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What do patient safety and buckets have in common? An introduction to non-technical skills

This is article thirteen in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

“I asked the nurse for more clampy things. I was doing a splenectomy and it wasn’t going as smoothly as I hoped. I was concentrating on ligating vessels and couldn’t think of the word, haemostat. Thankfully, the nurse had already put more on the trolley, but I didn’t even notice her doing that.”  - a veterinary surgeon.

Our brains process information. When there is too much information in the environment at any one time we select what to pay attention to. This may be driven by what is around us, such as a sudden noise or movement, but also by our experience. Information stored in our memory directs us to those things that we think to be important.    

When, as a member of the operating team, we are working through the steps in a procedure, we are using our short-term, or working memory store to hold the information we need. However, our working memory has limited storage capacity and can be easily disrupted. If we liken our working memory to a bucket and the information in our environment as liquid, when our bucket is not full, we can still manage to process more information (or liquid). But when our bucket is full, no new liquid can be added without removing what is already there - we are at full cognitive capacity. Equally, other things can disrupt working memory such as stress, lack of experience, distractions, fatigue, and hunger. These disruptors also work to fill our bucket, leaving less room for information. 

This is why we sometimes have trouble remembering things, like the word for ‘haemostats’, as our working memory buckets get full and we have to prioritise the most important information; in this example of the steps needed to remove a spleen. The nurse was able to contribute some of her bucket space and was able to anticipate what was needed. But what happens when buckets spill over? When our working memories are full, we may fail to communicate or miss information that is important for our patients.

Non-technical skills

In our previous article on Human Factors, we described that there were many factors that affect our behaviour and performance at work, which ultimately impact our patient care and outcomes. Traditionally, much CPD time has been dedicated to working effectively with clients to reach the best outcome for our patients, and rightly so – the client is an important part of the clinical team. But do we also know how to best work with each other?

We typically emphasise knowledge and technical skill (i.e. surgical dexterity and technique) as being the most important factors for good patient outcomes. We spend years acquiring and refining them in university and practice. However, we are now learning that non-technical skills (NTS), are just as important for good patient care and outcomes1.  

Non-technical skills are the cognitive, social, and personal resource skills that are necessary for optimal performance. As we become more developed in these areas, our knowledge and technical skills are used more effectively, allowing the team to work to their strengths 1,3,5

Non-technical skill training and assessment was born in the field of aviation, where it was realised that a pilot’s technical skill alone did not guarantee a safe flight. Training and assessment are now mandatory in most countries. Equally, research has shown that in human healthcare, expert technical skill and knowledge do not always lead to expected outcomes as NTS often play a role in adverse events2

In ‘Just a Routine Operation’, pilot Martin Bromiley talks about his experience of losing his wife during a routine procedure. This was the catalyst for Mr. Bromiley to bring his training as a pilot in Human Factors and NTS to healthcare, forming the Clinical Human Factors Group, which works with clinicians to make healthcare safer for patients and staff6. This led to the development of frameworks to formally train and assess surgical teams in NTS, such as the Non-Technical Skills for Surgeons (NOTSS) system2.

The NOTSS system was developed for use in human healthcare by a team of surgeons, psychologists and anaesthetists from the Royal College of Surgeons of Edinburgh and the School of Psychology, University of Aberdeen. It is a framework for structuring observation, feedback and rating of surgeons’ behaviours in the operating theatre, to help them develop abilities in the workplace2. Other systems were developed for the theatre team to include anaesthetists (ANTS) and scrub practitioners (SPLINTS) and describe behaviours unique to these roles2.

Human behaviour is similar across workplaces

While much of this background is drawn from aviation and human healthcare, human behaviour is similar across all kinds of workplaces, which is why NTS are critical for many different tasks, from the cockpit to the operating theatre5.

The behaviours described as NTS are all connected, one supports the others, so must be considered together, not in isolation. 

They include1,5:

  • Situational awareness
  • Teamwork and communication
  • Decision making
  • Leadership
  • Stress management
  • Coping with fatigue
Situational awareness

This is about knowing what’s going on around you. Developing and maintaining an awareness of the situation based on gathering data from the environment, understanding what it means and thinking about what may happen next. Here, the individual or team scans the environment and asks questions of other team members, verbalising what is seen and understood. The team talks about possible contingencies and makes plans for any anticipated problems.

Teamwork and communication

These are skills that an individual develops for working in a team context, to ensure that everyone has a shared picture of the situation and can complete tasks effectively. Here information is exchanged to establish a shared understanding to coordinate team activities and back each other up, which can reduce the stress on the team when everyone feels supported in their role. An environment that nurtures psychological safety is important so that everyone feels safe to speak up or ask for help.


These are skills in assessing a situation and choosing an appropriate course of action. Our level of situational awareness and information gathering affects our decision making. Teamwork and communication play a big role, as considering the options may be done with the help of the team. Once the decision has been made, then communicating it to the team and checking back to ensure that the decision was the correct one.


These are skills in leading the team and providing direction, demonstrating high standards of clinical practice, and being considerate about the needs of individual team members. This includes how you set and maintain standards, listen, and value other’s opinions, and appreciate that the way you cope with pressure has an effect on the performance of the team. Follow the links for more on compassionate and shared leadership.

