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Relationship between non-technical skills and technical performance during cardiopulmonary resuscitation: does stress have an influence?
  1. Ralf Krage1,
  2. Laura Zwaan2,3,
  3. Lian Tjon Soei Len4,
  4. Mark W Kolenbrander5,
  5. Dick van Groeningen1,
  6. Stephan A Loer1,
  7. Cordula Wagner6,7,
  8. Patrick Schober1
  1. 1 Department of Anaesthesiology, VU University Medical Center, Amsterdam, The Netherlands
  2. 2 Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, The Netherlands
  3. 3 EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
  4. 4 Department of Anaesthesiology, Rode Kruis Hospital, Beverwijk, The Netherlands
  5. 5 Department of Anaesthesiology, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
  6. 6 Department of Public and Occupational Health, EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
  7. 7 NIVEL, Netherlands institute of Health Services Research, Utrecht, The Netherlands
  1. Correspondence to Dr Ralf Krage, Department of Anaesthesiology, VU University Medical Centre, De Boelelaan 1117, Amsterdam 1081 HV, The Netherlands; r.krage{at}


Background Non-technical skills, such as task management, leadership, situational awareness, communication and decision-making refer to cognitive, behavioural and social skills that contribute to safe and efficient team performance. The importance of these skills during cardiopulmonary resuscitation (CPR) is increasingly emphasised. Nonetheless, the relationship between non-technical skills and technical performance is poorly understood. We hypothesise that non-technical skills become increasingly important under stressful conditions when individuals are distracted from their tasks, and investigated the relationship between non-technical and technical skills under control conditions and when external stressors are present.

Methods In this simulator-based randomised cross-over study, 30 anaesthesiologists and anaesthesia residents from the VU University Medical Center, Amsterdam, the Netherlands, participated in two different CPR scenarios in random order. In one scenario, external stressors (radio noise and a distractive scripted family member) were added, while the other scenario without stressors served as control condition. Non-technical performance of the team leader and technical performance of the team were measured using the ‘Anaesthetists’ Non-technical Skill’ score and a recently developed technical skills score. Analysis of variance and Pearson correlation coefficients were used for statistical analyses.

Results Non-technical performance declined when external stressors were present (adjusted mean difference 3.9 points, 95% CI 2.4 to 5.5 points). A significant correlation between non-technical and technical performance scores was observed when external stressors were present (r=0.67, 95% CI 0.40 to 0.83, p<0.001), while no evidence for such a relationship was observed under control conditions (r=0.15, 95% CI −0.22 to 0.49, p=0.42). This was equally true for all individual domains of the non-technical performance score (task management, team working, situation awareness, decision-making).

Conclusions During CPR with external stressors, the team’s technical performance is related to the non-technical skills of the team leader. This may have important implications for training of CPR teams.

  • acute care
  • cardiac arrest
  • education
  • teaching
  • resuscitation
  • training
  • safety

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  • Contributors RK, LZ, SAL, CW and PS contributed to the conception and design; RK, LZ, LTSL, MWK and DvG collected data; RK, LZ and PS analysed and interpreted the data; RK and PS drafted the first version of the article; LZ, LTSL, MWK, DvG, SAL and CW critically revised the article for important intellectual content. All authors read and approved the final version. RK and PS take responsibility as guarantors for the overall content.

  • Funding This article was funded by the Department of Anaesthesiology of the VU University Medical Center Amsterdam.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.