Impact of non-technical skills training on patient outcomes in surgery: a systematic review and meta-analysis

Background Non-technical skills (NTS) such as teamwork, communication and leadership are essential for surgical safety, but their impact on patient outcomes is uncertain. This systematic review evaluated whether NTS interventions improve operative and patient outcomes in surgical settings. Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, seven databases were searched for randomised and non-randomised studies of NTS interventions reporting patient or operative outcomes. Eligible interventions included team training, simulation, Crew Resource Management, Team Strategies and Tools to Enhance Performance and Patient Safety and in-theatre coaching. Risk of bias was assessed with the Cochrane risk-of-bias tool for randomized trials and Risk Of Bias In Non-randomised Studies - of Interventions tools, and findings were synthesised both quantitatively and narratively. Results 13 studies met inclusion criteria. NTS interventions consistently improved teamwork, communication and checklist adherence, with a statistically significant gain in validated performance scores (mean difference (MD) 6.91 points, 95% CI 2.95 to 10.9). Clinical outcomes were less consistent: individual large, system-level programmes reported reductions in complications and mortality (relative reductions ≈15–20%), but pooled controlled analyses did not demonstrate statistically significant improvements in complications (OR 0.91, 95% CI 0.45 to 1.86), readmission (OR 0.90, 95% CI 0.61 to 1.33) or length of stay (MD –0.84 days, 95% CI –3.40 to 1.73). Conclusions NTS training reliably improves observed teamwork and communication behaviours in the operating theatre, but the current evidence for a resulting benefit to patients is weak and dominated by non-randomised, higher risk of bias studies; the sole randomised trial found no significant benefit. Sustained, system-wide implementation with ongoing reinforcement and cultural alignment was associated with more consistent behavioural gains, but adequately powered randomised trials are needed before firm practice recommendations can be made. PROSPERO registration number CRD420250648285.