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Skills, Training, and Education

Glavin, Ronnie J. MB, ChB, MPhil

Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: February 2011 - Volume 6 - Issue 1 - p 4-7
doi: 10.1097/SIH.0b013e31820aa1ee
Concepts and Commentary

From the Anaesthetic Department, Victoria Infirmary, Glasgow, UK.

Reprints: Ronnie J. Glavin, Victoria Infirmary, Glasgow G42 9TY, UK (e-mail:

The author declares no conflict of interest.

Many of us use the terms “training” and “skills” when describing what we do and what we want our learners to achieve in the context of simulation-based education in healthcare. Terms such as “education” and “training” are often used interchangeably, and most of the time this causes very few problems. However, I believe that we are in danger of underrepresenting what we actually do in simulation-based courses. This may have important implications not only for us but also for those who purchase or commission our services. In this article, I would like to further explore “training” and “skills,” especially in the context of the educational sense of the terms. I shall focus on nontechnical skills (NTS), as that is an area of my professional interest.

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Flin et al1 describe these as the cognitive, social, and personal resource skills that complement technical skills and contribute to safe and efficient task performance. The term was first applied by the European Civil Aviation regulator in the 1990s in relation to airline pilots' behavior on the flight deck. It may seem strange to define something in terms of what it is not, but the point was to emphasize the importance of a set of abilities that had not been formally defined and were complementary to the traditional areas of the training programs of the day. The choice of words also reflected a term that would be more acceptable to cultures that traditionally were perceived as more practical and down-to-earth and do not readily embrace terms such as “human factors” or “soft skills.” The term NTS had not only to provide an umbrella term for the activities listed above but also had to be acceptable to those being trained (and now also assessed) in their use. The term was part of the buy-in process. This latter part has not been referenced because it is largely anecdotal, but in the 11 or so years that I have spent in the company of industrial and organizational psychologists and practitioners who pioneered the introduction of NTS into their own world of macho men in macho cultures, a recurring topic of conversation at social functions was the initial overt hostility to these concepts. I recall Dick Stark, a former Crew Resource Management (CRM) Training Captain with British Airways, telling me over lunch at a CRM meeting in 2002 of how on one occasion his chest was black and blue from British Airways pilots serially stabbing him with their index fingers while emphasizing their exception to the imposition of these new-fangled concepts at a drinks reception at the end of the first day of a CRM course in the 1990s. On my way home from facilitating courses at the Scottish Clinical Simulation Centre, I often share the 30-minute train journey with men who are returning from their 2-week stint on oil-drilling platforms in the North Sea. These are indeed macho men (no women work on North Sea oil platforms), and I fully understand why my colleagues from the Industrial Psychology Research Centre at the University of Aberdeen prefer to use the term NTS when researching with such groups of workers. The pioneering work in this field in now formalized with schemes such as NOTECHS—the assessment methodology of CRM skills used by the Joint Aviation Authority in Europe, and this term “nontechnical skills” is now an established part of the vocabulary of civil aviation in Europe. Although we have benefitted considerably from the experience and expertise of those who were involved in the development and formalization of these key concepts, my concern is less with the “nontechnical” and more to do with the “skills.”

My views are strongly influenced by the culture in which I work, but I am certain that my concerns transcend national and professional boundaries. Current policies in the United Kingdom in medical education have required that learners at different stages have to be able to demonstrate a variety of abilities in a range of practical skills. This initiative may have been introduced for good reason but in some cases has resulted in learners undergoing training not for their own benefit or for potential benefit to patients but to satisfy a burgeoning assessment bureaucracy. The unstructured way in which workplace-based assessment tools were introduced into postgraduate medical education in the United Kingdom in 2007, as part of the Modernizing Medical Careers (, reviewed October 28, 2010) program brought about situations in which doctors in training grades had to have boxes ticked to meet the administrative requirements of the changing regulatory framework. The bureaucratic process took precedence over the educational process. NTS feature as part of that assessment process and my fear is that a complex component of medical education will be reduced to a series of tricks or stunts, such as the use of Situation, Background, Assessment, and Recommendation or closed-loop communication. These tools can be very helpful but if not presented in an appropriate context may not achieve the goals that are intended for them. To develop this line of argument further, it is pertinent to review the terms “training” and “skills” in an educational framework. My argument is that by better understanding the place of skills in an educational framework, we can then have a more transparent set of intended learning outcomes and so be clearer as to what we can and should deliver because I believe that we currently deliver much more than skills in the strict educational sense of the term.

