Surgeons' non-technical skills in the operating room: Reliability testing of the NOTSS behavior rating system

Steven Yule, Rhona Flin, Nicola Maran, David Rowley, George Youngson, Simon Paterson-Brown

Research output: Contribution to journalArticle

387 Citations (Scopus)


Background: Previous research has shown that surgeons' intraoperative non-technical skills are related to surgical outcomes. The aim of this study was to evaluate the reliability of the NOTSS (Non-technical Skills for Surgeons) behavior rating system. Based on task analysis, the system incorporates five categories of skills for safe surgical practice (Situation Awareness, Decision Making, Task Management, Communication & Teamwork, and Leadership).

Methods: Consultant (attending) surgeons (n = 44) from five Scottish hospitals attended one of six experimental sessions and were trained to use the NOTSS system. They then used the system to rate consultant surgeons' behaviors in six simulated operating room scenarios that were presented using video. Surgeons' ratings of the behaviors demonstrated in each scenario were compared to expert ratings ("accuracy"), and assessed for inter-rater reliability and internal consistency.

Results: The NOTSS system had a consistent internal structure. Although raters had minimal training, rating "accuracy" for acceptable/unacceptable behavior was above 60% for all categories, with mean of 0.67 scale points difference from reference (expert) ratings (on 4-point scale). For inter-rater reliability, the mean values of within-group agreement (r (wg)) were acceptable for the categories Communication & Teamwork (.70), and Leadership (.72), but below a priori criteria for other categories. Intra-class correlation coefficients (ICC) indicated high agreement using average measures (values were .95-.99).

Conclusions: With the requisite training, the prototype NOTSS system could be used reliably by surgeons to observe and rate surgeons' behaviors. The instrument should now be tested for usability in the operating room.

Original languageEnglish
Pages (from-to)548-556
Number of pages9
JournalWorld Journal of Surgery
Issue number4
Early online date8 Feb 2008
Publication statusPublished - Apr 2008


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