Non-technical Skills in Cardiopulmonary Resuscitation: Improvement and Evaluation of a New Course Introduced to the Curriculum at a Medical School in Poland in 2018 to 2019

Non-technical skills (NTS) are important skills in emergency medicine and should be a necessity even at the stage of medical studies. The aim of this study was to assess how increasing the number of non-technical skills hours influenced the results of non-technical competences among medical students. In this investigation, 296 Polish medical students in the sixth year at Medical College in Krakow, Poland were included in the study. The students were divided into two research groups: I in 2018 and II in 2019. The groups differed in the number of total hours that focused on non-technical skills, in 2018: 60 hr, and 2019: 120 total hours. Non-technical competencies were assessed at the Crisis Resource Management station using sudden cardiac arrest scenarios. In 2018, the median was 20 points and the average of the points obtained in this group was 19.53 points (SD 5.39 points). In 2019, the median was 26 points and the average of points was 25.07 points (SD 5.23 points). Students who had more non-technical skills classes (120 hr) scored more points on the OSCE exam than group I (60 hr) (p < .001). The median of points in non-technical competences depended on the number of teaching hours in which the main emphasis was on the development of these skills. This investigation demonstrates that more teaching hours dedicated to improving the non-technical skills of students corresponded to better results on the cardiopulmonary resuscitation scenarios.


Background
Non-technical skills (NTS) can be defined as ''the cognitive, social and personal resource skills that complement technical skills, and contribute to safe and efficient task performance.''(Flowerdew et al., 2012) These skills are universal and can be widely used in all kinds of settings where teamwork and effective communication are paramount in completing objectives (Nasir et al., 2011).They cannot be acquired in a short time but must be learned and cultivated over an extended period of time (Nasir et al., 2011).NTS generally include: leadership, decision making, team work and situational awareness (Griffin et al., 2020).They are often grouped into three categories: social skills (e.g., leadership), cognitive skills (e.g., situational awareness) and personal resource factors (e.g., coping with stressors) (Griffin et al., 2020).NTS are a crucial factor in cardiopulmonary resuscitation (CPR) because they affect work efficiency, the healthcare quality and can reduce errors that can ultimately influence a patient's survival (Gabr, 2019;Gordon, 2013;Morey et al., 2002).Competencies such as: communication, teamwork and leadership play a relevant role in communication with patients and among members of the medical team (Berner & Ewertz, 2019;Boissy et al., 2016;Gluyas, 2015).Individual soft skills influence the course of action and the implementation of resuscitation algorithms (Andersen et al., 2010;Hunziker et al., 2011).
There is a growing awareness that most adverse events in medicine are caused by errors in communication and intra-team structure (Berner & Ewertz, 2019;Kemper et al., 2016;Uramatsu et al., 2017).In recent years, the importance of NTS has increased significantly, as depicted by the large number of publications and research tools currently being utilized to determine the level of these competences in healthcare professionals (Boet et al., 2018;Thistlethwaite et al., 2016).These skills are required already at the stage of medical studies.To verify the effectiveness of introducing NTS during medical studies, a single or a shortened course of NTS classes were organized at different universities and the progress of students was assessed (Hagemann et al., 2017;Nicolaides et al., 2021).
At the Faculty of Medicine the number of teaching hours developing NTS have significantly increased over the last 3 years.High-fidelity simulation classes were introduced with, among others, cardiac arrest scenarios.Due to the pioneering nature of these activities, it was necessary to evaluate the effectiveness of the introduced changes.
The aim of the study was to assess how the changes in the curriculum influenced the results of non-technical competences of medical students in cardiopulmonary resuscitation scenarios.In other words, to evaluate the effectiveness of the andragogical interventions and to determine what further changes should be made to improve the medical education process.An additional aim was to check if the gender of the students had an impact on NTS results.