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I shall begin with a brief overview of education as a concept and then explore some differences between education and training, including where the concept of skills in general fits into both, and finally address some of the challenges we face in the promotion and development of NTS.

The Anglo-American philosophical tradition takes the approach that we cannot give a satisfactory definition of a complex construct such as education, and the best we can hope to do is identify important concepts contained with the construct.2 Peters2 described the two most important concepts as purpose and value. An activity can only be educational if there is some intended purpose behind it and at the same time the activity should be of intrinsic value to the learner. The activity should be an end in itself. Ruskin3 has used the following phrase

Education does not mean teaching people to know what they do not know. It means teaching them to behave as they do not behave.” This phrase is not a definition of education but it captures the sense of education being an agent of change and transformation; a transformation in which the learner is a willing partner. Such a change in behavior requires more than knowledge. It requires a range of cognitive, psychomotor, and other abilities and a predisposition on the part of the learner to make use of those abilities.

Activities that would fall within the realm of education include instruction, induction, and initiation. Induction in this sense relates to ways of understanding or cognitive perspective. We can think of this as the theoretical underpinnings of our professions. The cognitive perspective of a European doctor of the 21st century is very different from that of an European doctor of the 10th century because of models of physiology, disease, and so on. Initiation describes the process of acquiring the value system of a community, such as a professional community.

Training as a concept differs in some key areas.4 Training can have a role in education, but it does not always share the transformative role of education, so its remit is often narrower by being confined to procedures or linked psychomotor activities. We talk of training someone to perform multiplication or to ride a bicycle but would not talk of training them to understand the theory of evolution or training them to develop a commitment to patient safety. Training can be educational but is not always so because training may be of extrinsic value to the learner. That is, the learner has acquired abilities for the service of an external agency. We can train someone to become a soldier, but the abilities required may be of little direct benefit to the learner but of great benefit to an organization such as those in control of a country or state.

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Professionals possess a range of abilities that allows them to help clients deal with problems; but they also possess a set of values that underpin what it is to be a professional. Each profession will have its own set of values, but all professions are linked by a common value system. This is because the relationship between professionals and their clients is not an even relationship. The professional has the power because the professional has the abilities needed by the client. This relationship could be exploitative in that the professional could prey on the client, the weaker member. Professions developed codes of practice to ensure that their members would not exploit their clients. The following quote from the Hippocratic Oath5 serves as an example, while also reflecting on the customs and practices of the Ionian Greeks of the fifth century BCE:

“In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.”

