Non-technical Skills Research Articles

Developing health professional students’ handover skills through a virtual, interprofessional handover workshop

Inter-professional education has been identified as a core theoretical pillar for improving learners’ non-technical skills (NTS) and consequently promoting safe patient handover in clinical practice. However, specific handover education, especially in an authentic interprofessional fashion, is rare. Contributing factors include pragmatic and logistical elements, which can potentially be addressed through virtual delivery. We developed a virtual inter-professional handover education programme for undergraduate healthcare students, based on a classroom-based version that we designed and piloted previously. The workshop used interactive large and small group activities to develop understanding of the reasons for poor handover, its implications for patient safety and the skills to undertake structured, focused handover. It specifically included exercises which emphasised the differences between single-profession and interprofessional handover and how miscommunication may arise and lead to errors. The workshop was delivered using Blackboard Learn, Microsoft Teams (version 12) and Vevox (November 2021 version) and based on materials which are readily available in the public domain. 37 students from four professions attended the workshop, which was evaluated using both in-workshop assessment and formal research elements. Handover knowledge and skills, attitudes towards inter-professional handover and confidence in giving and receiving handover increased following the workshop; in addition, students enjoyed taking part and were keen to apply their learning in practice. Content analysis of individual interviews also provides insights into how and why students learned and suggests that the underpinning SECTORS model is appropriate for explaining NTS acquisition in theoretical learning settings, as well as practice. Workshop delivery was both cost and resource effective.

Skills for the aspiring surgeon in Australia: A needs assessment

Introduction: The increasing duration of time before the commencement of formal surgical education training (SET) in Australia has emphasised the need for pre-SET “aspiring” surgical trainees to develop greater competency in both generic and specialty-specific skills to fulfil these public hospital positions, however there is no formalised curriculum or guide. This paper investigates current inconsistencies in the training of Australian pre-SET aspiring surgical trainees and attempts to define which skills are required. Methods: We conducted semi-structured interviews with pre-SET supervisors in general and specialty surgery fields at a large tertiary teaching hospital in Sydney, Australia, to assess expectations and competencies of pre-SET surgical trainees. A mixed-method analysis was used with inductive content analysis used for the rich interview data and quantitative analysis of 5-point Likert scale scores for the essential skills syllabus and eligibility requirements. Results: Eighteen interviews were conducted. Three major themes arose from inductive content analysis: participants perceived that pre-SET trainees met basic expectations, significant variability in skill level exists between trainees, and simulation was suggested as a potential solution to address gaps in training. Quantitative analysis of Likert scores suggests that trainee competency was inadequate (or not required) for several skills. For general surgery, trainee competency was deemed inadequate for proctoscopy, rigid sigmoidoscopy and appendicectomy. Conclusions: There is a critical need to clearly define the skills expected of pre-SET trainees and their role within the healthcare system. This study provides insights into the content of that skillset, which could be used to design relevant and useful training programs for pre-SET trainees. The value of simulation training was universally noted by participants. They believed that this could improve competency for pre-SET trainees in technical and non-technical skills.

No size fits all - a qualitative study of factors that enable adaptive capacity in diverse hospital teams.

Resilient healthcare research studies how healthcare systems and stakeholders adapt and cope with challenges and changes to enable high quality care. By examining how performance emerges in everyday work in different healthcare settings, the research seeks to receive knowledge of the enablers for adaptive capacity. Hospitals are defined as complex organizations with a large number of actors collaborating on increasingly complexity tasks. Consequently, most of today's work in hospitals is team based. The study aims to explore and describe what kind of team factors enable adaptive capacity in hospital teams. The article reports from a multiple embedded case study in two Norwegian hospitals. A case was defined as one hospital containing four different types of teams in a hospital setting. Data collection used triangulation of observation (115 h) and interviews (30), followed by a combined deductive and inductive analysis of the material. The study identified four main themes of team related factors for enabling adaptive capacity; (1) technology and tools, (2) roles, procedures, and organization of work, (3) competence, experience, knowledge, and learning, (4) team culture and relations. Investigating adaptive capacity in four different types of teams allowed for consideration of a range of team types within healthcare and how the team factors vary within and across these teams. All of the four identified team factors are of importance in enabling adaptive capacity, the various attributes of the respective team types prompt differences in the significance of the different factors and indicates that different types of teams could need diverse types of training, structural and relational emphasis in team composition, leadership, and non-technical skills in order to optimize everyday functionality and adaptive capacity.

