Circulating nurse´s non-technical skills: a literature review

Background: Circulating nurses are key members of the surgical team and play an essential role in ensuring patient safety in the operating room. They need to use non-technical skills to provide safe and efficient patient care. This study was conducted to identify the behaviors related to the circulating nurse´s nontechnical skills from the existing literature. Methods: A search of the literature between 1990 and 2020 was conducted using online sources, including Web of Science, MEDLINE, CINHAL, Scopus, OVID, and Cochran library. Furthermore, the publications of the Association of peri-operative registered nurses (AORN) and the National Association of Theater Nurses (NATH) were consulted. Then the skills were grouped into known categories of non-technical skills. Results: Behaviors related to circulating nurse´s non-technical skills were extracted from the existing literature. Then they were grouped into seven domains, including communication, leadership, coping, teamwork, situational awareness, task management, and decision-making and problem-solving. Furthermore, several improper behaviors were extracted. Conclusion : Circulating nurses need to use non-technical skills from the beginning until the end of surgery to perform efficiently. There is still a need for future work to identifying circulating nurses’ non-technical skills using other types of studies to develop an assessment tool.


Background
For more than one century, surgery has been a significant element of public health (1). More than 234 million major surgeries are undertaken every year worldwide. Regarding high rates of death and complications in major surgical procedures, surgical safety should be considered as a public health concern (2). In the operating room, interdisciplinary teams of healthcare professionals with different skills work together to deliver quality patient care (3). The operating room is high risk (4) and a very complex environment (5), in which occur approximately 50% of adverse events within a hospital (6).
The analysis of the adverse events has shown that the causes of these events are defects in nontechnical aspects of performance, rather than failures in technical expertise (7). In other words, these cognitive and social skills are being increasingly known as the leading cause of surgical errors (8). 3 Non-technical skills help to reduce surgical errors, effective response to face problems during surgery (9), contribute to safe task performance, and complement technical skills (10).
Circulating nurses are key members of the surgical team and play an important role in ensuring patient safety in the operating room (11). They control the events that happen outside the sterile area and provide team members (12). Circulating nurses remain outside the sterile field and keep the contacts with out of the operating room (13). They are responsible for the patient´s final check before surgery (14), and they support the activities of other team members and the patient (15). Circulating nurses control the traffic of the operating room and observe aseptic principles to prevent infections (16). Circulating nurse´s work relies on deployment of non-technical skills (11). They should follow the process of surgery and anticipate the needs of scrub nurses (17). The circulating nurses must remain focused, confident, calm, and in control during operation (18). They should observe the surrounding area to identify possible problems (19) and maintain patient safety (20). Therefore, their nontechnical skills are crucial in safe and successful surgery.
The number of studies on operating room nurse´s nontechnical skills is lower than other surgical team members (11). Yet, the scrub nurse´s non-technical skills have been studied in past years, and a behavioral marker system was developed (3,21,22). The circulating nurse´s non-technical skills were not considered widely before. Only in one ethnographic study, Redaelli listed the main categories of circulating nurse´s non-technical skills, without reporting key behaviors (11). The survey on circulating nurse´s non-technical skills is under-developed, while their skills are very important. In a former study, Circulating nurses where the team members with most numbers concerning communication patterns (12). In a previous research, it was revealed that 77% of the errors during the surgery were intercepted by circulating nurses (19). Identifying the circulating nurse´s nontechnical skills can be helpful in the development of a behavioral marker system, the assessment of their behaviors, and educating them to improve their skills. In this study, we aim to identify the behaviors related to circulating nurse´s nontechnical skills from the existing literature.

Methods
This review was conducted based on the instruction of the Cochran handbook (23). The search terms were selected based on non-technical skills previous researches. Communication, teamwork, leadership, situational awareness, monitoring, coping strategies, problem-solving, decision making, and task management are the non-technical skills that are indicated in previous researches on healthcare staff. The circulating nurses may be called as scout nurse, circulating practitioner, circulating technician, and operating room nurses; so all the terms were put in keywords.
A search of the literature between 1990 and 2020 was conducted using online sources including Web of Sscience, MEDLINE, CINHAL, Scopus, OVID, and Cochran library. Furthermore, the publications of the association of peri-operative registered nurses (AORN) and the National Association of Theater Nurses (NATH) were consulted. The searched terms were a combination of MeSH terms and keywords.
Non-technical skills¨, ¨Task management¨, ¨Teamwork¨, ¨Communication¨, ¨Situational awareness¨, Leadership¨, ¨Decision making¨, ¨coping¨, ¨monitoring¨, ¨problem-solving¨, ¨circulating nurse/practitioner/technician¨, ¨scout nurse¨, ¨intra-operative nurse¨ and ¨Operating room/Operating theatre¨ were included. Various combinations of the keywords were used.
Original articles, clinical trials, case reports, reviews, systematic reviews, and meta-analysis were included. The list of references for each review article was crosschecked for additional studies. The articles which were published in a language other than English and those that were not published in peer-reviewed journals were excluded from this study. Two authors screened the studies by title and abstract independently to consider potential eligibility. Then, they reviewed full texts to extract relevant studies. Disagreements between the authors were discussed, and after rechecking, they achieved complete agreement. The included studies were deeply analyzed to extract behaviors that are linked to circulating nurse´s non-technical skills. The behaviors were grouped based on the definition of known non-technical skills. Figure

