Take-Home Training in Laparoscopy.

When laparoscopy was first introduced, skills were primarily taught using the apprenticeship model. A limitation of this method when compared to open surgery, was that it requires more time to practise and more frequent learning opportunities in clinical practice. The unique set of skills required in laparoscopy highlighted the need for new training methods that reduce the need for supervision and do not put the patient at risk. Simulation training was developed to meet this need. The overall purpose of this thesis was to explore simulation-based laparoscopic training at home. The thesis consists of five papers: a review, a validation study, a study of methodology, a randomised controlled trial and a mixed-methods study. Our aims were to review the current knowledge on training off-site, to develop and explore validity for a training and assessment system, to investigate the effect of take-home training in a simulation-based laparoscopic training programme, and to explore the use of take-home training. The first paper in this thesis is a scoping review. The aim of the review was to explore the current knowledge on off-site laparoscopic skills training. We found that off-site training was feasible but that changes were required in order for it to become an effective method of training. Furthermore, the select-ed instructional design varied and training programmes were designed using a variety of educational theories. Based on our findings, we recommended that courses and training curricula should follow established education theories such as proficiency-based learning and deliberate practice. Principles of directed self-regulated learning could be used to improve off-site laparoscopic training programmes. In the second study, we set out to develop and explore validity evidence of the TABLT test. The TABLT test was developed for basic laparoscopic skills training in a cross-specialty curriculum. We found validity evidence to support the TABLT test as a summative test in a basic laparoscopic training programme. We also established a credible pass/fail level using the contrasting groups method. We concluded that the TABTL test could be used to assess novice laparoscopic trainees across different specialties and help trainees acquire basic laparoscopic competencies prior to supervised surgery. In the third study, we aimed to explore the consequences of the choice of standard setting method and whether there is a difference in terms of how high a score experienced and novice laparoscopic surgeons expect that novices should achieve during training. We used three different standard setting methods and found that pass/fail levels vary depending on the choice of standard setting method. We also asked experienced and novice laparoscopic surgeons how high a score they expected a novice laparoscopic surgeon should achieve on a test during training. We found a significant difference, with experienced surgeons setting a lower pass/fail level. We concluded that an established standard setting method supported by evidence should be used when setting a pass/fail level. In the first and second papers of this thesis, we found that off-site training is feasible and explored validity for the TABLT test. We used this knowledge in the fourth study to design a randomised controlled trial. The aim of the trial was to investigate the effect of take-home training in a simulation-based laparoscopic course. We hypothesised that training at home could help trainees plan their training according to their own schedule and thereby increase the effect of training. We found that participants had a distributed training pattern; they trained more frequently and in shorter sessions. We also found that participants were able to rate their own performance during unsupervised training and that selfrating was reliable. The fifth and final study of the thesis was a mixed-methods study that aimed to explore the use of take-home training. To meet this aim, we recruited participants from the intervention arm in our randomised controlled trial. All participants had access to the simulation centre and were given a port-able trainer to train on at home. Participants were asked to use a logbook during training. At the end of the course, they were invited to take part in focus group interviews and individual interviews. Based on data from logbooks, a descriptive statistical analysis was conducted and data from interviews were analysed using a content analysis. We found that participants took an individualised approach to training when training at home. They structured their training according to their needs and external requirements. We concluded that mandatory training requirements and testing help determine when and how much participants train. We also found that self-rating can guide unsupervised training by giving clear goals to be reached during training. From the papers included in the thesis, we found that the literature describes training at home as a feasible method of acquiring laparoscopic skills. Nonetheless, changes to current training programmes are needed in order to make this method effective. We then developed and explored validity evidence for the TABLT test. We also established a reasonable pass/fail level and went on to explore the immediate consequences of the pass/fail level. Using our knowledge from the review, we conducted a randomised controlled trial and a mixed-method study. Based on these studies we found that training at home allows for distributed learning, that self-rating guides unsupervised training, and that mandatory training requirements and testing strongly influence training patterns. Access to training, guidance during training, and mandatory training requirements will make take-home training not just feasible but also effective.