Stress management

When we are no longer able to cope with acute or chronic stress, it can affect our standard of patient care, ability to work in a team, make us more prone to making mistakes, and may even result in illness. However, through understanding our stressors and identifying resources to address them, it is possible to minimise the effects of stress.  

Coping with fatigue

People will experience fatigue differently, and under a variety of conditions. Fatigue has detrimental effects on our ability to think clearly, motor skills, communication and social skills. Measures can be taken to reduce fatigue, which includes paying attention to sleep, diet and taking time to adapt to different work schedules, such as shift work.

Non-technical skills in the veterinary profession

In a study from 2015, Oxtoby et al reviewed 225 VDS insurance claims and identified cognitive limitations as contributing to 51% of claims. Lack of technical knowledge or skill contributed to 14% of claims4. While information regarding non-technical skills specific to the veterinary profession is currently limited, we may already intuitively know they play a role in good patient outcomes. If you have ever been susceptible to tunnel vision whilst operating on a patient (perhaps a splenectomy too?) and missed a step or forgot a vital piece of information, then you yourself will know this to be true.

You may now be thinking, ‘How can I learn non-technical skills?’. The good news is that we all innately have these skills and have developed them over time. However, we may have gaps or weaknesses that are revealed under stress. This framework provides a language for improvement and a reference point for application in the veterinary profession. 

As we continue to expand our understanding of NTS, there are several practical tools that you can use every day to develop and support good behaviours. These encourage the team to build shared understanding and support each other by spreading out the cognitive load (preventing buckets from spilling over!) and backing each other up.

In coming articles, we will discuss tools to grow and support non-technical skills in your team in more detail. Where a topic has already been covered, follow the hyperlink provided. This includes the use of:

  1. Clinical and wellbeing checklists – coming next month!
  2. Sterile cockpit – avoiding unnecessary distraction during critical phases of a procedure
  3. CUSS – a tool for graded assertiveness
  4. 10 for 10 – slowing down to speed up
  5. Speak back and read back (closed communication loop) and cross-checking
  6. Team brief and debrief

Checklist: What can you do next?

  • Watch Martin Bromiley’s 'Just a Routine Operation' and learn that we all have a role to play in creating a culture where everyone feels safe to speak up when something is not right.
  • Listen to John Williams and Pam Mosedale discuss how systems and meetings can aid communication, and the role that checklists can play in establishing shared leadership in veterinary practice.
  • Read our Surgical Safety Checklist Manual to learn more about checklists and how to introduce them to other members of the team. It includes templates specific to veterinary practices.
  • Listen to Laura Playforth and Pam Mosedale as they discuss how incivility can increase errors and impact patient care and outcomes. You can then check out Civility Saves Lives, a website run by health care professionals aiming to raise awareness of the power of civility in medicine.
  • Read RCVS Knowledge’s Rolling take 5- Questions to discuss as a team to help improve communication between shift teams, to identify areas for improvement, to identify processes that have worked well, and flag up required support for the team.
  • Listen to Margaret Mary Devaney and Anita Malana’s podcast on QI, Safety Systems, and Just Culture in the NHS.
  • Listen to Suzette Woodward, a paediatric intensive care nurse who is now a Professor in patient safety, discuss the latest safety concepts and science that are sweeping the NHS - as well as what we could do differently. 
  • Read our previous feature, Compassion- at the heart of practice.
  • Sign up for the free RCVS Edward Jenner Leadership Development Programme. Suitable for all veterinary professionals, it covers key concepts specific to the veterinary sector. Delegates can work through the course at their own pace, whilst engaging and discussing learning with fellow online learners.


1Flin R., Youngson G. and Yule S. (eds) (2016)  Enhancing surgical performance: A Primer in Non-Technical Skills.  Boca Raton, FL: CRC Press

2Non-technical skills for surgeons [NOTSS] [online] Available from: [Accessed 28 September 2021]

3Jasani, S. Human factors, non-technical skills and professionalism [Royal Veterinary College, University of London][Podcast].  Available from:  [Accessed  28 September 2021]

4Oxtoby, C. et al. (2015) We need to talk about error: causes and types of error in veterinary practice. Veterinary Record, 177 (17), p. 438.

5Flin, R., O’Connor, P. and Crichton, M.  (2008) Safety at the sharp end: A guide to non-technical skills. Boca Raton, FL: CRC Press

6Clinical Human Factors Group [CHFG] [online]. Available from:  [Accessed 6 October 2021]

About the authorAngela Rayner

Angela Rayner BVM&S PgDipPSHCF MRCVS

Angela is a Quality Improvement Advisor for RCVS Knowledge, Director of Quality Improvement for CVS, and is an RCVS Knowledge Champion for her role in improving CVS’ systems for controlled drugs auditing.

In 2021, Angela completed a MSc in Patient Safety and Clinical Human Factors at the University of Edinburgh. The programme supports healthcare professionals in using evidence-based tools and techniques to improve the reliability and safety of healthcare systems.

It includes how good teamwork influences patient outcomes, key concepts around learning from adverse events and teaching safety, understanding the speciality of clinical human factors, as well as the concept of implementing, observing and measuring change, monitoring for safety, and it focusses on quality improvement research and methodologies.   

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October 2021