This particular skill refers to the capacity to recognize and comprehensively understand our surroundings, but also to the identification and evaluation of the possible existing risks based on the information received from multiple sources, to anticipate future events. Three phases can be distinguished7:

• 1

  Perception of the surrounding elements: this refers to adequately obtaining relevant information despite difficult conditions (environmental noise, poor illumination, etc.).

• 2

  Understanding: this involves the integration, interpretation and adequate comprehension of the information received. In other words, it implies the capacity of people to develop a mental model that makes sense of the available information.

• 3

  Prediction or projection: based on the information received and interpreted, people must be able to anticipate the appearance of future events and adopt measures to deal with them.

Decision-making refers to the capacity of people to judge or choose the best option suited to the needs of assessed or foreseen events, as well as unforeseen events, based on the multiple options that characterize a situation. In general, decisions are made by people after a prior evaluation of the situation, with the identification of the problem, the establishment of a diagnosis, and the evaluation of risks. Once the decision has been made and applied, it is advisable to re-evaluate the patient's response to the decision.8

Communication is a crucial skill that serves as a vehicle for transmitting information and constructing a common world with shared mental models. Although communication is encompassed within social skills, it is not just another human skill. Indeed, communication is the most important skill, since it serves as a binding link with the rest of human skills and a structuring element of human actions.9 Furthermore, in daily clinical practice, when caring for patients in a medical or surgical emergency, deficient communication between healthcare professionals may occur, and such ineffective communication in turn is the root cause of 60–80 % of all adverse effects and sentinel events.5,10 The main causes of these team communication problems are essentially related to the lack of use of a specific methodology, or shortcomings in professional training.11 In order to minimize these problems, healthcare professionals must seek to establish effective communication, defined as that which allows the exchanging of messages in such a way that the perception of the receiving person is identical to that of the person emitting the message. In other words, the aim is to generate a mental model shared among the different intervening individuals. This objective must be met when the healthcare professionals interact and transfer information to other people (whether patients or their families), or when they speak with other healthcare professionals.3,8

Although some people possess innate communication skills referred to as both verbal and non-verbal language, such skills - in the same way as with all skills - require training from the start, with the search for improvement based on standardized communication techniques.11,12 In this respect, closed-loop communication processes are essential,13 in the same way as structured communication techniques such as “SBAR” (Situation-Background-Assessment- Recommendation)14 or its variants (e.g., “ISBAR” [Identify-Situation-Background- Assessment-Recommendation] and “iSoBAR” (identify-Situation-observations-Background-Agreed plan-Read back]).15 Regarding closed-loop communication, in stressing and high-complexity situations this strategy allows the professionals (issuers and receivers) belonging to the team to check that the message has been correctly understood, guaranteeing that all the team members exchange information in a clear, concise and unambiguous manner.13 With regard to SBAR, this verbal or written communication tool is easy to use and very useful for the healthcare team members for exchanging essential and concise patient information (e.g., nurse to nurse, nurse to physician or physician to physician), reducing the need for repetition and the risk of mistakes in situations of crisis.14

On the other hand, healthcare professionals must be able to give “bad news” to patients and/or their families – a difficult task that requires professionalism, patience and training. The different training programs available for this purpose include multiple structured tools. One of the best-known is SPIKES (Strategy, Perception, Invitation, Knowledge, Empathy, Summary).16,17 SPIKES is a communication tool focused on the patient that includes a structured listening format that globally proposes the following: gathering all the information available on the patient and his or her situation; providing understandable information adjusted to the needs and desires; reducing the emotional impact which bad news has upon the receptor; and including the person in the intervention plan (Table 217).

Critical situations in general are complex events that cannot be resolved by a single or by various people sequentially. Scenarios of this kind require the simultaneous participation of different professionals as a team to solve the problem.

A team is defined as two or more individuals that work together to reach a common series of goals, with specific competencies and specialized work roles, using shared resources and communicating together to coordinate.18 This definition includes two key elements within the work as a team. Firstly, ultimate success depends not only on the intervention of the individual as a member of the team but also on the skill of all its components to operate in a coordinated and effective way. This means that each professional must have general teamwork competencies or skills. Secondly, teamwork is closely linked to other human skills. In high-stress situations, such as a life-threatening emergencies, adequate leadership and effective communication among the different team members are crucial to ensure that a group of healthcare professionals can work together in an optimal way.19–22 This distinguishes a team consisting of a group of experts from a high-performance expert team.23

The team must have a person acting as the orchestra director, with a well-defined role: Leadership. Leadership is the series of management or directive skills that an individual has for influencing the behavior of a certain person or group of persons, causing this team to work with enthusiasm, giving the best of themselves to obtain a desired result. This implies the development and communication of a futuristc view, motivating people and securing their commitment.24 Leaders must have multiple qualities and should adapt to the available human team, the resources and the needs arising during healthcare. In the event of an emergency situation with a novice team, an autocratic position might be the most appropriate option. In contrast, in the event of a very complex scenario with a very experienced multidisciplinary team, the leader should be more open to listening to the comments and following the recommendations of the team.25–27

Humans are not machines, and our inherent nature implies that prolonged shifts and the lack of sleep expose healthcare professionals to tiredness, stress or distractions that favor the appearance of errors.

