title: Non-technical skills and health care provision in low- and middle-income countries: a systematic review.
abstract: BACKGROUND
  Health care workers must possess high levels of medical knowledge, technical skills and also non-technical skills (NTS) in order to provide safe, effective and patient-centred care. Although there has been a recent proliferation of NTS assessment and training tools developed in high-income countries, little is known about NTS in low- and middle-income countries (LMICs), which face a variety of provider-level and system-level challenges. The aim of this study was to identify the NTS used by providers in LMICs that have been studied, describe how they are assessed and taught, and explain the contextual factors in LMICs that affect their use.
  
  
  METHODS
  We conducted a systematic literature review in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines for primary research publications from January 1994 to December 2013 on evaluation or teaching of NTS used by health care workers in LMICs using MEDLINE, Embase, CIHHAL and Web of Science. Bibliographies of relevant manuscripts were also hand-searched to identify all potentially eligible manuscripts.
  
  
  RESULTS
  We identified 21 manuscripts from 17 LMICs involving eight types of health care providers and trainees. These studies covered five NTS categories: decision making, communication, teamwork, leadership and stress management. The most commonly used methods were questionnaires, interviews and observations, and 43% (n = 9) scored > 10 points using the Medical Education Research Study Quality Instrument. Although many studies highlighted the ways in which overburdened health care systems, lack of provider empowerment and deficiencies in provider training had an impact on providers' use of these NTS, no context-specific assessment or educational tools were identified.
  
  
  CONCLUSIONS
  There is growing worldwide interest in understanding and teaching critical non-technical skills to health care providers. This review highlights several studies describing a variety of important non-technical skills. However, these skills must be further characterised in order to develop context-specific tools for assessing and teaching NTS that are sensitive to the local challenges that are common across a variety of LMIC contexts.
authors.affiliation: Brigham & Women's Hospital, Boston, Massachusetts, USA.
authors.forename: John
authors.initials: J
authors.lastname: Scott
authors.affiliation: Brigham & Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Dianali
authors.initials: D
authors.lastname: Revera Morales
authors.affiliation: Brigham & Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: McRitchie
authors.affiliation: Brigham & Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Riviello
authors.affiliation: Brigham & Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Douglas
authors.initials: D
authors.lastname: Smink
authors.affiliation: Brigham & Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Steven
authors.initials: S
authors.lastname: Yule
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D000066491:Clinical Decision-Making; D003142:Communication; D003906:Developing Countries; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000193:education / Q000592:standards*; D006801:Humans; D007400:Interprofessional Relations; D007857:Leadership; D013192:Staff Development; D013315:Stress, Psychological / Q000517:prevention & control