This course was designed with the combined knowledge and expertise of the Wolfson Endoscopy Unit at St. Marks Hospital and the Centre for Patient Safety and Service Quality at Imperial College. Faculty consisted of two consultant gastroenterologists accredited for Bowel Cancer screening (AH, STG) and a psychologist with expertise in team performance and patient safety (NS). Ethical approval was granted by NRES Committee London (08/H0719/54).

Bowel cancer screening accreditation units across England were informed about the training intervention to be delivered in London (United Kingdom) via email flyer and invited to attend with a full Bowel Cancer screening team. Four teams were selected based on confirmation of attendance of a complete screening team.

Participants were senior teams, with the screening endoscopists performing a minimum of 1000 screening procedures at baseline and at least 150 screening procedures annually thereafter. Specialist screening practitioners and endoscopy nurses were senior nurses at the higher end of the scale. Specialist screening practitioners had 0-5 years (n = 4), 5-10 years (n = 2) and > 10 years (n = 1) of experience in specialist post. Endoscopy nurses were also experienced with 0-5 years (n = 2) 5-10 years (n = 3) and > 10 years (n = 3) years of experience as dedicated endoscopy nurses. Endoscopy administrative staff included a senior endoscopy unit manager.

A full day’s training with didactic and interactive teaching methods was developed by experts and modelled on relevant patient safety training interventions in other specialties[26,27]. Real BCS clinical examples were utilised to illustrate the importance of human factors, adverse events and non-technical skills for endoscopy patient safety. Teaching methods employed included didactic lectures, interactive discussion, small group exercises and video analysis of real endoscopy scenarios.

This course was evaluated in depth following Kirkpatrick’s training intervention evaluation framework[23] under the following areas.

Participants’ knowledge of safety: Knowledge was assessed pre and post course using 20 Multiple Choice Questions (MCQ). The MCQs were completed at the beginning of the training day and immediately after the training was completed. These were written by the faculty and selected from a sample of 30 questions that were piloted and validated prior to the course with a sample of medical students (n = 5), Endoscopy nurses (n = 5), Specialist Screening Practitioners (n = 4) and BCS endoscopists (n = 2). The most discriminatory questions were selected.

Participants’ attitudes to safety: Patient safety attitudes relevant to BCS were assessed at the beginning of the training day and immediately after the training was completed using a modified version of a validated questionnaire[28,29]. Safety attitudes were quantified on a 5 point scale (1: strongly disagree, 5: strongly agree) for each category.

Participants’ global course evaluations: A detailed course satisfaction evaluation focussing on content, training material and faculty was captured using a 5-point Likert scale and free text comments boxes.

Participants’ knowledge of and attitudes towards safety were the main course learning outcomes to be compared pre- and post-training. Participants’ descriptive evaluations (obtained post-training) were recorded as per standard good training practice.

A course leaflet and a course manual were issued to all delegates. These included the course aims, evaluation materials, presentation slides and relevant literature including the Endoscopic Non-Technical Skills rating tool[30] (these are available upon request via the corresponding author).

Descriptive analyses were completed including the delegates’ age, gender and professional background. Patient safety knowledge and attitudes were measured pre- and post-training. The paired t-test was used to determine differences in the percentage (%) of correct MCQ responses. Safety attitudes were assessed on a 5-point ordinal scale (1: strongly disagree, 5: strongly agree). The pre- and post-course responses were analysed using Wilcoxon tests. Free text comments were analysed qualitatively and emerging themes in participants’ comments were tabulated[31,32].

There was a highly significant improvement in post course patient safety knowledge in the context of BCS endoscopy (Table 2).

A change in patient safety attitudes was observed for 12/41 (29%) of items assessed. A significant change in participants’ attitudes was found following the training in the areas of perceived patient safety knowledge and awareness (Table 3 categories A and B). There was no significant change in perceived influence on patient safety (C), attitudes towards error management (D), error management actions (E) or personal views following an error (F).

The overall feedback was positive: 91% of delegates strongly agreed/agreed that they were satisfied with the course. Both quantitative (Table 4) and qualitative (Table 5) measures indicate that the participants viewed the training intervention very favourably.

This is the first multi-disciplinary patient safety and non-technical skills training intervention targeted towards BCS endoscopy teams. The key findings of this study are that training improved patient safety knowledge scores and some patient safety attitudes in expert teams after a single days training. In endoscopy patient safety training to multiple teams without special resources such as simulation is feasible. Importantly, expert endoscopy teams value non-technical skills training and believe this should be developed and disseminated.