Values are intrinsic to professions and the activity of initiation described above is intended to promote adoption of the value system of that profession by would be members. What are these values? Some values sets have been described. For example, Stern6 describes four core professional values for medicine as excellence, humanism, accountability, and altruism on a base of clinical competence, communication skills, and an ethical and legal understanding. Kearney7 has described a set of professional values for Canadian Anesthesiologists. Values are usually demonstrated through behaviors. If we take “excellence” from Stern's list, then examples of behaviors of excellence may include changes in one's practice in light of new knowledge, learning new techniques, auditing one's own performance, and acting on the findings of such an audit. This is why I chose to use Ruskin's statement from above because how we act and the value system that underpins those actions is of fundamental importance to professionals. Unlike cognitive or psychomotor elements, values are acquired by less didactic methods. Can we teach professional values in simulation-based education? I contend that we already promote existing values when instructing in skills labs or simulation centers. Let me illustrate by considering venepuncture. The core components of the skill— successfully placing a needle into a vein—could not be more basic. However, if we compare the instruction process in a skills laboratory with that of an established intravenous drug user instructing a potential recruit, the differences become apparent. In the case of the trainee healthcare professional, this skill is taught in a context that promotes some of those core values listed by Stern. Humanism is demonstrated by explaining the procedure and attempting to make it as stress free and pain free as possible. Excellence is demonstrated by confirmation of patient identity and adopting antisepsis measures. Accountability is demonstrated by appropriate documentation and identification of self to the patient. These values are not confined to this procedure and may already have been introduced to the learner, but reinforcement of these values through the behaviors listed above (and all of the others that are taught) is part of the process. This same principle applies to more complex skills such as lumbar puncture or central venous catheter insertion where the underlying value systems are promoted even if the accompanying behaviors are modified (greater attention to asepsis and antisepsis for example). The intended learning outcomes for courses taking place in skills labs or simulation centers may concentrate on psychomotor or procedural elements; they may include cognitive elements but very rarely make the underlying values explicit. This does not mean that these values are not being promoted; instead, it reflects a focus on those learning outcomes that have been made explicit in curriculum documents or learning agreements or course documentation.

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I use a technical procedure to illustrate how some of the generic values listed by Stern may be incorporated into a routine daily activity. The process is no different when applied to activities within the nontechnical skill list. One could argue that confirming patient identity and the procedure to be undertaken are not only examples of excellence but also examples of situation awareness, specifically gathering information to ensure that the right procedure is being done to the right patient. Introducing procedures such as World Health Organization surgical checklist (, reviewed October 28, 2010) easily serve as behaviors consistent with excellence. The existing generic group of values will apply to NTS elements. However, I believe that the transfer from the teaching setting to the workplace requires a high degree of commitment to these actions, which in turn means a stronger sense of the value in question. Let me illustrate with another example of situation awareness. A procedure that may be taught to recalibrate mental models and reduce the likelihood of fixation error is the three-challenge rule. The cognitive components of the technique are not difficult to master, and the theory underpinning the technique is also easy to understand. However, when a junior trainee is expected to apply the three-challenge rule to a more senior attending in a culture with a steep hierarchy and a high power distance, then that behavior is less likely to take place unless the trainee also has a strong commitment to what is right for the patient and a strong commitment to professional excellence. Now, I believe from conversations with colleagues who instruct and design courses in simulation centers and skill centers that these issues are explored and the challenges of adopting new behaviors are addressed, but I also believe that it is done without explicit reference to professional values. Course materials will make the skills explicit and will make any cognitive components explicit but will not make reference to the set of professional values.

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Now we come to the main theme of my concerns. Those who know little of our activities from direct experience but have a large role to play in funding or commissioning activity at our centers may not appreciate the extent of our possible contribution to the professional development of those participating in our courses. The value of what we can and do contribute is not recognized. We become a training center in the worst educational sense of the word. We train our participants to be able to behave in a way that is not for their benefit but for a purely external purpose such as allowing an employer to tick a box to satisfy an external regulator. In the real world, we may sometimes have to cooperate with such activities to secure funding, etc. However, I believe that we are in danger of selling ourselves short of what we can and currently do provide. Simulation-based education is one of the few educational activities in which learners have the time and opportunity to be guided in their reflection of a clinical task that they have just undertaken. We have taken pride in our ability to use not only clinical and technical frameworks but also nontechnical frameworks to help make sense of what has just happened and how learners may use those findings to change subsequent behavior. I believe that we are able to rise to the challenge of helping learners explore their personal and professional value systems in the context of their professional role. The importance of these values systems in influencing subsequent behavior is not new, but the opportunities we have to develop the framework of values is of great potential benefit not only for our learners but also for those charged with the responsibility for overseeing the educational process of healthcare professionals.

We may be seen as a solution to a short-term problem by offering short training courses in procedural or psychomotor skills. However, if such courses are not grounded in other curricular activities, then the likelihood of bringing about a change in the subsequent behavior of the learners is greatly reduced.

