The Ecological-Dynamics Framework for Medical Skills.

Physicians are required to move and manipulate equipment to achieve motor tasks such as surgical operations, endotracheal intubations, and intravenous cannulation. Understanding how movements are generated allows for the analysis of performance, skill development, and methods of teaching. Ecological-Dynamics (ECD) is a theoretical framework successfully utilized in sports to explain goal-directed actions and guide coaching and performance analysis via a Constraint-Led Approach (CLA). Its principles have been adopted by other domains including learning music and mathematics. Healthcare is yet to utilize ECD for analyzing and teaching practical skills. This article presents ECD theory and considers it as the approach to understand skilled behavior and developing training in medical skills.

Learner drivers (and their parent-supervisors) benefit from an online hazard perception course incorporating evidence-based training strategies and extensive crash footage.

We previously found that a six-session online hazard perception training course, which incorporates evidence-based learning strategies and footage of over a hundred real crashes, improved hazard perception skill and reduced risk-taking intentions in novice drivers who had passed their on-road driving test within the previous three years. However, one issue with targeting crash-prevention training at individuals who are already driving unsupervised is that drivers are at their highest crash risk immediately after they pass their on-road driving test. That is, the training may arrive too late to protect drivers while they are at their most vulnerable. It is also possible that it may prove difficult to persuade drivers to complete an unsupervised training course if they are already licensed to drive independently. Given that learner drivers cannot drive unsupervised, and that they are typically supervised by a parent, one potential strategy is to target the training at learners and to ask their parents to provide one-on-one mentoring throughout the course. We therefore recruited learner driver/parent-supervisor dyads to participate in a randomized control study, with the objective of examining the effects of the hazard perception training course on aspects of driving behaviour associated with crash risk (as measured using validated computer-based tests). Outcome measures included two hazard perception skill assessments (a response time hazard perception test and a verbal response hazard prediction test), and three tests assessing aspects of risk-taking propensity in driving (speed choice, following distance, and gap acceptance). Learners who completed the course (N = 26) significantly improved their scores on both hazard perception skill measures, and also chose safer following distances, compared with a waitlist control group (N = 23). However, the training did not significantly reduce learners' speed choice or gap acceptance propensity. The hazard perception skill of parent-supervisors, who observed the course but did not complete it, also improved on both hazard perception measures, relative to controls. Additionally, both learners and their parent-supervisors reported a range of positive effects on the learners' real-world driving performance. These results suggest that this type of hazard perception training could be beneficial if deployed during the learner phase of driver licensing.

A human factors approach to subcutaneous insulin chart design improves user-performance: An experimental study.

Insulin is a high-risk medicine that has been implicated in serious adverse events for hospital inpatients, including medication-error related deaths. Most insulin errors occur during administration, and "wrong dose" is the most common type. A paper-based subcutaneous insulin chart (the "NSIC") was developed for the Australian Commission on Safety and Quality in Health Care, using a range of human factors methods, with the aim of reducing the opportunity for errors. The present lab-based study empirically assessed whether the NSIC's human factors design translates into improved user-performance in the determination of insulin doses, compared with a pre-existing chart. Forty-one experienced nurses and 48 novice chart-users completed 60 experimental trials (30 per chart), in which they determined doses to administer to patients. Both groups determined insulin doses faster, and made fewer dose errors, when using the NSIC. These results support the utility of the usability heuristics employed in developing the chart.

A thousand years of crash experience in three hours: An online hazard perception training course for drivers.

A key goal of driver training is to teach drivers to avoid crashes. However, in traditional driver training, drivers are unlikely to see even a single example of the class of event that we want them to learn to avoid. We developed a six-session automated online hazard perception training course for drivers, which incorporates a range of evidence-based strategies and employs extensive video footage of real crashes. We evaluated this course in a randomized control trial by examining its effects on previously-validated computer-based measures of hazard perception, hazard prediction, speed choice, following distance, and gap acceptance propensity, as well as self-rated measures of driver skill, safety, and real world transfer. We found that the course resulted in significant improvements in hazard perception response time and hazard prediction scores, and significantly longer vehicle following distances. Additionally, all participants in the trained group reported that their real world driving behaviour had improved. No significant training effects were found for the other measures. The results suggest that the course can improve key behaviours associated with crash risk.

