Experiences using an instrument for non-technical skills in nurse anaesthesia education .

Content Analysis Coding



NANTS-no was experienced by the participants as a means of promoting excellent non-technical skills and cooperative learning in nurse anaesthesia education. There was however a need for promoting organizational acceptance of the instrument in the working environment. The findings were interpreted as NANTS-no helping to Forge a path towards clinical excellence. A summary of the categories and themes is presented in Fig. 2, and the results are presented for each of the three themes in the text that follows.

Fig. 2
figure 2

Summary of the analysis of experiences with using NANTS-no (main theme, themes, categories and sub-categories)

In order to demonstrate differences and nuances in the way in which the SNAs, mentors and clinical supervisors experienced using the instrument, quotations are attributed to the relevant participant instead of to the focus group using abbreviations and numbers, for example, student nurse anaesthetist (SNA1), mentor (M6) and clinical supervisor (CS2).

Promotion of excellent non-technical skills

The participants described using NANTS-no as promoting excellent non-technical skills in student nurse anaesthetists, by raising awareness of the importance of these skills in anaesthesia and helping the students to internalize the skills.

Using NANTS-no was seen as raising awareness by shifting the focus in nurse anaesthesia education to include non-technical skills and providing a vocabulary for these tacit skills. In this way NANTS-no highlighted the skills that were expected of a nurse anaesthetist in their daily work:

“I realized that this covers much of what we do all the time, what you have done as a nurse anaesthetist for the past 30 years, what you have always done…it is just putting it into words.” (M5)

Non-technical skills were experienced as being a part of their professional identity and role as a nurse anaesthetist. However, since non-technical skills could also be regarded as something personal, being judged on behaviour could sometimes be an uncomfortable experience. The mentors and clinical supervisors regarded NANTS-no as a means of ensuring professional suitability and that future colleagues had the right skill-set. One mentor commented that there was no room for poor nurse anaesthetists in such a responsible job, while becoming the same kind of nurse anaesthetist as their mentor was not necessarily seen as a goal by the SNAs. By focusing on non-technical skills, NANTS-no was seen as shaping professional behaviour, and providing a standard of excellence for which to strive throughout their career.

The participants regarded the process of SNAs internalizing these skills as one involving self-awareness and critical reflection, which could then motivate towards changes in behaviour. The first step was for SNAs to become aware of their own strengths and weakness. According to the mentors, the level of self-awareness in SNAs varied, and some took longer than others to gain sufficient insight. The SNAs described using NANTS-no to reflect critically on their clinical progress and align their own view with their mentor’s observations.

“It’s about knowing yourself. Whether your behaviour is on target or way off the mark. Whether you see yourself as others see you. That is not a given, you know” (SNA2).

NANTS-no was experienced as aiding self-awareness by opening the way for a process of dialogue and reflection which could act as a catalyst for enabling change in the SNAs. Many SNAs felt that being rated with a low score and given tangible examples of what needed improving was motivational for both personal and professional development. However, not all the SNAs agreed on this. It was also important to receive encouragement and positive feedback about what they were proficient at.

Changing behaviour was regarded by some mentors as potentially challenging, as it required motivation and willingness to make the necessary effort. A positive aspect of NANTS-no was the way it aided the mentors in making students aware of how they could make changes without it being regarded as criticism of their personality. This was because negative feedback was based on the instrument, not the mentor’s opinion.

“I really wish we had an instrument like this when I was doing my training. I was a quiet, timid kind of person who didn’t dare do much, and my student is just the same. We looked at the team-working category [in NANTS-no], which states you have to take on a role and speak loudly and clearly. So, I wasn’t pointing out something negative about her as a person, or her personality. This was something important.” (M1)

The SNAs described various ways in which they actively worked on improving their non-technical skills, such as taking the lead in an acute situation, being more assertive or trying to be a supportive team-member. However, at the start of their training they regarded it as important to concentrate on just a few NANTS-no elements, then gradually increase the number when they felt ready.

Promotion of cooperative learning

The participants described using NANTS-no as promoting cooperative learning by enabling both a more structured mentoring process and reliable evaluation of SNAs.

The SNAs experienced NANTS-no as providing a common language for non-technical skills, which made it easier for mentors to follow their progress. Furthermore, it was seen as facilitating a common understanding of what was being observed and assessed.

“We do it together, the assessment. Both of us have the same points that we are assessing – what was your assessment, what was mine, how can we help me to learn these things? So, it’s a kind of professional partnership” (SNA12)

By comparing and discussing their assessments, the mentors and SNAs felt they gained a shared understanding of the student’s clinical progress. According to one of the focus groups, this resulted in a more structured and systematic approach to mentoring. Using NANTS-no enabled the mentors to give the students structured feedback and use their time more efficiently, while simultaneously ensuring that they observed and assessed the students’ non-technical skills.

“I have become very aware of these things myself and use NANTS for all it’s worth as a mentor.” (M1)

(sounds of agreement)

“That’s also what I meant when I said I felt like I have more time. There aren’t any more hours in the day, but it makes it easier to use the few available gaps in between.” (M3)

“In a more structured way, perhaps?” (M2)

(sounds of agreement)

“Because you are able to identify faster the areas, you actually want to… reflect over.” (CS1)

By making the mentors more aware of how they worked together with their students, NANTS-no was seen as changing the way in which they mentored their students. Nevertheless, as one SNA pointed out, whether NANTS-no was used as a mentoring aid was dependent on the mentor. Some mentors still preferred to do things the way they had always done them. The SNAs regarded NANTS-no as contributing to a clearer definition of roles in the mentoring process: “I think it’s a good thing that my mentor is my mentor and not my best friend” (SNA12). They differentiated between the mentor’s and clinical supervisor’s role. Since the supervisor only worked with the students occasionally rather than daily like the mentors, they were regarded as potentially having a different overall view of the students’ progress.