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In an accompanying article, Nestel et al8 have expressed their dissatisfaction with the term NTS and propose its replacement by a term that gives greater recognition to the wide range of activities contained with this domain.

The crux of their argument concerns the role of terminology and its possible impact on the attitudes of learners to the domains of practice falling within specific terms, such as NTS. I hope that I have successfully conveyed that I share those concerns. I began with a description of the negative attitudes that were conveyed by the term “human factors” in nonhealthcare contexts, but my own concern is with the “skills” component because I believe that, at present, the use of “skills,” as the term is understood by educationalists, does not do justice to the complexity of NTS/human factors that we promote and teach in the context of simulation-based education.

We could debate the impact and effect of those who control language and terminology. While this would be an interesting intellectual exercise as we compared the “Ideal Speech Situation” of Habermas9 with the use of language by the state in Orwell's 1984,10 it would probably be of little practical benefit.

I share the belief that NTS/human factors are intricately linked with every other element of clinical practice. The challenge we face as educators in healthcare is to develop a framework that is of practical use to teachers and learners in healthcare and that allows components of clinical practice to be dissembled and reassembled. Initiatives such as CanMEDS 2005 (, reviewed October 28, 2010), the Accreditation Council of Graduate Medical Education (, reviewed October 28, 2010), and the General Medical Council (, reviewed October 28, 2010) have given a lead by listing some major generic headings, but how we translate these and their equivalents in other healthcare professions into useful and practical tools that can help prepare our learners for their professional duties and responsibilities is a task that is far from complete. A sense of overall framework (a top-down) approach has been provided; we can use our experiences in both the simulation and clinical settings to add to a bottom-up approach that brings the curricula of our learners to life.

Nestel et al may have entered this process through their dissatisfaction with the term “nontechnical”; I entered the process because of my concern with the term “skills,” but together I believe that we have provided tangible examples of the need for a revised educational taxonomy in healthcare.

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I have described the importance of value in relation to education in terms of both the intrinsic value to the learner and the set of values that are promoted as part of the initiation into a culture. I have looked at the importance of a professional set of values underpinning our clinical activities and the influence of such values on behaviors in the clinical setting. The use of the term “skills” in a strict educational sense is restrictive and by not dealing with the cognitive and affective aspects of our course content does not fully reflect what we promote, encourage, and instruct in the context of simulation-based education. At present, I believe that a lack of a suitable framework and a suitable set of behavioral markers describing those professional behaviors we wish to see at the level of our individual courses gives rise to some of the difficulty in making this aspect of our work explicit. One method of addressing this deficiency is the development of an educational taxonomy that unites the different strands of professional activity in healthcare into a more logically coherent framework. I see this as an iterative process in which we in simulation-based education can not only use the product but also contribute to its construction.

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1. Flin R. CRM (non-technical) skills—applications for and beyond the flight deck. 2nd ed. In: Kanki B, Helmreich R, Anca J, eds. Crew Resource Management. San Diego, CA: Academic Press; 2010:181–202.
2. Peters RS. Ethics and Education. London: George Allen & Unwin; 1966:23–43.
3. Rowntree D. Educational Technology in Curriculum Development. London: Paul Chapman Publishing; 1982:31.
4. Chambers JH. The Achievement of Education. Lanham, MD: Harper and Row; 1983:24–25.
5. Temkin O, Temkin CL. Ancient Medicine: Selected Papers of Ludwig Edelstein. Baltimore, MD: Johns Hopkins Press; 1987:3–64.
6. Stern DT. Measuring Medical Professionalism. New York, NY: Oxford University Press; 2006:19–20.
7. Kearney RA. Defining professionalism in anaesthesiology. Med Educ 2005;39:769–776.
8. Nestel D, Walker K, Simon R. Non-technical skills—an inaccurate and unhelpful descriptor? Simul Healthc 2011;6:2–3.
9. Finlayson JG. Habermas: A Very Short Introduction. Oxford: Oxford University Press; 2005:28–46.
10. Orwell G. 1984. London: Penguin; 1970.

Communication; Human Factors; Education

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