Quantitative systematic review: Sources of inaccuracy in manually measured adult respiratory rate data.

AIMS: To identify the potential sources of inaccuracy in manually measured adult respiratory rate (RR) data and quantify their effects. DESIGN: Quantitative systematic review with meta-analyses where appropriate. DATA SOURCES: Medline, CINAHL, and Cochrane Library (from database inception to 31 July 2019). REVIEW METHODS: Studies presenting data on individual sources of inaccuracy in the manual measurement of adult RR were analysed, assessed for quality, and grouped according to the source of inaccuracy investigated. Quantitative data were extracted and synthesized and meta-analyses performed where appropriate. RESULTS: Included studies (N = 49) identified five sources of inaccuracy. The awareness effect creates an artefactual reduction in actual RR, and observation methods involving shorter counts cause systematic underscoring. Individual RR measurements can differ substantially in either direction between observations due to inter- or intra-observer variability. Value bias, where particular RRs are over-represented (suggesting estimation), is a widespread problem. Recording omission is also widespread, with higher average rates in inpatient versus triage/admission contexts. CONCLUSION: This review demonstrates that manually measured RR data are subject to several potential sources of inaccuracy. IMPACT: RR is an important indicator of clinical deterioration and commonly included in track-and-trigger systems. However, the usefulness of RR data depends on the accuracy of the observations and documentation, which are subject to five potential sources of inaccuracy identified in this review. A single measurement may be affected by several factors. Hence, clinicians should interpret recorded RR data cautiously unless systems are in place to ensure its accuracy. For nurses, this includes counting rather than estimating RRs, employing 60-s counts whenever possible, ensuring patients are unaware that their RR is being measured, and documenting the resulting value. For any given site, interventions to improve measurement should take into account the local organizational and cultural context, available resources, and the specific measurement issues that need to be addressed.

Eye-tracking reveals how observation chart design features affect the detection of patient deterioration: An experimental study.

Particular design features intended to improve usability - including graphically displayed observations and integrated colour-based scoring-systems - have been shown to increase the speed and accuracy with which users of hospital observation charts detect abnormal patient observations. We used eye-tracking to evaluate two potential cognitive mechanisms underlying these effects. Novice chart-users completed a series of experimental trials in which they viewed patient data presented on one of three observation chart designs (varied within-subjects), and indicated which observation was abnormal (or that none were). A chart that incorporated both graphically displayed observations and an integrated colour-based scoring-system yielded faster, more accurate responses and fewer, shorter fixations than a graphical chart without a colour-based scoring-system. The latter, in turn, yielded the same advantages over a tabular chart (which incorporated neither design feature). These results suggest that both colour-based scoring-systems and graphically displayed observations improve search efficiency and reduce the cognitive resources required to process vital sign data.

Computer-based hazard perception test scores are associated with the frequency of heavy braking in everyday driving.

Computer-based hazard perception tests are used in a number of countries as part of the driver licensing processes, and hence evaluating the validity of such tests is crucial. One strategy for assessing the validity of the scores generated by a hazard perception test is to determine whether they can predict on-road driving performance. Only a few prior studies have attempted this, all relying on the subjective ratings of an examiner who was present during a single brief drive and was not blind to the driver's demographic characteristics, potentially contaminating the outcomes. Additionally, only one such study focused on the most relevant participant group with respect to the validity of tests used in licencing processes, namely young drivers. We sought to remedy this situation in the present project by measuring young drivers' performance over an extended period of everyday driving via g-force triggered video cameras ("dashcams") installed in their own vehicles. As a precursor to the dashcam study itself, we developed a new computerized hazard perception test and assessed the validity of its scores by more traditional means (Study 1). As expected, test scores distinguished between high-risk and lower-risk driver groups, and correlated with scores on an established hazard perception test previously shown to predict crash risk. In the subsequent dashcam study (Study 2), the frequency of heavy-braking events (controlling for distance driven) was used as a more objective measure of driving performance. Results indicated that drivers with higher rates of heavy braking had slower hazard perception response times, further supporting the use of these scores as a valid measure of drivers' ability to exercise hazard perception skill during real driving. More generally, this study also demonstrates the viability of using low-cost off-the-shelf dashcams to measure real-world driving behaviour.

