Development of a knowledge, skills, and attitudes framework for training in laparoscopic cholecystectomy

doi:10.1016/j.amjsurg.2013.08.049

The American Journal of Surgery

Volume 207, Issue 5, May 2014, Pages 790-796

https://doi.org/10.1016/j.amjsurg.2013.08.049 Get rights and content

Abstract

Background

The implementation of duty-hour restrictions and a heightened awareness of patient safety has changed resident education and training. A new focus has been placed on high-yield training programs and simulation training has naturally grown to fill this need.

Methods

This article discusses the development of a training framework, knowledge, skills, and attitudes, and the design of a surgical simulation curriculum. Five residents were recruited for a pilot study of the curriculum.

Results

A successful framework for curriculum development was implemented using laparoscopic cholecystectomy as the example. The curriculum consisted of classroom and virtual reality simulation training and was completed in 3.1 to 4.8 hours.

Conclusions

The current curricula that have been developed for surgical education cover the breadth of a surgical residency well. This curriculum went beyond these curricula and developed a structured framework for surgical training, a method that can be applied to any procedure.

Section snippets

Methods

The goal of this framework was to approach surgical education in a way that is similar to real life, through gaining knowledge, skills, attitudes, and behaviors. A surgeon first develops the knowledge base for the disease and treatment, and then continues to build on the knowledge base as he/she practices the technical intricacies of the procedure. Throughout this time, nontechnical and team skills also develop. Typically, nontechnical skills are not formally taught, rather surgeons are trained

Results

Five surgical residents completed the curriculum as a pilot program to test the feasibility of delivery and to identify any potential issues and areas for improvement within the curriculum.

Comments

Existing curricula that have been developed for surgical education cover the breadth of a surgical residency well. The intention of this curriculum was to go beyond these curricula and develop a framework for surgical training: a method that can be applied to any procedure. For example, to expand upon this curriculum the knowledge section could be replaced with specifics for the chosen surgical procedure, with a set of hints and tips from senior surgeons. This introductory knowledge is

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Cited by (15)

