Abstract
Surgeons and medical staff training and education are critical elements in advancing surgical technology. The qualitative descriptive study understood surgical personnel’s experience in ambulatory surgical centers in the northeastern part of the United States who learn new, advanced medical-surgical technology through in-services and on-the-job the acquired level of skill competency perceived following training.
The goal was to know how in-service and on-the-job training influence the confidence in skill-building among surgical staff. The research addressed how surgical personnel perceives learning new, advanced medical-surgical technology through in-services at ambulatory surgical centers. The study used a sample population of surgical staff sharing their experiences and perceptions with operating room competency following the in-services or on-the-job training on new medical-surgical technologies. A qualitative descriptive design was used to analyze and interpret data collected via questionnaires. The findings elaborated on how surgical personnel at ambulatory surgical centers experience on-the-job training regarding learning and using advanced medical-surgical technology.
Results further demonstrated the most frequent shortcomings of in-service and on-the-job training include inappropriate methods, lack of follow-up and motivation, ineffective trainers, team disturbances, rushed training, and low productivity. The study concluded that knowledgeable and competent operating room staff should be willing to use, recommend and or approve the use of new technologies. Leaders in the field of surgical technology are encouraged to construct better training sessions, employ qualified trainers, and allocate resources for training.
Summary
Surgeons are the healthcare staff who perform some of the most life-threatening medical operations. As a result, these professionals need focused training to ensure they are acquainted with the current technological trends relevant in their specific surgical fields. The nature of present diseases has resulted in several conditions, which require incisions. According to Hall et al. (2017), there were a total of 48.3 million surgical and nonsurgical procedures were performed across the United States in hospital operating rooms and ambulatory surgical centers in 2016. Annually, on average, 1 out of 25 people is admitted for surgery of some type.
Surgeons, anesthesiologists, certified registered nurse anesthetists (CRNAs), surgical technologists, and patients have relied upon medical technological advancements. This study’s focus was to develop an in-depth knowledge of the attitudes and experiences of surgeons and staff regarding the training and education in advanced surgical technology.
The advancement in technology has resulted in improved medical attention and procedures. Scholars and practitioners have addressed the need and value of modern technologies. For instance, the machines have improved operating room efficiency (Deutsch et al., 2015), quality of health care outcomes (Ekkelenkamp et al., 2016), and surgical staff job satisfaction (Acton, 2013a), and patient safety and satisfaction (Champagne, 2013). Multifactorial causes behind operating room medical technologies include the inability to meet healthcare providers and patients (WHO, 2010). Among these causes is the lack of working knowledge of operating room medical technologies, procedural skill(s), or procedure-based competencies (Moore et al., 2015).
A deficiency in learning curves (Acton, 2013b; Deutsch et al., 2015; Jaffe et al., 2017; Moore et al., 2015; Panait et al. 2014; Romeo, 2016; Stanford et al., 2015), among other reasons, has been studied to contribute to a lack of advanced education and training in operating room medical technologies (Gallagher et al., 2014; Roberts et al., 2006). Learning the surgeons and surgical staff’s mindset toward new surgical technologies that require different skill sets than the traditional open form of surgery would help with training and in-service procedures.
Compromised quality, less efficiency in care, and subsequent decrease in patient satisfaction due to lengthy learning curves affect learners’ perception (McLaughlin, 2012). Especially significant are the beliefs and attitudes that the surgeons and staff harbor regarding strategies, methods, and tools for advanced technical training and education, and this comprise the topic of this study citation. The surgeon and staff’s competency with new surgical technologies must be maintained to take full advantage of such technologies’ value. Knowledgeable, skilled, and competent operating room staff should be willing to try, use, and even recommend or approve new technologies (WHO, 2010). The team could make proper and innovative use of new surgical support technologies.
Background of the Study
Historically, performing surgeons had to demonstrate procedural competence, continually evolving experience, domain knowledge, landmark knowledge (recognition and recall of the anatomy), and conventional procedural knowledge and a willingness to share that knowledge (Dubé & Rostom, 2016; Jang et al., 2017; McLaughlin, 2012; Sharma et al., 2016; Sood et al., 2015; WHO, 2010). Studies by McLaughlin (2012), Sharma et al. (2016), and Jaffe et al. (2017) conclude that surgical staff must engage in such practices to achieve efficiency and maintain patient safety. These outcomes can be achieved using standardized, anticipatory knowledge regarding operating room preparation procedure, set-up, patient preparation, the surgical procedure, and patient recovery plans.
The Accreditation Council of Graduate Medical Education endorsed six core competencies that every physician should demonstrate: patient care, medical knowledge, practice-based learning and improvement, interpersonal communication skills, professionalism, and systems-based practice (Roberts et al., 2006). To meet these requirements of the Accreditation Council of Graduate Medical Education, educators need to include surgical education that supports the development of knowledge, skills, and practices utilized in the operating room. Therefore, each medical graduate is expected to meet the requirements, demonstrating a person’s willingness to learn and adhere to the fundamental core competencies.