The effects of awareness and count duration on adult respiratory rate measurements: An experimental study.

AIMS AND OBJECTIVES: To investigate whether awareness of manual respiratory rate monitoring affects respiratory rate in adults, and whether count duration influences respiratory rate estimates. BACKGROUND: Nursing textbooks typically suggest that the patient should ideally be unaware of respiratory rate observations; however, there is little published evidence of the effect of awareness on respiratory rate, and none specific to manual measurement. In addition, recommendations about the length of the respiratory rate count vary from text to text, and the relevant empirical evidence is scant, inconsistent and subject to substantial methodological limitations. DESIGN: Experimental study with awareness of respiration monitoring (aware, unaware; randomised between-subjects) and count duration (60 s, 30 s, 15 s; within-subjects) as the independent variables. Respiratory rate (breaths/minute) was the dependent variable. METHODS: Eighty-two adult volunteers were randomly assigned to aware and unaware conditions. In the baseline block, no live monitoring occurred. In the subsequent experimental block, the researcher informed aware participants that their respiratory rate would be counted, and did so. Respirations were captured throughout via video recording, and counted by blind raters viewing 60-, 30- and 15-s extracts. The data were collected in 2015. RESULTS: There was no baseline difference between the groups. During the experimental block, the respiratory rates of participants in the aware condition were an average of 2.13 breaths/minute lower compared to unaware participants. Reducing the count duration from 1 min to 15 s caused respiratory rate to be underestimated by an average of 2.19 breaths/minute (and 0.95 breaths/minute for 30-s counts). The awareness effect did not depend on count duration. CONCLUSIONS: Awareness of monitoring appears to reduce respiratory rate, and shorter monitoring durations yield systematically lower respiratory rate estimates. RELEVANCE TO CLINICAL PRACTICE: When interpreting and acting upon respiratory rate data, clinicians should consider the potential influence of these factors, including cumulative effects.

Assessing colonoscopic inspection skill using a virtual withdrawal simulation: a preliminary validation of performance metrics.

BACKGROUND: The effectiveness of colonoscopy for diagnosing and preventing colon cancer is largely dependent on the ability of endoscopists to fully inspect the colonic mucosa, which they achieve primarily through skilled manipulation of the colonoscope during withdrawal. Performance assessment during live procedures is problematic. However, a virtual withdrawal simulation can help identify and parameterise actions linked to successful inspection, and offer standardised assessments for trainees. METHODS: Eleven experienced endoscopists and 18 endoscopy novices (medical students) completed a mucosal inspection task during three simulated colonoscopic withdrawals. The two groups were compared on 10 performance metrics to preliminarily assess the validity of these measures to describe inspection quality. Four metrics were related to aspects of polyp detection: percentage of polyp markers found; number of polyp markers found per minute; percentage of the mucosal surface illuminated by the colonoscope (≥0.5 s); and percentage of polyp markers illuminated (≥2.5 s) but not identified. A further six metrics described the movement of the colonoscope: withdrawal time; linear distance travelled by the colonoscope tip; total distance travelled by the colonoscope tip; and distance travelled by the colonoscope tip due to movement of the up/down angulation control, movement of the left/right angulation control, and axial shaft rotation. RESULTS: Statistically significant experienced-novice differences were found for 8 of the 10 performance metrics (p's < .005). Compared with novices, experienced endoscopists inspected more of the mucosa and detected more polyp markers, at a faster rate. Despite completing the withdrawals more quickly than the novices, the experienced endoscopists also moved the colonoscope more in terms of linear distance travelled and overall tip movement, with greater use of both the up/down angulation control and axial shaft rotation. However, the groups did not differ in the number of polyp markers visible on the monitor but not identified, or movement of the left/right angulation control. All metrics that yielded significant group differences had adequate to excellent internal consistency reliability (α = .79 to .90). CONCLUSIONS: These systematic differences confirm the potential of the simulated withdrawal task for evaluating inspection skills and strategies. It may be useful for training, and assessment of trainee competence.

