Conscious competence learning cycle
For the majority of trainers, training effectively requires them to move from unconscious competence back a stage to conscious competence. Conscious competence enables explicit deconstruction of the task and the ability to provide explicit explanation of how to successfully complete it. The more novice the trainee, the simpler the deconstruction steps need to be. The individual steps or stages can then be verbalised in an understandable form to the trainee to facilitate learning and skills acquisition.
If trainees understand how the acquisition of a certain knowledge or skill will enable them to perform better, they enter into instructional situations with a clearer sense of purpose and see what they learn as more personal .
To train endoscopy effectively requires explicit knowledge of the techniques needed to perform colonoscopy. It also requires explicit knowledge of how to train technical skills. Good trainers need to be consciously competent in both endoscopy and the training techniques to facilitate skill acquisition (Fig. 5.2).
Training effectively: conscious competence of both colonoscopy technique and training skills
Previous training will influence the ability of individuals to demonstrate conscious competence. The conscious competence phase was frequently bypassed in endoscopy training: trainers acquired skills predominantly through experiential learning. It is a challenge for a trainer who has never been through the conscious competent phase to be able to deconstruct their automated actions. Consequently training of trainees tends to replicate that of the trainers themselves. With increasing understanding of colonoscopy technique, and improved training delivered by consciously competent trainers, trainees, at least in the UK, no longer bypass the conscious competence phase.
Critical Reflection and Analysis
Reflection enables the trainees and trainers to analyse strengths and weakness. Critical reflection is the process where, after reflecting on the whole activity, critical moments are identified for further analysis. In endoscopy training, critical moments are defined as actions or behaviours which lead to either a good outcome (successfully overcoming a difficult problem – to be reinforced), or more commonly, when a trainee struggles in the face of a challenge or difficulty (which often forms the basis for targeted training or feedback). Critical analysis by the trainer is used to promote reflection by the trainee and helps to determine how future actions and behaviours should be modified to improve the outcome when they are encountered again. Core skills a trainer must acquire are the ability to identify critical moments during a procedure, and reflect on these to identify the key learning points.
A Framework for Training Technical Skills
In recent years there has been increasing recognition of the need to train health professionals to teach effectively, but relatively little attention to developing consciously competent technical skills trainers. Bypassing the conscious competence phase of teaching technical skills has two adverse consequences. Firstly, the trainers are less able to develop their own training skills because it is more difficult to self-diagnose what could be done to improve when training does not go well – or even worse, there is failure to recognise when training has gone badly. Secondly, they will be limited in their ability to develop future trainers effectively, similar to the difficulty in trying to train colonoscopy without conscious competence of the procedure.
To help trainers become consciously competent during a training episode it is helpful to deconstruct what constitutes good training. The following section of this chapter uses the Set – Dialogue – Closure framework to deconstruct and then describe the essential components of effective technical skills training. The framework is used in TCT and LapCo TT courses and feedback indicates it is a highly effective approach to teaching technical skills training. The framework provides a set of competencies which trainers can use as a checklist to help then reflect on, and improve their training.
The Set refers to the period before the commencement of training and can be considered the preparation phase of training. The set has both physical and verbal components. The verbal component should include preparation, assessment of the skill level of trainee, alignment of agendas of both the trainer and trainee and agreement of an educational contract. The physical component of the set relates to the training environment. The trainer should ensure that the environment is designed and set up to facilitate effective training including equipment, ergonomics and position of the trainer.
Dialogue refers to the delivery of the actual training.
Closure is the phase after formal training has been completed. It is in this phase that the trainer should begin to summarise and reflect on the training episode, before facilitating performance enhancing feedback. To complete closure, the trainer agrees with the trainee learning objectives for the next training session.
Components of the Set
The Verbal Set
Effective training requires preparation and structure. In a busy clinical environment preparation time for training is limited. It is important to have a structure to follow to ensure all the key components of preparation are covered.
Making a brief assessment of a trainee is particularly important if trainee and trainer have not met before, or if it is some time since the trainer trained a trainee. It is not possible to make a detailed formal assessment of the trainee’s skills in the few moments before a training episode. However, it should be possible, with a few well-directed questions, to determine what stage the trainee is at, what particular difficulties they are having and what experience they have. With an e-portfolio this initial assessment is easier and more reliable, particularly if it includes formal competency assessments and learning objectives agreed during the most recent training sessions.