Traditional surgical education consisted of self-directed study, didactic learning, simulation or cadaver laboratories, and scrubbing in cases performed by an expert or under a proctor or mentor. Advanced surgical technologies require the continued need for knowledge and knowledge-sharing and a need for a shared purpose (Dubé & Rostom, 2016) and shared workload (Entezami et al., 2012). When individuals with different learning curves are involved, various surgical innovations are necessary, including supportive ways to meet individuals’ needs.
With advances in surgical technologies, such as minimally invasive surgical procedures including colonoscopies, endoscopies, laparoscopies, and laser surgery, steeper or more significant learning curves require additional or diverse training approaches needs of operating room staff. The learning curve refers to the time and number of repetitions required to achieve an acceptable (proficient) outcome of the given task (Moore et al., 2015; Sood et al., 2015; WHO, 2010).
Education and training required for surgical technological advancements have also advanced to shorten or support the steep learning curves towards maintaining efficiency and patient safety concurrently. Such education includes training devices for surgeons to use robotic operating systems; surgical simulators, such as box trainers for laparoscopic surgery, animal models, virtual reality surgical simulators; and full procedural simulators. One such device is the epiduroscopy training simulator for spatial cognition learning, as well as ultrasound-assisted surgery and color Doppler-guided surgery.
Surgical technology training and support might maximize surgical procedures’ efficiency and assure or improve patient safety and satisfaction. Much research is available on the need for ongoing education to the best of the author’s knowledge, but no studies were found on the experience of surgical staff attending training and in-services (Deutsch et al., 2015; Jaffe et al., 2017; Romeo, 2016; Stanford et al., 2015). The focus of this study was on learning how surgeons and surgical staff members perceive in-services used as training in the use of advanced technology used in surgery.
Problem Statement
The advancement of medical and surgical technologies has brought forward more effective training and education mechanisms to achieve competency for surgical staff. The research problem involves a lack of understanding of surgical personnel’s experiences attending in-services to learn new, advanced medical-surgical technology (Jaffe et al., 2017; Romeo, 2016). The deficiency exists due to learning curves (Acton, 2013b; Deutsch et al., 2015; Jaffe et al., 2017; Moore et al., 2015; Panait et al., 2014; Romeo, 2016; Stanford et al., 2015), and among other reasons, the delivery pattern used to train staff in surgical medical technology (Gallagher et al., 2014).
Some researchers have determined that less than half (36%) of endoscopy trainees self-reported their skill level as proficient (Stanford et al., 2015). Reportedly, inexperienced trainees may perform more than 180 procedures before being considered competent (Ekkelenkamp et al., 2016). New surgical technologies require different skill sets than traditional open surgery once required (Stanford et al., 2015). Learning new skills and becoming competent with advanced technology is a necessary part of surgical success.
Much research on the competencies of surgical staff exists. No specific research into the most effective education and training to accommodate different learning curves to achieve surgical competency using new surgical technologies are available (Ekkelenkamp et al., 2016). Researchers should determine which education and training types effectively attain surgical staff competencies with new surgical support technologies. Maintaining a standard of excellence for graduating surgical residents requires a comprehensive and consistent surgical education pattern (Champagne, 2013). Also, the same expectation applies to achieving and sustaining competency, efficiency, and knowledge-sharing efforts for all surgical staff using advanced surgical technologies.
Purpose of the Study
The purpose of this qualitative descriptive study was to understand the experiences of surgical personnel in ambulatory surgical centers in the northeastern part of the United States who learn new, advanced medical-surgical technology through in-services, on-the-job training, and the associated acquired level of skill competency. The aim was to learn how surgical personnel perceives their skill level or competency with medical-surgical technology following this training type. The training approach addressed in the research is generally defined as operating room training, emphasizing applying theoretical knowledge and operational room personnel’s professional practice.
The need for training and education for advanced surgical technologies has now been closely and expansively investigated. In studies conducted by Ekkelenkamp et al. (2016), McLaughlin (2012), Moriates et al. (2015), and Phillips (2013), education improved the quality of health care outcomes. According to Acton (2013a) and McLaughlin (2012), it enhanced surgical staff job satisfaction. Champagne (2013), Deutsch et al. (2015), El Bardissi and Sundt (2012), and McLaughlin (2012) indicate that training led to increased patient safety and satisfaction. The researchers’ efforts revealed why it is essential for hospitals to have a culture of in-service training.
Few researchers to date have focused on training from the perspective of the learners. Scholars have preferred to study the use of advanced equipment in the operating room in specific surgical procedures (Ekkelenkamp et al., 2016). Quantitative studies and mixed studies have explicitly focused on implementing medical-surgical technologies, and as such, a plethora of information on training and use of advanced technologies is available. The purpose of the study was to enlighten the means of enhancing knowledge and skill acquisition regarding the use of modern technology by surgeons and the operating room team and the potential associated hazards (Matern & Koneczny, 2007). The research results could furthermore be used to inform policy and practices in attempts to facilitate rapid improvement in the use of new equipment, the application of non-technical skills, the success of surgeries, and the satisfaction and safety of all.