Results
The formerly developed behavioral marker systems to assess surgical team´s non-technical skills include some exemplar behaviors that are related to nursing sub-team and circulating nurse´s nontechnical skills (24)(25)(26)(27)(28)(29)(30). Only one ethnographic study (11) has been conducted to extract the circulating nurse´s non-technical skills; however, the study not reported exemplar behaviors, so we 5 studied the references that are related to nursing and operating room to extract more behaviors.
After reviewing the related studies and textbooks, we extracted the circulating nurse´s nontechnical skills´ behaviors. We used the definition ¨social, cognitive, and personal recourse skills that contribute to safe task performance and complement technical expertise (10)¨ and known non-technical skills to categorize these skills.

Communication
Communication is the exchange of information among surgical team members (22). This category is a very important element in nursing jobs. The circulating nurse should communicate appropriately with the patient, surgical team members, and others in the surgical ward. They can talk to the patient to decrease his/her fear and stress before the start of surgery (31)(32)(33). Circulating nurses should use a proper tone of voice as they stand foots away from the surgical bed (34) and talk about only relevant issues to the surgery (12). They give necessary information to the team members during the surgery and hand-offs (35). Table one shows the circulating nurse´s communicational skills.

Leadership
Regarding circulating nurse´s duties, his/her leadership is not defined as ¨the capability to lead the surgical team¨; instead, it's better to describe it as ¨heading the surgical team members occasionally by guiding them toward corrective actions when they have deviated¨ (11). Circulating nurses have a crucial leadership role (36), as they are known as ¨in charge of the operating room¨ (37). They control the operating room traffic (31,38) and do not let unnecessary entrances. They lead the time out process (39,40) and orchestrate the surgery process within the operating room (31). Table 2 shows the circulating nurse´s leadership behaviors.

Coping skills
Operating room nurses are subject to stress, as there are several stressors in the operating room (41). Circulating nurses should be able to cope with stressful situations (11), as they are the most stressed team member in the peri-operative phase of surgery (42). They should adopt quickly to changes (23) because their reaction against stressful situations can affect other team members and the process of surgery. In such cases, they might reposition instruments smoothly (11). Staying calm 6 and dominant facing emergency situations and complications, being able to adapt with unpredicted and new conditions, Concentrating on the task that should be done at that moment, and a problemsolving based approach in stressful circumstances are the behaviors that were mentioned in the literature.

Teamwork
Circulating nurses should be able to work within the surgical team, cooperate with others, and stay coordinated with them. They function as an extra pair of hands and legs for surgical team, (43) and they help to prepare the operating room before start the surgery (44). Circulating nurses help other team members; for example, they help anesthesiology technicians during changes in patient status (15), induction, and intubation (45) and supporting sterile team members by providing their needs (45,46). They could do it actively by walking around the operating room and helping team members (47).
Circulating nurses also play an important role in coordinating activities in the operating room. They coordinate sterile team members with anesthesiologists (46), coordinate whole team activities (23) and needs (48) with out of the operating room. Table 3 shows the circulating nurse´s extracted teamwork skills.

Situational awareness
Situational awareness refers to the perception of elements in an environment within the volume of space and time, understanding and comprehension of their meaning, and projecting their status in the near future (49). People, tools, patient, and instruments are considered as the elements of the operating room. A circulating nurse attends to the patient and reminds behind him/her during the induction of anesthesia. During the surgery, they watch and seek surgical procedure and monitor the sterile team´s needs (45). They should be able to anticipate the process of surgery and adjust his/her roles to meet the needs (17). Circulating nurses should ensure the patient´s safety and comfort (31) and should gather information about the patient-related issues (16). They should check the presence (50) and the correct function of the devices (16,45) in the operating room before the start of surgery. Table 4 shows the behaviors related to the circulating nurse´s situational awareness.

