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  • Journal article
    Kneebone R, 2017,

    Medicine: Discovery through doing.

    , Nature, Vol: 542, Pages: 294-294, ISSN: 0028-0836
  • Journal article
    Kneebone RL, 2017,

    The individual and the system

    , Lancet, Vol: 389, Pages: 360-361, ISSN: 0140-6736
  • Journal article
    Kneebone RL, 2017,

    Materiality and thread

    , Lancet, Vol: 389, Pages: 246-247, ISSN: 0140-6736
  • Journal article
    Kneebone RL, 2017,

    Performing magic, performing medicine

    , Lancet, Vol: 389, Pages: 148-149, ISSN: 1474-547X
  • Journal article
    Kneebone RL, 2017,

    Bespoke practice

    , Lancet, Vol: 389, Pages: 28-29, ISSN: 0140-6736
  • Journal article
    Kneebone RL, 2017,

    Making medicine bespoke

    , Lancet, Vol: 389, Pages: 19-19, ISSN: 1474-547X
  • Journal article
    Bezemer J, Cope A, Korkiakangas T, Kress G, Murtagh G, Weldon SM, Kneebone Ret al., 2016,

    Microanalysis of video from the operating room: an underused approach to patient safety research

    , BMJ Quality & Safety, Vol: 26, Pages: 583-587, ISSN: 2044-5423
  • Journal article
    Cope A, Bezemer J, Mavroveli S, Kneebone Ret al., 2016,

    What attitudes and values are incorporated into self as part of professional identity construction when becoming a surgeon?

    , Academic Medicine, Vol: 92, Pages: 544-549, ISSN: 1938-808X

    Purpose: To make explicit the attitudes and values of a community of surgeons, with the aim of understanding professional identity construction within a specific group of residents.Method: Using a grounded theory method, the authors collected data from 16 postgraduate surgeons through interviews. They complemented these initial interview data with ethnographic observations and additional descriptive interviews to explore the attitudes and values learned by surgeons during residency training (2010-2013). The participants were attending surgeons and residents in a general surgical training program in a university teaching hospital in the United Kingdom.Results: Participating surgeons described learning personal values or attitudes that they regarded as core to "becoming a surgeon" and key to professional identity construction. They described learning to be a perfectionist, to be accountable, and to self-manage and be resilient. They discussed learning to be self-critical, sometimes with the unintended consequence of seeming neurotic. They described learning effective teamwork as well as learning to take initiative and be innovative, which enabled them to demonstrate leadership and drive actions and agendas forward within the health care organization where they worked.Conclusions: To the authors' knowledge, this is the first study to systematically explore the learning of professional identity amongst postgraduate surgeons. The study contributes to the literature on professional identity construction within medical education. The authors conclude that the demise of the apprenticeship model and the rise of duty hours limitations may affect not only the acquisition of technical skills but, more important, the construction of surgeon professional identity.

  • Journal article
    Kneebone RL, Frampton S, 2016,

    John Wickham's new surgery: 'minimally invasive therapy", innovation, and approaches to medical practice in twentieth-century Britain

    , Social History of Medicine, ISSN: 1477-4666

    The term ‘minimally invasive’ was coined in 1986 to describe a range of procedures that involvedmaking very small incisions or no incision at all for diseases traditionally treated by open surgery.We examine this major shift in British medical practice as a means of probing the nature of surgical innovationin the twentieth century. We first consider how concerns regarding surgical invasiveness hadlong been present in surgery, before examining how changing notions of post-operative care formed afoundation for change. We then go on to focus on a professional network involved in the promotionof minimally invasive therapy led by the urologist John Wickham. The minimally invasive movement,we contend, brought into focus tensions between surgical innovation and the evidence-based modelof medical practice. Premised upon professional collaborations beyond surgery and a re-positioning ofthe patient role, we show how the movement elucidated changing notions of surgical authority.

  • Journal article
    Bezemer J, Murtagh G, Cope A, Kneebone Ret al., 2016,

    Surgical decision making in a teaching hospital: a linguistic analysis

    , ANZ JOURNAL OF SURGERY, Vol: 86, Pages: 751-755, ISSN: 1445-1433
  • Journal article
    Kneebone RL, 2016,

    Simulation reframed

    , Advances in Simulation, Vol: 1, ISSN: 2059-0628

    BackgroundSimulation is firmly established as a mainstay of clinical education, and extensive research has demonstrated its value. Current practice uses inanimate simulators (with a range of complexity, sophistication and cost) to address the patient ‘as body’ and trained actors or lay people (Simulated Patients) to address the patient ‘as person’. These approaches are often separate.Healthcare simulation to date has been largely for the training and assessment of clinical ‘insiders’, simulating current practices. A close coupling with the clinical world restricts access to the facilities and practices of simulation, often excluding patients, families and publics. Yet such perspectives are an essential component of clinical practice.Main bodyThis paper argues that simulation offers opportunities to move outside a clinical ‘insider’ frame and create connections with other individuals and groups. Simulation becomes a bridge between experts whose worlds do not usually intersect, inviting an exchange of insights around embodied practices—the ‘doing’ of medicine—without jeopardising the safety of actual patients.Healthcare practice and education take place within a clinical frame that often conceals parallels with other domains of expert practice. Valuable insights emerge by viewing clinical practice not only as the application of medical science but also as performance and craftsmanship.Such connections require a redefinition of simulation. Its essence is not expensive elaborate facilities. Developments such as hybrid, distributed and sequential simulation offer examples of how simulation can combine ‘patient as body’ with ‘patient as person’ at relatively low cost, democratising simulation and exerting traction beyond the clinical sphere.The essence of simulation is a purposeful design, based on an active process of selection from an originary world, abstraction of what is c