Population and Sample
This descriptive study focused on the population responsible for surgical care in accredited hospitals and ambulatory centers in the northeastern part of the United States. The general population included surgeons, anesthesiologists, CRNAs, and surgical technologists. Thirteen participants were used to obtain a manageable number of responses. According to the U.S. Bureau of Labor Statistics, there are 7330 surgeons, 4340 anesthesiologists, 24320 surgical technologists, and 8550 CRNAs in the Northeastern United States. The size of this study population is 44,540 health professionals engaging in surgical procedures in the northeastern part of the United States.
Working with surgical staff using advanced technological surgical equipment was vital to a credible study and validated results. It has been studied that small samples are suitable for qualitative studies because the sample represents a particular and in-depth perspective of the topic (Smith, J. et al., 2009). The study sample consisted of a total of 13 participants who met the inclusion criteria for the research.
The inclusion criteria governing study participation included:
- Experience working in the surgical center.
- Attended in-services on new technologies for at least two different modalities.
- Worked within the last two to three years.
- Participants had experience with in-person/team-based training as well as technologically mediated training.
- The participants could speak meaningfully about the advantages and disadvantages of either face-to-face training or a technology-based form of delivery.
Significance of the Study
The information garnered from the responses of the operating room personnel and surgeons based on their perceptions and experiences of various forms of educational delivery is critical in formulating the needed interventions. This study may add clarifying insights into the learning experience. This study’s results might also provide the insights necessary to develop guidelines for curriculum development for medical training. They can also aid in educational efforts to assist surgeons and operating room personnel in maintaining advanced technology competency.
Numerous researchers examined the effectiveness of training in the operating room or “the value of delivering a theater induction curriculum” (Patel et al., 2012, p. 266). Studies focusing on training in using the advanced equipment in the operating room in specific surgical procedures (Ekkelenkamp et al., 2016) are negligible. By extending the understanding of operating room personnel’s experiences regarding the continual learning of new technology, the current study aims to reduce the existing gap in the body of knowledge.
This study also sheds light on the means of enhancing knowledge and skill, as well as the associated hazards (Matern & Koneczny, 2007, p. 1965). The surgeons and the operating room team’s responses offer robust, informative insight on the effectiveness of training in advanced surgical technology for those who have experienced both types of training: in-service and on-the-job training. The research might also help leaders develop “a strong motivation” among the staff to use new technology (Christensen, 2013, p. 251). Gordon et al. (2012) also expected a rapid improvement in the use of new equipment and nontechnical skills as well as in the success of surgeries. This descriptive study’s findings can clearly understand the most efficient and effective means of training operating room personnel.
Nature of the Study
The qualitative descriptive design focuses on context and interpretation regarding how and why (Patton & Cochran, 2002; Rossman & Rallis, 2003), whereas a quantitative research design presents results in quantities. An in-depth description of experiences is imperative to learn the most accessible and most effective training approaches for operating room staff competency with new medical-surgical technologies.
Based on the study objectives and the focus, qualitative methods are considered the most appropriate for the current study. With the more open, intuitive approach of a descriptive design, a researcher can learn the participants’ attitudes, intentions, and experiences. One purpose of a descriptive design was to know how individuals experience a phenomenon (Yin, 2017) towards preparing a fundamental framework for additional research on the phenomenon.
To meet this study’s purpose, using a qualitative descriptive design encompasses the study focus (Patton & Cochran, 2002) on the surgical staff. Other techniques, such as ethnography, which researchers use to study a group’s culture and its traditions and more, require the researchers to immerse themselves within the culture (Rossman & Rallis, 2003). Another qualitative design is grounded theory, which is used to generate and develop an idea or add to an existing one (Rossman & Rallis, 2003).
This study aimed not to add contemporary academic literature to the educational domain but to add insights into a new literature application. They utilize a qualitative descriptive design to learn how surgeons and surgical staff experience education and training in advanced technological surgery is the most appropriate design for this study.
A sample of 13 surgical staff members participated in the research study by responding to the questionnaire’s questions on SurveyMonkey. Participants had working experience in the surgical field and had attended in-services training on new technologies utilizing at least two different modalities within the last two or three years. Participants also had experience with some form of in-person/team-based training as well as technologically mediated training. As such, the participants were well-informed to highlight the pros and cons of diverse forms of learning with a relevant basis for comparison.
Through responses to the participants’ questionnaire responses, the researcher collected descriptions for data analysis using the thematic analysis approach outlined by Braun and Clarke (2012). Responses to the questionnaire yielded insights into surgical staff’s education experiences contributing toward necessary efficiency and competency for patient safety and satisfaction. Correspondingly, to meet these requirements on education and training issues, the industry offered advanced surgical technology solutions. The written data provided a well-rounded context for interpreting each participant’s data.