A novel training device for tip control in colonoscopy: preliminary validation and efficacy as a training tool.

BACKGROUND: Effective control of the colonoscope tip is one of the most fundamental components of colonoscopy skill. Mastering fine tip control can be problematic for novice trainees, yet no validated training regimes exist for developing this specific skill component in isolation. We aimed to conduct a preliminary validation of a novel training device for colonoscopic tip control, and to assess its efficacy as a training tool. METHODS: In study 1 (validation), 13 experienced colonoscopists and 16 novices used a colonoscope to accurately track 28 targets on each of four concave "training surfaces" as quickly as possible, and we compared their performance. In study 2 (pre-post-training study), another 16 novices were tested before and after a six-session training program. In both studies, the main outcome measurements were completion time (measured automatically by the device) and variability of individual performance (the SD of each individual's completion times across trials). RESULTS: Compared with novices, experienced colonoscopists were faster (P < 0.0001) and their performances less variable (P < 0.0001). With training, novices became faster (P < 0.0001) and more consistent (P = 0.003), and these improvements also generalized to novel training surfaces (P's < 0.01). After training, the novices' tip control performance was indistinguishable from that of the experienced colonoscopists (P's > 0.05). The composite measures of completion time used in both studies all had acceptable to excellent internal consistency reliability (α's ranged from 0.72 to 0.93). CONCLUSIONS: We found that performance measures derived from using the device to assess skill can discriminate between experienced colonoscopists and novices in terms of their ability to control and guide the colonoscope tip precisely, providing preliminary evidence to support the construct validity of the metrics. The device is also an effective training tool for this fundamental component of colonoscopy skill.

The impact of crosstalk on three-dimensional laparoscopic performance and workload.

This is the first study to explore the effects of crosstalk from 3D laparoscopic displays on technical performance and workload. We studied crosstalk at magnitudes that may have been tolerated during laparoscopic surgery. Participants were 36 voluntary doctors. To minimize floor effects, participants completed their surgery rotations, and a laparoscopic suturing course for surgical trainees. We used a counterbalanced, within-subjects design in which participants were randomly assigned to complete laparoscopic tasks in one of six unique testing sequences. In a simulation laboratory, participants were randomly assigned to complete laparoscopic 'navigation in space' and suturing tasks in three viewing conditions: 2D, 3D without ghosting and 3D with ghosting. Participants calibrated their exposure to crosstalk as the maximum level of ghosting that they could tolerate without discomfort. The Randot® Stereotest was used to verify stereoacuity. The study performance metric was time to completion. The NASA TLX was used to measure workload. Normal threshold stereoacuity (40-20 second of arc) was verified in all participants. Comparing optimal 3D with 2D viewing conditions, mean performance times were 2.8 and 1.6 times faster in laparoscopic navigation in space and suturing tasks respectively (p< .001). Comparing optimal 3D with suboptimal 3D viewing conditions, mean performance times were 2.9 times faster in both tasks (p< .001). Mean workload in 2D was 1.5 and 1.3 times greater than in optimal 3D viewing, for navigation in space and suturing tasks respectively (p< .001). Mean workload associated with suboptimal 3D was 1.3 times greater than optimal 3D in both laparoscopic tasks (p< .001). There was no significant relationship between the magnitude of ghosting score, laparoscopic performance and workload. Our findings highlight the advantages of 3D displays when used optimally, and their shortcomings when used sub-optimally, on both laparoscopic performance and workload.

The effect of performance feedback on drivers' hazard perception ability and self-ratings.

Drivers' hazard perception ability has been found to predict crash risk, and novice drivers appear to be particularly poor at this skill. This competency appears to develop only slowly with experience, and this could partially be a result of poor quality performance feedback. We report an experiment in which we provided high-quality artificial feedback on individual drivers' performance in a validated video-based hazard perception test via either: (1) a graph-based comparison of hazard perception response times between the test-taker, the average driver, and an expert driver; (2) a video-based comparison between the same groups; or (3) both. All three types of feedback resulted in both an improvement in hazard perception performance and a reduction in self-rated hazard perception skill, compared with a no-feedback control group. Video-based and graph-based feedback combined resulted in a greater improvement in hazard perception performance than either of the individual components, which did not differ from one another. All three types of feedback eliminated participants' self-enhancement bias for hazard perception skill. Participants judged both interventions involving video feedback to be significantly more likely to improve their real-world driving than the no feedback control group. While all three forms of feedback had some value, the combined video and graph feedback intervention appeared to be the most effective across all outcome measures.

