Non-Technical Skills in Healthcare: a Pilot Study

Non-technical skills (NTS) represent a set of cross-disciplinary competencies that optimize the coordination of individual professionals within a healthcare team. In the healthcare sector, NTS were introduced in the late 1980s based on the Crisis Resource Management (CRM) system initially developed in U.S. aviation. CRM is a framework that integrates all non-technical competencies essential for effective teamwork under crisis conditions. This approach emphasizes the importance of human factors and NTS in patient safety within healthcare settings, where emotional impact and stress levels among practitioners are notably high [1].

An analysis of national industry statistics indicates that most workplace incidents in healthcare arise from unsafe behaviors rather than deficiencies in personal protective equipment. This highlights the need to assess often-overlooked work elements, such as risk perception, attribution of meaning, decision-making, and discretionary orientation of workplace conduct, with particular attention to the “human factor” [2].

Human error cannot be entirely eliminated, but early identification, preventive actions, and the promotion of NTS can mitigate the impact of such errors. NTS complement technical competencies and enable more effective and safer performance. The najor NTS include leadership, communication, teamwork, task management, critical thinking, decision-making, and situational awareness. These are defined as “cognitive, social, and personal resource skills that complement technical abilities and contribute to the safe and efficient completion of tasks” [1]. 

The lack of non-technical skills is associated with an increased probability of errors, and thus, hence the likelihood of adverse events. Developing strong NTS could reduce risks and optimize work activities. 

An innovative approach to risk and incident prevention in the workplace should emphasize workers training in non-technical skills, as these skills are used daily, often unconsciously (Servadio, 2014).

NTS should be utilized to raise awareness among healthcare providers about their own needs, enhance their skills, improve teamwork, increase organizational efficiency, and promote education and patient safety.

Objective
This study aims to conduct an initial analysis of a tool designed to evaluate the perception and attitudes of nursing students at a university in Northern Italy regarding NTS, correlating their responses with variables such as year of study, hours of clinical training, and training location. 

Study Design and Sampling 

An observational study was conducted, involving nursing students in their second, third, and final years of the degree program. 

Procedures

The questionnaire, prepared and provided in digital format, was distributed to all nursing students via the university’s official platform, following authorization from the President of the Nursing School. The questionnaire was administered between September 2022 and October 2022. Participation was voluntary, with each student participating only after providing informed consent. 

Instrument (or Materials) 

The instrument used was a questionnaire created ad hoc by the researchers, based on scientific evidence from the literature. The questionnaire included:

• Two open-ended questions probing the definition of NTS and a list of four or five terms associated with NTS.
• 15 items to evaluate attitudes, which respondents rated on a 6-point Likert scale from 1 = strongly disagree to 6 = strongly agree, with intermediate values indicating varying levels of agreement (e.g., "It is appropriate for nurses to have leadership skills").
• 10 items to assess perception, rated on a 6-point Likert scale from 1 = never to 6 = always, with intermediate values indicating varying frequency (e.g., “In their professional practice, nurses do not exercise leadership skills”). Three items on the perception scale were reverse-scored, so these items were inverted in the calculation of summary data. The questionnaire also included questions about socio-demographic aspects: gender, year and location of the program, location of the most recent clinical training, and total hours of clinical training completed. 

Ethical Considerations
The researchers declared to provide participants with complete information about the study before enrollment and obtained informed consent after ensuring participants were adequately informed. The study was conducted in full compliance with international ethical principles and in accordance with international standards of good clinical practice. 

Data Analysis 

Factor analyses were conducted on the two scales used. Bartlett's test indicated high correlations among items (Bartlett’s test of sphericity: χ²(105)=1540.337; p<.001). The reliability of the scale was excellent (α=0.978). For the attitude scale, explained variance was 77%, identifying a single factor.

For the perception scale, Bartlett’s test also showed significant correlations among items (Bartlett’s test of sphericity: χ²(45)=200.869; p<.001). The reliability of the total perception scale was acceptable (10 items, α=0.734). The explained variance for the perception scale was 51%, identifying two factors that we named “positive perception” (6 items, α=0.816) and “negative perception” (4 items, α=0.62).

To assess the distribution of the two variables, we used the Shapiro-Wilk test due to the sample size being under 100. The analysis showed a non-normal distribution for the “attitude” variable (p<0.000), while “positive perception,” “negative perception,” and “total perception” were normally distributed (p>0.05). Therefore, non-parametric tests were used to evaluate differences for the attitude variable, while parametric tests were used for the other variables. 

Study Implications 

The ability to assess nursing students’ perceptions and attitudes toward NTS in their second and third years of study at a university in Northern Italy could help determine the students' level of knowledge regarding NTS. Based on the results obtained, the topic of NTS could be further developed and integrated into the study program, with activities dedicated to training and implementing NTS.