The use of Braun and Clarke’s (2012) thematic analysis helps to identify and describe these themes relative to surgical competence, operating room efficiency, and patient safety and satisfaction. The data source included descriptions by surgical staff trained and educated in proper advanced surgical technology delivered through various training forms. In this study, the data took on meaning in the context of the theory of adult education developed by Knowles (2015). The theoretical foundation underlying this study is Knowles’ theory of andragogy which served as a guide to evaluate the presentation of new information
Research Questions
Research questions allows for rational analysis by guiding the development of the study. This study aimed to learn about surgical staff’s experiences in using advanced surgical technologies in terms of settings and frequency of use. This study was also intended to describe staff willingness to use their knowledge and skill to contribute to operating room efficiency, staff knowledge-sharing willingness, staff job satisfaction, patient safety, and patient satisfaction. Under investigation was the participants’ overall commitment to contributing to the development of the healthcare facility by improving technology-associated policies and procedures. The purpose of the research study was to pursue and explore the following research questions:
- RQ 1: How do surgical personnel describe their experience of learning new, advanced medical-surgical technology through in-services at ambulatory surgical centers in the northeastern United States?
- RQ 2: How Do Surgical Personnel at Ambulatory Surgical Centers Experience On-the-Job Training to Learn to Use New, Advanced Medical-Surgical Technology?
Current Content
The Learning Process
Recent changes in health care policy and technology have demanded renewed approaches in curricula to medical training and competency assessment (Thomas et al., 2015). On the policy side, since about 1997, residency work-hour limits and the rise of competency-based assessment have transformed the way surgeons are trained (Lillemoe et al., 2017). Heightened awareness of patient safety has also resulted in an augmented focus on how surgeons are trained (Harrysson et al., 2014).
Doctors and surgeons are now assessed using a stricter admissions process to select the best-qualified applicants responsible for patient care. This transformation’s becoming more stringent assessment process aims to prepare medical professionals to understand the health care industry’s dynamic nature positively and respond to its fluidity. The health care industry’s focus on bolstering nationwide surgical training methods has progressed explicitly over the years.
Since about 1997, many residents studying surgery had decided to further their studies by partaking in subspecialty training following their residency period for general surgery (Cullinan et al., 2018). Despite the ongoing trend, some directors of fellowship programs, according to Cullinan et al. (2018), have vocalized feelings of their students being unprepared for the fellowship experience. Surgical education has been undergoing a transition to this kind of competency-based evaluation and promotion; little data remains on the efficacy of these changes.
Surgical professionals must be trained to adapt to the healthcare industry’s ever-changing nature (Cullinan et al., 2018). Those changes include the maintenance and care of disease, the move toward minimally invasive surgery and nonsurgical procedures, and a cap on work hours. The Accreditation Council for Graduate Medical Education enforced the 80-hour workweek in 2003, requiring a minimum of four days off per month for house officers (Healy et al., 2018).
These sweeping changes included the hours in which interns were permitted to work, which were not to exceed 16-hour shifts, while postgraduate residents’ hours were reduced from 30 to 28 hours per week (Healy et al., 2018). Although this measure was intended to improve patients’ and surgeons’ safety, it placed a cap on the learning provided within a timeframe. If students are accepted into medical school, they must complete four years of undergraduate medical academia, culminating with a medical degree (Alfredson & Isaksson, 2014). The medical school experience is continually adapting to reflect ongoing advancements in science, medicine, and technology, along with breakthroughs and social challenges.
Such advancements are vital for the surgical setting, given the critical importance of a high level of expertise and accuracy in such an invasive field. As Rashid (2017) states, new approaches to training in a hospital setting are required to ensure the efficacy and safety of educational interventions on site. Indeed, the adult education principles and strategies and well-structured practical surgical training must be intertwined to introduce new frameworks for training.
As of late, the health care industry has witnessed a shift in focus from the treatment of acute illnesses to managing, maintaining, and treating chronic conditions, particularly those related to aging. Following the completion of a 4-year undergraduate medical school, students must complete their residency training if they chose to pursue licensure and board certification in a particular medicine area (Jeppson et al., 2015; Taylor et al., 2016). These programs may last from 3 to 7 years, but specialty training can last up to 11 years after a student has received his doctoral degree.
Education forms the foundation of a surgical resident’s experience, and this progress through the educational process is not in isolation as there is concurrent progress in technology. Residents and professionals alike are then tasked with ensuring they are up to date with innovative health care technologies because advancements in surgical technologies have been shown to have beneficial effects (Alfredson & Isaksson, 2014). These advancements can provide medical professionals with information about everything that surrounds the treatment process, from start to finish, occurring internally and externally of the patient.