This training intervention resulted in significant improvements in patient safety knowledge in highly experienced multi-disciplinary BCS teams. This highlights that experienced endoscopists and nurses in BCS training centres were able to improve their knowledge after just a single day’s training, despite there being a large volume of novel information to assimilate in a single day.

Patient safety attitudes were more complex: Perceived patient safety knowledge and awareness both significantly improved, however influence on patient safety and attitudes towards error management did not change following the intervention. This finding may be explained by the fact that these are self-selected senior attendees with an interest in patient safety and teamwork skills. The baseline patient safety attitude scores were quite high and the training is therefore likely to have had less impact on attitude in these teams. This may also be explained by the fact that attitudes can be quite deeply embedded and less likely to be significantly changed after a single day’s training. This is corroborated by Arora et al[26]’s study of safety skills training in surgical residents, where similarly, there was no significant change in 4 out of the 6 safety attitude domains following training. Overall, this is a common finding in such training courses[26,27,33] - some attitudes improve, and some remain unchanged. A one-day course alone cannot change deeply held attitudes about safety; typically these take longer to change and are associated with changes in the clinical workplace as well.

Nevertheless, the safety attitudes questionnaire responses revealed important areas to target for subsequent training: The highlighted stems in Table 3 show items in the attitudes questionnaire that did not significantly change following training. These areas could be targeted in future training courses for example by making explicit a “take home message” of key patient safety actions the teams could implement in their own clinical practice.

The strengths of this study comprise inclusion of diverse multidisciplinary expert teams, use of a validated safety attitudes questionnaire and a robust evidence-based approach to course set-up and evaluation. Weaknesses include a small sample size in terms of absolute numbers, although this novel training intervention targeted 4 out of 10 Bowel Cancer screening training centres in England. Delivering interactive small group training and video analyses is not feasible for larger groups, and the educational strategy was not intended to be purely didactic.

There was inevitably also a degree of selection bias, with interested, motivated teams and those with the capacity to cancel clinical commitments more likely to attend. Participants therefore consisted of interested endoscopy leads already actively engaging in patient safety measures. It could be argued that any positive benefit may be attenuated, as the baseline appreciation of these issues is high in this select group. There are, however, also advantages to targeting motivated groups from the point of view of future implementation: trained interested experts can become “champions” for this type of training and hence drive its implementation on a wider national scale. Additionally, from a design perspective, a control group for comparison purposes would have been very desirable. As in other similar studies[26,27,33], however, we felt it was not feasible to obtain a closely matched group of experts willing to accurately complete the extensive MCQ and safety attitudes questionnaire without the incentive of training. Finally, we cannot provide definitive evidence from this single study that teamwork training directly impacts adverse events in endoscopy. It is difficult to prove that training interventions of this type improve patient safety due to the relative rarity of severe adverse events, the complexity of medical error and the length of follow up required for such a study. It is, however, well accepted that team training can improve safety attitudes and behaviours and in the surgical arena a reduction in mortality has also been shown[34,35].

There are many benefits to training multi-disciplinary teams, such as promoting cohesive team working and breaking down inter-professional communication barriers. By adopting the approach of training the core team, it is more likely that improvement measures will be translated to patient care compared to limiting training to a single profession. However, this brings challenges to designing and implementing a training intervention that is suitable for all the professional sub-groups. One of the challenges is to ensure that the educational content is appropriate for the varied skill sets of the different professional groups. It is acknowledged that perception of patient safety varies by professional subgroup[36] and these differences may be more difficult to address in a multi-disciplinary team training intervention. Whilst knowledge and attitudes were directly assessed, patient safety skills assessment was beyond the scope of this course. Furthermore, whilst a full day’s training offers the opportunity to cover the fundamentals of endoscopy patient safety, it remains a “one-off” teaching intervention with no guarantee that knowledge acquired will be retained or practically applied in each team’s respective screening centre. Translating knowledge, skills and attitudes acquired during patient safety training to actual clinical practice is important but difficult to ascertain. To address this it is possible to use the validated non-technical skills framework for endoscopy to assess the team’s safety behaviours in the workplace - this was beyond the scope of this training but can be done scientifically[37]. Training sustainability has to be balanced with the time, resources and logistics of travel and loss of service provision involved in extending such training to its full potential, and is work in progress.

