Translation and Psychometric Properties of the Persian Version of Oxford Non-technical Skills 2 System: Assessment of Surgical Teams’ Non-technical Skills in Orthopedic Surgery Wards

Document Type : RESEARCH PAPER


1 Department of Ergonomics, School of Health and Nutrition, Shiraz University of Medical Sciences, Shiraz, Iran

2 Department of Occupational Health Engineering, School of Health, Tehran University of Medical Sciences, Tehran, Iran

3 Department of Anatomy, School of medicine, Shiraz University of Medical Sciences, Shiraz, Iran

4 Department of Biostatistics and Epidemiology, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran


Background: Non-technical skills are interpersonal and cognitive skills involved in safe performance and preventing
adverse events during surgery. it is necessary to dominate the non-technical skills to ensure patient safety. This study
has aimed to assess the validity and reliability of Oxford Non-technical skills 2 system (Oxford NOTECHS 2) in Iran and
to evaluate surgical teams’ non-technical skills in orthopedic surgery wards.
Methods: This cross-sectional study was conducted in Tehran, Iran during 2015. The level of evidence is III based on
Canadian Task Force on the Periodic Health Examination. We followed the Beaton’s guideline for Persian translation
and cross-cultural adaptation of the checklist. In this study, 60 orthopedic surgical team members working in two
selected public hospitals were selected by cluster random sampling method.Oxford NOTECHS 2 system which is
consisted of four subscales including leadership and management, teamwork and collaboration, decision-making
and problem-solving, and situational awareness was used to collect the data.
Results: The overall mean score of non-technical skills was 69.52±6.64. The mean score for surgery, anesthesia, and
nursing sub-teams were 24.98±3.71, 21.12±4.29, and 23.42±3.60, respectively. The teams’ scores in total, leadership
and management, teamwork and collaboration, problem solving and decision making, and situational awareness at
the standard level were 74.70%, 76.95%, 73.75%, 66.87%, and 74.70% of maximum score, respectively.
Conclusion: The validity and reliability of the Persian version of Oxford NOTECHS 2 scale in Iran was confirmed. The
results of this study showed that surgical teams’ non-technical skills were at a moderate level in orthopedic surgery
wards. The minimum score of the surgical teams’ non-technical skills belonged to anesthesia and maximum to surgery
sub-team. Using the training programs and setup workshop is recommended to improve the surgical teams’ nontechnical
skills, especially surgery-nursing sub-team.
Level of evidence: III


