Non-technical skills and health care provision in low- and middle-income countries: a systematic review John Scott, Dianali Revera Morales, Andrew McRitchie, Robert Riviello, Douglas Smink & Steven Yule CONTEXT 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 litera- ture review in accordance with preferred report- ing items for systematic reviews and meta- analyses guidelines for primary research publica- tions 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. Bibli- ographies 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, communi- cation, teamwork, leadership and stress manage- ment. The most commonly used methods were questionnaires, interviews and observations, and 43% (n = 9) scored > 10 points using the Medi- cal Education Research Study Quality Instru- ment. 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. CONCLUSION 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. How- ever, 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. Medical Education 2016: 50: 441–455 doi:10.1111/medu.12939 Discuss ideas arising from the article at www.mededuc.com discuss. Brigham & Women’s Hospital, Boston, Massachusetts, USA Correspondence: John Scott, Center for Surgery and Public Health, Department of Surgery, Brigham & Women’s Hospital, SurgEd Office CA-034, 75 Francis Street, Boston, Massachusetts 02115, USA. Tel: 617-525-7300; E-mail: jwscott@partners.org 441 ª 2016 John Wiley & Sons Ltd. MEDICAL EDUCATION 2016; 50: 441–455 medical education in review