The phenomenal growth in medical robots’ use since the mid-1980s has resulted in a wide range of surgical procedures. Surgeons perform more quickly and accurately (with fewer errors) on robotic systems (Jeppson et al., 2015; Taylor et al., 2016). Robotically-assisted surgery can be performed more proficiently at a lower workload and with the investment of less mental effort, allowing surgeons more significant cognitive resources for dealing with other demands in the operating room (Moore et al., 2015). Surgery requiring related technologies is referred to as smart surgery, which entails robotic surgery and computer-assisted surgery (Morgan, 2014).
To be recognized as “smart,” these technologies must offer a level of health or financial benefits that are not solely based on technological innovation (Morgan, 2014). The challenge is that residents and professionals alike must be continually adapting to and learning how to utilize these technologies.
Operating Room Shortcomings
Despite these demonstrated benefits of advanced surgical technologies, operating room medical technology frequently does not meet healthcare providers’ and patients’ needs (WHO, 2010). Such technology has become insufficient to address patients’ and doctors’ requirements solely, as financial restrictions deem implausible for some institutions, particularly those with low economic status, to obtain specific medical devices (Egeland et al., 2017). A machine does not have to be used even if it offers some level of benefit.
A need exists for new educational approaches that address training operating room staff on advanced surgical technology to ensure that health care providers are enabled to maximize the benefits of these devices when applicable, which could lead to an overall improved provider and patient satisfaction (Stanford et al., 2015). Today the old models of teaching surgical skills are inadequate to effectively train surgeons to be competent with rapidly progressing technology, which requires the advancement of skills beyond a fixed point in time, such as residency education (Romeo, 2016).
The nationwide health care industry has been perceived as a source of disagreement and dispute, an outdated sector considering the nation’s needs, and a combination of both (Grover et al., 2016). According to Grover et al. (2016), it has been suggested that medical professionals are inadequately trained for their positions. Some universities have been pegged for placing too heavy an emphasis on the residency training’s academic aspect, with students learning more in the educational setting than in an immediate environment (Grover et al., 2016). These extensive curricula do not sufficiently provide students with an accurate assessment of the real-life scenario.
Competency-Based Education
Several universities have focused on resolving the dilemma mentioned above by mandating a structure that facilitates the growth of knowledge, attitude, and procedures regarding problem-solving scenarios. Otherwise known as competency-based education, this learning style’s objective was to prepare students for both challenging and unexpected circumstances, owing to the dynamic nature of the health care industry (Cervantes-Sanchez et al., 2015; Courteau et al., 2015).
Competencies are also used to assess healthcare professionals’ individual characteristics to determine whether they maintain desirable traits for their positions (Courteau et al., 2015). For example, quality orthopedic surgeons are characterized as being “trustworthy, hard-working and efficient, self-directed learners, detail-oriented, and personable” (Nemani et al., 2014, p. 164). Educators of surgeons need to focus on key areas, which advance the skills and knowledge of the medics, to improve health outcomes.
This situation is particularly challenging, as these traits are more likely to be learned during a professional’s childhood and adolescence than in academic and clinical-based settings (Nemani et al., 2014). Professionals who maintain these qualities, Nemani et al. (2014), are more likely to succeed in clinical settings, with efficiency assessments including quality evaluations by faculty and peer-reviewed scholarship. Courteau et al. (2015) also suggested that competency-based education includes the assessment of Entrustable Professional Activities (EPAs). These EPAs are jobs or accountabilities delegated to a student while unsupervised, following the successful demonstration of the necessary aptitude to do so. This assessment presents an additional layer to the evaluation process.
While competencies measure preferable characteristics of health care professionals, EPAs reference the description of the professionals’ performance, which often demands training that requires the professional to complete the task multiple times before proficiency (Courteau et al., 2015; Williams et al., 2017). This learning style can be understood as being aligned with the old saying, “Practice makes perfect.” Although this would be an ideal assessment tool, surgeons perform several procedures to assume aptitude measures whenever any procedure is performed (Courteau et al., 2015). According to Williams et al. (2017), a lack of scholarship still surrounds the process of how supervising surgeons determine the readiness of a resident to perform procedures with success autonomously.
A need also exists for revised and renewed competency measures to ensure patient safety with the continued and rapid progress in technology. Despite technological and health care innovations, patients continue to succumb to unnecessary complications associated with medical treatments, coupled with four to eight million instances of serious harm.
When these numbers are observed from a day-to-day perspective, approximately 1,096 deaths occur each day, followed by 10,959 to 20,918 bouts of serious harm (Ulrich & Kear, 2014). According to Ulrich and Kear (2014), this number of daily deaths is comparable to three 747 airplane crashes every day. These high numbers undoubtedly task the health care industry to uncover ways to improve procedural proficiency to ensure safety and success.
More recently, Moriates et al. (2015) argued that a range of foundational competencies—from basic knowledge of health policy to systems-level design—need to be defined related to health care values that span all professions and training stages. Sears et al. (2014) referred to the objective structured clinical examination (OSCE), which offers a means of determining a learner’s abilities. An OSCE entails a particular situation purposely created by the evaluators that enable the learner to demonstrate both knowledge and skills in that situation (Sears et al., 2014).
