href="#ulink_a6317e7a-24c1-5418-a2a1-cd316fdd9708">Figure 4.3 Set‐up of an endoscopy suite during training to optimize the trainer’s view of the patient’s face, the monitor, and the trainee’s hands.
Finally, it is important for the trainer to maintain a sense of control over the procedure, trainee, and environment during a teaching encounter, as patient safety must not be compromised for the sake of training. Essential to this are ground rules or agreed upon parameters for teaching during the procedure [25]. The ground rules, which will vary across trainees and cases, outline the roles and responsibilities of the trainee and trainer during the teaching session, make clear the time allocated for training, and provide pre‐defined criteria for trainer interventions (i.e., stopping or taking over the procedure) that can be expected by the trainee. Establishing ground rules helps to ensure patient safety, reinforces the trainer’s control of the session, and establishes the trainer as the team leader.
The learning objectives and ground rules form the basis of an educational contract, which is an agreement between the trainer and trainee as to how the teaching encounter will be structured and conducted. It is important that decisions are made ahead of the training encounter so that the trainer and trainee’s expectations are both realistic and aligned. An effective educational contract enables the trainee to focus on their skills development while ensuring that the trainer maintains control over the training encounter.
Training
The training encounter refers to the time from the point the trainee starts the procedure until they complete it, or the training encounter is terminated. During this component, there are several evidence‐based educational principles that can be applied by trainers to enhance learning. Performance enhancing instruction, or formative feedback provided during the learning encounter, is a key motivator for trainees and one of the most important determinants of endoscopy skill acquisition [32, 33]. During the procedure, instruction should be based on direct observation of performance, should be informative, and when possible, should focus on the agreed upon learning objectives for the training session. The use of learning objectives, instructional feedback, and correction to enhance performance forms the basis for deliberate practice, a foundational element for the development of expertise [34]. To guide their observations and feedback, trainers can use endoscopy assessment tools with strong evidence of validity for use during training [35], such as the Assessment of Competence in Endoscopy (ACE) tool [36], the Gastrointestinal Endoscopy Competency Assessment Tool (GiECAT) [37, 38], or the JAG’s Direct Observation of Performance Skills (DOPS) tool for colonoscopy [39]. Such tools help to highlight key areas that are required for skillful endoscopy performance and are discussed in more detail in Chapter 39 of this volume.
Feedback should be tailored to the skill level of the trainee. The process of skill acquisition has been described as a sequential process involving three major phases: cognitive, associative, and autonomous [40]. In the cognitive phase, the trainee is focused on developing a mental understanding of the procedure and considerable cognitive effort is required. While skill acquisition is rapid, performance is inconsistent, inefficient, and error filled. Feedback during this phase is often more directive (i.e., specific instruction on how to do or not to do something) and is best focused on how the procedure is performed correctly and identifying and rectifying common errors to improve the trainee’s understanding of the procedure [4]. Instructions should be clear, concise, and focused on distinct skills (e.g., torque steering, loop resolution) so that the trainee is not overwhelmed [41].
During the associative phase, performance becomes more fluid, efficient, and reliable with fewer mistakes. Additionally, less cognitive activity is required. Instruction and feedback during this phase should be more facilitative, focusing on helping the trainee to reflect on what happened. The trainer should analyze the trainee’s performance, recognize areas of strength, and identify errors and corresponding corrective actions [42, 43]. In the final autonomous phase, the procedure is performed skillfully, consistently, and efficiently. Performance is largely automatic with little conscious awareness devoted to skill execution. Instruction is best focused on helping the trainee build their conscious awareness so that they can deconstruct their automated actions, and explicitly explain what is occurring and what to do.
Decision training focuses on having the trainee pinpoint critical challenges during the procedure, identify solutions, and choose the best approach. It is important to incorporate decision training for trainees in associative and autonomous phases of skill acquisition [30]. Questioning on the part of the trainer fosters active engagement and reflection and encourages the trainee to think independently and to consider potential solutions as opposed to simply being informed of the best option. Incorporation of problem‐solving and active decision‐making helps foster lasting skill development and build a trainee’s capability for self‐reflection which is key to developing conscious competence.
Performing two tasks simultaneously can be challenging as humans only have a finite capacity to process information in their “short‐term” or working memory. When working memory becomes overloaded, learning and performance suffer. This phenomenon is termed cognitive overload or dual task interference [44]. In providing instruction during a training encounter, it is important for the trainer not to cognitively overload the trainee with too much information. In the context of endoscopy, continual feedback (concurrent feedback) has been showing to hinder learning [45] as it likely places a high extraneous cognitive load on trainees such that they focus their attention on listening to the feedback, as opposed to engaging in problem‐solving and learning from the task at hand. Additionally, the provision of continuous instruction may impose excessive cognitive demands on the trainer, ultimately disrupting the trainer’s concentration and impairing feedback provision. To minimize cognitive overload when providing performance enhancing instruction during a procedure, it is important for the trainer to ask the trainee to stop (assuming it is safe to do so), stabilize the endoscope, and direct their attention to the trainer. Additionally, feedback should focus on simple, well‐defined, and achievable points, and questions should be limited in number and complexity to avoid overburdening the trainee. This is particularly important for less experienced trainees who are struggling and have limited additional attentional capacity. For similar reasons, trainees should be encouraged to refrain from providing verbal commentary on their performance because this requires cognitive effort and can result in decreased performance and learning.
Cognitive load can also impair training effectiveness if the training tasks are too difficult. Complex tasks drain cognitive resources and make a trainee less able to attend to and respond to instruction [46]. Studies carried out in the simulated environment suggest that learning is enhanced if task difficulty is gradually increased to align with a trainee’s developing skill level over time [47, 48]. To maximize learning early in training, tasks should be broken down into smaller units (e.g., torque steering, loop resolution) and objectives should be discrete and manageable (e.g., navigating the splenic flexure) [2]. This strategy, termed chunking (breaking up a complex procedure into smaller, more manageable parts or “chunks”), has been shown to be useful in many skill areas [49]. As the trainee improves at the task, difficulty can be increased and/or the amount of support a trainee is receiving (i.e., the amount of instruction) can be gradually withdrawn to challenge them [14, 50] (See also Chapter 2).
Trainers must also be aware of the words and phrases they use to explain things. Often many different terms are used to explain the same concept (e.g., “deflect the tip down” yields the same results as “turn the big wheel up”) and non‐specific terminology is used (e.g., “go a little bit over there”). The use of non‐standardized terminology can lead to confusion. It is, therefore, recommended to use a common language to ensure consistency and clarity of instruction and avoid confusion. For example, directive instruction for colonoscopy can be restricted to the 14 terms:
1 stop
