The document discusses non-technical skills that are important for anesthesiologists, including situation awareness, decision making, teamwork, and stress management. It describes how the Anesthetists' Non-Technical Skills (ANTS) system was developed to identify and rate non-technical skills in four categories (task management, team working, situation awareness, and decision making) based on observational studies. The ANTS system provides a standardized way to assess and provide feedback on anesthesiologists' non-technical performance.

1. NON TECHNICAL
SKILLS OF
ANAESTHESIOLOGI
ST
MODERATOR- DR. VALECHA
SPEAKER – DR. RUCHI

2. INTRODUCTION
• The term ‘non-technical skills’ was first applied
to safety by the European civil aviation
regulator in relation to airline pilots’ behaviour
on the flight deck but is now used by a number
of professions .
• Non-technical skills can be defined as ‘ the
cognitive, social, and personal resource skills
that complement technical skills, and contribute
to safe and efficient task performance.
• NTS typically include situation awareness,
decision-making, team work, leadership, and
the management of stress and fatigue.

3. Safety & efficiency in any field of work is not just limited to
possession of thorough academic knowledge & skilful
application of the technical skills, but it also encompasses
the basic human behaviour & attitude of individuals
during the course of performance of their duties.
• Deficiencies in non-technical skills can increase the
chances of error, which in turn can increase the chances
of an adverse event.
• Detailed investigations of adverse health care events
have shown that in almost 80% of the cases the
underlying cause is poor application of NTS like poor
communication, inadequate monitoring, failures to cross-check
drugs and equipment.
• Good non-technical skills (e.g. vigilance, anticipation,
clear communication, team coordination) can reduce the
likelihood of error and consequently of accidents

4. Two categories of NTS have been recognized:
1. Cognitive & Mental skills which include
planning, decision making, situation
awareness etc.
2. Social & Interpersonal skills like coordinated
team work, leadership, communication etc.

5. BEGINNING OF ANTS
• To identify the NTS various methods were used
by different researchers and data collection was
grouped under the following headings:
1. Incident Reporting
2. Observational studies in real life
3.Virtual observational studies in simulation
centres.
4.Attitude Questionnaires &
5. Theoretical Models.

6. Incident Reports
• Cooper & Colleagues while investigating the
cause of preventable incidents involving human
error or equipment malfunction found that 82%
of the incidents were due to human errors like
• poor communication
• failure to recognize a developing problem
(Inattention, Carelessness, Haste, Fatigue)
• failure to follow set personal routine or
institutional practice
• flawed decision making (Distraction, Insufficient
preparation)
• excessive dependency .

7. Observational Studies
• These allow human behaviour to be examined in real
operating environment & in Simulation centers. In
real time studies observations are made either
directly or by setting up a number of video cameras
for analysis at a later stage.
• Limitations of such studies include normal behaviour
of the team is altered in the presence of the
researchers, inability to directly observe the entire
team all the time as well as the issues related to
consent & confidentiality.
• Despite these limitations these studies have
observed in 40% of times the behaviour of the
different teams was unsatisfactory & was below the
set standard in the area of Communication &
Coordination affecting the decision making process
as well as affecting the overall clinical performance

8. • Salient points observed were carelessness,
haste, inattention, distraction, failure to follow
set routine institutional guidelines & excessive
dependence on other personnel
• These observational studies show that key
skills necessary for better performance are
Verbal Communication, Individual & Team
Situational Awareness, Problem Recognition,
and Decision Making & Reevaluation.

9. Attitude Questionnaire
• Questionnaire based surveys have shown
similar findings in respect of importance of
Communication & Coordination in addition to
technical proficiency.

10. Training
• Anaesthesiologists in the USA were among the
first to adapt the aviation Crew Resource
Management (non-technical) skills approach
for anaesthetic training and devised an
Anaesthetic Crisis Resource Management
course as part of their simulation centre
training programme.
• Aim of this course is to prevent, ameliorate &
resolve critical incidents.