The evaluator dictates both the environment and the situation and assesses the learner according to that learner’s knowledge base. Also included in the assessment are the learner’s perspectives, mannerisms, and behaviors to determine whether the learner’s level of people skills complements or counteracts the situation at hand.
Educational Benefits of Surgical Training Programs
The advancement in surgical technology, such as robotically assisted surgical devices, has necessitated new surgical competency measures that allow physicians to be evaluated for preparedness in evolving operating room environments (Center for Devices and Radiological Health, 2019).
In general, surgical training programs have been demonstrated to mitigate learning curves for surgeons using both non-robotically assisted and robotically assisted surgical technologies. Correspondingly, the emergence of global surgery has led to residency programs that integrate international surgical knowledge into students’ training, particularly concerning clinical settings with poor resources (Swain et al., 2015). The evident and lack of fundamental training for surgeons in the rapidly developing industry calls for significant concern and the need for more profound research in both the non-robotically and robotically assisted surgical technologies.
In traditional surgical training, adequate training programs have been shown to help trainees meet and exceed different evaluative metrics, such as laparoscopic knot-tying performance. Surgical training programs are designed to acclimatize surgical residents with the practice of procedures and operations under the guidance of a supervising surgeon (Nemani et al., 2018). The objective is for the surgical supervisors to measure the skills of the residents to determine the students’ level of competency (Nemani et al., 2018).
Molinas et al. (2017) found that psychomotor training could improve learning times for the learning curve of laparoscopic intra-corporeal knot tying. Since the supervisors’ assessment of the student’s performance can be subjective, the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) was created to provide a standard and unbiased medium to measure the laparoscopic surgical skills (Nemani et al., 2018). The earlier students were exposed to surgical training programs, the greater the student’s confidence in undergoing surgical training, and the greater the training results (Karmali, 2017; Sharma et al., 2016).
The more years of training that residents undergo, the greater is the quality of the residents’ performance (Williams et al., 2017). The greater the quality, according to Williams et al. (2017), the more autonomy is ultimately afforded to these surgeons. Improved quality was further confirmed in a study focusing on 27 supervising surgeons who assessed 1,490 operations under the scope of 127 unique procedures that were completed by 31 residents.
Training for Competency
Training programs has also been shown to be effective in robotic-assisted surgical training, although more formalized and universal approaches are still adopted. According to Sridhar, Briggs, Kelly, and Nathan (2017), residents must undergo formal training that provides instructions based on skill acquisition and safety measures before conducting the procedures independently. Formal training of residents is particularly relevant because the incidence of robotic surgery has been studied to increase exponentially over the past ten years, with more than 650,000 performed worldwide in 2015 (Aridhar et al., 2017).
More than 1.5 million procedures have been performed utilizing the da Vinci Surgical System–a specific surgical robot used to make minimal incisions–as of 2015 (Fisher et al., 2015). The robotic surgery training process can be divided into two components: patient-side training and console training (Aridhar et al., 2017). Patient-side training is the first aspect surgeons must learn during their residency.
Patient-side training introduces the resident to the surgical process while facilitating the succession of skills unique to the resident (Aridhar et al., 2017). Through this process, the resident understands how to operate the robotic arms (Aridhar et al., 2017). Console training is the interface that essentially dictates the movement of the robotic arms, which can be learned via online courses (Aridhar et al., 2017). Despite the scholarships available for training and credentialing robotic surgery in specific fields, it has yet to be standardized (Gross et al., 2016).
No single curriculum outlines the teaching of robotic surgical technologies, deeming the learning process as largely unstructured (Fisher et al., 2015). This lack of consistency extends into the health care settings, with requirements for resident surgeons varying from hospital to hospital and institution to institution (Fisher et al., 2015). The unified theory of acceptance and use of technology provides the three main barriers to adopting robotic-assisted surgery for both users and nonusers: The perceived ease of use and complexity, perceived usefulness, and perceived behavioral control (Benmessaoud et al., 2011).
Another factor slowing the development of training programs has been the slowness with which robotic technologies are incorporated into curricula. This slowness also results from the lack of defined curricula relevant to robotic surgical tools (Fisher et al., 2015). The lack of a standardized outline of curricula relating to robotic technology in surgery translates into no standardized means to measure the existing performance. Although most surgical residents have robotically-assisted surgical technology at several institutions and have participated in robotic surgical cases, the residents who have received formal training before participating in a robotic case are very few (Farivar et al., 2015).
A successful robotically assisted training curriculum must be based on didactic learning, reading, bedside training, simulation, and training in the operating room (Winder et al., 2016). The emerging concern is that as the health care industry and, consequently, surgical measures continue to progress and evolve, the industry is tasked with remaining up-to-date (Rogula et al., 2015). Studies show that the healthcare industry has to assume the responsibility to provide ongoing training and education for residents and professionals alike (Rogula et al., 2015), assuming the responsibility to provide continuing training and education for residents and professionals is time-consuming and costly.
