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CONCLUSION 137
having to adapt to the technology. The culture of the workplace should also be sup-
portive including a flattened hierarchy within the team so the SFA has full psychological
safety and does not practice and behave defensively. SFAs have the added pressure of
having to make a mental and psychological shift when training and practising as an
SFA which is moving away from the scrub or anaesthetic practitioner role. Psychological
vulnerability can encroach in when the SFA has to make the transition and at the same
time wants to keep the team happy by helping and supporting the perioperative team.
This means less interactions with the surgeons, less mental rehearsal before the next
case and less time to take a mental, physical and psychological break. SFA must man-
age this and prioritise self-
care so they are better prepared and ready to assist the sur-
geon which means safer practice and care to the patients. Last but not least, civility
among the team will go a long way and in fact could save life (Cheetham and
Turner2020) as it will preserve mental bandwidth which is the ability to perform at
one’s best (Brubakk etal.2019).
CONCLUSION
While human factors and ergonomics enhance patient safety, service improvement
and staff well- being, SFAs need to also be proactive and keep improving their
knowledge and skills through reflections as advocated by the PCC (2018). This chapter
has demonstrated the centrality of HFEs in the workplace and how SFAs could adopt
the principles in their everyday practices, tasks and behaviours. The whole team must
learn together and celebrate successes together.
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141
Surgical First Assistant: The Essentials of Practice, First Edition. Editedby JulieQuick andMarkOwen.
© 2025John Wiley & Sons Ltd. Published 2025 by John Wiley & Sons Ltd.
CHAPTER 12
Non- technical Skills
Mandy Mangham
1
and Julie Quick
2
1
Registered Nurse. Surgical Care Practitioner. The Royal Wolverhampton NHS
Trust. HCA Healthcare UK. Associate Member of the Royal College of Surgeons of
England. Affiliate member of the Faculty of Perioperative Care with the Royal
College of Surgeons of Edinburgh. Casual Lecturer at Birmingham City University.
Committee Member of the Association of Surgical Care Practitioners
2
Birmingham City University, Birmingham, UK
INTRODUCTION
Part Two explored many of the clinical skills required by the surgical first assistant
(SFA) and of equal importance are the non- technical skills that should complement
the technical skills required by any practitioner (Forrest and Mckimm 2019). Most
adverse events in health care usually originate from non- technical aspects of
performance rather than technical ability (Allard et al. 2020). The Royal College of
Surgeons of Edinburgh (2019) defines non- technical skills as the cognitive, social and
personal skills that a practitioner requires to provide safe and effective patient care.
The inclusion of an SFA within the extended surgical team enhances the application
of non- technical skills during surgery and benefits not only the multidisciplinary
team but the patient as well (Royal College of Surgeons2014a).
The SFA will need to acquire and develop non- technical skills as they gain expe-
rience as a non- medical surgical assistant within the perioperative setting (Hall
etal.2016). This chapter identifies the non- technical skills required by the SFA and
provides examples of behaviours expected of the SFA to ensure patient safety as well
as considering managing fatigue.
142 Chapter 12 Non- technical Skills
CLASSIFICATION OFNON- TECHNICAL SKILLS
Various models of non- technical skills have been proposed but a classification system
or taxonomy, for non- technical skills based on the expected behaviours demonstrated
by practitioners within perioperative setting, was originally developed by researchers
from the University of Aberdeen based on an approach used in aviation following
research into healthcare-
related adverse events (Mitchell 2008). A joint project by
NHS Education for Scotland (NES) and the Royal College of Surgeons was started in
2003 and the non- technical skills for surgeons (NOTSS) was published. NES and the
University of Aberdeen went on to develop similar taxonomies for other perioperative
practitioners (SPLINTS, ANTS and ANTS- AP) with each including a behavioural rat-
ing system. Krage etal. (2017) argue that behavioural skills contribute to developing a
safe and effective team and so non- technical skills education has been customised
across many safety- critical occupations and embedded into healthcare organisation
programmes and professional standards.
