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Development and impact of an endoscopic non-technical skills (ENTS) behavioural marker system
  1. Srivathsan Ravindran1,2,
  2. Adam Haycock2,3,
  3. Katherine Woolf4,
  4. Siwan Thomas-Gibson2,3
  1. 1 Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
  2. 2 Department of Surgery and Cancer, Imperial College London, London, UK
  3. 3 Wolfson Unit for Endoscopy, St Mark's Hospital, Harrow, London, UK
  4. 4 Faculty of Medical Sciences, University College London, London, UK
  1. Correspondence to Dr Srivathsan Ravindran, Joint Advisory Group on Gastrointestinal Endoscopy, London NW1 4LE, UK; sravindran1{at}


Background Non-technical skills (NTS) are crucial to effective team working in endoscopy. Training in NTS has been shown to improve team performance and patient outcomes. As such, NTS training and assessment are now considered essential components of the endoscopy quality assurance process. Across the literature, other specialties have achieved this through development of behavioural marker systems (BMS). BMS provide a framework for assessing, training and measuring the NTS relevant to healthcare individuals and team. This article describes the development and impact of a novel BMS for endoscopy: the endoscopic non-technical skills (ENTS) system.

Methods The initial NTS taxonomy for endoscopy was created through a combination of literature review, staff focus groups and semi-structured interviews, incorporating the critical decision method. Framework analysis was conducted with three individual coders and generated a skills list which formed the preliminary taxonomy. Video observation of Bowel Cancer Screening endoscopists was used to identify exemplar behaviours which were mapped to relevant skills in the NTS taxonomy. Behavioural descriptors, derived from video data, were added to form the basis of the ENTS system.

Results A taxonomy of 33 skills in 14 separate categories were identified through framework analysis. Following video analysis and behaviour mapping, 4 overarching categories and 13 behavioural elements were identified which formed the ENTS framework. The endoscopy (directly observed procedural skills) 4-point rating scale was added to create the final ENTS system. Since its development in 2010, the ENTS system has been validated in the assessment of endoscopy for trainees nationally. ENTS informs a number of training initiatives, including a national strategy to improve NTS for all endoscopists.

Conclusions The ENTS system is a clinically relevant tool, validated for use in trainee assessment. The use of ENTS will be important to the future of training and quality assurance in endoscopy.

  • endoscopy
  • behavioural marker system
  • non-technical skills
  • training
  • assessment

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  • Collaborators Roland Valori; John Anderson; Paul Bassett

  • Contributors AH, KW and ST-G conducted the original research study. SR drafted and edited the manuscript. All authors contributed and approved the final manuscript.

  • Funding AH was part-funded through the Masons Grant.

  • Competing interests KW reports grants from National Institute for Health Research, non-financial support and other from Royal Colleges of Physicians (UK), other from Health Education England, grants and other from General Medical Council, outside the submitted work. ST-G reports educational grants from Norgine, Aquilant and Olympus.

  • Ethics approval Ethical approval was granted by the UK National Research Ethics Service (08/H0719/54).

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

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. No data available.

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