Training the Trainer in advanced Laparoscopic surgery-LAPCO TT Nader Francis & Mark Coleman  

Contents Scope for Training the Trainer (TT) Development and structure of LAPCO –TT Assessment and evaluation of TT Summary & take home message

Challenges with training in advanced laparoscopy Technical Limitations of laparoscopy Challenging pathology Long learning curve Non-technical Situation awareness Decision making Task management Leadership Communication and teamwork Organisational context Time constrains Financial constrains Meeting targets

Learning curve in laparoscopic colorectal surgery Conversion Complications 152 143 103 Op time Blood loss 96 87 LN harvest Hospital stay 103 Miskovic et al 2010. Learning curve and in laparoscopic colorectal surgery: systematic review

NTP in Laparoscopic Colorectal surgery - England Welcome to LAPCO National Training Programme for Laparoscopic Colorectal Surgery The National Training Programme for Laparoscopic Colorectal Surgery has been developed by the Department of Health to train NHS consultant colorectal surgeons in England. The aim is to give all suitable patients with colorectal cancer access to a fully trained laparoscopic colorectal surgeon according to the 2006 206 surgeons Engaged with NTP- 1/3 Colorectal Consultants in England. 139 consultants undergoing training 67  NTP Trainers

Scope of Lapco TT Need to structure the framework of training Efficacy and efficiency of training Shorten the learning curve Ensure patient safety A national course to provide training tools to all national trainers Evaluate the impact of TT course Course aims 6

Lapco TT ▪ JAG Endoscopy Training the Trainer model (Roland Valori and John Anderson) ▪ Designed a Lapco TT course curriculum Piloting TT in laparoscopic colorectal surgery Roland Valori John Anderson

Pilot Lapco TT 2010

Lapco TT - Course Faculty Course Facilitators: Mark Coleman & Nader Francis Funded by Cancer Action Team (DoH) Course Faculty: ● Greg Wynn ● John Griffith ● Tom Cecil ● Charles Maxwell Armstrong ● Amjad Parvaiz ● Rob Longman ● Ian Jenkins ● Andrew Miller ● Matthew Clarke ● Austin Acheson Course Organiser & NTP Programme Manager Laura Langsford

DAY 1 – Core competencies Conscious competence Framework of training (Set- Dialogue & Closure) Taking over in theatre Performance enhancing instruction Performance enhancing feedback Assessment of training Optimising the training environment Dealing with difficult trainee

Day1 – Dry skills training

Day 2 – Live theatre ● Review of learning objectives and re-visit The training framework ● Coaching local trainee for 20 minutes ● Debrief ○ Trainer debriefs local trainee ○ Facilitator debriefs trainer ● Course review and evaluation

Unconscious Incompetence Conscious competence Unconscious Incompetence Conscious Incompetence Unconscious Competence When it comes to the technical skill teaching side; the model of conscious competence is very relevant. If we consider our earliest experiences of practical skills learning, such as walking, or later – driving we may remember a period of conscious incompetence…. Brief description of the diagram with examples such as learning to walk, learning to drive, then group discussion on conscious competence for LCS – which box do the group fall into? Is it easy to teach a skill when you are unconsciously competent yourself? take home message Knowing your stage and appreciating the role of conscious competence in performance and training 13

Framework of technical skills training From TCT Endoscopy Guide-with permission

Progress with TT LAPCO Pilot course Plymouth-March 2010 First course Portsmouth June 2010 3 courses a year (2 facilitator/ 4 faculty and 6 delgates) To Date: Run 7 courses at Bradford, St Marks, Basingstoke, Colchester, Portsmouth, Nottingham 47 national trainers/ experts in laparoscopic colorectal surgery have attended the course with very positive feedback

Lapco TT - Educational Assessment 10 minute recorded simulated training session before & after course Mini STTAR for training and behaviour – 2 assessors Trainers interviewed on attitudes pre and post course qualitative evaluation Assessment using Observer XT behavioural analysis software by two assessors Hugh Mackenzie

Structured Training Trainer Assessment Report (STTAR)   Structure Teaching Behaviour Attributes Role Model Training Structure Training behaviour during case Characteristics demonstrated Technical and non-technical skills 1-7 N/A SET Contextual conversation  Ground rules Motivated Communication with team Define aims Knowledge Confident Takes control Align agendas Concerns Insight into ability Ensures patient safety Environment preparation Case-specific Non-threatening Foresight DIALOGUE Standard part of procedure Aims focused Guiding verbal input Approachable Competence (Overall) Ability matched task Questioning/ option generation Articulate Strategic Deconstruction Encouraging, positive reinforcement Listens Knowledgeable Accessible demonstration Corrective feedback Patient Patient-focused Particularly in difficult part Stretch (allow to struggle) Warning verbal input Calm Excellent decision making DIALOGUE (Difficult) Informing Strategy justification Comfortable in silence Leader Take over when appropriate Directing verbal input Supportive/rescuing Team skills Active assistance/facilitating Controlling verbal input (stop) Emotionally intelligent CLOSE Ask trainee’s opinion Encourage self-reflection Honest Excellent teacher Appropriate use of materials Positive and negative reinforcement Professionalism Performance critique Analytical Self-reflects Excellent communicator Learning point agreement Approachable (allows discussion) Inspirational Seeks feedback Sub-total scores: TOTAL Comments:

STARR form Assessment - Overall

STARR form Assessment - Stages

Software analysis of events Pre – Course Scenario Post – Course Scenario SET length 1 minute 14 seconds 1 minute 59 seconds Identifying trainee knowledge 8 times 14 times Identifying concerns 1 time 5 times Laying Ground rules 0 times 6 times CLOSURE No Trainers One Trainer

Conclusions Changes In behaviour can be demonstrated immediately after the TT course Trainers use a more structured approach to training, increasing the time and detail within the ‘Set’ Further studies are required to ascertain whether these changes are maintained whilst training in their own clinical environment

Summary Advanced laparoscopic surgery is technically challenging and requires comprehensive training to achieve competence A structured framework of teaching is required This can be achieved at a national level and potentially could be adapted to other specialities in advanced laparoscopic surgery Course aims 22

Acknowledgements Course Development Roland Valori John Anderson Fiona Carter Co-facilitator Mark Coleman Course organiser Laura Langsford Educational Assessment George Hanna Hugh Mackenzie Tamzin Cuming Susannah Wyles

Thank you