Health care leaders have a general disagreement about the benefits of surgical robots to operating room procedures. Dispute complicates the development of training programs for robotic-assisted surgical training. Robotic training in general surgical residency does not amount to extra operating room time (Honaker et al., 2015). The use of complex surgical robotic equipment increases the risks of technological failures, increases communication requirements for the whole team, and can reduce the ability to maintain vision in the operative field (Catchpole et al., 2016). Covens et al. (2016) argued that robots provide no measurable benefits to learning curves in surgical training. Surgical robot costs are higher, and the health outcomes are comparable.
Smyth et al. (2013) stated that the surgical robot decreased the learning curve for experienced surgeons. This learning curve dropped so that by the seventh time the surgery was performed, the robot’s operation time was faster than surgeries performed by surgeons who had previously completed 1,000 traditional laparoscopic surgeries (Smyth et al., 2013). On the contrary, Bach et al. (2014) reported a lack of a straightforward understanding of the right learning curve for robot-assisted laparoscopic surgery for prostatectomy and upper tract procedures.
Researchers stated that a clearer understanding of how to bolster the educational process might substantially affect surgical residents’ development (Bach et al., 2014). Einarsson (2014) stated that robotic surgery does not benefit the patient compared with traditional laparoscopic surgery.
Einarsson also affirmed that the new technology’s complexity lengthens the learning curve for professionals because of the need to understand how to manipulate the technology and successfully utilize its range of capabilities. The researcher claimed that no evidence exists indicating that robotically assisted surgery decreases the surgery period or improves the safety measures of the surgery (Einarsson, 2014). In consideration of the varying perspectives of the researchers, ambiguity surrounds the notion of whether robotic-assisted surgery provides the health care industry with positive, negative, or null results.
Medical Virtual Reality
Another venue for educating health professionals in advanced technological surgical equipment is medical virtual reality. One of the problems concerning a medical student’s transition to a health practitioner is the lack of sufficient surgical practice. It can be managed by the implementation of virtual technologies in the medical field. Javaid and Haleem (2020) suggest that introducing medical virtual reality can provide students and surgeons with scenarios, preparing them for the actual work. Not only does it signify the use of sophisticated medical equipment, but it also follows the ideas of the theory of andragogy in adult learning.
The question remains as to why operating room medical technology cannot meet healthcare providers’ and patients’ needs (Byczkowski, 2020). One possible answer is the lack of operating room working knowledge and procedural skill(s)—or procedurally based competency—with medical technology and deficiency resulting from lengthy learning curves (Acton, 2013b; Deutsch et al., 2015; Jaffe et al., 2017; Moore et al., 2015; Panait et al., 2014; Romeo, 2016; Stanford et al., 2015). Studies evidence that a lack of or insufficient advanced operating room medical technology education or training would demonstrate incredibly negative results (Gallagher et al., 2014; Roberts et al., 2006). Because a compromise in the quality outcome of care might occur in conjunction with less efficiency of care and negatively impacted provider and patient satisfaction, this study intends to explore the in-service training and education for the surgeon and staff competency with new surgical technologies.
The process involved a sample population of surgical staff sharing their experiences and perceptions with operating room competency following the in-services or on-the-job training on new medical-surgical technologies. The study results led to a clearer understanding of how different education or training modalities prepare staff to use new technologies in actual practice in the operating room and to derive insights to improve hospital education/training practices.
Lack of Knowledge about Effective Surgical Training Methods
Surgical training and education programs have proven beneficial for non-robotic and robotic surgical training alike. Lack of knowledge about the learning methods influencing the acquisition of surgical skills can lead to devastating effects. Concerning the steeper learning curves posed by advanced surgical technology, research has shown that surgeons themselves lack self-awareness about how they learn (Jaffe et al., 2017). Practicing surgeons use various training methods when learning new procedures and technologies though there is an evident disconnect between commonly used training methods and those deemed most effective (Jaffe et al., 2017). The disconnect is further enhanced by the transition from traditional surgical procedures to robotically assisted techniques.
Traditionally, surgical training has entailed an apprenticeship relationship between the resident and the supervising surgeon, which essentially occurs in the operating room (Zendajas et al., 2013). According to Zendajas et al. (2013), this relationship is problematic because mentoring can be time-consuming and cause harm to the patient because of the resident’s lack of awareness. This situation is particularly prevalent in laparoscopic surgery, which, according to Zendajas et al. (2013), requires special skills that involve exceptional focus.
According to Saidideen et al. (2013), experts in laparoscopic surgery are sufficient at overseeing and assessing their procedures with a tailored aptitude to identify problems or mistakes. On the contrary, residents do not yet have this ability and tend to look to others—especially their supervisors—to identify their errors and provide solutions (Saidideen et al., 2013). Questions surround the ability to design curricula that integrate effective learning processes that apply to procedural methods (Spruit et al., 2014). Surgical training has received a lack of theoretical, and pedagogical attention. Rashid (2017) argued that surgeon-oriented training programs should integrate more educational concepts, such as theories of adult learning.