11. Information gathered from these courses,
observations and Questionnaire led to the
beginning of a project on
ANAESTHETISTS’ NON TECHNICAL
SKILLS (ANTS)

12. TAXONOMY OF ANTS
• The ANTS System comprises a three level
hierarchy.
• At the highest level are four skill categories
and beneath these are fifteen skill elements .
• Each element has a definition and some
examples of good and poor behaviours that
could be associated with it, this forms the
main framework of the system.

13. ANTS FRAMEWORK
TASK MANAGEMENT •Planning and preparing
•Prioritizing
•Providing and maintaining standards
•Identifying and utilizing resources
TEAM WORKING •Coordinating activities with team
members
•Exchanging information
•Using authority and assertiveness
•Assessing capabilities
•Supporting others
SITUATION
AWARENESS
•Gathering information
•Recognizing and understanding
•Anticipating
DECISION MAKING •Identifying options
•Balancing risks and selecting options
•Re-evaluating

14. • TASK MANAGEMENT: Skills for organising
resources and required activities to achieve goals.
1. Planning and preparing – developing in advance
primary and contingency strategies for managing
tasks, reviewing these and updating them if
required to ensure goals to be met; making
necessary arrangements to ensure plans can be
achieved.
Behavioural markers for good practice-- lays out
drugs and equipment needed before starting
case.
Behavioural markers for poor practice--does not ask
for drugs or equipment until the last minute or
does not have emergency/alternative drugs

15. 2.Prioritising – scheduling tasks, activities, issues
etc., according to importance, being able to
identify key issues and allocate attention to
them accordingly, and avoiding being
distracted by less important or irrelevant
matters.
• Behavioural markers for good practice--
negotiates sequence of cases on list with
Surgeon
• Behavioural markers for poor practice-- fails to
allocate attention to critical areas

16. 3. Providing and maintaining standards –
supporting safety and quality by adhering to
accepted principles of anaesthesia; following
codes of good practice, treatment protocols or
guidelines, and mental checklists.
• Behavioural markers for good practice--cross-checks
drug labels, checks machine at
beginning of each session, maintains accurate
anaesthetic records
• Behavioural markers for poor practice--does
not check blood with patient and notes, fails
to confirm patient identity and consent details

17. 4. Identifying and utilising resources –
establishing the necessary, and
available,requirements for task completion
(e.g. people, expertise, equipment, time) and
using them to accomplish goals with minimum
stress, work overload on individuals and the
whole team
• good practice-- allocates tasks to appropriate
member(s) of the team.
• poor practice--overloads team members with
task

18. • TEAM WORKING: Skills for working in a group to ensure
effective joint task completion and team member
satisfaction.
5. Co-ordinating activities with team members – working
together with others to carry out tasks, for both
physical and cognitive activities; understanding the
roles and responsibilities of different team members,
and ensuring that a collaborative approach is
employed.
• Behavioural markers for good practice-• confirms roles
and responsibilities of team members, discusses case
with surgeons or colleagues
• for poor practice-• does not co-ordinate with
surgeon(s) and other groups• relies too much on
familiarity of team for getting things done – makes
assumptions,takes things for granted

19. 6. Exchanging information – giving and receiving the
knowledge and data necessary for team co-ordination
and task completion
good practice--gives situation updates/reports key events
poor practice-- gives inadequate handover briefing
7. Using authority and assertiveness – leading the team
and/or the task, accepting a non-leading role when
appropriate; adopting a suitably forceful manner to
make a point
good practice- takes over task leadership as required
poor practice--does not allow others to put forward
their case

20. 8. Assessing capabilities – judging different team
members’ skills, and their ability to deal with a
situation.
good practice-asks new team member about their
Experience
poor practice-allows team to accept case beyond its
level of expertise
9.Supporting others – providing physical, cognitive
or emotional help to other members of the team
Good practice- acknowledges concerns of others
Poor practice- asks for information at difficult/high
workload time for someone else