Task management
7 Task management refers to the capacity of organizing resources to achieve the surgical team´s goals (22) and also maintain operating room standards. Circulating nurses should remain in the operating room until the end of surgery, like other team members (51,52). They need to manage and prioritize their tasks to do efficiently (53) and do housekeeping of the operating room (54). Circulating nurses should do their duties with precision, for example, in opening the sterile packs (55). They should manage the specimens properly and pay attention to counting protocols such as recording count results immediately and correctly (45). Circulating nurses review and prepare patient's documents (56) and know their roles and act toward them (57). Table 5 shows the circulating nurses´ skills in managing their tasks.

Decision-making and problem-solving
Circulating nurses can help in decision-making and problem-solving when the team faces problems.
Behaviors like ¨participating in decisions by raising their opinion¨, ¨offering alternatives when necessary, using analytical decision making regarding the events¨, and ¨trying to identify and solve problems¨ were indicated in the literature.

Improper behaviors
Through reviewing the literature, we found some inappropriate behaviors that are against the circulating nurse´s non-technical skills and could endanger patient safety by deviating the surgery process. Table 6 shows these behaviors.

Discussion
This review was conducted to extract the circulating nurse´s non-technical skills from the existing literature. The skills categorized into seven domains, including communication, leadership, coping, teamwork, situational awareness, task management, and decision-making and problem-solving. They use these skills from the beginning until the end of surgery. Furthermore, we founded some improper behaviors regarding these skills from the literature.
The result of the review showed that circulating nurses need to have more communication, teamwork, situational awareness, and task management skills than leadership and decision making. This result can be due to the roles in the operating room; surgeons, as the surgical team´s formal leader, have 8 more authority to make decisions and lead the team. On the other way, circulating nurses do the majority of their work with coordinating and management of the operating room. They could only be asked to give their opinion based on their expertise in problem-solving and decision-making, or they help indirectly with acting promptly and providing team members what they need. They manage and control the operating room to provide a comfortable environment for the patient and team members.
Circulating nurses play a vital role in the operating rooms, and their efficient performance extremely is related to deploying non-technical skills. Circulating nurses perceive the operating room as a complex environment that needs high activity and teamwork (58), as technological advances increase their workload and stress (59). They may be impacted by technological and technical factors more than any other member of the surgical team (60). The use of non-technical skills in the operating room can help circulating nurses to do their tasks better in such situations and ensure patient safety.
They play a vital role in error recovery and ensuring patient safety (19) by maintain high vigilance and observing other team members from a better point of view; this way, they can protect the sterile field. If a circulating nurse is absent during the surgery process, the communicative bridge between the operating room and hospital will be disconnected, and it could cause delays in the process of surgery and failures.
Individual assessment of circulating nurse´s non-technical skills has not be conducted before. Only in studies using behavioral marker systems such as the observational teamwork assessment for surgery (OTAS) (24) and Oxford non-technical skills system (NOTCHES II) (27) the nursing sub-team, including scrub and the circulating nurse is assessed. As being the team member who has the most interactions with materials, equipment, and technologies (61), and regarding the importance of circulating nurse´s non-technical skills in safe surgery and patient safety (20), the study of their behaviors is important.
This study can be a starting point to develop a tool for the assessment of circulating nurse´s nontechnical skills and find their strengths and weaknesses in applying these skills. Maybe an interview study could complement our results to develop a tool for assessment of circulating nurse´s nontechnical skills.

Conclusion 9
The circulating nurse´s non-technical skills have not been studied widely. Circulating nurses need to use non-technical skills to work efficiently and ensuring safe surgery. They have more skills in managing tasks, communication, teamwork, and situational awareness than other leadership and decision-making. There is still a need for investigation on the circulating nurse´s non-technical skills.

Ethics approval and consent to participate
This study was approved by the ethics committee of Shiraz University of Medical Sciences.

Consent for publication
Not applicable.

Availability of data and materials
All data generated or analyzed during this study are included in this published article.

Competing interests
The authors declare that they have no competing interests.

Funding
This study was financially supported by Shiraz University of Medical Sciences as a part of a Ph.D.

Author Contribution
RK, MH, and ZZ designed and conceived the study. JJ and AF analyzed the data. MH, RK, and SG performed the literature search. HN prepared data analyzation. All authors edited, reviewed, and approved the manuscript.