In order to understand what was expected of them at a specific level, the SNAs wanted constructive and specific feedback. By providing tangible examples to explain their assessment, the mentors described using NANTS-no to illustrate where the students demonstrated proficiency as well as to point out what needed improving.

“We sat together, me, my mentor and the clinical supervisor, and went through NANTS. They gave me specific feedback about what they thought I needed to work on. So, in that way I think you learn more than when I took my nursing degree, the feedback then could be rather diffuse and general.” (SNA5)

This kind of structured feedback was regarded as valuable by the SNAs in aiding them to work systematically on improving their non-technical skills. Although the mentors considered NANTS-no made it easier to give negative feedback, the SNAs felt it was difficult for a mentor to be honest when a student had very poor skills.

Although assessing behaviour was regarded as new and unfamiliar by the participants, NANTS-no contributed to a reliable evaluation of the SNAs skills by demonstrating a measurable progress and increasing the objectivity of the evaluation. Regular use of the NANTS-no rating scale made the SNAs’ progress more visible to both the students and their mentors, although some mentors felt that the actual score was not as important as the direction in which it pointed.

Both the SNAs and mentors discussed whether it would be less confusing to use NANTS-no to assess a student’s non-technical skills at the end of each training period in relation to an expected level, rather than as a scale for the whole training. However, using the same scale to measure the SNAs’ progress throughout their training was regarded as one of the most valuable aspects of the instrument.

“… look we agreed that the scale should maybe be organized to score each period, but if one looks at it as an evaluation instrument for the whole training, it’s an advantage to have one scale for the whole thing” (SNA7)

“Yes. I don’t think there is any point having one score for … one dividing it up to rate each period, because you won’t get an overall view then” (SNA11)

The SNAs experienced being evaluated with NANTS-no as less subjective than other clinical evaluations because they were all evaluated on the same objective criteria in a systematic way. This ensured that an evaluation measured their progress more fairly, and was not based on the individual mentor’s hang-ups, gut feelings, or on personal chemistry. However, some SNAs felt that rating skills did not necessarily make the evaluation more objective as a score could always be influenced by the mentor’s or supervisor’s impression of the SNA. The mentors confirmed that they found it difficult to be completely objective when they worked with the student daily, although using NANTS-no encouraged them to reflect over their own behaviour in a more objective way. Nonetheless, they regarded NANTS-no as particularly useful for exemplifying why an SNA failed to pass his or her clinical training.

Promotion of organizational acceptance

The participants described promoting acceptance of NANTS-no as an ongoing process that encompassed the practicalities and feasibility of implementing the instrument in the anaesthesia departments.

Implementation was regarded as dependent on the instrument’s perceived usability and nurse anaesthetists’ familiarity with it. NANTS-no’s schematic format was described as well organized, giving a complete overview of a nurse anaesthetist’s non-technical skills. Although the SNAs described NANTS-no as compact and requiring little effort to use, many of the mentors found it overwhelming at first. The full-version contained a large amount of text, but this was regarded as necessary to use it optimally. Various participants commented on overlap in some of the NANTS-no elements and categories that hindered familiarization, although the examples of good and poor behaviour helped to clarify the meaning of the elements. However, the participants were generally positive to using NANTS-no.

A major impediment to implementation was seen as lack of familiarity with the instrument, both on an individual and departmental level. Some participants commented that it was only used on “high days and holidays”, and it was like starting afresh each time:

“I would really like to use it a bit more, so I’ve got it under my skin, because I have to go back and look at the elements to see how to score them. I don’t always remember them well enough, so it’s a bit difficult to use it «bedside» without having the instrument with you… but it’s probably a case of practice. If you use it enough, then it will sit properly” (CS4)

Participants experienced that NANTS-no worked well once they were familiar with the instrument, and using it regularly increased their proficiency. The mentors felt that the SNAs had a higher degree of familiarity, and there was a need for better training in the use of NANTS-no. It was also problematic that the instrument was not properly implemented in the anaesthetic department. Gaining acceptance for NANTS-no was described as a maturation process that would take time.

The feasibility of implementing NANTS-no was challenged by scoring barriers and the instrument’s terminology. Rating behaviour and interpersonal skills was regarded as strange and unfamiliar. The mentors regarded it as challenging since providing anaesthesia is a complex process, and an SNA might demonstrate good situational awareness, then miss a small detail that pulled their score down. Using the rating scale to assess whether a student should pass at the end of their training, however, was seen as meaningful. The mentors also expressed concerns about making false judgements and setting too low a score, particularly during the first period of training. It was therefore often easiest to select a score in the middle of the scale.

Although SNAs found using the rating scale became easier over time, it was often difficult to give themselves a high score.

“We find it a bit challenging to put a number on ourselves. At least in my opinion, it’s not always so easy. One is maybe a bit too cautious or too daring rating some of the elements.” (SNA4)

“It has something to do with the Norwegian spirit of egalitarianism, if you like” (SNA1)

Some mentors agreed that the SNAs rated themselves lower than their mentors. However, one clinical supervisor considered that the SNAs understood the rating scale well and were realistic in their self-assessments. She found it surprising that assessments made by three different people often ended up being very similar.

A further challenge for the mentors was using NANTS-no to compare students to a qualified nurse anaesthetist, particularly during their first clinical training period when they could only expect low scores. They accepted however that the SNAs understood the system and found it less problematic. In addition, the terminology in the rating scale was seen as problematic, as the use of «N—not observed» was unclear while some of the rating descriptors at the lower end of the scale such as «poor» or «marginal» were regarded as both harsh and demotivating. However, this was not mentioned as a problem by the SNAs.