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Training and Nontechnical Skills: The Politics of Terminology

2011; Lippincott Williams & Wilkins; Volume: 6; Issue: 1 Linguagem: Inglês

10.1097/sih.0b013e31820f9a55

1559-713X

David M. Gaba,

Innovations in Medical Education

As indicated in the Introduction, this set of articles was stimulated by the article by a stellar cast of prominent simulation educators led by the first author Debra Nestel.1 The key thrust of their argument is that the term “nontechnical skills” is a poor choice of words to describe a complex set of “human factors,” and they allege that by continuing to use this term, the field of simulation (among others) is being harmed. I do not have a dog in this fight per se, but—to continue the metaphor—I used to own another canine that bears some relation to the current hounds having a tussle. My group is arguably responsible for bringing the concepts of performance other than medical diagnosis and treatment into the realm of understanding clinical work through simulation-based experiments and then for training clinicians using simulation to improve such skills. I went back to look at my own writings on the topic in the late 1980s and early 1990s. Interestingly, I never used the term “nontechnical skills,” at least not until after it had been introduced into the field in the late 1990s by Professor Rhona Flin and colleagues, psychologists from the University of Aberdeen. In the piece by Ronnie Glavin,2 a collaborator of Flin in measuring nontechnical skills in healthcare, he describes some of the history of Flin's use of the term nontechnical skills first in oil drilling and aviation, and he provides some interesting information about the ramifications of using this terminology with people on the front lines of some of those industries. In my own writing and speaking, I originally used the term “behaviors,” “behavioral performance,” or “behavioral skills” to refer to the aspects of performance that seemed necessary for good dynamic decision making, sound team management, and teamwork. These were distinguished from “medical and technical” performance or skills—doing the specific elements of medical diagnosis, treatment, and the physical procedures thereof. Over the last decade, I like many others have adopted “nontechnical skills” as the typical generic term for these behaviors. In my own perception, everyone in healthcare and in other fields seem to get the difference we are suggesting (ie, they understand what is meant by nontechnical skills even if we don't have a precise definition). I accept that the term nontechnical skills may lack precision. Perhaps it seems odd to refer to something by what it is “not.” Actually such terms are quite common, both in general English (eg, nonexistent, nonprofit, nonviolent, and nonfiction) and in various branches of science and medicine (eg, non-Euclidian geometry, nonlinear, non-Abelian group, nonflammable, noncommunicable, non-Hodgkin lymphoma, and nondepolarizing muscle relaxants). Thus, I don't really see a particular problem just by something being called “non-XXX.” I should also note that “nontechnical skills” is a name in common parlance, but no one claims that the term itself is a formal definition. Nestel et al cite the definition of “nontechnical” in the Oxford English Dictionary (OED)—often considered the dictionary of dictionaries. However, in this case, I find the OED to be impoverished, surprisingly so because it relies on reports of how words are used in practice and not on a model of how they “ought” to be used. First of all, the OED lists more than a dozen definitions of technical, perhaps one of which of note is “of a sport, activity, etc. requiring a high level of skill or technique.”3 I believe that among clinicians, there is a widely shared understanding that “technique” refers to the psychomotor techniques of particular procedures that require (among other things) manual dexterity. In this sense, nontechnical refers to activities that are not merely manual procedures requiring dexterity. Perhaps more to the point about the OED is how it seemingly missed the fact that in actual spoken and written use, there are now two fairly widely used meanings of the term nontechnical. Search engines have made simple what was once laborious, ie, the OED's landmark process of finding instances of the use of words and terms in actual writing or speech (the history of which is artfully described in a fascinating book by Simon Winchester).4 My Google search of the term “nontechnical skills” produced 8,500,000 hits. Among the first couple of hundred they seem to fall into two categories. One is indeed the type of use promulgated by Flin et al, which is now commonplace in healthcare. The other comes from the world of “human resources,” often applied to scientific and engineering fields and seems to describe job skills related to fundamental human behaviors such as teamwork, communication ability, and oral and written communication. So, in this case, I have to think that Google might just trump the OED. Language doesn't stand still—it evolves constantly. Maybe it is just an accident of history that so many people use the term nontechnical skills. Maybe it is an imperfect term. But, my guess is that—using equally common if imperfect metaphors—“that ship has sailed”; “the train has left the station.” It is a term of art now ingrained in usage just like the other “non”-based colloquial terms. Nestel et al suggest that we use the term “human factors” instead of nontechnical