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Nontechnical Skills: An Inaccurate and Unhelpful Descriptor?

Nestel, Debra PhD; Walker, Katie RN, RM, RCHN; Simon, Robert EdD; Aggarwal, Raj PhD; Andreatta, Pamela PhD

Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: February 2011 - Volume 6 - Issue 1 - p 2-3
doi: 10.1097/SIH.0b013e3182069587
Concepts and Commentary

From the Faculty of Medicine, Nursing & Health Sciences, Gippsland Medical School (D.N.), Monash University, Melbourne, VIC, Australia; Department of Health and Ageing (K.W.), Simulated Learning Environments, National Health Workforce Taskforce, Melbourne, VIC, Australia; Center for Medical Simulation (R.S.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; Division of Surgery, Department of Surgery & Cancer, Imperial College (R.A.), London, United Kingdom; and Department of Medical Education (P.A.), Clinical Simulation Centre, University of Michigan, Dearborn, MI.

The authors declare no conflict of interest.

Reprints: Debra Nestel, PhD, Monash University, Gippsland Medical School, Australia (e-mail:

The Oxford English Dictionary defines technical as an adjective “of a person: Skilled in or practically conversant with some particular art or subject” or “of a thing: Skilfully done or made.”1 Nontechnical is defined as an adjective “not relating to or involving science or technology; not requiring or assuming specialized or technical knowledge.”1 Based on this definition, it is easy to conclude that technical skills are of high value and requires special training, while nontechnical skills (NTS) are less valuable and do not require such training. We believe the term NTS has been inaccurately appropriated from general usage to medical education and training.

The term “NTS” has emerged as a descriptive category of clinical practice elements usually referring to communication, interpersonal, decision-making, situational awareness, professionalism, leadership, and teamwork skills.2 Technical skills are rarely defined in medical literature but most likely refer to cognitive, psychomotor, and dexterity skills associated with physical examinations, clinical procedures, surgery, specialized medical equipment, and medicines.

The term “human factors” is sometimes used to describe the complex skills and underpinning knowledge of NTS. We propose that this is preferable as it defines the “skills” or “behaviors” in a positive sense; for what they are rather than what they are not. Further, these skills are in fact highly technical and stem from rich academic traditions. During the last several decades, the science of human factors and communication has advanced dramatically. Peer-reviewed journals publish research of basic science and empirical phenomena that have vastly improved clinical practice.

We posit that the term NTS is misleading, inaccurate, and oversimplifies critical aspects of professional clinical practice. We draw on our experiences in the social sciences and clinical practice to illustrate our perspective.

The discipline of human factors now forms part of under- and postgraduate medical curricula. Communication is an example of a specialized body of knowledge and skills relevant in almost every facet of clinical practice. Although a generic skill, effective application in varied contexts of clinical practice is highly technical, requiring training, practice, and feedback to achieve excellence. Patient-centered communication consists of structural components that can be learned and assessed. Like steps in procedural or operative skills, interpersonal communication can be broken into component parts to focus on the development of expertise and then reconstructed as a coherent whole and integrated with other facets of clinical practice.

Several comprehensive instruments have been published in the name of NTS in surgery and anesthesia.2–6 The instruments are based on the use of behavioral markers of observable skills that imply knowledge and skills are applied in ways similar to assessments of procedural and operative skills.7 These instruments define helpful categories of behaviors and then characterize skills in specific clinical settings. Training programs designed to teach assessors to use the instruments are recommended because there are indeed “technical” elements associated with applying the measures in terms of their content and methodology. A notable exception in the literature describes “technical elements of teamwork,” elucidating the complexity of interactions in the operating theater.8

We argue that communication, decision-making, situational awareness, professionalism, leadership, and teamwork skills are inextricably linked with every other element of clinical practice. Human factors considerations within the realm of healthcare have theoretical underpinning, are interdependent, and have specific task and context importance. A strong reductionist paradigm in clinical practice, in part, creates the challenge. Viewing these skills as either “technical” or “not technical” is problematic.

Because the medical profession formally teaches and assesses the broad complex of clinical practice skills, it is important to consider the implications of terminology. The use of a deficit model, that is, “nontechnical,” to describe these skills may contribute to the development of negative attitudes and tends to devalue them for trainees embarking on careers in a changing environment for which expertise in all facets of clinical practice is essential. We are concerned that devaluing a whole set of important skills may induce trainees to consider that the skills cannot be learned, are not specialized, and are not worthy of the effort to learn.

An important principle in communication is that messages are mutually understood. There appears to be little discrepancy in what researchers define as NTS and this is one argument to maintain its use. However, we also have a responsibility to use language accurately. Language also evolves such that what may have once been appropriate is no longer correct. We urge our colleagues to reflect on the use of the term, NTS, and its potential negative implications for education and training.

In conclusion, we applaud the excellent work done by many colleagues and researchers in this field. We have no issue with the content, simply the terminology. Even our preferred term “human factors” has limitations. It is subject to interpretation. Some might argue it is less well understood than NTS. We hope that it is not too late to reframe this thinking. We may need to conceive of “skills” in a different way to avoid reduction in two broad categories. Our goal is to use encompassing and positive terms to describe the complex sets of skills required for safe and competent clinical practice.

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1.Oxford English Dictionary Online. Oxford University Press. Available at: Accessed January 2010.
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Nontechnical skills; Human factors; Simulation-based education; Leadership; Teamwork; Communication; Decision making

© 2011 Society for Simulation in Healthcare