A Comparison of Nurses’ Situation Awareness and Eye-Tracking Data in Precardiac Arrest Simulations

BackgroundEye tracking has emerged as a new technology for assessing nurses' visual attention in simulation, but its relationship with situation awareness, a precursor to clinical decision-making, remains to be defined. This study compared role-based situation awareness and visual attention using eye-tracking in simulation. MethodsNewly hired nurses participated in a cardiac arrest simulation as part of an orientation program. Eye-tracking data were collected to assess visual attention during the prearrest period. Participants completed a situation awareness questionnaire after the simulation. Data were compared according to participants' roles in the simulation. ResultsResults suggest a role-based difference in nurses' visual attention and situation awareness: designated nurses (n = 12) looked at the patient more often, for longer periods and were more aware of signs of patient deterioration than teammates (n = 14). Conclusions: This study was the first to combine eye-tracking and situation awareness data to compare two nursing roles during a precardiac arrest simulation. The findings also suggest gaps and learning needs in nurses' understanding of signs of patient deterioration and other nontechnical skills.

NEO-SAFE: a clinical model forpatients andhealthcare personnel safety inprimary level hospitals.

Patient safety is a major concern in medicine. Approximately, 4 million infants die each year worldwide and 23% of these deaths are caused by perinatal asphyxia. To prevent the long-term damage of asphyxia, the resuscitation flowchart must be perfectly and promptly performed. However, high effectiveness in performing resuscitation can only be achieved and maintained if the algorithm is frequently executed. Therefore, maintaining a high level of patient care is difficult in some remote centres. The aim of this study was to evaluate the effectiveness of a new organizational model of care-network between Hub & Spoke hospitals to improve both the safety of the newborns in hospitals with a low number of births and the well-being of operators. Our project, NEO-SAFE (NEOnatal SAFety and training Elba), began in 2017 and involved the neonatal intensive care unit and the NINA Center of the Pisa University Hospital (hub) and the Hospital of Elba Island (spoke). It consisted of a continuous training program, both with 'classic' training course and 'on-job tutoring' (on side and remotely), of the health workers at spoke (i.e. nurses, midwives, and paediatricians). All four milestones of the study design were achieved. During the project, NINA Center instructors organized training courses for the staff in Portoferraio. These courses were based on learning technical and non-technical skills in a training course of increasing difficulty. Staff training needs were also monitored during the project by means of periodic questionnaires, sentinel events, and specific requests. The curve described by the rate of newborns transfer to the Pisa neonatal intensive care unit (hub) shows a monotonous decreasing trend line. On the other hand, this project allowed operators to develop greater self-confidence and greater safety in managing emergency situations, reducing stress for them and improving patient safety. The project allowed the creation of a safe, effective, low-cost, and reproducible organizational model for centres with a low number of births. Moreover, the tele-medicine approach is an important improvement in the assistance and is a window on the future.

Comparison Between Surgical Trainee Self-Assessment With Supervisor Scores in Technical and Nontechnical Skills to Identify Underperforming Trainees