Main Subjects

1. Hull L, Arora S, Kassab E, Kneebone R, Sevdalis N.
Observational teamwork assessment for surgery:
content validation and tool refinement. J Am Coll
Surg. 2011; 212(2):234-43.e1-5.
2. Mitchell L, Flin R. Non-technical skills of the operating
theatre scrub nurse: literature review. J Adv Nurs.
2008; 63(1):15-24.
3. Mitchell L, Flin R, Yule S, Mitchell J, Coutts K, Youngson
G. Thinking ahead of the surgeon. An interview study
to identify scrub nurses’ non-technical skills. Int J
Nurs Stud. 2011; 48(7):818-28.
4. Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR,
Rogers SO, Zinner MJ, et al. Patterns of communication
breakdowns resulting in injury to surgical patients. J
Am Coll Surg. 2007; 204(4):533-40.
5. Flin R. Non-technical skills for anaesthetists, surgeons
and scrub practitioners (ANTS, NOTSS and SPLINTS).
London: The Health Foundation; 2013.
6. Yule S, Flin R, Maran N, Rowley D, Youngson G,
Paterson-Brown S. Surgeons’ non-technical skills
in the operating room: reliability testing of the
NOTSS behavior rating system. World J Surg. 2008;
7. Haugen AS, Softeland E, Eide GE, Sevdalis N, Vincent
CA, Nortvedt MW, et al. Impact of the World Health
Organization’s Surgical Safety Checklist on safety
culture in the operating theatre: a controlled
intervention study. Br J Anaesth. 2013; 110(5):807-15.
8. Mitchell L, Flin R, Yule S, Mitchell J, Coutts K, Youngson
G. Evaluation of the scrub practitioners’ list of
intraoperative non-technical skills system. Int J Nurs
Stud. 2012; 49(2):201-11.
9. Yule S, Flin R, Paterson-Brown S, Maran N. Nontechnical
skills for surgeons in the operating room: a
review of the literature. Surgery. 2006; 139(2):140-9.
10. Flin R, Patey R, Glavin R, Maran N. Anaesthetists’ nontechnical
skills. Br J Anaesth. 2010; 105(1):38-44.
11. Undre S, Sevdalis N, Healey AN, Darzi S, Vincent CA.
Teamwork in the operating theatre: cohesion or
confusion? J Eval Clin Pract. 2006; 12(2):182-9.
12. Flin R, Glavin R, Maran N, Patey R. Framework for
Observing and rating anaesthetists’ non-technical
skills; anaesthetists’ non-technical skills (ANTS)
system handbook v1. 0. 2012. Aberdeen, Scotland:
University of Aberdeen; 2014.
13. Passauer-Baierl S, Hull L, Miskovic D, Russ S, Sevdalis
N, Weigl M. Re-validating the Observational Teamwork
Assessment for Surgery tool (OTAS-D): cultural
adaptation, refinement, and psychometric evaluation.
World J Surg. 2014; 38(2):305-13.
14. Seelandt JC, Tschan F, Keller S, Beldi G, Jenni N,
Kurmann A, et al. Assessing distractors and teamwork
during surgery: developing an event-based method for
direct observation. BMJ Qual Saf. 2014; 23(11):918-29.
15. Sevdalis N, Davis R, Koutantji M, Undre S, Darzi A,
Vincent CA. Reliability of a revised NOTECHS scale for
use in surgical teams. Am J Surg. 2008; 196(2):184-90.
16. Morgan L, Hadi M, Pickering S, Robertson E, Griffin
D, Collins G, et al. The effect of teamwork training on
team performance and clinical outcome in elective
orthopaedic surgery: a controlled interrupted time
series study. BMJ Open. 2015; 5(4):e006216.
17. Rutherford JS, Flin R, Mitchell L. Non-technical skills
of anaesthetic assistants in the perioperative period:
a literature review. Br J Anaesth. 2012; 109(1):27-31.
18. Flin R, Patey R. Non-technical skills for anaesthetists:
developing and applying ANTS. Best Pract Res Clin
Anaesthesiol. 2011; 25(2):215-27.
19. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N,
Patey R. Anaesthetists’ Non-Technical Skills (ANTS):
evaluation of a behavioural marker system. Br J
Anaesth. 2003; 90(5):580-8.
20. Wauben LS, Dekker-van Doorn CM, van Wijngaarden
JD, Goossens RH, Huijsman R, Klein J, et al. Discrepant
perceptions of communication, teamwork and
situation awareness among surgical team members.
Int J Qual Health Care. 2011; 23(2):159-66.
21. Gillespie BM, Harbeck E, Kang E, Steel C, Fairweather
N, Chaboyer W. Correlates of non-technical skills
in surgery: a prospective study. BMJ Open. 2017;
22. Robertson ER, Hadi M, Morgan LJ, Pickering SP, Collins
G, New S, et al. Oxford NOTECHS II: a modified theatre
team non-technical skills scoring system. PLoS One.
2014; 9(3):e90320.
23. Sharma B, Mishra A, Aggarwal R, Grantcharov TP. Nontechnical
skills assessment in surgery. Surg Oncol.
2011; 20(3):169-77.
24. Graham J, Hocking G, Giles E. Anaesthesia nontechnical
skills: can anaesthetists be trained to
reliably use this behavioural marker system in 1 day?
Br J Anaesth. 2010; 104(4):440-5.
25. Hull L, Arora S, Kassab E, Kneebone R, Sevdalis N.
Assessment of stress and teamwork in the operating
room: an exploratory study. Am J Surg. 2011;
26. Vosoughi AR, Roustaei N, Mahdaviazad H. American
orthopaedic foot and ankle society ankle–hindfoot
scale: a cross-cultural adaptation and validation study
from Iran. Foot Ankle Surg. 2018; 24(3):219-23.
27. Mishra A, Catchpole K, McCulloch P. The Oxford
NOTECHS System: reliability and validity of a tool
for measuring teamwork behaviour in the operating
theatre. Qual Saf Health Care. 2009; 18(2):104-8.
28. Undre S, Sevdalis N, Healey AN, Darzi A, Vincent CA.
Observational teamwork assessment for surgery
(OTAS): refinement and application in urological
surgery. World J Surg. 2007; 31(7):1373-81.
29. Kalantari R, Zakerian SA, Mahmodi Majdabadi M,
Zanjirani Farahani A, Meshkati M, Garosi E. Assessing
the teamwork among surgical teams of hospitals
affiliated to social security organizations in Tehran city. J Hospital. 2016; 15(3):21-9.
30. Makary MA, Sexton JB, Freischlag JA, Holzmueller
CG, Millman EA, Rowen L, et al. Operating room
teamwork among physicians and nurses: teamwork
in the eye of the beholder. J Am Coll Surg. 2006;
31. Sexton JB, Makary MA, Tersigni AR, Pryor D, Hendrich
A, Thomas EJ, et al. Teamwork in the operating
room: frontline perspectives among hospitals and
operating room personnel. Anesthesiology. 2006;
32. Morgan L, Pickering SP, Hadi M, Robertson E, New
S, Griffin D, et al. A combined teamwork training
and work standardisation intervention in operating
theatres: controlled interrupted time series study.
BMJ Qual Saf. 2015; 24(2):111-9.