.¹² Arguably, even more so now than when Gaba made this observation in 2011. Therefore, we encourage authors, reviewers, and journal editors to support and encourage the use of the term non-technical skills rather than inaccurate and confusing alternatives.

Paul O'Connor: Conceptualization; writing—original draft; writing—review and editing. Angela O'Dea: Conceptualization; writing—review and editing.