Methods
The analysis was conducted in the medical faculty at Medical College.The project took place between the years 2017 and 2019 and was divided into two research groups, each made up of Polish medical students: Group I (2018) and Group II (2019).A Purposive selecting strategy was the chosen method of selecting participants-to study a specific subgroup of people: Sixth year medical students.In order to be included in this investigation, participants must have met basic academic criteria to qualify for the final Objective Structured Clinical Examination (OSCE) used to assess competencies of the students at the end of the NTS training and knowingly and voluntarily agreed to being enrolled into the investigation.There were no specified exclusion criteria.
In 2017, the OSCE for the sixth year was organized for the first time.Therefore, students from group I took this exam under different conditions: the OSCE was only for volunteers and its results were not considered when completing the studies.This examination is standardized and evaluators require extensive training prior to not only teaching the skills covered in the NTS classes but also in how to adequately assess skills at the conclusion of the course.An exam coordinator had been selected prior to the start of the OSCE to ensure that examination conditions were consistent between different students.
In total, 240 students took part in the study -133 in group I and 107 in group II.These groups differed in the number of total hours of training that focused on educating and developing non-technical competences.These differences are presented in Table 1 (found in the Methods section.)Students from group II had twice as many hours dedicated to these skills as group I. NTS classes appeared as part of Emergency Medicine and Laboratory Training in Clinical Skills.For details on educational subject description, see Additional file 1.
The number of hours of medical simulation within this framework gradually increased.Not only was the number of hours increased, but special attention was placed on extending the curriculum to encompass a wider breadth of material.What was stressed more vigorously after the alternations to the curriculum included how to communicate properly with patients in various situations such as breaking bad news and dealing with aggression, intra-team communication, leading teams, discussing treatment options, obtaining informed consent, and  (Nicolaides et al., 2021;Uramatsu et al., 2017).The NTS Assessment Card consisted of nine questions assessing whether the respondent had mastered a given skill-on a four-point scale (1-for the lowest rate, 4-for the highest).
At the CRM station, students led a three-person resuscitation team in a hospital setting.Each scenario lasted a maximum of 10 min and began with a sudden cardiac arrest (simulator).Scenarios differed in possible comorbidities, the cause, and the mechanism of the cardiac arrest.Before starting the exam, the student was given information about the task and his specific role on the team, along with a short vignette about the patient (see Additional file 3).Standardized clinical scenarios were designed to test the student's knowledge and skills in the field of advanced life support and non-technical competences.The results from the Assessment Card of two consecutive groups that participated in the study were analyzed.
The NTS Assessment Card was discussed in detail in meetings with examiners before the exam.The group of examiners were instructors and academic teachers (doctors, nurses and EMT) who taught CRM classes daily and were already familiar with this topic.These instructors also conducted classes for groups I and II.Each of the CRM instructors were certified in running medical simulations.The instructors participating in the exam as team members had detailed instructions on their role in this scenario (what was permissible and disallowed, how to behave, etc.).
Statistical analysis was performed using the StatSoft STATISTICA program and R program, version 4.0 (R Core Team, 2020).The test assumptions were checked and due to the lack of a normal distribution, a non-parametric test t-student equivalent was used-the Mann-Whitney U test.The analysis of quantitative variables was performed by calculating the average, standard deviation, median and quartiles.The level of statistical significance was 0.05.
Approval from the Bioethics Committee was obtained prior to the start of this investigation.Participants were free to opt in or out of the study at any point in time.Anonymity was assured and any personally identifiable data was randomized and encrypted.