This study aims to compare trainee self-assessment with supervisor assessment to identify differences in correlations of the demographic data and evaluate whether the instrument can be utilized to identify underperforming trainees. A novel instrument was designed based off the Royal Australasian College of Surgeons original 9 competencies utilizing the JDocs framework and covers 48-items across all surgical competencies. A multiple regression model using age, gender, postgraduate year, IMG status, and level of training as the variables was performed with backwards elimination, and pairwise comparisons made to identify the degree and direction of influence each variable contributed to trainee and supervisor ratings. Surgical trainees employed in tertiary centers within the Australian Capital Territory and South-East New South Wales health network in Australia. A total of 36 of 59 (61%) trainees responded. Two grossly incomplete responses were excluded from further analysis resulting in 34 completed self-assessments for analysis. There was a total of 68 supervisor assessments provided by 25 different nominated supervisors. Of these assessments, 67 were fully completed and one was partially complete. We identified that for both self-ratings and supervisor ratings, the most significant correlation is with the postgraduate year of the trainee, with correlation identified in 7 out of 9 competencies, although in different competency domains. International Medical Graduate status is associated in 2 of 9 self-ratings, and in 3 of 9 supervisor ratings. Underperforming trainees were able to be identified through supervisor assessment but not self-assessment. The supervisor assessment form was able to identify underperforming trainees. Our findings resonate with existing literature in other specialty fields, and surgical units that employ assessment forms should feel more confident in the interpretation of the data and provision of feedback to trainees.

Training for managing impacted fetal head at caesarean birth: multimethod evaluation of a pilot

BackgroundImplementation of national multiprofessional training for managing the obstetric emergency of impacted fetal head (IFH) at caesarean birth has potential to improve quality and safety in maternity care, but is...

Relationship between stress and resident non-technical skills during interdisciplinary trauma simulations

BackgroundNon-technical skills, such as communication and situation awareness, are vital for patient care and effective surgical team performance. Previous research has found that residents’ perceived stress is associated with poorer non-technical skills; however, few studies have investigated the relationship between objectively assessed stress and non-technical skills. Accordingly, the purpose of this study was to assess the relationship between objectively assessed stress and non-technical skills. MethodsEmergency medicine and surgery residents voluntarily participated in this study. Residents were randomly assigned to trauma teams to manage critically ill patients. Acute stress was assessed objectively using a chest-strap heart rate monitor, which measured average heart rate and heart rate variability. Participants also evaluated perceived stress and workload using the 6-item version of the State-Trait Anxiety Inventory and the Surgery Task Load Index. Non-technical skills were assessed by faculty raters using the non-technical skills scale for trauma. Pearson’s correlation coefficients were used to examine relationships between all variables. ResultsForty-one residents participated in our study. Heart rate variability (where higher values reflect lower stress) was positively correlated with residents’ non-technical skills overall and leadership, communication, and decision-making. Average heart rate was negatively correlated with residents’ communication. ConclusionHigher objectively assessed stress was associated with poorer non-technical skills in general and nearly all non-technical skills domains of the T-NOTECHS. Clearly, stress has a deleterious effect on residents’ non-technical skills during trauma situations, and given the importance of non-technical skills in surgical care, educators should consider implementing mental skills training to reduce residents’ stress and optimize non-technical skills during trauma situations.

What defines a great surgeon? A survey study confronting perspectives.

The definition of a great surgeon is usually reported by surgeons themselves. The objective of the study was to define a multifaceted definition of a great surgeon, by confronting patients', healthcare workers', and surgeons' perspectives. An online open-ended questionnaire was created to identify three qualities and three shortcomings defining a great surgeon. Age, gender, and profession of respondents were collected. Responses with a similar meaning were combined into word groups and labeled within four themes: human qualities, technical surgical skills (TSS), non-technical skills (NTS), and knowledge. Multivariate analyses were conducted between themes and respondent characteristics. Four thousand seven hundred and sixty qualities and 4,374 shortcomings were obtained from 1,620 respondents including 385 surgeons, 291 patients, 565 operating theater (OT) health professionals, and 379 non-OT health professionals. The main three qualities were dexterity (54% of respondents), meticulousness (18%), and empathy (18%). There was no significant difference between professional categories for TSS. Compared with surgeons, non-OT health professionals and patients put more emphasis on human qualities (29 vs. 39% and 42%, respectively, p < .001). OT health professionals referred more to NTS than surgeons (35 vs. 22%, p < 0.001). Knowledge was more important for surgeons (19%) than for all other professional categories (p < 0.001). This survey illustrates the multifaceted definition of a great surgeon. Even if dexterity is a major quality, human qualities are of paramount importance. Knowledge seems to be underestimated by non-surgeons, although it essential to understand the disease and preparing the patient and OT team for the procedure.