Sample
The total sample of students who responded to the questionnaire was 71. Gender distribution was as follows: 74.6% (53) female, 22.6% (16) male, and 2 (2.8%) preferred not to specify. The age range of the sample was 20 to 45 years (M=23.8; SD=4.268).

Regarding the year of study, the distribution was as follows: 44 (62%) were graduating students, 2 (2.8%) were in their second year, and 25 (35.2%) were in their third year. Due to the low number of responses from second-year students, they were excluded from the evaluation of differences across variables.

Regarding clinical training locations, respondents were distributed as follows: General Surgery 14 (19.7%), Operating Room 7 (9.9%), Emergency and Urgent Care 8 (11.3%), Medicine 12 (16.9%), Pediatrics 16 (22.5%), and Other 14 (19.7%). 

Analytical Results

The first open-ended question asked respondents to define NTS, and only 49 participants (69%) responded. Of these, 13 participants (26.5%) provided incongruent answers. The responses of the remaining 36 participants (73.4%) can be summarized as follows (Table 1).

• Cognitive, behavioral, and interpersonal skills that are not specific to a profession's technical expertise but are equally important for safely achieving operational practices.
• Skills that go beyond technical abilities, based on relational or behavioral skills.
• Essential skills for the nursing profession, aimed at reducing the likelihood of adverse events for patients.

For the second question, which asked participants to list 4-5 words evoking the term NTS, 32 participants (45%) provided incongruent answers. The remaining 55% (39 participants) responded with suitable terms (communication, critical thinking, decision-making, active listening, adaptability, problem-solving, relational skills, interdisciplinary teamwork, activity management, group coordination).

Considering the total sample, the following table shows the values of the four measured variables. 

Table 1: Perceptions 

The tables on the following pages show how the variables of attitude, positive perception, negative perception, and total perception vary according to the following factors: gender, training location, training hours (categories), and year of study.

Regarding the variable "attitude towards NTS," the data in (Table 2) show substantial equality in the measured values between male and female students, confirmed by the non-significance of the Mann-Whitney U test for independent samples (p = 0.448).

Table 2: Behaviour vs Gender.

Note: Respondents who did not specify their gender were excluded from the statistical analysis due to the small number. 

The data in (Table 3) seem to suggest a more positive attitude in students who completed internships in the operating room and emergency departments, although the Kruskal-Wallis test showed no significant differences between the various internship settings.

Table 3: Behaviour vs Training Areas. 

Note (*): Examples of departments included: general surgery, neurosurgery…

Note (**): Examples of departments included: Emergency Room, 118 (Emergency Medical Services), Emergency Surgery, Emergency Medicine

The same consideration applies to the attitude related to the number of internship hours, where the data in (Table 4) show more favorable attitudes among students with fewer internship hours, but here too statistical tests do not reveal significant differences in the recorded measures.

Table 4: Behaviour vs Training Hours Categories.

Considering the variable "year of study," (Table 5) shows a higher average attitude towards NTS among third-year students compared to those about to graduate; however, statistical tests indicate no significant difference between the measurements.

Table 5: Behaviour vs Year of Study.

Note: Respondents in their second year were excluded from the statistical analysis due to the small sample size. 

Similarly, the tables on the following pages show the distribution of the "perception" values relative to the descriptive variables of the sample. 

Similarly, for the measure of perception towards NTS by gender (Table 6), statistical tests show no significance, although the data suggest a more positive and total perception among females, with a more negative perception among males.

Table 6: Perception vs Gender.

Note: Respondents who did not specify their gender were excluded from the statistical analysis due to the small sample size.

Regarding the internship area (Table 7), the data show a higher perception of NTS in the pediatric area compared to other areas, but the ANOVA test also showed no significant difference between the measures.

Table 7: Perception vs Internship Areas.

Note (*): Examples of included departments: General Surgery, Neurosurgery...
Note (**): Examples of included departments: Emergency Room, 118, Emergency Surgery, Emergency Medicine...

For the average scores regarding perception based on internship hours (Table 8), the data indicate a higher score among students with fewer internship hours, but, again, the ANOVA test did not reveal any statistically significant differences.

Table 8: Perception vs Internship Hour Classes.

Note (*): Examples of included departments: General Surgery, Neurosurgery...

Note (**): Examples of included departments: Emergency Room, 118, Emergency Surgery, 

Considering the year of study, the averages show a higher perception among third-year students compared to those about to graduate but the differences were not significant.

Finally, (Table 9) shows the correlations between continuous variables. These correlations were significant between attitude and positive perception, as well as between both positive and negative perceptions with the total perception.

The following table presents only continuous variables and the correlations between them

Table 9: Correlations and Perception vs Year of Study 

Note: Respondents from the second year were excluded from the statistical analysis due to the small number of participants. 