Results
In this investigation, 240 students took part, aged 24 to 30.103 male students and 139 female students results were analyzed.
It was analyzed how increasing the number of NTS hours affects the overall results of non-technical competences of medical students.The maximum number of points that could be obtained was 36 points.In group I, the average of the points obtained was 19.53 points with a standard deviation of 5.39 points.In group II, the average of points was 25.07 points with a standard deviation of 5.23 points.In 2018, the lowest number of points obtained is 10, and the highest 31.A year later, the minimum number of points obtained is also 10, and the maximum is 35.The study showed statistically significant differences in the NTS level between group I (with fewer NTS teaching hours) and group II (Me I vs. II: 20 points vs. 26 points; p \ .001).The median of points in group I was significantly lower than the results in group II.Approximately 50% of students from group II obtained from 21 to 29 points, while the same percentage of students from group I scored a minimum of 16 and a maximum of 23 points.The quartiles and the median of all groups are presented in Table 2.
In a secondary part of this investigation, the grades for the assessed non-technical skills were analyzed.In both groups, the minimum number of points for all questions is 1 point, and the maximum is 4 points.Students from group II scored significantly more points for eight out of nine examined competencies compared to group I.In the study, however, no statistically significant difference was observed in the level of competencies: giving instructions.In both groups, the median for this skill was 4 (group II) and 3.5 points (group I), and it was the highest rated non-technical competence.The minimum number of points obtained by students in both groups was 1 point, which concerned all nine competences.Each of these skills was rated at a maximum of 4 points-in both study groups.The lowest median in groups I and II was the component, ''global assessment.''Detailed results of the analysis are presented in Table 3.It was examined whether the sex of the respondents had an impact on their NTS scores.The minimum for male and female students was 1 point, and maximum 4 points.Analyzes were performed in both groups.In group II, women scored significantly more points for analyzing the situation than men (3 points vs. 2.5 points, respectively; p = .04).It is similar in the case of the competence: global assessment (women vs. men: 2 vs. 1; p= 0.004).In group I, there were no statistically significant differences in the level of competence depending on the sex of the respondents.The exact results are presented in Table 4.

Discussion
Non-technical skills have been tested in various settings (Flynn et al., 2017;Nicolaides et al., 2021;Weller et al., 2003).However, the number of publications on student training is still inadequate, and the key problem is the lack of descriptions of interventions and their theoretical foundations (Flynn et al., 2017;Gordon, 2013;Nicolaides et al., 2021;Weller et al., 2003).The aim of this study was to assess how the increased number of NTS classes affects the results of these competences in cardiopulmonary scenarios.The curriculum at Medical College includes Medical Simulation and Communication in Medicine.The results of group I, which had 60 NTS hours in the program, and group II, which had twice as many of these classes, were compared.Students who had more NTS classes received more points than those who took half as many classes.This means that increasing the number of NTS hours positively influences the development of these competences in medical students under stress conditions such as final exams.This is consistent with other research showing that even a small amount of teaching hours dedicated to this can develop these competences (Hagemann et al., 2017).Not only this, but specially organized NTS courses increase the level of these skills in both healthcare professionals as well as students (Flynn et al., 2017).One study also states as a conclusion that these types of educational interventions developed students' non-technical skills faster than technical skills (Wunder, 2016).This is another aspect that should be explored in the future.Almost every one of the competences tested in the fields of ''Leadership,'' ''Communication,'' ''Teamwork'' and ''Decision-making'' was better developed in students with more extensive training.The exception was ''Giving clear orders''-in this case, the study did not show any significant differences between the groups.Significant progress has been made in implementing leadership development programs, according to one study.Uniformity of curricula is an added advantage (Sonnino, 2016).Analyzing these results, the increased number of NTS classes positively influenced the development of such competences as ''Information gathering'' and ''Dissemination of information within the team'' and the use of ''Closed-loop communication.''The differentiation of responses in both studied groups was similar.Medical simulation classes have a beneficial effect on the development of non-technical students' competences.This is consistent with the results of other studies in which classes, such as medical simulations, allow teachers and students to assess their skills and identify further educational needs in this field (Jorm et al., 2016;Pearson & McLafferty, 2011).These types of courses force students to be actively engaged in the lessons which can also help stimulate further learning, which have been supported by other studies in the teaching NTS competencies (Brown et al., 2016;Kr€ uger et al., 2009;Lewis et al., 2012).
The secondary endpoint of this study was also to check whether the gender of students taking the exam in 2018 and 2019 has an impact on their NTS.Research shows that gender may influence the variability in interpersonal aspects of professional and private life as well as medical practice (Roter et al., 2002;Steingart et al., 2010;Weisman & Teitelbaum, 1989).The literature on the subject includes studies in which women obtained statistically significantly better results than men in the study of communication and interpersonal skills and Non-Technical Skills for Surgeons adapted to the US surgical context (Pradarelli et al., 2020;van Zanten et al., 2007).In this study, women obtained more points only for the ability to ''Use a freeze frame in a scenario,'' ''Analyze the situation'' and ''Drawing conclusions.''In the remaining cases, the differences in points were not statistically significant.It can therefore be concluded that the gender of the students did not affect their NTS skills significantly.

