‘Verbalising the tacit’ : Development and validation of the Non-Technical Skills for Operating Room Nurses (NOTSORN) tool

Abstract

Background: The surgical team collaborates to provide the patient with the best care and treatment possible. The application of well-developed non-technical skills (cognitive and social skills) are essential for preventing surgery-related patient harm. The non-technical skills of each team member can be trained by using designated tools based on the crew resource management framework. These tools operationalise the non-technical skills by defining the skills and providing examples of behaviours related to the skill, and have previously been developed for surgeons, anaesthetists, nurse anaesthetists and scrub practitioners. However, a tool for the operating room nursing profession has not been developed. Aim: The overall aim of this PhD thesis was to explore how Development and validation a new non-technical skills tool for operating room nurses may contribute towards high-quality operating room nursing practice. The following aims were developed for the three individual studies: 1. To identify the non-technical skills of operating room nurses 2. To explore operating room nurses’ descriptions of their practices in search for non-technical skills not included in the crew resource management framework 3. To establish the face- and content validity of the Non-Technical Skills for Operating Room Nurses (NOTSORN) tool Methods: This project was a mixed-method, multi-item instrument development, and used a parallel, sequential, multiphase design in which quantitative and qualitative methodologies were used in the data collection, analysis, and presentation of results. The four phases of the study included two mixed-methods studies, one qualitative study, and two syntheses. The phases are detailed as follows. 1) Item generation a) Study 1 included a three-round Delphi technique involving an expert panel of operating room nurses (N = 106) and on-line surveys comprising quantitative and qualitative questions. The data were analysed using descriptive statistics (quantitative) and deductive thematic analysis (qualitative). b) Study 2 included a qualitative exploration of open-ended questions from Round II of the previous Delphi survey (N = 96), and the data were analysed using inductive thematic analysis. 2) Synthesis I was an iterative refinement of items identified in Studies 1 and 2, and a thematic organisation of items into a bi-lingual draft behavioural marker system, the NOTSORN tool. 3) Study 3 involved a bi-lingual, mixed-methods face and content validation of the NOTSORN tool using a two round Delphi technique to measure the content validity index. The expert panel comprised 25 Norwegian and international operating room nurse educators, researchers, and stakeholders. Quantitative data informed the content validity (descriptive statistics), and qualitative data informed the bilingual iteration of the NOTSORN tool. 4) Synthesis II was a qualitative synthesis that integrated the results of the first three stages and addressed the overall aim of exploring how the NOTSORN tool may contribute to high-quality operating room nursing practice. Results: In Study 1, consensus indicated that the crew Resource management categories of teamwork, situation awareness, leadership, decision-making, and communication are important in the work of operating room nurses. For each category, the thematic analysis developed descriptions of non-technical skills and their related behaviours. Several of these results have not previously been identified in relation to operating room nursing. In Study 2, the inductive thematic analysis developed two themes that identified the non-technical skills not included in the crew resource management framework. These results complemented the results of Study 1 in the item generation for the non-technical skills tool. Synthesis II developed a draft NOTSORN tool based on Studies 1 and 2. The qualitative data from Study 3 were used to refine the content of both versions of the NOTSORN tool. The quantitative results confirmed excellent content validity at the item- and scale levels of the Norwegian and English NOTSORN tool. The thematic analysis in the integrated Synthesis II identified three themes that highlighted that the NOTSORN tool may contribute to high-quality operating room nursing practice by ensuring patient safety and well-being, by stimulating continuous learning, and promoting teamwork. Conclusion: This PhD project provides the international operating room nursing profession with the validated NOTSORN tool. Systematic use of the NOTSORN tool may be a contribution towards high-quality operating room nursing practice. This thesis confirms that the tool captures the countless NTS needed in operating room nursing. The NOTSORN tool’s verbalisation of formerly unspoken and tacit skills may contribute to the general acknowledgement of operating room nurses’ responsibilities, competence, and contribution to patient safety. Furthermore, its operationalisation of cognitive and social skills may stimulate continuous learning for operating room nurses and students and improve surgical teamwork.