Our training intervention has been compared with three other similarly designed patient safety training interventions in our research group: Arora et al[26] delivered a half day training programme to surgical residents with significant improvement in knowledge and some improvement in safety attitudes, consistent with our results. This study has similarities with our own particularly in its design, but differed in the duration of training and the demographic of participants (trainees of a single specialty versus expert teams). Ahmed et al[27] developed a training programme for senior doctors to become faculty leaders for a patient safety programme targeted towards trainees. This was a longitudinal study over a two-year period with evaluations taking place pre and post course as well as 8 mo post course. This study showed sustained improvements in patient safety knowledge, attitudes and reported skill. This study differed from ours in its aim to train faculty to deliver patient safety training to “Foundation Trainees”. The number of participants was much greater as this was a regional training initiative. The concept of this study showed that senior clinicians are keen to partake in patient safety training and that “training the trainers” is feasible and a resourceful way of utilising clinical expertise. Hull et al[33]’s study was designed to address the inequalities in patient safety measures in developing countries. A single day’s surgical safety training was delivered to clinical and non-clinical participants in Columbia. Similarly, assessments showed improvements in knowledge and attitudes following training. Additionally observation skills using a validated surgical teamwork rating tool[38] also improved following training. This training intervention aimed to bridge the gap for patient safety training in developing settings. The 4 studies are summarised (Table 6).

Compared to other studies, our study is the only one that targeted a specific expert team with BCS endoscopists representing a highly skilled cohort of endoscopists. The other training interventions had a broader range of participants. One of the limitations of our study is that we did not have sufficient data to support long-term retention of knowledge or skills acquired from the training. Further developments of our training intervention could include observational assessment (live or recorded) of a BCS team conducting a colonoscopy, and rating the teamwork and non-technical skills pre and post course.

Participants’ feedback included suggestions that team training should be mandatory for all endoscopy teams in order to improve patient safety, and that teamwork optimisation was a highly important but under-recognised theme. The video case analyses of endoscopy teams were well received and suggested course developments included endoscopy team simulations with structured feedback. Additionally, it was thought that the training intervention was highly relevant to day-to-day endoscopy practice and just as important (if not more so) for non-BCS endoscopy teams.

As a pilot training intervention, this is the first step in a phased roll out of training where resources permitting, the remaining six BCS training centres will also receive teamwork training. This would then enable a core Faculty to be trained across England facilitating teamwork training to all endoscopists through JAG. By imparting patient safety and non-technical skills training to motivated teams, the foundation has been laid to “train the trainers”. This would enable local team training and thus facilitate wider dissemination of endoscopy teamwork and patient safety issues. Recent work in the domain of surgical non-technical skills has shown a United Kingdom cross disciplinary consensus regarding the importance of training faculty to assess and de-brief non-technical skills performance[37].

Although this study used BCS teams, this training is highly transferable to other endoscopy teams: emergency endoscopy, upper and lower GI therapeutic endoscopy as well as surveillance procedures. It could also be readily adapted for prospective GI trainees, which would enable patient safety issues to be embedded at an earlier stage in training and more widely disseminated.

Further developments could also include a practical scenario utilising a simulated or real endoscopic procedure(s). Trained faculty would closely observe the endoscopy team in action in diagnostic, therapeutic and emergency cases followed by a structured “de-brief”[39] of the patient safety issues and relevant non-technical skills using the Endoscopic Non-Technical Skills framework as a guide.

This study shows it is feasible and valuable to deliver a comprehensive training package addressing endoscopic patient safety, non-technical skills and adverse event analysis using a multifactorial approach. This type of human factors training is novel in endoscopy and cancer screening. As patient safety is a clear priority in the context of expanding screening services, we take the view that such training should be disseminated and developed within training endoscopy units to promote safe, high quality care. Strategies to incorporate endoscopic non-technical skills and patient safety into routine endoscopy training should be explored and developed at a national and international level.

Non-technical skills are increasingly being recognised as an important factor in the safe management of patients. These skills are rarely taught and often neglected in assessment of clinicians. Similarly training for extended clinical teams is rarely addressed but is also likely to be relevant in how well clinical care is delivered. Endoscopy increasingly involves complex therapeutic procedures requiring high performance of individuals and teams. Training needs to address these developing needs.

This paper describes a novel approach to training whole endoscopy teams in key aspects of safe delivery of endoscopic care, in the setting of Bowel Cancer Screening. Well recognised training methodology was used to teach and assess learning in key areas.

This is the first published paper describing such innovative training and establishes a benchmark in the delivery of endoscopy team training and the concept of endoscopists non-technical skills.

This methodology could be rolled out to all areas of endoscopy and even to other practical skills-based specialties. A growing awareness of factors affecting the delivery of safe healthcare now requires action to address the gap in training and support of clinical teams.

The article is interesting and original. A larger participation from the screening centers would have given more weight to the study. Overall it presents an interesting approach worth considering. Future evolution might be presented in a following work.