Technology-enhanced learning for surgeons
2021, Surgery (United Kingdom)
Citation Excerpt :
Training pathways have shifted their focus from time in training towards competency-based models,2 and a variety of technologies have been adopted to respond to these changes including online courses, e-portfolios and simulation. The broad aim of this approach is to develop the knowledge, skills and attitudes of learners within the non-traditional learning environments with the hopes that these attributes will be transferred to the clinical setting.3 The COVID-19 pandemic has led to a significant reduction in learning opportunities for all trainees, although the surgical specialties have been particularly affected.4
Modern surgical education is a rapidly changing field with the development of new and more accessible technology creating the opportunity to enhance a learner's experience. The appropriate use of technology within a structured learning programme that has educational principles embedded can result in safe and effective development for learners. This article aims to highlight some of the available and more innovative technology that can be utilized to develop a learner's knowledge, technical and non-technical skills and attitudes as they progress in surgical training.
Nontechnical Skills (NTS) in the Undergraduate Surgical and Anesthesiology Curricula: Are We Adequately Preparing Medical Students?
2021, Journal of Surgical Education
Citation Excerpt :
Moreover, these frameworks should be developed in close collaboration between surgeons and anesthesiologists to facilitate a shared model of NTS that optimizes and complements behaviors among OR team members. Different strategies to deliver the content of a dedicated NTS model exist.34,42,53,54 In particular, simulation-based learning has been demonstrated to create sustainable behaviors through incorporation of teamwork values in collective performance, making it ideal for teaching NTS.55,56
Nontechnical skills (NTS) encompass interpersonal, cognitive, and personal resource skills that can mitigate surgical errors and improve patient outcomes. However, inconsistencies in medical student awareness around NTS suggest limited exposure to these skills. This study aimed to determine the prevalence and content of NTS in medical school surgery and anesthesiology education.
Learning objectives from clerkship core surgery and anesthesiology rotations were collected from Canadian anglophone medical schools. Two raters independently classified each objective under one of the Non-Technical Skills for Surgeons (NOTSS) or Anaesthetists’ Non-Technical Skills (ANTS) “Categories” and “Elements” of NTS, or as a non-NTS objective. Rater disagreements were resolved by group consensus. Group discussion was also held to identify examples of objectives that could help develop future curricula. Descriptive statistics were used to determine the number of NTS objectives from each school and within each NOTSS and ANTS Categories and Elements.
Learning objectives were obtained from 12 out of 14 Canadian medical schools. A total of 2116 surgery objectives and 571 anesthesiology objectives were reviewed. Of these, 16 (0.76%) and 26 (4.55%) were identified as NTS objectives in surgery and anesthesiology, respectively. Of the NOTSS and ANTS Categories, “Situation Awareness” and “Decision Making” were represented by only one objective each in both specialties. Approximately half of the NOTSS and ANTS Elements were not represented by a single objective. Group discussion yielded examples of NTS objectives that were excellent, could use improvement, or were too vague to be classified as NTS.
A paucity of objectives in the clerkship perioperative curricula involve NTS. These findings suggest that NTS are unlikely being adequately introduced as critical skillsets of surgeons and anesthesiologists in undergraduate perioperative education. Future curriculum development should involve greater medical student exposure to NTS as key components of their surgery and anesthesiology education.
Development and implementation of a national quality improvement skills curriculum for urology residents in the United Kingdom: A prospective multi-method, multi-center study
2019, American Journal of Surgery
Citation Excerpt :
The approach of using an evidence review as part of curriculum development has been used before within surgery, both for entire areas of surgical care as well as for specific procedures. For example, evidence review has been used in the development of training curricula for residents for surgical ward-based care14; and for laparoscopic cholecystectomy.15 Such reviews allow identification of both content and delivery methods and also assessment tools as evidenced in the existing literature.
Surgical quality improvement (QI) is a global priority. We report the design and proof-of concept testing of a QI skills curriculum for urology residents.
‘Umbrella review’ of QI curricula (Phase-1); development of draft QI curriculum (Phase-2); curriculum review by Steering Committee of urologists (Attendings & Residents), QI and medical education experts and patients (Phase-3); proof-of-concept testing (Phase-4).
Phase-1: Six systematic reviews were identified of 4332 search hits. Most curricula are developed/evaluated in the USA; use mixed teaching methods (incl. didactic, QI exercises & self-reflection); and introduce core QI techniques (e.g., Plan-Do-Study-Act). Phase-2: curriculum drafted. Phase-3: the curriculum was judged to represent state-of-the-art, relevant QI training. Stronger patient involvement element was incorporated. Phase-4: the curriculum was delivered to 43 urology residents. The delivery was feasible; the curriculum implementable; and a knowledge-skills-attitudes evaluation approach successful.
We have developed a practical QI curriculum, for further evaluation and national implementation.
Defining the Key Competencies in Radiation Protection for Endovascular Procedures: A Multispecialty Delphi Consensus Study
2018, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
All participants gave written consent prior to the start of the study and their identity remained hidden during the study's course. The first round Delphi statements were defined prior the start of the study, based on radiation protection literature and international recommendations and adapted to the knowledge/skills/attitudes framework.1,5,8–10,18 All statements were reviewed by the research team, comprising three vascular surgeons and one physicist.
Radiation protection training courses currently focus on broad knowledge topics which may not always be relevant in daily practice. The goal of this study was to determine the key competencies in radiation protection that every endovascular team member should possess and apply routinely, through multispecialty clinical content expert consensus.
