The 5-item non-technical skills scale for trauma (T-NOTECHS) with five response categories is developed to assess non-technical skills in trauma team resuscitations. This validated instrument assesses behavioral aspects in teamwork. Outcome instruments should undergo a robust adaptation process followed by psychometric validation to maintain their measurement properties when translated into different languages. The translatability of the T-NOTECHS into a non-Anglo-Saxon language has not been thus far unraveled. The authors aimed to assess whether the T-NOTECHS would be translatable into a non-Anglo-Saxon language and to investigate its psychometric properties for simulated multi-professional trauma team resuscitations.
The T-NOTECHS translated well into a difficult non-Anglo-Saxon language. The rigorous adaptation process used here can be recommended in the translation of observational performance assessment instruments. The translated version demonstrated fair reliability and good construct validity for assessing team performance in simulated multi-professional trauma team resuscitations. The translated T-NOTECHS instrument can be used to assess the efficacy of simulated in-situ trauma team resuscitations allowing benchmarking and international collaboration.
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Non-technical skills are challenged during trauma resuscitation. Non-technical skills include social, cognitive and personal skills. They play an important role in the prevention of critical incidents that may lead to severe permanent disability or patient death in trauma team resuscitations [1]. In these resuscitations, non-technical skills are needed to maintain patient safety and enhancing good medical care. Good teamwork and non-technical performance are also associated with a significant decrease in disposition time [2].
During the last few years researchers and clinicians have begun to pay increased attention to non-technical skills and their effects on improving team work performance. Educating surgeons, anesthesiologists, resident surgeons and nurses is essential for making the trauma team work well together and developing their non-technical skills. Simulation-based training of non-technical skills improves these skills and thus elevates the quality of trauma resuscitation [2]. Even a short, structured two-hour trauma team simulation training course has found to be effective in improving non-technical skills among health care professionals [3]. No Nordic research that focuses on valid assessment methods and rating instruments for non-technical skills were found in a recent integrative review [4]. Therefore Nordic and international comparison of education effectiveness in simulated learning situations is challenging.
Instruments for rating non-technical skills (NOTECHS) are widely used and needed to assess team performance [5,6,7,8]. Steinemann et al. (2012) developed a modified version of the NOTECHS instrument (Fig. 1) to assess trauma team performance [8]. The T-NOTECHS can be used for teaching purposes, assessing learning outcomes and the teamwork skills of multi-professional trauma resuscitation teams [8]. As the language of the T-NOTECHS instrument is English, it may not be directly applicable to study populations across languages and observers due to linguistic differences and differences in the cultural or health care environment. It is of the utmost importance that the instruments used in outcome measurements are reliable and valid.
Thus far, no instruments for assessing the non-technical skills performance of trauma resuscitation teams have been available in Finnish despite of active simulation training in Finland. The present study sought to evaluate the translatability of the T-NOTECHS into a non-Anglo-Saxon language, and to investigate the psychometric properties across in-situ full-scale multi-professional trauma team simulations. The authors hypothesized that the translated version of the T-NOTECHS would be reliable and valid for assessing team performance in simulated multi-professional trauma team resuscitations.
The T-NOTECHS (Fig. 1) comprises five teamwork behavioral items. These items are Leadership, Co-operation and Resource management, Communication and interaction, Assessment and decision-making, and Situation awareness/Coping with stress. Each item is scored on a 5-point scale. Item scores and the total scale score range from one to five. The lowest score of one point indicates that the team did not demonstrate the target teamwork behavior. The highest score of five points indicates flawless teamwork performance. Inter-rater reliability for video review of simulated trauma resuscitations was 0.44 by intraclass correlation coefficient (ICC) [8].
The pre-final version was pre-tested by five healthcare professionals, including two trauma nurses, a specialist in emergency medicine, an emergency medical system field manager and a primary care nurse, all of whom were familiar with trauma teams. The pre-testing was conducted in two different multi-professional high fidelity in-situ full-scale trauma team simulation scenarios. Thereafter, the pre-testers were cognitively debriefed to reveal any discrepancies or problems in choosing the right item, or in understanding the items or their clarifications, and whether they would re-phrase any of the items in Finnish Version 2.
The study was implemented undertaken in Central Finland Central Hospital, Jyväskylä, Finland. The Central Finland Central Hospital provides emergency trauma treatment for a catchment area of 270,000 people.
This study confirmed that the T-NOTECHS instrument is translatable into a difficult non-Anglo-Saxon language, Finnish, that is a synthetic language, includes consonant gradation and consonant clusters, and lacks grammatical gender. The present psychometric testing of the non-Anglo-Saxon version of the T-NOTECHS instrument showed a level of reliability comparable to that of the original English version and gave further insight of its good construct validity for assessing team performance in simulated multi-professional trauma team resuscitations. All predefined hypotheses of reliability and validity were met. The T-NOTECHS instrument seemed to measure one latent construct (non-technical skills).
There was felt to be an urgent need to assess the efficacy of the training program with appropriate assessment methods. However, no non-technical skills rating instruments for assessing trauma team performance were available in Finnish. Hence, the T- NOTECHS instrument was translated into Finnish and adapted to the Finnish culture and its measurement properties were investigated.
The average measures ICC indicates inter-rater reliability. In the present instance, it was hypothesized that the ICC value would exceed 0.40. The actual ICC value of 0.54 confirmed the hypothesis, and thus indicated a fair level of reliability among the 61 real-time trauma team simulation resuscitations. Compared to the present findings, Steinemann et al. reported a lower relative reliability of 0.44 for the T-NOTECHS instrument [7]. Steinemann used three raters who rated a total of 33 simulation cases in real time (immediately after resuscitation). These differences between the original study of Steinemann et al. and the present study could be due to the different trauma team resuscitation settings or to the numbers of simulations or raters. Furthermore, in the present study, CR was used to estimate the absolute reliability of the scale. The CR refers to a cut-off value where the absolute difference between two measurements can be estimated with a probability of 95%. In the present study, the absolute reliability of the T-NOTECHS instrument in the in-situ trauma team resuscitations was 1.53. The CR may yield a more accurate assessment of the absolute reliability of a scale than the standard error of measurement as it presents a true difference between the raters.
The authors conclude that the T-NOTECHS translated well into a difficult non-Anglo-Saxon language. The rigorous adaptation process used in this paper can be recommended in the translation of non-technical skills instruments. Psychometric testing of the translated version provided evidence of fair inter-rater reliability and construct validity for the T-NOTECHS for assessing team performance in simulated real-time hospital multi-professional trauma team resuscitations. The T- NOTECHS is a suitable instrument for assessing non-technical skills in performance in simulated trauma team resuscitations that include surgeons, anesthesiologists and/or resident physicians. The translated T-NOTECHS instrument can be used to assess the efficacy of simulated in-situ trauma team resuscitations allowing benchmarking and international collaboration.
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