Population and Sample
The current study surveyed medical staff in the ambulatory surgical center. The study size was 44,540 health professionals engaging in surgical procedures in the northeastern part of the United States. Table 1 below shows the codes used to study the population for analysis of the findings. Table 2 shows the categorization of the codes identified in table 1 into themes.
Table 1. Data Analysis Codes.
Table 2. Grouping of Codes to Form Themes.
Results
The results’ presentation is organized by research questions with the presentation of results related to each research question. The results from the analysis of the open-ended questionnaire items are organized by theme. In detail and arranged, the results from close-ended questionnaire items are presented separately under the related research questions.
RQ1: How Do Surgical Personnel Describe Their Experience of Learning New, Advanced Medical-Surgical Technology Through In-Services at Ambulatory Surgical Centers in the Northeastern United States?
Surgical professionals were asked to describe how their in-service training regarding advanced medical technology. The results were entered in table 3, which shows that lack of follow-up was the most frequently cited shortcoming of in-service training. Lack of motivation, inappropriate methods, and inappropriate curriculum were cited by fewer than half of the participants. Participants’ open-ended responses provided clarifications on the close-ended responses.
Table 3. Response Frequencies for Shortcomings and Drawbacks of In-Service Training.
All 11 participants provided responses to this questionnaire item. One theme was identified in the responses to the item.
Theme 1: In-Service Training Should Be Focused and Reinforced
Participants’ responses to the open-ended item were consistent with their responses to the close-ended item presented in Table 3. The seven participants who recommended follow-ups for trainees indicated that the follow-ups should be scheduled in advance by the manufacturers’ training representatives, be conducted in person at the hospital, and assess trainee competence with the equipment to retrain if necessary. P3 described this area for improvement by stating: “Follow-up will help increase competence. The company or manufacturer can schedule follow-up after each training as continuing education for a better outcome.”
P10 said, “There should be scheduled dates for the reps [training representatives] from the manufacturers to come in for follow-ups and possible retraining.” P6 recommended that responsibility for arranging follow-ups lies with the equipment manufacturer and that the purpose of follow-ups be to ensure training effectiveness, stating, “The manufacturer should always schedule follow-up training to ensure the efficiency of the staff in handling the equipment.”
The six participants indicated that in-service methods and curriculum were inappropriately conflated with the intended curriculum to teach it. Overall, the six participants indicated that should be made to convey the relevant curriculum more clearly rather than change the intended training content. P1 suggested that training presentations were often unfocused and off-topic in stating that needed improvements were, “Go to the point, talk about the focus instrument or the equipment only. Teach with the right media.” P4 also alluded to experiences of unfocused training by stating, “Sometimes the equipment is not discussed in the training session.” P2 alluded to experiences of unclear presentations resulting from inadequate media in recommending that future in-service training should, “Always use media that will have clear visual and audio.”
RQ2: How Do Surgical Personnel at Ambulatory Surgical Centers Experience On-the-Job Training to Learn to Use New, Advanced Medical-Surgical Technology?
Two questionnaire items were relevant to answering the second research question. Table 4 indicates the response frequencies for the research question.
Table 4. Response Frequencies for Shortcomings and Drawbacks of On-the-Job Training.
In the third step of data analysis, the codes were grouped into themes. Codes were categorized when they expressed meanings that converged different aspects of an overarching theme relevant to answering a research question. In NVivo, nodes representing codes were grouped as child nodes under the same parent node, which meant a theme such as team disturbances, rushed training, ineffective trainer, and low productivity. The 14 codes were grouped into five themes and received a preliminary label indicating the meaning of their contents.
The fourth step of the analysis involved reviewing and refining the themes by comparing them to the original data to represent patterns in participants’ responses accurately. In the fifth step of the analysis, the themes were named and defined to indicate their relevance to answering the research questions. The sixth step of the analysis consisted of creating the presentation of the results provided in this chapter. Table 2 shows how the codes identified during the second step of the analysis were grouped to form the finalized themes.
Inadequate in-service training among healthcare providers reduces patient outcomes quality. In-service training is an essential financial support for continue making the healthcare workforce competitive. Angus et al. (2014) suggested that different techniques should enable surgical personnel to process and apply information. These techniques include clinical simulations, case-based learning, and feedback are effective in-services training techniques. In line with this study’s findings, Arunachalam and Ansell (2017) share that didactic techniques involve passive training, which is not appropriate for preparing surgical personnel.
Repetitive interventions are more effective in improving learning outcomes and equip individuals with experience in handling patients in critical conditions. Badash et al. (2016) agreed that computer-based learning is more effective for in-service training than live instructions. Additionally, it is more cost-effective than any other method. The results of this study suggest that the choice of an effective in-service training technique, such as follow-up, as shown in Table 5, improves the knowledge and skills of surgical personnel, which in turn enhances the clinical practice behaviors.
References
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