Simulation-Based Education in the Artificial Intelligence Era.

Simulation-based medical education (SBME) has been widely implemented in skill training in various clinical specialties. SBME has contributed not only to patient and medical safety but also to undergraduate and specialist education in the healthcare field. In this review, we discuss the challenges and future directions of SBME in the artificial intelligence (AI) era. While SBME fidelity or methods may become highly complicated in the AI era, the fact is that learners play a central role. As SBME and clinical education are complementary, mutual feedback and improvement are essential, especially in non-technical skill development. For the development of sustainable SBME in the clinical field in the AI era, continuous improvement is needed by academia, educators, and learners.

Exploring the Impact of Entrustable Professional Activities on Feedback Culture: A Qualitative Study of Anesthesiology Residents and Attendings.

Entrustable professional activities (EPAs) were introduced as a potential way to optimize workplace-based assessments. Yet, recent studies suggest that EPAs have not yet overcome all of the challenges to implementing meaningful feedback. The aim of this study was to explore the extent to which the introduction of EPAs via mobile app impacts feedback culture as experienced by anesthesiology residents and attending physicians. Using a constructivist grounded theory approach, the authors interviewed a purposive and theoretical sample of residents (n = 11) and attendings (n = 11) at the Institute of Anaesthesiology, University Hospital of Zurich, where EPAs had recently been implemented. Interviews took place between February and December 2021. Data collection and analysis were conducted iteratively. The authors used open, axial, and selective coding to gain knowledge and understanding on the interplay of EPAs and feedback culture. Participants reflected on a number of changes in their day-to-day experience of feedback culture with the implementation of EPAs. Three main mechanisms were instrumental in this process: lowering the feedback threshold, change in feedback focus, and gamification. Participants felt a lower threshold to feedback seeking and giving and that the frequency of feedback conversations increased and tended to be more focused on a specific topic and shorter, while feedback content tended to focus more on technical skills and more attention was given to average performances. Residents indicated that the app-based approach fostered a game-like motivation to "climb levels," while attendings did not perceive a game-like experience. EPAs may offer a solution to problems of infrequent occurrence of feedback and invite attention to average performances and technical competencies, but may come at the expense of feedback on nontechnical skills. This study suggests that feedback culture and feedback instruments have a mutually interacting influence on each other.

Exploring everyday work as a dynamic non-event and adaptations to manage safety in intraoperative anaesthesia care: an interview study

BackgroundSafety has been described as a dynamic non-event and as constantly present in professionals’ work processes. Investigating management of complex everyday situations may create an opportunity to elucidate safety management. Anaesthesia has been at the frontline of enhancing patient safety – testing and implementing knowledge from other high-reliability industries, such as aviation, in the complex, adaptive system of an operating room. The aim of this study was to explore factors supporting anaesthesia nurses and anaesthesiologists in managing complex everyday situations during intraoperative anaesthesia care processes.MethodsIndividual interviews with anaesthesia nurses (n = 9) and anaesthesiologists (n = 6) using cognitive task analysis (CTA) on case scenarios from previous prospective, structured observations. The interviews were analysed using the framework method.ResultsDuring intraoperative anaesthesia care, management of everyday complex situations is sustained through preparedness, support for mindful practices, and monitoring and noticing complex situations and managing them. The prerequisites are created at the organization level. Managers should ensure adequate resources in the form of trained personnel, equipment and time, team and personnel sustainability and early planning of work. Management of complex situations benefits from high-quality teamwork and non-technical skills (NTS), such as communication, leadership and shared situational awareness.ConclusionAdequate resources, stability in team compositions and safe boundaries for practice with shared baselines for reoccurring tasks where all viewed as important prerequisites for managing complex everyday work. When and how NTS are used in a specific clinical context depends on having the right organizational prerequisites and a deep expertise of the relevant clinical processes. Methods like CTA can reveal the tacit competence of experienced staff, guide contextualized training in specific contexts and inform the design of safe perioperative work practices, ensuring adequate capacity for adaptation.