Sources of inaccuracy in the measurement of adult patients' resting blood pressure in clinical settings: a systematic review.

BACKGROUND: To interpret blood pressure (BP) data appropriately, healthcare providers need to be knowledgeable of the factors that can potentially impact the accuracy of BP measurement and contribute to variability between measurements. METHODS: A systematic review of studies quantifying BP measurement inaccuracy. Medline and CINAHL databases were searched for empirical articles and systematic reviews published up to June 2015. Empirical articles were included if they reported a study that was relevant to the measurement of adult patients' resting BP at the upper arm in a clinical setting (e.g. ward or office); identified a specific source of inaccuracy; and quantified its effect. Reference lists and reviews were searched for additional articles. RESULTS: A total of 328 empirical studies were included. They investigated 29 potential sources of inaccuracy, categorized as relating to the patient, device, procedure or observer. Significant directional effects were found for 27; however, for some, the effects were inconsistent in direction. Compared with true resting BP, significant effects of individual sources ranged from -23.6 to +33 mmHg SBP and -14 to +23 mmHg DBP. CONCLUSION: A single BP value outside the expected range should be interpreted with caution and not taken as a definitive indicator of clinical deterioration. Where a measurement is abnormally high or low, further measurements should be taken and averaged. Wherever possible, BP values should be recorded graphically within ranges. This may reduce the impact of sources of inaccuracy and reduce the scope for misinterpretations based on small, likely erroneous or misleading, changes.

Assessment of colorectal polyp recognition skill: development and validation of an objective test.

BACKGROUND: The quality of colonoscopy is known to vary. The extent to which colonoscopists can recognize the presence of subtle colorectal lesions by visually distinguishing them from the surrounding mucosa (i.e., polyp recognition skill) may be one of several attributes that influence polyp detection rates. The aim of the present study was to develop and validate the first objective test of polyp recognition skill. METHODS: Validation study. Twenty-eight experienced colonoscopists and eighty novices took a preliminary 280-item computer-based polyp recognition test. Items were genuine endoscopic images which participants assessed for the presence of "likely polyps." Half included clinically identified polyps. Participants clicked on a suspected lesion or a button marked "no likely polyp", and the main outcome measures were accuracy and response latency. The best items were selected for the final 50-item test. RESULTS: In the preliminary test, experienced colonoscopists correctly identified more polyps than novices (P < .0001) and better discriminated between clinically identified polyps and non-polyp features (as measured by d', P < .0001). For polyp items, the experienced group also responded faster (P < .01). Effect sizes were large for accuracy (Cohen's d = 3.22) and d' (Cohen's d = 3.22). The 50 final test items produced comparable results for accuracy, d', and response latency. For both versions of the test, score scale reliability was high for both polyp and non-polyp items (α = .82 to .97). CONCLUSIONS: The observed experienced-novice differences support the construct validity of the performance measures derived from the tests, indicating that polyp recognition skill can be quantified objectively. The final test may potentially be used to assess trainees, but test sensitivity may be insufficient to make fine-grained distinctions between different skill levels among experienced colonoscopists. More sensitive future tests may provide a valuable supplement to clinical detection rates, allowing objective comparisons between skilled colonoscopists.

The efficacy of training insertion skill on a physical model colonoscopy simulator.