Tiredness and fatigue can affect analysis and decision-making, complex mental tasks and situational awareness.28,29 Sleep deprivation results in longer periods of ineffective, deficient and variable performance.30 As cognitive function decreases, we take longer to integrate information and there is a delay in executing a response. Likewise, fatigue secondary to long work shifts reduces alertness, slows the carrying out of tasks, and in sum hurts professional performance and patient safety.31

The scientific evidence points to a relationship between the level of stress and human performance.32,33 Although a degree of stress is necessary for healthcare professionals to stay alert and respond adequately in the face of an emergency, extreme stress levels hurt patient safety. On one hand, very low-stress levels lead to boredom and a lack of attention to tasks, while in contrast very high stress levels - often due to the work conditions and conflicts inherent to human interactions - lead to burnout syndrome, characterized by the following triad: emotional exhaustion, low professional performance, and depersonalization.32,33

Crisis Resource Management (CRM) conceptualizes and contemplates the behavioral skills needed to optimize the performance of a clinical team to improve its precision, efficiency and adaptability, to guarantee patient safety.41,42

The main principles underlying CRM are closely related to those commented above in relation to non-technical skills.

CRM has been shown to have a significant influence in improving clinical team and patient communication, and in reducing the presence of adverse events. Nevertheless, the evidence of the impact of this methodology on patient evolution and mortality in the long term is not solid36,43.

This program was created in the United States in 2006 by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense. It is under constant revision, and there is already a 3.0 version that can be consulted openly on the web.44

The main aim of the TeamSTEPPS is to integrate teamwork in clinical practice, being able to improve patient safety, promote a safety culture, and ensure quality and efficiency in patient care.45,46

The full program has three phases. The first phase evaluates the needs and identifies specific areas for improvement based on a standardized questionnaire developed by the AHRQ.47 The second phase involves TeamSTEPPS trainer education and posterior training of the participants from different Departments. Lastly, a third phase addresses maintenance and monitoring to integrate the methodology in clinical practice, and to diffuse the improvements in teamwork performance obtained by the TeamSTEPPS within the organization.48

Training is multimodal through scenarios, case studies, videos and clinical simulations. There are several course modalities in the second phase, involving a shorter course and another deeper and more extensive course.48

The main principles of the TeamSTEPPS are very similar to those of the CRM, including team structure (organization, definition of roles and responsibilities), leadership (coordination of the team, evaluation of its behavior, the assignment of tasks, team motivation), mutual support through adequate feedback, situational awareness (re-evaluation, anticipation) and communication.45

The main advantage of TeamSTEPPS is that the methodology used to implement the program is clear and homogeneous. It offers standardized checklists for assessing performance,49 along with concise work tools and clear cognitive aids for each of the aforementioned work areas.44

The TeamSTEPPS method is widely implemented at the international level. However, in Spain, and in contrast to the CRM, it has not been developed to the same extent, and few publications on this regard are available.45

With regard to the evidence of its benefits, several studies have shown that the TeamSTEPPS reduces the number of errors in the healthcare setting, with an increase in patient satisfaction.40,45

In addition to these human skill training programs, behavior observation scales have been introduced50–62 that can be used by qualified evaluators to objectively score the human skills of a group of healthcare professionals in a real or simulated scenario. Such behavior scales afford a common language to structure teaching, and serve as a basis for posterior debriefing. Most of these evaluation tools are designed to be used with multidisciplinary teams in real-life or simulated settings (Table 3. Behavior observation scales). Such instruments focus on two or more of the 5 most common human skill categories, i.e., communication, leadership and/or teamwork, situation awareness, decision making and task management. In choosing the most appropriate tool for the training of these skills in the management of critically ill patients, the teachers must select those that adapt best to the clinical setting in which the trainees are to be formed and also select those tools that have been previously validated.

In this training process we need a key element to implement such training programs, a teaching methodology that will serve as the basis: clinical simulation. There is general agreement that training in human skills essentially requires a safe learning context in which error should be seen as an opportunity to allow the trainees to improve as professionals and as persons, without placing the patient’s life at risk.63,64

In summary, the science of the Human Factor is a discipline that seeks to design systems that make work more effective and efficient while guaranteeing safety by minimizing errors and supporting resilience in responding to the latter and to the unexpected events that may arise. Correct implementation of the Human Factor principles favors “making it easy to do things well and hard to do things wrong”, and that when errors do occur, they prove less likely to cause harm to patients.

Within the Human Factor, we have human skills that properly refer to people individually. The following have been identified in the literature as being the most important: decision-making, communication, teamwork and leadership, situational awareness and the management of stress and fatigue. Adequate training in these skills by healthcare professionals plays a key role in the care of the critically ill patient by complementing theoretical knowledge and the mastering of technical skills.