Research
Research Directions
Research Areas
Current Research Projects
Contextualised learning and Patient Focused Simulation
There is a growing awareness of context as a key field for research in surgical education. The SEG has pioneered the concept of Patient Focused Simulation (PFS), where scenario-based clinical simulations are used for teaching and assessing clinical procedures on conscious patients. An innovative combination of Simulated Patients (trained actors) and inanimate models within a structured framework is being explored across a range of procedures and complexities.
These include:
- bedside tasks (e.g. urinary catheterisation, intravenous infusion)
- basic surgical procedures (e.g. mole excision and wound closure)
- high technology invasive investigations (e.g. flexible endoscopy)
- full scale surgical operations (e.g. complex vascular surgery)
When learners use PFS, they perform each procedure on a model or computer simulator attached to an actor within a realistic scenario. Clinicians therefore have to interact with a ‘real’ patient while performing a technical task. Each scenario explores communication skills and professional behaviours in addition to technical expertise. Participants receive feedback from a range of perspectives, including that of the patient.
Further work will explore a wider range of procedures, such as minimal access surgery, local anaesthetic hernia repair, invasive cardiology and complex surgical operations.
Developing new professional roles
Two large pilot projects, initially funded by the Department of Health’s Changing Workforce Programme, are developing new professional roles within surgery. In each case a successful pilot, with a high national profile, is being consolidated by further training programmes. Both projects have implications for workforce redesign at a national level, and are creating widespread interest.
- The Perioperative Specialist Practitioner (developed in response to the Working Time Directive) provides integrated pre and postoperative care, working closely with other members of the surgical team to offer a seamless patient-centred service.
- The Surgical Care Practitioner aims to expand the role of surgical practitioners in a range of surgical specialties and to develop effective training regardless of previous experience.
An innovative training strategy combines intensive modules at Imperial (using simulated environments, virtual reality and a range of learner-centred techniques) with supervised clinical practice within each participant’s home Trust. Comprehensive evaluation maps the evolution of both roles within a range of NHS Trusts. Both roles have generated widespread interest and further courses began in October 2006. Successful participants will be eligible for Imperial’s Certificate of Advanced Studies.
In addition, a nurse minor surgery programme has been running for several years. Led by Shirley Martin (Surgical Care Practitioner), this aims to give nurses from different backgrounds the skills they need to perform minor surgery safely and to the highest possible standards.
Communication is a key component of these new roles projects. Dr Debra Nestel (Senior Lecturer in Communication at Imperial) works closely with the SEG on many research projects. She is currently developing comprehensive communication modules for the New Roles programmes. These make extensive use of simulated patients, role play and reflection based on each participant’s own practice.
Communication Skills web pages
Teaching and learning in surgical environments
Teaching and learning within surgical domains is an under-researched field. Projects currently at the design stage will explore educational activity within the operating theatre and the procedures clinic and develop theory-based interventions to improve existing practice.
Research Areas
Surgical technical competence has come under increasing scrutiny in recent years. This has led to a need for an objective method of assessment of the technique and dexterity of surgeons; which traditionally has been subjective and on an ad hoc basis The introduction of Calmanised training with a fixed training period has also focussed the medical communities attention on the necessity of maintaining standards and ensuring surgical competence in perhaps a shorter training period. Most of the important qualities necessary for competent practice are assessed in written and clinical examination. However, at no stage is technical ability objectively appraised during training. Research in the department in this area is divided into three areas:
- Virtual Reality Simulators
- Objective Assessment of Surgeons
- Objective Assessment of new technologies
1) Virtual Reality Simulators
Initial work in dexterity and assessment occurred in minimal access surgery. This involved the MIST-VR (Minimally Invasive Surgical trainer in Virtual Reality), which led to the department's interest in Virtual Reality simulators as a means of surgical dexterity assessment. A computer can produce objective assessment when a simulated task is being undertaken: the time taken, the path length of the instrument (i.e. how far the instrument travels) and how far this deviates from the ideal path length, number of errors made i.e. collisions between instruments and the number of movements. These objective methods have allowed us to study a number of issues including the effect of sleep deprivation on surgical trainees. Current work in the department involves a number of simulators including endoscopy and virtual operating
2) Objective Assessment of Surgeons
From the work in minimal access surgery also came the Imperial College Surgical Assessment Device, which uses electromagnetic tracking to measure the economy of movement of the surgeon. This device combined with video assessment using Objective Structured Assessment of Technical Skills (OSATS) have given us powerful objective methods of assessment. These have been applied to various tasks, both on live operating and bench models to produce means of measuring surgical dexterity. These techniques have been applied to a large number of models that are suitable for assessment at different levels of surgical skills.
3) Objective Assessment of new technologies
A new and exciting development of these principles and objective methods of assessment allow new technologies to be compared to current standards. Assessment methods also permit the learning curves of these new technologies to be examined and training around the new technology can then be tailored to this. This can be on an individual basis i.e. until the subject has reached a certain standard or across a group of subjects a given amount of training will bring them to an acceptable level of performanceCurrent Research Projects
Current research projects
Integrated Procedural Performance Instrument (IPPI)
This concept addresses the assessment of clinical procedural skills. Its focus is the Foundation Programme for doctors, and the project is supported by the Department of Health’s Modernising Medical Careers. This project aims to create a national assessment tool for clinical procedures.
IPPI is a patient-centred, learner-focused approach to assessing clinical procedures. Realistic scenarios combine Simulated Patients (trained actors) with medical models. The patient’s experience is at the centre of the process. IPPI presents a sequence of clinical procedure scenarios, each using an inanimate model or item of medical equipment in conjunction with a Simulated Patient (SP). Each participant interacts with the ‘patient’ while performing the technical task on the model.
A panel of 8 scenario stations recreate commonly performed clinical procedures, using the combination of simulated patient and model described above. Each scenario addresses a specific technical task (e.g. venepuncture) in addition to professionalism and/or communication issues (e.g. an angry patient whose first language is not English).
The scenarios build up a composite picture of technical skills, communication skills and professional behaviours across a range of challenging clinical situations. Scenarios are rated using the Imperial College Feedback and Assessment System (ICFAS), which uses computer technology to provide detailed feedback. Although this feedback is very detailed, participants (learners) can choose when and how often to access it, and how much detail they wish to see at any time. Unlike many assessments, the learner retains control over the feedback process after the assessments have taken place.
The IPPI project is being developed in collaboration with Dr Debra Nestel (d.nestel@imperial.ac.uk) and Dr Fernando Bello (f.bello@imperial.ac.uk).
More information- IPPI website
Mapping and managing surgical stress
Funded by the BUPA Foundation, this project is exploring the effect of stress upon surgeons’ clinical practice in the operating theatre. Work in this under-researched area is generating widespread interest.
The project has 3 key phases:
- Key stressors and coping strategies have been identified, using qualitative analysis of individual in-depth interviews with surgeons.
- Observational studies are investigating surgeons’ behaviour during stressful situations within the high-fidelity simulated operating theatre at Imperial (St Mary’s Campus). Realistic ‘operations’ allow surgeons to examine from a range of behaviours within a safe learning environment. A stress measurement tool combines objective (physiological) and subjective measures of stress.
- Training interventions using a range of strategies are being developed and evaluated.