Background and study aims: Prior research supports the validity of performance measures derived from the use of a physical model colonoscopy simulator - the Kyoto Kagaku Colonoscope Training Model (Kyoto Kagaku Co. Ltd., Kyoto, Japan) - for assessing insertion skill. However, its use as a training tool has received little research attention. We assessed the efficacy of a brief structured program to develop basic colonoscope insertion skill through unsupervised practice on the model. Participants and methods: This was a training study with pretesting and post-testing. Thirty-two colonoscopy novices completed an 11-hour training regime in which they practiced cases on the model in a colonoscopy simulation research laboratory. They also attempted a series of test cases before and after training. For each outcome measure (completion rates, time to cecum and peak force applied to the model), we compared trainees' post-test performance with the untrained novices and experienced colonoscopists from a previously-reported validation study. Results: Compared with untrained novices, trained novices had higher completion rates and shorter times to cecum overall (Ps < .001), but were out-performed by the experienced colono-scopists on these metrics (Ps < .001). Nevertheless, their performance was generally closer to that of the experienced group. Overall, trained novices did not differ from either experience-level comparison group in the peak forces they applied (P > .05). We also present the results broken down by case. Conclusions: The program can be used to teach trainees basic insertion skill in a more or less self-directed way. Individuals who have completed the program (or similar training on the model) are better prepared to progress to supervised live cases.

Accuracy of polyp localization at colonoscopy.

BACKGROUND AND STUDY AIMS: Accurate documentation of lesion localization at the time of colonoscopic polypectomy is important for future surveillance, management of complications such as delayed bleeding, and for guiding surgical resection. We aimed to assess the accuracy of endoscopic localization of polyps during colonoscopy and examine variables that may influence this accuracy. PATIENTS AND METHODS: We conducted a prospective observational study in consecutive patients presenting for elective, outpatient colonoscopy. All procedures were performed by Australian certified colonoscopists. The endoscopic location of each polyp was reported by the colonoscopist at the time of resection and prospectively recorded. Magnetic endoscope imaging was used to determine polyp location, and colonoscopists were blinded to this image. Three experienced colonoscopists, blinded to the endoscopist's assessment of polyp location, independently scored the magnetic endoscope images to obtain a reference standard for polyp location (Cronbach alpha 0.98). The accuracy of colonoscopist polyp localization using this reference standard was assessed, and colonoscopist, procedural and patient variables affecting accuracy were evaluated. RESULTS: A total of 155 patients were enrolled and 282 polyps were resected in 95 patients by 14 colonoscopists. The overall accuracy of polyp localization was 85 % (95 % confidence interval, CI; 60 - 96 %). Accuracy varied significantly (P < 0.001) by colonic segment: caecum 100 %, ascending 77 % (CI;65 - 90), transverse 84 % (CI;75 - 92), descending 56 % (CI;32 - 81), sigmoid 88 % (CI;79 - 97), rectum 96 % (CI;90 - 101). There were significant differences in accuracy between colonoscopists (P < 0.001), and colonoscopist experience was a significant independent predictor of accuracy (OR 3.5, P = 0.028) after adjustment for patient and procedural variables. CONCLUSIONS: Accuracy of localization of polyps is imprecise and affected by position within the colon and colonoscopist, including their level of experience. Magnetic endoscope imaging may improve the localization of lesions during colonoscopy.

The viewpoint-specific failure of modern 3D displays in laparoscopic surgery.

PURPOSE: Surgeons conventionally assume the optimal viewing position during 3D laparoscopic surgery and may not be aware of the potential hazards to team members positioned across different suboptimal viewing positions. The first aim of this study was to map the viewing positions within a standard operating theatre where individuals may experience visual ghosting (i.e. double vision images) from crosstalk. The second aim was to characterize the standard viewing positions adopted by instrument nurses and surgical assistants during laparoscopic pelvic surgery and report the associated levels of visual ghosting and discomfort. METHODS: In experiment 1, 15 participants viewed a laparoscopic 3D display from 176 different viewing positions around the screen. In experiment 2, 12 participants (randomly assigned to four clinically relevant viewing positions) viewed laparoscopic suturing in a simulation laboratory. In both experiments, we measured the intensity of visual ghosting. In experiment 2, participants also completed the Simulator Sickness Questionnaire. RESULTS: We mapped locations within the dimensions of a standard operating theatre at which visual ghosting may result during 3D laparoscopy. Head height relative to the bottom of the image and large horizontal eccentricities away from the surface normal were important contributors to high levels of visual ghosting. Conventional viewing positions adopted by instrument nurses yielded high levels of visual ghosting and severe discomfort. CONCLUSIONS: The conventional viewing positions adopted by surgical team members during laparoscopic pelvic operations are suboptimal for viewing 3D laparoscopic displays, and even short periods of viewing can yield high levels of discomfort.