Trainer’s and Trainee’s Agendas
Trainees often have a concept of what they expect from the training episode (trainee’s agenda). If the trainer’s agenda differs from this, there is potential for failing to maximise the training opportunity. It is important to determine what the trainees believe they need and adapt to this. If the training episode is driven solely by the trainer, it may deliver effective training, but it will be less well received by the trainee. It is the responsibility of the trainer to be flexible and respond to the challenge of aligning the agendas of trainee and trainer. The learning objectives for each training episode should be a composite of the trainee’s and the trainer’s agendas .
In the early stages of training the trainee is less able to articulate clear goals and objectives – ‘they don’t know what they don’t know’. As training progresses they become much more aware of their training needs, especially if encouraged to critically reflect on their performance. They will then take increasing responsibility for setting learning objectives (Fig. 5.3). Thus a good trainer will encourage the trainee to develop a strong reflective style. This will enable the trainee to achieve the goal of developing responsibility for setting their own learning objectives in an efficient way, when there is no longer a trainer to guide them.
Setting Learning Objectives
If trainees understand how the acquisition of a certain knowledge or skill will enable them to perform better, they enter into instructional situations with a clearer sense of purpose and see what they learn as more personal. In the immediate period before training it is helpful for the trainer and trainee to agree what they will focus on during the procedure or operation – the learning objective(s). Due to the highly variable nature of colonoscopy, it is not always possible for the agreed learning objectives to be addressed and new ones might need to be formulated as the training proceeds.
An educational contract is an agreement between the trainer and trainee of how they would like the training episode to be conducted . The contract should be agreed before training commences. The processes of assessment, aligning agendas and setting learning objectives form the basis of the contract. In addition, it is important to establish ground rules, such that the trainer and trainee are clear about their respective roles and responsibilities during the training. Most importantly, clear ground rules ensure patient safety, as there will be no uncertainty about who is in control of the procedure and leading the team. Ground rules also establish circumstances in which the trainer might stop the training episode and take over the procedure.
If done effectively, an educational contract enables the trainee to develop their skills and have realistic expectations of what the training can achieve, whilst ensuring the trainer maintains control over the training and the trainee. Creating an educational contract often only requires a few minutes.
The Physical Set
The physical set refers to the positioning of the patient, support staff, equipment, trainee and trainer. Ideally the training environment should be completely free of interruptions and distractions. The intention is to ensure that the environment is safe for patients and staff, but also to ensure the trainee and trainer are as ergonomically comfortable as possible. If sub-optimal, the trainee and trainer may tire or be distracted, and less attention and energy will be directed into the training.
Components of the Dialogue (Instruction and Training)
The dialogue refers to the time from the point the trainee starts the procedure until he/she completes it, or the training episode is terminated.
Instruction during an endoscopic procedure is a critical skill that many trainers find challenging. Having a structured approach facilitates instruction and improves skills acquisition. Conscious competence is a fundamental requirement for effective instruction and without it a trainer will always struggle to make the best of the opportunity. The key aspects of instruction are:
Type of instruction
Timing of instruction
Knowing when to say nothing
Performance enhancing training
Using competency frameworks
Trainers have, historically, used different words or phrases to explain the same thing. For example, deflect the tip up is the same as turn the big wheel anticlockwise or big wheel down. It is confusing for a trainee to be exposed to different terms for the same action. Instructions directing attention to movement effects are better for enhancing learning than those directing attention to a trainee’s arm and hand movements. This may be because directing trainees’ attention to an external focus, away from the trainee’s hands, allows performance to be mediated by automatic control processes . The implication for training endoscopy is that learning should be improved by instruction focusing on the monitor view, “tip up or tip down” rather than focusing on hand movements, “thumb down or up on big wheel”. Anecdotally this approach has proved successful during endoscopic training courses in the UK. It is recommended that directive instruction for colonoscopy be restricted to 12 terms:
With these 12 terms or manoeuvres, it is possible to instruct a trainee to insert the instrument safely, ultimately completing the procedure unassisted and in a controlled manner . The completion of this task is dependent on the trainee having the ability to perform the manoeuvres individually and when required, in complex sequences. Washing the lens is an additional term, which may be added to the list, but while clear views are essential, washing the lens does not directly enhance intubation. The use of the words, slowly and stop provides the trainer (and trainee) with increased control over actions and ultimately tip control and problem solving.
Type of Instruction
Broadly speaking instruction can be directive/didactic, or inquisitorial. Asking questions and discussing how to diagnose and solve problems is much the preferred technique. However, for less experienced trainees, or when a more experienced trainee is struggling, a directive approach is more appropriate. The broad types of instruction are as follows:
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