Limitations and Strengths of the Study
It was important to use assessment tools that are reliable and useful.This can be achievable in an academic setting through the implementation of the OSCE examination scheme where scenarios are standardized to limit as many confounding factors as possible.Standardization of study, equal test conditions for all and appropriate preparation of all evaluators are the main strengths of the research project.OSCE is one of many different assessment tools for the NTS (Fischer et al., 2017;O'Keeffe et al., 2020;Pugh et al., 2015).The results of previously conducted projects are considered reliable and objective (Stalmach-Przygoda et al., 2020).In this study the OSCE was a good choice, which satisfies all the requirements.However, final exams are a great source of stress for students, and a previous research project has shown that the OSCE exam is a strong stress factor for them (Majumder et al., 2019).The results of individual students may have been influenced by such disruptive factors such as stress, team management skills and level of fatigue associated with subsequent OSCE stations.However, these are random variables and could occur in both groups studied.The only variable in the study that differentiates the effectiveness of learning is the difference in curricula (different number of teaching hours).There is no variable that could be additionally used in predicting efficiency.
The results of all students may have been affected by the stress of taking the exam and being assessed.Another limitation is the subjective assessment of the examiner.The varying behavior of the instructors who participated as support staff may also have contributed to the exam.However, efforts have been made to minimize differences in assessment and in the performance of role-playing instructors in the scenarios.The CRM station was one of the seven stations in the OSCE exam, which lasted a total of about 2 hr.Students go to the next stations in a different, randomly selected order.The CRM result could have been influenced by the order in which the student took it.Fatigue may have been a disruption to the study.

Recommendations
Creating a range of NTS teaching with a large number of teaching hours, different levels of training, a variety of scenarios, with particular emphasis on the development of useful communication techniques and tools.

Conclusions
It appears that students who had more classes in medical simulation rooms and completed more diverse scenarios in the field of medical team management in emergency scored more points on the OSCE exam during sudden cardiac arrest scenarios.The average number of points in non-technical competences depends on the number of teaching hours in which the main emphasis is on the development of these skills.The study did not prove that the gender of the subjects had a significant influence on their NTS scores.The study showed that it is possible to effectively teach non-technical competences to medical students and prepare students to effectively use NTS when they are under the stress related to the assessment procedure.
The development of these skills is therefore crucial and should be implemented during medical studies and constantly improved.

Table 1 .
Study Group Division Depending on the NTS Course.Emphasis is placed on communication skills in the doctor-patient relationship.There were classes focused on this specified problem.Non-technical competencies were assessed during the OSCE at the Crisis Resource Management (CRM) station by trained instructors (see Additional file 2).They used an optimized Non-Technical Skills Assessment Card, prepared based on the modified Ottawa Crisis Management Checklist Global Rating Scale

Table 2 .
Points Obtained by Students Related to the NTS.

Table 4 .
Comparison of the NTS Results (Median) Depending on the Sex of the Respondents for Groups.

Table 3 .
NTS Points Obtained by Students Regarding Skills.