Shared Mental Models and Technical Assessment in Video Assisted Thoracoscopy Surgery Lobectomies

BACKGROUND The majority of errors in healthcare in general, and the operating theatre in particular, are caused by human factors1,2. Hindering of these errors can be accomplished by good non-technical skills (NTS), including good teamwork and efficient communication within the operating room (OR) team3,4. NTS are defined as 'the cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance'5.

Previously, safety studies have analysed and measured adverse events as an indication of patient safety4,6. A new safety theory by Erik Hollnagel, named Safety II, argues that instead of only investigating adverse events as a 'measure' for safety, we should also be investigating what happens when these do not occur or when they are avoided as equally important7. This broader perspective on patient safety has also been advocated by others8-10.

In an explorative, interview-based study, we took a Safety-II perspective when examining which NTS were most important for ensuring safe and efficient video-assisted thoracoscopic surgery (VATS) lobectomy, a high risk minimally invasive surgery with complementary and overlapping scope of practice between the surgical and anaesthesia subteams. The multi-professional teams identified specific important NTS that served as the basis for shared mental models (SMMs) regarding the patient, the current situation or the resources within the team. These mental models were accomplished through communication and coordination, and enabled the team to anticipate problems and stay ahead of the situation11. These teams performing high-risk procedures emphasized the importance of the six identified NTS for them to be able to obtain an accurate SMM to enable them to be ahead which they viewed as most important for a successful and safe operation.

Some of the first to look at SMM as a requirement for effective team performance was Cannon-Bowers and Salas in the 1990s12. They defined SMMs as common or overlapping cognitive representations of task requirements, procedures, and role responsibilities. More recent, SMMs have been specified as a shared understanding of the task (including equipment), the situation and resources of other team members. In turn, this will enable them to understand and interpret the situation and what the other team members know, what they need to know and what they are doing12-14. Moreover, others have found identical or similar constructs to SMMs, i.e. team mental models/shared situation models/team knowledge/team situation awareness, and the importance of these constructs for patient safety is largely agreed upon15-21.

SMMs are more than the sum of individual mental models20,22. They need to be similar, accurate and shared within the team; however, what level of information sharing and team monitoring in the team will result in high team performance is less clear17,18,23.