Fig. 12.1
Stages of learning
Competence is defined as performing the task safely and within a reasonable timeframe [19]. The concept of conscious competence has been noted in medical education where learners moving from conscious competence, where they can perform a technique but have to think about it, to unconscious competence where they have acquired mastery of the technique and no longer have to think about it [20]. However, it is worth saying here that a trainee without adequate insight might have ‘Unconscious Incompetence’; a lack of awareness that they are unable to perform a procedure satisfactorily. That insight should be provided by the trainer. Through a process of training by the acquisition and application of skills and knowledge, the trainee becomes ‘Consciously Competent’; they are aware that they can perform the procedure and each of the key steps therein. As they progress further they can develop the skill to perform the procedure, which is to say, they can perform the procedure without deconstruction – ‘Unconscious Competence’. All competent surgeons will have a limit to their competency and will be conscious of that limit; the boundary where they go from competence to incompetence. In most cases they have the insight and situational awareness to know the limit and seek help. A good example would be a situation that requires a different surgical expertise.
Conscious Competence as a Trainer
The same model of conscious competence can be applied to the ability of a trainer. Most trainers are accomplished surgical experts who can perform MAS procedures without thought; they are ‘Unconsciously Competent’ for most cases they perform. This is not a useful realm to be in as a trainer. A good trainer is one who can deconstruct each task and train by explanation and demonstration, in other words be a ‘Consciously Competent Trainer’. The more a trainer remains consciously competent, the greater the chances trainees have to acquire skills. Of course, as a trainee progresses to conscious competence themselves, the trainer, though still present, no longer needs to explain and deconstruct. Equally if a trainee cannot perform a part of a procedure, the trainer may not be able to proceed with the training episode without taking over temporarily – this can be defined as conscious incompetence as a trainer. Hopefully by deconstruction and/or taking over, conscious competence as a trainer can be restored such that control can be handed back to the trainee to allow the training to proceed. We explore taking over in the OR in the next section.
Performance Enhancing Instruction
This section explores examples of the effects of different levels of verbal instruction from a trainer to a trainee during a surgical procedure. During the process of training, different types of verbal instruction are used. It is necessary for trainers to have a good understanding of the effects of differing instruction on the trainee’s ability. This can be divided into 5 levels (Fig. 12.2). Level 1 is where no comment or instruction is provided by the trainer to the trainee. Although this might be completely appropriate where a trainee is competent to proceed, level 1 instruction will be unlikely to obtain any learning benefit. Level 2 is negative criticism (e.g. ‘that’s rubbish!’, or ‘that’s not how I do it’). Other than in a light-hearted context, level 2 is likely to be detrimental to both morale and performance and can impact negatively on the trainee’s confidence. Although, it is understandable that in certain occasions, criticism may be required, this needs to be carried out in a constructive way, rather than in a patronizing and insulting manner. Level 3 is positive but non-specific (e.g. ‘that’s great, well done!’, or ‘you’re the best!’). This level might help morale, but is also unlikely to result in an improvement, as it lacks clarity on what exactly they have achieved well. Level 4 is instruction that is directive but not specific or focused, which entails providing some instructions but perhaps vague and non-specific (e.g. ‘up a bit, down a bit, left, right’). Finally, level 5 is directive, specific and focused. Equally important in level 5 is to ask questions of the trainee: ‘what do you need to know?’, or ‘are you happy with my instructions?’ By using level 5 instruction, the coaching would be trainee-focused and the performance of the trainee is more likely to be optimal.
Fig. 12.2
Levels of instructions during coaching
Strategy to Avoid Taking Over
One of the main challenges in surgical training is to avoid a situation where the trainer takes over the procedure from the trainee, thereby depriving the latter of a valuable training opportunity. This section explores the moment where the performance of an operation is interrupted by the trainer whose temptation is to take over. The aim of this session is to promote the adoption of a framework whereby this might be avoided.
Lack of progress during surgical training usually occurs when a trainee cannot proceed safely. This might be identified by either the trainer or trainee. The trainee might be aware of the reasons for inability to proceed or the trainer might halt the procedure. In MAS this is most often due to anatomical uncertainty, an inadequate view or a lack of ability to interpret the anatomy from the screen. In many instances the trainer will take over, often for the remainder of the procedure, thus losing a valuable training opportunity for the trainee. If the reason for failure to progress can be identified and resolved without taking over, the training episode can proceed and will benefit the trainee.
The first step (see Fig. 12.3) is to stop the procedure. Stopping or rather pausing the procedure should be agreed on during the “SET” phase as an opportunity to explain the causes of the lack of progress. Trainees need to understand that, when the trainer is asking them to stop it is not offending them, but rather to discuss progress or the lack of it. The second step is to ask the trainee to identify the reason that this part of the procedure is not going as planned. The third step is for the trainer to explain the reason for the problem if the trainee failed to identify the reason(s) and develop a matched understanding. The fourth is for the trainer to instruct the trainee how to proceed in such a way as to rectify the problem. The fifth is for the trainee to explain how they plan to proceed and for the trainer check that their explanation in steps three and four has been understood. Finally in step 6 the trainee recommences the procedure and the trainer judges the trainee’s capability to proceed. If progress from that point remains hesitant, it might be necessary to repeat the six-point plan more than once as required.
Fig. 12.3
6 point process to avoid taking over in theatre
By using this six-point plan accompanied by good preparation in the ‘Set’, the trainer is less likely to take over and the trainee more likely to benefit for the training episode
Post-operative: The ‘Closure’ or Feedback
Feedback is a vital part of training [21]. The main priorities are to reflect on the procedure just completed and develop learning objectives that are likely to result in improvements in future performance.
For psycho-motor skills acquisition, feedback is the foundation of effective training and is considered one of the most important variables, aside from practice [21].
There are two types of feedback [22]:
Concurrent feedback: which is referred to the feedback received during the performance and is covered in the previous section (performance enhancing instructions).
Terminal feedback, which is referred to the feedback provided after the completion of the task. The potential use of terminal feedback as a learning tool in simulation-based surgical training is significant and results in better learning when compared to concurrent feedback. The downfall of terminal feedback in clinical settings is that errors cannot be allowed to progress due to patient safety.
Feedback Model in LAPCO TT
There are a number of ways to provide feedback, which have been discussed in Chap. 5. However, we will examine here the model, which was adopted for the LAPCO TT programme. Feedback can take place after a single procedure, operating list or training placement. Often service pressures result in feedback being overlooked, but it is a vital opportunity to summarize and crystallize a training episode in such a way that is likely to result in performance improvement.
The means whereby this can be achieved is to start by shared reflection between the trainer and trainee to gain an understanding of how the procedure went. Usually this takes the form of a question from trainer to trainee: “how do you think that went?’. This allows the trainee to reflect on their performance and allows the trainer to see whether the trainee’s perspective matches their own. This is often followed by an exploration of the trainer’s perspective: ‘yes, I agree, that went well’. Then, the trainer asks the trainee to reflect on the areas of difficulty and allow them to analyse and identify the reasons, come up with learning objectives and take-home messages. There should be only one or two main points that they need to focus on for the next cases.
For feedback to be effective there are several considerations to take into account:
The physical environment where feedback takes place. Ideally this should be quiet and confidential, so the trainer and trainee can engage in a frank discussion without being overheard.
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