Enhancement of the technical and non-technical skills of nurse anesthesia students using the Anesthetic List Management Assessment Tool in Iran: a quasi-experimental study.

This study investigated the effect of evaluations based on the Anesthetic List Management Assessment Tool (ALMAT) form on improving the technical and non-technical skills of final-year nurse anesthesia students at Ahvaz Jundishapur University of Medical Sciences (AJUMS). This was a semi-experimental study with a pre-test and post-test design. It included 45 final-year nurse anesthesia students of AJUMS and lasted for 3 months. The technical and non-technical skills of the intervention group were assessed at 4 university hospitals using formative-feedback evaluation based on the ALMAT form, from induction of anesthesia until reaching mastery and independence. Finally, the students' degree of improvement in technical and non-technical skills was compared between the intervention and control groups. Statistical tests (the independent t-test, paired t-test, and Mann-Whitney test) were used to analyze the data. The rate of improvement in post-test scores of technical skills was significantly higher in the intervention group than in the control group (P˂0.0001). Similarly, the students in the intervention group received significantly higher post-test scores for non-technical skills than the students in the control group (P˂0.0001). The findings of this study showed that the use of ALMAT as a formative-feedback evaluation method to evaluate technical and non-technical skills had a significant effect on improving these skills and was effective in helping students learn and reach mastery and independence.

Resuscitation team training in Rwanda: A mixed method study exploring the combination of the VAST course with Advanced Cardiac Life Support training

IntroductionThe influence of non-technical skills training on resuscitation performance in low-resource settings is unknown. This study investigates combining the Vital Anaesthesia Simulation Training Course with Advanced Cardiac Life Support training on resuscitation performance in Rwanda. MethodsParticipants in this mixed method study are members of resuscitation teams in three district hospitals in Rwanda. The intervention was participation in a 2-day Advanced Cardiac Life Support course followed by the 3-day Vital Anaesthesia Simulation Training Course. Quantitative primary endpoints were time to initiation of cardiopulmonary resuscitation, time to epinephrine administration, and time to defibrillation. Qualitative data on workplace implementation were gathered during focus groups held 3-months post-intervention. ResultsForty-seven participants were recruited. Quantitative data showed a statistically significant decrease in time to cardiopulmonary resuscitation, epinephrine administration, and defibrillation from pre- to post-Advanced Cardiac Life Support, with times of [43.3 (49.7) seconds] versus [16.5 (20) sec], p = <0.001; [137.3 (108.9) sec] versus [51.3 (37.9)], p = <0.001; and [218.5 (105.8) sec] versus [110.8 (87.1) sec], p = <0.001; respectively. These improvements were maintained following the Vital Anaesthesia Simulation Training Course, and at 3-month retention testing. Qualitative analysis highlighted five key themes: ability to initiate cardiopulmonary resuscitation; team coordination for task allocation; empowerment; desire for training and mentorship; and advocacy for system improvement. ConclusionA modified 2-day Advanced Cardiac Life Support course improved resuscitation time indicators with retention 3-months later. Combining the Vital Anaesthesia Simulation Training Course and Advanced Cardiac Life Support led to better team coordination, empowerment to act, and advocacy for system improvement. This pairing of courses has promise for improving Advanced Cardiac Life Support skills amongst healthcare workers in low-resource settings.ClinicalTrials.gov Identifier: NCT05278884.