The first case highlights that respondents who showed a positive attitude towards NTS also exhibited a positive perception of them, although the correlation is weak. In the second case, the correlation between positive and negative perceptions with the total perception supports the validity of the scale, as both factors (positive and negative perception) showing a strong and significant correlation with total perception (high correlation index “r”).

Non-technical skills (NTS) are behavioral and interpersonal abilities that are not specific to the technical expertise of a profession but are equally important for the successful execution of tasks with the utmost safety. They are "social and cognitive non-technical work skills (NTWS), which include communication, leadership, teamwork, decision-making, and situational awareness" [3].

In the healthcare field, nursing staff are considered the most at risk, with constant and sustained exposure to stress factors due to a hostile working environment. However, the literature has not identified an Italian tool to assess NTS performance in the healthcare sector. 

Field research deepened the topic, focusing particularly on the positive effects of NTS and their importance for nursing students. The sample consisted of 71 responses from nursing students at a university in Northern Italy, with a higher response rate from final-year students compared to second- and third-year students, and a greater representation of female students than male students. Regarding the internship locations, the sample was predominantly distributed across the General Surgery, Medicine, and Pediatrics departments, with a smaller proportion in other departments. 

The study allowed us to explore the respondents' understanding of the definition of NTS. Only 36 participants answered this question, providing a definition of NTS consistent with the one found in the literature. Amiria Lynch defined NTS as "social skills encompassing communication, teamwork, leadership, cognitive abilities such as decision-making, situational awareness, and personal resource skills such as managing stress and dealing with fatigue" [2]. Similarly, the students in the sample affirmed that NTS are non-technical skills based on relational or behavioral abilities that enable safe practice.

Another question, answered by only 39 participants, asked students to describe NTS using key terms: communication, critical thinking, decision-making, active listening, adaptability, problem-solving, relational skills, interdisciplinary teams, activity management, and group coordination. These responses align with the literature, which identifies NTS with the following key terms: teamwork, communication, leadership, decision-making, and situational awareness [3-8]. 

These similarities suggest that the students have a correct perception of the topic, aligned with the literature, although the response rate and sample size do not represent the entire nursing student population, so generalizations cannot be made [9-15]. 

The variables of attitude, positive perception, negative perception, and total perception of NTS were then analyzed in relation to gender, internship location, and year of study. In Tables 2-5, it can be observed that the average Likert scale responses regarding attitude toward the descriptive variables of the sample are always above the median, with no significant differences [16-25]. 

Similarly, Tables 6-8 show the average responses regarding perception relative to the considered socio-demographic data. These tables show that the average scores are almost always above the median. Specifically, in relation to gender, the data suggest a better overall and positive perception among female students, and a more pronounced negative perception among male students, although in general, the mean positive perception is almost always higher than the mean negative perception for each descriptive variable of the sample [26-35]. 

From the analysis of the data in it emerged that there is a statistically significant correlation between attitude and positive perception (0.303). This suggests that respondents who exhibited a positive attitude towards NTS also demonstrated a positive perception of them [36]. 

The analyzed data also show a good average for concepts such as leadership, leadership ability, decision-making, and stress management. From a critical review of the relevant articles, Brouquet, Blanié, Benhamou, & Allard also emphasized the importance of implementing NTS as they would improve stress management and reduce fatigue [9]. Regarding leadership skills, the literature indicates that NTS enhance care safety and can be improved through simulations [10]. Leadership, in the literature, is an NTS that enables effective management of medical emergencies, making the team safer and more efficient. Additionally, it is important because it reduces medical errors and increases patient safety [11, 3, 12]. 

Another skill of significant importance is decision-making, a cognitive ability that allows for the best management of medical emergencies. It requires the ability to diagnose situations and make judgments on appropriate courses of action [2, 5]. 

Based on these findings, it could be asserted that the respondents provided answers consistent with the reviewed literature, and it can be inferred that students consider NTS to be useful and important skills. 

The bibliographic research highlights a growing interest in NTS within healthcare settings worldwide. Authors agree that NTS can increase healthcare efficiency by improving care safety and reducing adverse patient outcomes [13-], and that they should be included in university curricula since they reduce stress and fatigue caused by the work environment [5]. 

Our study revealed limited knowledge among students on the subject, which nevertheless seems to align with the conclusions of the reviewed literature. It seems that students give considerable importance on some of the NTS examined, considering them useful and essential [37-43]. 

The limitations of this study are related to the sample size and the relatively small number of participants, which prevent us from extending our conclusions to the entire nursing student population. Therefore, this study could be considered a pilot study to be replicated, with the aim of identifying gaps in the subject matter and potentially addressing them through targeted interventions. Given the results, it would be important to propose training and simulation courses within the university context in order to equip students with the tools to gain greater confidence and better prepare them for the path that will lead them to become healthcare professionals.

Each author declares that they have no commercial relationships related to the activities carried out, which could result in any conflict of interest concerning the article developed.

The authors declare that they have not received any funding from any organization.

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