21. • SITUATION AWARENESS: Skills for developing and
maintaining an overall awareness of the work setting
based on observing all relevant aspects of the theatre
environment (patient, team, time, displays,
equipment); understanding what they mean, and
thinking ahead about what could happen next.
11.Gathering information – actively and specifically
collecting data about the situation by continuously
observing the whole environment and monitoring all
available data sources and cues and verifying data to
confirm their reliability (i.e. that they are not
artefactual)
good practice- watches surgical procedure, verify status
poor practice-does not ask questions to orient self to
situation during hand-over

22. 12. Anticipating – asking ‘what if’ questions and
thinking ahead about potential outcomes and
consequences of actions, intervention, non-intervention,
etc
• good practice- reviews the effects of an
intervention
• poor practice- does not foresee undesirable
drug interactions

23. • DECISION MAKING: Skills for reaching a
judgement to select a course of action or make a
diagnosis about a situation, in both normal
conditions and in time-pressured crisis situations
13.Identifying options – generating alternative
possibilities or courses of action to be considered
in making a decision or solving a problem.
14.Balancing risks and selecting options – assessing
hazards to weigh up the threats or benefits of a
situation, considering the advantages and
disadvantages of different courses of action

24. • 15. Re-evaluating – continually reviewing the
suitability of the options identified, assessed
and selected; and re-assessing the situation
following implementation of a given action.
• good practice-• re-assesses patient after
treatment or Intervention
• poor practice-• fails to allow adequate time
for intervention to take effect

25. • In addition to the ANTS framework, a
Behaviour Rating Scale was designed where
each element was rated on a set of 4-point
rating scales for rating observed behaviours in
relation to the elements and categories, and
space also to write brief comments, and an
option for indicating the non observed skill for
that particular scenario.

26. ANTS System rating options
Rating Label Description
4—Good Performance was of a consistently high
standard, enhancing patient safety; it
could be used as a positive example for
others.
3—Acceptable Performance was of a satisfactory
standard but could be improved.
2—Marginal Performance indicated cause for concern;
considerable improvement is needed.
1—Poor Performance endangered or potentially
endangered patient safety; serious
remediation is required.
Not observed Skill could not be observed in this
scenario.

28. • The ANTS ratings are made at any place where
anaesthesia is being delivered, like operation
theatre or remote areas of anaesthesia delivery
(MRI, ECT) or in simulator facilities and now even
in intensive care units and for neonatal
resuscitation.
• The tool is designed to be used by experienced
anaesthetists to rate the non-technical skills of
another anaesthetist who has achieved basic
technical competence and provide feedback on
the behavioural aspects of performance.
• Managing stress and coping with fatigue are not
explicit categories, as they can be difficult to
detect unless when extreme

29. • Video Replay and Debriefing act as powerful way
of allowing scenario participants to reflect on
their actions and facilitate further exploration of
the cognitive processes.
• The Advantage of such skills is that, by
identifying specific behavioural examples during
performance with illustration of the positive and
negative impacts of their actions, course
participants rapidly build their understanding and
develop confidence.
• ANTS is also used to test the efficiency of
simulator-based training programme on
anaesthesia crisis management.

30. LIMITATIONS
• Relative lack of clinicians who are familiar with its
use and are therefore unable to give recurrent
feedback.
• Some faculty members feel less confident in
their own understanding of non-technical skills.
• The session duration is not well defined to
deliver formal instruction for the use of the ANTS
system.
• Anesthesiologist even from the same unit, do not
always agree on what is safe anaesthetic practice.
This present a considerable problem for
professional assessment of technical, and
nontechnical skills.

31. Conclusion
Non technical skills is important to mitigate the
effects of the errors in the areas where
SAFETY is a paramount concern.
• It is important to remember that non-technical
skills should not be considered in
isolation to other aspects of anaesthetic
competence. Successful task performance
depends on the effective integration of both
technical and non-technical skills for any given
situation.

32. REFERENCES
• www.abdn.ac.uk/iprc/ants
• Divekar D. Nontechnical skills in anaesthesiology.
Pravara MedRev 2009; 4: 4–10
• Anaesthetists’ non-technical skills R. Flin , R. Patey, R.
Glavin and N. Maran British Journal of Anaesthesia
105 (1): 38–44 (2010)
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