Non-technical skills in the operating room: Crisis resource management principles

Non-technical skills in the operating room: Crisis resource management principles - IJCA- Print ISSN No: - 2394-4781 Online ISSN No:- 2394-4994 Article DOI No:- 10.18231/j.ijca.2023.025, Indian Journal of Clinical Anaesthesia-Indian J Clin Anaesth

Optimalisasi Peningkatan Komunikasi Lewat Program Training Untuk Usaha Mikro, Kecil, Dan Menengah (UMKM), Komunitas Kepemudaan Dan Mahasiswa

Soft skills training is a program designed to improve and develop soft skills such as interpersonal, leadership, communication, collaboration, adaptability, creativity, and other non-technical skills. This study aims to make a positive contribution in improving communication skills within the scope of SMEs, communities and students. This community service research aims to identify the optimization of one of the BCTI unit programs, namely Raising the Level of Speech which is given to MSMEs, Communities and Students. By using a qualitative descriptive method, because the research focus is to describe and provide an overview of the information on the object being studied. The research that has been done has shown that the Speech Level Raise training program is running effectively. Because participants who took part in the training experienced increased speaking skills and felt helped and useful for their needs. This program is also aligned with Sustainable Development Goal 4, namely Quality Education which ensures inclusive and equitable quality education and promotes lifelong learning opportunities for all.

A sensor-based framework for layout and workflow assessment in operating rooms

Due to their large sizes and impediments to personnel workflows, integrating robotic technologies into the existing operating rooms (OR) is a challenge. In this study, we developed an ultra-wideband sensor-based human-machine-environment framework for layout and workflow assessments within the OR. In addition to providing best practices for use of the framework, we also demonstrated its effectiveness in understanding layout and workflow inefficiencies in 12 robotic-assisted surgeries (RAS) across 4 different surgical specialties. We found avoidable movements as the circulating nurse covers at least twice the distance of any other OR personnel before the patient cart (robot) is docked. OR areas of congestion and undesirable personnel-pair proximities across RAS phases that impose extra non-technical skill challenges were determined. Our findings highlight several implications for the added complexity of integrating robotic technologies into the OR, which can serve as drivers for objective evidence-based recommendations to combat RAS OR layout and workflow inefficiencies.

Gaze behavior is related to objective technical skills assessment during virtual reality simulator-based surgical training: a proof of concept.

Simulation-based training allows surgical skills to be learned safely. Most virtual reality-based surgical simulators address technical skills without considering non-technical skills, such as gaze use. In this study, we investigated surgeons' visual behavior during virtual reality-based surgical training where visual guidance is provided. Our hypothesis was that the gaze distribution in the environment is correlated with the simulator's technical skills assessment. We recorded 25 surgical training sessions on an arthroscopic simulator. Trainees were equipped with a head-mounted eye-tracking device. A U-net was trained on two sessions to segment three simulator-specific areas of interest (AoI) and the background, to quantify gaze distribution. We tested whether the percentage of gazes in those areas was correlated with the simulator's scores. The neural network was able to segment all AoI with a mean Intersection over Union superior to 94% for each area. The gaze percentage in the AoI differed among trainees. Despite several sources of data loss, we found significant correlations between gaze position and the simulator scores. For instance, trainees obtained better procedural scores when their gaze focused on the virtual assistance (Spearman correlation test, N = 7, r = 0.800, p = 0.031). Our findings suggest that visual behavior should be quantified for assessing surgical expertise in simulation-based training environments, especially when visual guidance is provided. Ultimately visual behavior could be used to quantitatively assess surgeons' learning curve and expertise while training on VR simulators, in a way that complements existing metrics.

COLLABORATIVE TEAM TRAINING IN IMMERSIVE VIRTUAL REALITY IS SUPERIOR TO INDIVIDUAL LEARNING FOR PERFORMING TOTAL HIP ARTHROPLASTY: A RANDOMIZED CONTROLLED TRIAL