skills. Although I am not a specialist in human factors, it was part of my engineering degree. I have been working on human factors topics for 25 years and was a member of the editorial board of the premiere journal, Human Factors. Thus, I am a huge proponent of the inclusion of human factors issues and human factors experts in dealing with healthcare processes for efficiency, effectiveness, quality, and safety. But, the term “human factors” is surely much broader than is the content of the term “nontechnical skills” as we use it in simulation. Human factors is itself a term with odd origins and ambiguity. It covers diverse topics throughout the cycle of human-system interaction, including among other things equipment design, task design, environmental design, training, and performance assessment or personnel selection.5 To use the term human factors to cover the subset that is “nontechnical skills” likely would be more confusing. I do share the position of Nestel et al that all of us in the simulation community, as well as everyone in healthcare, should respect the endeavors of educators, psychologists, and social scientists working on issues of human factors as they relate to human performance. That Nestel et al are prominent and admired experts in this area is what makes their article worth thinking about. I am not, however, persuaded that any changes in terminology are either warranted or likely to be possible. Turning to the philosophical approach of Glavin, the major thrust of his argument that interests me is about the words “training” and “skills.” Describing clinical simulation as “training” rather than education, he says, may “sell ourselves short,” in part because only education imparts values. I don't entirely see it that way. For me, education refers to achieving in the learner a broad conceptual understanding, whereas training refers to learning the actual elements of performance at some meaningful undertaking—typically meaning “work.” To me, training someone to be good at their work often includes the transmission of values and is of inestimable value. Perhaps of greater importance, Glavin suggests that using the term “skills” tends to imply that complex performance—whether medical/technical or behavioral (nontechnical)—can be distilled to a few “skills” that can be easily measured (say on a checklist) and whose acquisition allows an employer to “tick a box to satisfy an external regulator.” It is this risk of oversimplifying the complexity of clinical performance that I believe is the key to Glavin's argument. What makes this discussion about training and skills important are the potential consequences of terms when they are adopted in highly politicized processes such as funding decisions, or in performance assessment, examination, or credentialing of clinicians. Glavin argues that using the term skills feeds into this process in a way that may obfuscate the true complexity of clinical work and simulation endeavors. He says “Those who know little of our activities from direct experience but have a large role to play in funding or commissioning activity at our centers may not appreciate the extent of our possible contribution to the professional development of those participating in our courses.” While I am sympathetic to this view, I don't think the terminology is the root of the problem. Rather, more needs to be done about defining the process of how to turn our notions of what makes a good clinician into actual mechanisms to improve the work of individual clinicians. There is no magic to identify people who cannot “do the job” very well or, conversely, to identify those who “have what it takes.” We must also develop some sort of mechanisms to better mold and measure their performance, determining whether it is adequate or not. What should we call the elements of adequate performance if not “skills”? I haven't seen in either of the preceding commentaries any suggestions of a better word to use. And, I believe that the word is appropriate for each of the technical, clinical, and behavioral activities that we are addressing. I do not believe that the answer to this problem is to modify terminology. That would probably be a losing battle anyway. The terms skills and nontechnical skills are both well entrenched in the literature and in common parlance. The unique ability of simulation to present cases of known etiology reproducibly to different individuals or groups has provided healthcare with a very important new window on performance of clinicians. Thus, the answer may be for the simulation community to become more involved in the academic, bureaucratic, and political processes that link our work to the practical mechanisms of performance development, gatekeeping, monitoring, and control. Members of our community largely understand what is meant by imperfect terms such as skills and nontechnical skills. Our continuing involvement in how these issues are addressed by accreditors, regulators, and governments will ensure that the concepts are used appropriately and in a fashion consistent with the goal of improving patient care. In summary, these provocative articles make us think harder about what we do, why we do it, and what it all means in the bigger picture. While I don't agree with all the suggestions made in these two commentaries, I am grateful for how they have helped to reveal and crystallize the challenges we have in making simulation achieve its true potential. ACKNOWLEDGMENTS The author thank Jeff Cooper, PhD, for insightful suggestions in the editing process.