At the time of writing, no system of non- technical skills has been developed spe-
cifically for the role of the SFA but since the extended surgical team consists of mem-
bers from multi- disciplinary teams such as medicine, nursing and operating
department practice, the wider belief that education in non-
technical skills would
benefit the whole team began to develop. In 2013, Flin etal. recognised seven NTSs
that are required across the multidisciplinary team:
• Situation awareness
• Decision- making
• Communication
• Teamwork
• Leadership
• Managing stress
• Coping with fatigue (Flin etal.2013)
One benefit of the NTS taxonomy is that the classification helps provide a common
language which reduces potential misunderstandings and enhances the discussion on
non- technical issues to improve patient safety. NHS England and NHS Improvement
(2020) acknowledge the multifactorial reasons behind patient safety incidents and
focus on systems and processes and their wider effects on the performance of the
healthcare professional, rather than apportioning blame solely on the individual.
Each of the NTS identified by Flin etal. (2013) is discussed here in relation to the SFA.
SITUATION AWARENESS
Situation awareness is the ability to have an awareness of the surroundings within the
operating theatre (Flin et al.2013). This includes being aware of the patient, team
members, resources and environment. One of the first responsibilities of the SFA is to
Situation Awareness 143
ensure they have gathered information about the patient to provide safe and effective
assistance. This includes attending the team brief and other safety checks including
checking patient consent. The SFA needs to be able to anticipate the needs of the sur-
geon so they may provide immediate assistance and request correct instrumentation
from the scrub practitioner, so they need an awareness and understanding of the sur-
gical procedure. The SFA should be able to understand the information they have
gained and be able to safely prioritise tasks that require immediate attention, such as
in an emergency, and being able to communicate this information to the multi-
disciplinary team and, where appropriate, the patient.
Communication andTeamwork
Communication and teamwork are essential components of perioperative practice.
The SFA should be experienced in communication strategies within the periopera-
tive setting as well as team collaboration. The RCS (2019) promotes the establish-
ment of a shared understanding within the team by the sharing of relevant
information about the patient and the proposed surgical procedure. This information
is shared and gathered at the team brief, the second step of the NatSSIPS2 (Centre
for Perioperative Care2023). The SFA will need to use this information to plan the
care they provide as a non- medical surgical assistant, for example, identifying any
allergies the patient may have that could affect the selection of antiseptic skin prep-
aration solution or dressings.
An essential aspect of the team brief is for team members to identify their role
and responsibilities. While the PCC recommend the use of the SFA title, Krish-
namoorthy and Britton (2022), the Royal College of Surgeons (2014a) and Abra-
ham etal. (2019) all observe that there remain many job titles within the remit of a
non- medical surgical assistant as well as overlapping areas of practice, which may
confuse team members. Declaring information to identify the SFA title and respon-
sibilities during the list will reduce any confusion about the role and allow trans-
parency. This is especially important when some SFAs may revert to the role of the
scrub practitioner on some lists. During the team brief, the SFA may also need to
communicate to the surgeon any stages of the surgery they are not proficient in, or
may be outside their scope of practice, for example, mccif they are expected to
suture the wound (see Chapter2 for more information on the scope of practice).
This allows the surgeon to recruit another assistant who can assist with these
stages of the operation.
One key role of any surgical assistant is to speak up if they are concerned at any
point during the operation. Speaking up can be difficult within healthcare but hesitancy
to do so can contribute to never events. The SFA needs to be assertive and speak up if
they have any concerns regarding any aspect of the surgery or care provided. Speaking
up can be difficult in the operating theatre due to historical hierarchies that Hanssen
etal. (2020) suggest still exist. Agha etal. (2015) identified that some cultural aspects of
the perioperative environment are often implicated in adverse events. Empowering the
wider perioperative and surgical teams to speak up when an issue arises leads to positive
team interactions, thus decreasing risks to the patient (Lee etal.2024).