Superior teamwork in the operating theatre is associated with improved technical performance and clinical outcomes. Yet modern rota patterns, workforce shortages, and increasing complexity of surgery, means that there is less familiarity between staff and the required choreography. Immersive Virtual Reality (iVR) can successfully train surgical staff individually, however iVR team training has yet to be investigated. We aimed to design a multiplayer iVR platform for anterior approach total hip arthroplasty (AA-THA) and assess if multiplayer iVR training was superior to single player training for acquisition of both technical and non-technical skills.An iVR platform with choreographed roles for the surgeon and scrub nurse was developed using Cognitive Task Analysis. Forty participants were randomised to individual or team iVR training. Individually- trained participants practiced alongside virtual avatar counterparts, whilst teams trained live in pairs. Both groups underwent five iVR training sessions over 6-weeks. Subsequently, they underwent a real-life assessment in which they performed AA-THA on a high-fidelity model with real equipment in a simulated theatre. Teams performed together and individually trained participants were randomly paired up. Videos were marked by two blinded assessors recording the NOTSS, NOTECHS II and SPLINTS scores - validated technical and non-technical scores assessing surgeon and scrub nurse skills. Secondary outcomes were procedure time and number of technical errors.Teams outperformed individually trained participants for non-technical skills in the real-world assessment (NOTSS 13.1 ± 1.5 vs 10.6 ± 1.6, p =0.002, NOTECHS-II score 51.7 ± 5.5 vs 42.3 ± 5.6, p=0.001 and SPLINTS 10 ± 1.2 vs 7.9 ± 1.6, p = 0.004). They completed the assessment 28.1% faster (27.2 minutes ± 5.5 vs 41.8 ±8.9, p&lt;0.001), and made fewer than half the number of technical errors (10.4 ± 6.1 vs 22.6 ± 5.4, p&lt;0.001).Multiplayer training leads to faster surgery with fewer technical errors and the development of superior non-technical skills for anterior approach total hip arthroplasty. The convention of surgeons and nurses training separately, but undertaking real complex surgery together, can be supplanted by team training, delivered through immersive virtual reality.

Curriculum for training in endoscopic mucosal resection in the colon: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

Endoscopic mucosal resection (EMR) is the standard of care for the complete removal of large (≥ 10 mm) nonpedunculated colorectal polyps (LNPCPs). Increased detection of LNPCPs owing to screening colonoscopy, plus high observed rates of incomplete resection and need for surgery call for a standardized approach to training in EMR. 1 : Trainees in EMR should have achieved basic competence in diagnostic colonoscopy, < 10-mm polypectomy, pedunculated polypectomy, and common methods of gastrointestinal endoscopic hemostasis. The role of formal training courses is emphasized. Training may then commence in vivo under the direct supervision of a trainer. 2 : Endoscopy units training endoscopists in EMR should have specific processes in place to support and facilitate training. 3: A trained EMR practitioner should have mastered theoretical knowledge including how to assess an LNPCP for risk of submucosal invasion, how to interpret the potential difficulty of a particular EMR procedure, how to decide whether to remove a particular LNPCP en bloc or piecemeal, whether the risks of electrosurgical energy can be avoided for a particular LNPCP, the different devices required for EMR, management of adverse events, and interpretation of reports provided by histopathologists. 4: Trained EMR practitioners should be familiar with the patient consent process for EMR. 5: The development of endoscopic non-technical skills (ENTS) and team interaction are important for trainees in EMR. 6: Differences in recommended technique exist between EMR performed with and without electrosurgical energy. Common to both is a standardized technique based upon dynamic injection, controlled and precise snare placement, safety checks prior to the application of tissue transection (cold snare) or electrosurgical energy (hot snare), and interpretation of the post-EMR resection defect. 7: A trained EMR practitioner must be able to manage adverse events associated with EMR including intraprocedural bleeding and perforation, and post-procedural bleeding. Delayed perforation should be avoided by correct interpretation of the post-EMR defect and treatment of deep mural injury. 8: A trained EMR practitioner must be able to communicate EMR procedural findings to patients and provide them with a plan in case of adverse events after discharge and a follow-up plan. 9: A trained EMR practitioner must be able to detect and interrogate a post-endoscopic resection scar for residual or recurrent adenoma and apply treatment if necessary. 10: Prior to independent practice, a minimum of 30 EMR procedures should be performed, culminating in a trainer-guided assessment of competency using a validated assessment tool, taking account of procedural difficulty (e. g. using the SMSA polyp score). 11: Trained practitioners should log their key performance indicators (KPIs) of polypectomy during independent practice. A guide for target KPIs is provided in this document.