Observation chart design features affect the detection of patient deterioration: a systematic experimental evaluation.

AIM: To systematically evaluate the impact of several design features on chart-users' detection of patient deterioration on observation charts with early-warning scoring-systems. BACKGROUND: Research has shown that observation chart design affects the speed and accuracy with which abnormal observations are detected. However, little is known about the contribution of individual design features to these effects. DESIGN: A 2 × 2 × 2 × 2 mixed factorial design, with data-recording format (drawn dots vs. written numbers), scoring-system integration (integrated colour-based system vs. non-integrated tabular system) and scoring-row placement (grouped vs. separate) varied within-participants and scores (present vs. absent) varied between-participants by random assignment. METHODS: 205 novice chart-users, tested between March 2011-March 2014, completed 64 trials where they saw real patient data presented on an observation chart. Each participant saw eight cases (four containing abnormal observations) on each of eight designs (which represented a factorial combination of the within-participants variables). On each trial, they assessed whether any of the observations were physiologically abnormal, or whether all observations were normal. Response times and error rates were recorded for each design. RESULTS: Participants responded faster (scores present and absent) and made fewer errors (scores absent) using drawn-dot (vs. written-number) observations and an integrated colour-based (vs. non-integrated tabular) scoring-system. Participants responded faster using grouped (vs. separate) scoring-rows when scores were absent, but separate scoring-rows when scores were present. CONCLUSION: Our findings suggest that several individual design features can affect novice chart-users' ability to detect patient deterioration. More broadly, the study further demonstrates the need to evaluate chart designs empirically.

The Conflicting Evidence of Three-dimensional Displays in Laparoscopy: A Review of Systems Old and New.

OBJECTIVE: To describe studies evaluating 3 generations of three-dimensional (3D) displays over the course of 20 years. SUMMARY BACKGROUND DATA: Most previous studies have analyzed performance differences during 3D and two-dimensional (2D) laparoscopy without using appropriate controls that equated conditions in all respects except for 3D or 2D viewing. METHODS: Databases search consisted of MEDLINE and PubMed. The reference lists for all relevant articles were also reviewed for additional articles. The search strategy employed the use of keywords "3D," "Laparoscopic," "Laparoscopy," "Performance," "Education," "Learning," and "Surgery" in appropriate combinations. RESULTS: Our current understanding of the performance metrics between 3D and 2D laparoscopy is mostly from the research with flawed study designs. This review has been written in a qualitative style to explain in detail how prior research has underestimated the potential benefit of 3D displays and the improvements that must be made in future experiments comparing 3D and 2D displays to better determine any advantage of using one display or the other. CONCLUSIONS: Individual laparoscopic performance in 3D may be affected by a multitude of factors. It is crucial for studies to measure participant stereoscopic ability, control for system crosstalk, and use validated measures of performance.

A competency framework for colonoscopy training derived from cognitive task analysis techniques and expert review.

BACKGROUND: Colonoscopy is a difficult cognitive-perceptual-motor task. Designing an appropriate instructional program for such a task requires an understanding of the knowledge, skills and attitudes underpinning the competency required to perform the task. Cognitive task analysis techniques provide an empirical means of deriving this information. METHODS: Video recording and a think-aloud protocol were conducted while 20 experienced endoscopists performed colonoscopy procedures. "Cued-recall" interviews were also carried out post-procedure with nine of the endoscopists. Analysis of the resulting transcripts employed the constant comparative coding method within a grounded theory framework. The resulting draft competency framework was modified after review during semi-structured interviews conducted with six expert endoscopists. RESULTS: The proposed colonoscopy competency framework consists of twenty-seven skill, knowledge and attitude components, grouped into six categories (clinical knowledge; colonoscope handling; situation awareness; heuristics and strategies; clinical reasoning; and intra- and inter-personal). CONCLUSIONS: The colonoscopy competency framework provides a principled basis for the design of a training program, and for the design of formative assessment to gauge progress towards attaining the knowledge, skills and attitudes underpinning the achievement of colonoscopy competence.