144 Chapter 12 Non- technical Skills
Where challenging a colleague is difficult, Weller and Long (2019) suggest using
the PACE acronym (Table12.1) to gradually probe and challenge the practitioner,
escalating it to a senior clinician or manager if the concern is not alleviated.
Non- medical assistants are well placed to support junior members of the wider peri-
operative team (Quick2013; RCSn.d.; Abraham etal.2019). As the SFA is often an expe-
rienced theatre practitioner and practice assessor or supervisor, the SFA could be asked to
teach junior members of the team to perform a surgical scrub or supervise an SFA trainee.
Barr and Dowding (2016) identify that communication may be verbal, non- verbal,
written or visualisation. The experienced theatre practitioner and SFA will be aware of
the challenges and barriers to effective communication within the operating theatre and
will be used to implementing different strategies to overcome these. Hall etal. (2016) tell
us that the SFA should possess the personal qualities of confidence and courage alongside
competence during surgery. Being confident to speak up can reduce potential misunder-
standings or ambiguity between the operating surgeon and the SFA; however, there may
be situations where communication becomes particularly difficult such as during an
emergency. This type of situation places emphasis on using clear and concise verbal com-
munication skills, which are vital to maintaining patient safety (McCulloch etal.2011).
One way to ensure this is by using the closed- loop communication technique. This con-
sists of three phases: transmission of the information, read- back of the given information
and confirmation of the information received (Flemming and Carpini2019).
McClelland (2019) identified that while theatre practitioners will use the same
communication skills as other team members, they may demonstrate different behav-
iours. A practitioner may use different communication behaviours, such as using a
prelude in their communication with surgeons to influence decision- making. McClel-
land provides an example of a scrub practitioner asking if they can give some advice
to a surgeon to act as a buffer in a challenging situation. This mirrors the use of prob-
ing to act as a non- confrontational method of communication as identified in
Table12.1. As an experienced theatre practitioner, the SFA may illicit similar behav-
iour and utilise NTS skills differently in order to promote patient safety, although
more research is needed to confirm this.
Theatre practitioners must simultaneously cope with distractions which can
impact on communication between team members (Osborne- Smith and Hodgen2017).
The SFA will need to prioritise requests or interruptions from other sources and know
when to delegate this task to others so that they can focus on the physical task that they
are performing within the surgical team. Focusing on the procedure is an essential
behaviour that the SFA should always demonstrate but Higham and Vincent (2021)
TABLE12.1 PACE acronym to assist with speaking up (Adapted from Weller and
Long2019).
Probe– use of questions to voice your concern in a non- confrontational way
Alert– state what your disagreement is
Challenge– provide evidence
Escalate/emergency– report to a senior clinician, manager
Situation Awareness 145
identified that lapses in concentration are more likely to be associated with distraction
during a procedure that has been done many times before. For the SFA, these distrac-
tions could be excessive noise, a particular moment during the surgery where addi-
tional concentration is needed or from conversations outside of the surgical team.
Unnecessary conversations during surgery should be avoided as this diverts the SFA’s
attention (Hall etal.2016). Strategies such as the ‘Sterile cockpit’ and ‘Below 10,000
Feet’, taken from aviation, can be applied in the operating theatre to challenge
unwanted behaviour such as reducing noise and increasing staff focus to ensure patient
safety (Tominson2018). The SFA is bound by their regulatory standards or codes to
speak up (NMC2018; HCPC2023) and so the sterile cockpit, where no one talks, can
be requested during safety critical episodes of communication or care such as the team
brief, during a critical step in a procedure or simply when time to think is needed.
Task Management
Mitchell and Mitchell (2011) define task management within the non- technical skills
taxonomy as planning and preparing essential equipment. All members of the multi-
disciplinary perioperative team, including the SFA, are responsible for ensuring
equipment and resources required such as implants are available and confirm this
within the team brief. The SFA is now a user of surgical instruments rather than han-
dler of instruments, a role undertaken by the scrub practitioner, and the SFA has an
additional responsibility to know how to safely use the instruments they will be using
during the operation. As with any medical device, the SFA should ensure training is
current, and their knowledge is kept updated (Quick and Hall2014).
