Evaluating Current Practices in Operative Nontechnical Skills Training and Feedback in General Surgery Residency: A Mixed Methods Approach

Background: Non-technical skills (NTS) are the interpersonal and cognitive abilities that are critical to accomplishing high-risk tasks. Deficiencies in NTS, including communication, teamwork, leadership, and decision-making, are linked to errors in the operating room. Structured training and feedback in NTS remain inconsistent and have not been integrated into daily training. This dissertation addresses this gap by evaluating current NTS training and feedback practices and developing a rubric to enhance the effectiveness of NTS feedback. Methods: We conducted five complementary studies to assess current NTS training and feedback. The first was a systematic review aimed at identifying intraoperative NTS training interventions for general surgery residents in the United States. Second, a mixed-method survey to compare residents' and faculty's perceptions of formative feedback on technical skills (TS) versus NTS feedback. Third, we created and validated a rubric for assessing both TS and NTS feedback using literature review, stakeholder perspectives, and a modified Delphi panel. Fourth, we conducted a retrospective analysis of narrative feedback from the University of Nebraska Medical Center (UNMC) general surgery program’s work placement assessment tool (SIMPL) to examine resident, attending, and case factors associated with providing or receiving narrative feedback. Lastly, we applied the rubric to evaluate the frequency and effectiveness of NTS narrative feedback. Results: The systematic review revealed that most NTS training took place in simulation environments and was rarely integrated into routine clinical practice. Survey findings (n = 79) revealed that while both faculty and residents agreed on what makes NTS feedback effective, they perceived it as occurring less frequently and being more difficult to deliver than TS feedback. The rubric demonstrated high interrater reliability (ICC > 0.84 across domains). In the SIMPL dataset, only 24% of evaluations included NTS feedback; of those, 20% met criteria for effective feedback. Conclusions: Despite the importance of NTS development in general surgery residents, NTS feedback remains infrequent and often lacks the qualities that promote learner growth. The validated rubric offers a feasible and reliable approach for assessing and enhancing feedback effectiveness. It can be incorporated into faculty development initiatives to promote more meaningful engagement with NTS in surgical training.