Consensus was obtained through a two round modified Delphi methodology. The expert panel consisted of European vascular surgeons, interventional radiologists, and interventional cardiologists/angiologists experienced in endovascular procedures. An initial list of statements, covering knowledge skills, technical skills and attitudes was created, based on a literature search. Additional statements could be suggested by the experts in the first Delphi round. Each of the statements had to be rated on a 5- point Likert scale. A statement was considered to be a key competency when the internal consistency was greater than alpha = 0.80 and at least 80% of the experts agreed (rating 4/5) or strongly agreed (rating 5/5) with the statement. Questionnaires were emailed to panel members using the Surveymonkey service.
Forty-one of 65 (63.1%) invited experts agreed to participate in the study. The response rates were 36 out of 41 (87.8%): overall 38 out of 41(92.6%) in the first round and 36 out of 38 (94.7%) in the second round. The 71 primary statements were supplemented with nine items suggested by the panel. The results showed excellent consensus among responders (Cronbach's alpha = 0.937 first round; 0.958 s round). Experts achieved a consensus that 30 of 33 knowledge skills (90.9%), 23 of 27 technical skills (82.1%), and 15 of 20 attitudes (75.0%) should be considered as key competencies.
A multispecialty European endovascular expert panel reached consensus about the key competencies in radiation protection. These results may serve to create practical and relevant radiation protection training courses in the future, enhancing radiation safety for both patients and the entire endovascular team.
Training Tools for Nontechnical Skills for Surgeons—A Systematic Review
2017, Journal of Surgical Education
Development of nontechnical skills for surgeons has been recognized as an important factor in surgical care. Training tools for this specific domain are being created and validated to maximize the surgeon’s nontechnical ability. This systematic review aims to outline, address, and recommend these training tools.
A full and comprehensive literature search, using a systematic format, was performed on ScienceDirect and PubMed, with data extraction occurring in line with specified inclusion criteria.
Systematic review was performed fully at King’s College London.
A total of 84 heterogeneous articles were used in this review. Further, 23 training tools including scoring systems, training programs, and mixtures of the two for a range of specialities were identified in the literature. Most can be applied to surgery overall, although some tools target specific specialities (such as neurosurgery). Interrater reliability, construct, content, and face validation statuses were variable according to the specific tool in question.
Study results pertaining to nontechnical skill training tools have thus far been universally positive, but further studies are required for those more recently developed and less extensively used tools. Recommendations can be made for individual training tools based on their level of validation and for their target audience. Based on the number of studies performed and their status of validity, NOTSS and Oxford NOTECHS II can be considered the gold standard for individual- and team-based nontechnical skills training, respectively, especially when used in conjunction with a training program.
Clinical strategies to aim an adequate safety profile for patients and effective training for surgical residents: The laparoscopic cholecystectomy model
2016, Annals of Medicine and Surgery
Citation Excerpt :
The major advantages include the absence of any risk for the patient, the capability to expose of the trainee to a wide range of clinical scenario including those less clinically frequent or those more catastrophic or extremes and the possibility of a structured debriefing. The environmental setting maximizes the possibility not only of testing the operative skills without any clinical risk, but also to supervise and guide the trainee during the process since the trainer can control and decide the inputs of the simulation. [6,13,14]. The major limit of the present study is represented by its retrospective modality.
Training programs for resident surgeons represent a challenge for the mentoring activity. The aim of the present study is to investigate the impact of our training program for laparoscopic cholecystectomy on patient's safety and on the modulation of the residents' exposure to clinical scenario with different grades of complexity.
This is a retrospective study based on a clinical series of laparoscopic cholecystectomy performed in a teaching hospital. Study population was grouped according to the expertise of the attending primary operator among resident surgeons. Four groups were identified: consultant (C), senior resident (SR); intermediate level resident (IR); junior resident (JR). The intraoperative and postoperative outcomes were confronted to evaluate the patient's safety profile.
447 patients were submitted to LC: 96 cases were operated by a C, 200 by SR, 112 by IR and 39 by JR. The mean operative time was the longest for the JR group. A statistically higher rate of conversion to open approach was registered in C and IR groups in comparison to JR and SR groups. However, in C and IR groups, patients had worse ASA score, higher BMI and more frequent past history of previous abdominal surgery, cholecystitis or pancreatitis. Overall, it was not registered any statistically significant difference among the groups in terms of length of hospital stay and prevalence of major postoperative complications.
Applying an educational model based on both graduated levels of responsibility and modulated grade of clinical complexity can guarantee an high safety profile.

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: The authors deny any current or previous support received from industry or organizations that might have influenced this work. There was no influence of any study sponsors in regard to study design, collection, analysis or interpretation of data, or writing or publication of the manuscript.

: Hull and Sevdalis are affiliated with the Imperial Center for Patient Safety and Service Quality (www.cpssq.org), which is funded by the National Institute for Health Research, UK. Aggarwal is affiliated with the Department of Surgery and Cancer, Imperial College London and Clinician Scientist Award from the National Institute of Health Research, UK. Harrysson is affiliated with Stanford School of Medicine and was funded my Stanford School of Medicine.

: The authors declare no conflicts of interest.

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Surgical EducationDevelopment of a knowledge, skills, and attitudes framework for training in laparoscopic cholecystectomy

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Comments

Surgery

Surgery

AORN J

Surgeon

Am J Surg

J Gastrointest Surg

J Thoracic Cardiovasc Surg

Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery

Ann Surg

Randomized clinical trial of virtual reality simulation for laparoscopic skills training

Br J Surg

Surgical Education
Development of a knowledge, skills, and attitudes framework for training in laparoscopic cholecystectomy