Leadership andDecision- Making
Leadership is a non- technical skill that should be demonstrated by all registered prac-
titioners and the SFA as an experienced member of the theatre team should display an
appropriate level of leadership qualities and communication skills (Denton 2021).
Howie and Yule (2021) state that although it may be expected that the surgeon per-
forms the role of the leader within the perioperative environment due to the clinical
decisions that need to be made during surgery, other members of the multidisci-
plinary team, including the SFA, will most definitely be required to demonstrate lead-
ership behaviours at certain times, if not all.
As an experienced team member, there may be times when the SFA is required to
take the lead, provide clarification or seek advice to assist with decision- making to main-
tain patient safety (Royal College Surgeons of Edinburgh 2019). The three traditional
styles of leadership are classified as autocratic, democratic and laissez- faire. Autocratic
leaders hold the power and control, expecting their perceived subordinates to conform to
the plan, whereas a democratic style leader will encourage their team to participate in the
decision- making process (Gopee and Galloway2017). The laissez- faire leader will pass
on all decision- making responsibilities to their subordinates, which may be interpreted
146 Chapter 12 Non- technical Skills
as an abdication of duty (Robert and Vandenberghe2021). However, this leadership style
can be effective when working alongside experienced, skilled practitioners.
Barr (2019) believes that the new era of leaders, especially within the NHS, is now
encouraged to adopt either a transactional or a transformational style of leadership. A
transactional leader focuses on achieving tasks based on a reward or punishment
system (Richards2020). Transformational leaders influence others by encouraging and
inspiring their team (Collins etal.2020). There may be times when, as an experienced
theatre practitioner, the SFA must change their usual style of leadership management,
for example, needing to become an autocratic leader during an emergency (Barr2019).
MANAGING STRESS ANDFATIGUE
The perioperative environment is a dynamic and demanding setting. As a non- medical
surgical assistant, some SFAs may find themselves providing assistance every day
while others may only assist a few days per month. It is worth remembering that few
surgeons operate or assist every day in theatre as they attend wards and outpatient
clinics to consult with their patients. It is therefore essential that the SFA considers
their own health and well- being to reduce stress and fatigue.
Healthcare is one of the top three prevalent occupations where musculoskeletal
injuries are common (Health and Safety Executive (HSE)2023). One of the challenges
of assisting is the working position of the surgical assistant. The SFA is more at risk of
developing musculoskeletal injuries if they work within a fixed or constrained body
position and a place of work that does not allow sufficient recovery between move-
ments (HSE2023). Lack of rest breaks and dehydration can worsen injury to muscles.
Strategies to avoid musculoskeletal injuries for the SFA are to stand as close to the
surgical site as possible and set the feet into a wide solid base. Keep the back straight
and flex the knees, keeping the head and shoulders up. Table height can be adjusted,
if possible and use stands and stools when available.
Other aspects of SFA well- being are discussed in the previous chapter on
human factors.
REFERENCES
Abraham, J., Bailey, L., Coad, J. etal. (2019). Non- medical practitioner roles in the UK:
who, where, and what factors influence their development? British Journal of Nursing
28 (14): 930– 939. https://doi.org/10.12968/bjon.2019.28.14.930.
Agha, R.A., Fowler, A.J., and Sevdalis, N. (2015). The role of non- technical skills in sur-
gery. Annals of Medicine and Surgery 4 (4): 422– 427.
Allard, M.A., Blanié, A., Brouquet, A., and Benhamou, D. (2020). Learning non- technical
skills in surgery. Journal of Visceral Surgery 157 (3): S131– S136.
Barr, J. (2019). Leadership in Healthcare, 4e. London: Sage Publishing.