  • Journal article
    Korzeniowski P, Brown DC, Sodergren M, Barrow A, Bello Fet al., 2016,

    Validation of NOViSE – a novel Natural Orifice Virtual Surgery Simulator

    , Surgical Innovation, Vol: 24, Pages: 55-65, ISSN: 1553-3514

    The goal of this study was to establish face, content and construct validity of NOViSE – the first force-feedback enabled virtual reality (VR) simulator for Natural Orifice Transluminal Endoscopic Surgery (NOTES). Fourteen surgeons and surgical trainees performed three simulated hybrid trans-gastric cholecystectomies using a flexible endoscope on NOViSE. Four of them were classified as “NOTES experts” who had independently performed ten or more animal or human NOTES procedures. Seven participants were classified as ‘Novices’ and three as ‘Gastroenterologists’ with no or minimal NOTES experience. A standardized five-point Likert-scale questionnaire was administered to assess the face and content validity. NOViSE showed good overall face and content validity. In 14 out of 15 statements pertaining to face validity (graphical appearance, endoscope and tissue behaviour, overall realism), ≥50% of responses were “agree” or “strongly agree”. In terms of content validity, 85.7% of participants agreed or strongly agreed that NOViSE is a useful training tool for NOTES and 71.4% that they would recommend it to others. Construct validity was established by comparing a number of performance metrics such as task completion times, path lengths, applied forces, etc. NOViSE demonstrated early signs of construct validity. Experts were faster and used a shorter endoscopic path length than novices in all but one task. The results indicate that NOViSE authentically recreates a trans-gastric hybrid cholecystectomy and sets promising foundations for the further development of a VR training curriculum for NOTES without compromising patient safety or requiring expensive animal facilities.

  • Journal article
    Huddy JR, Weldon SM, Ralhan S, Painter T, Hanna GB, Kneebone R, Bello Fet al., 2016,

    Sequential simulation (SqS) of clinical pathways: a tool for public and patient engagement in point-of-care diagnostics.

    , BMJ Open, Vol: 6, Pages: e011043-e011043, ISSN: 2044-6055

    OBJECTIVES: Public and patient engagement (PPE) is fundamental to healthcare research. To facilitate effective engagement in novel point-of-care tests (POCTs), the test and downstream consequences of the result need to be considered. Sequential simulation (SqS) is a tool to represent patient journeys and the effects of intervention at each and subsequent stages. This case study presents a process evaluation of SqS as a tool for PPE in the development of a volatile organic compound-based breath test POCT for the diagnosis of oesophagogastric (OG) cancer. SETTING: Three 3-hour workshops in central London. PARTICIPANTS: 38 members of public attended a workshop, 26 (68%) had no prior experience of the OG cancer diagnostic pathway. INTERVENTIONS: Clinical pathway SqS was developed from a storyboard of a patient, played by an actor, noticing symptoms of oesophageal cancer and following a typical diagnostic pathway. The proposed breath testing strategy was then introduced and incorporated into a second SqS to demonstrate pathway impact. Facilitated group discussions followed each SqS. PRIMARY AND SECONDARY OUTCOME MEASURES: Evaluation was conducted through pre-event and postevent questionnaires, field notes and analysis of audiovisual recordings. RESULTS: 38 participants attended a workshop. All participants agreed they were able to contribute to discussions and like the idea of an OG cancer breath test. Five themes emerged related to the proposed new breath test including awareness of OG cancer, barriers to testing and diagnosis, design of new test device, new clinical pathway and placement of test device. 3 themes emerged related to the use of SqS: participatory engagement, simulation and empathetic engagement, and why participants attended. CONCLUSIONS: SqS facilitated a shared immersive experience for participants and researchers that led to the coconstruction of knowledge that will guide future research activities and be of value to stakeholders concerned with the inv

  • Journal article
    Kneebone RL, 2016,

    Performing surgery: commonalities with performers outside medicine

    , Frontiers in Psychology, Vol: 7, ISSN: 1664-1078

    This paper argues for the inclusion of surgery within the canon of performance science. The world of medicine presents rich, complex but relatively under-researched sites of performance. Performative aspects of clinical practice are overshadowed by a focus on the processes and outcomes of medical care, such as diagnostic accuracy and the results of treatment. The primacy of this “clinical” viewpoint—framed by clinical professionals as the application of medical knowledge—hides resonances with performance in other domains. Yet the language of performance is embedded in the culture of surgery—surgeons “perform” operations, work in an operating “theater” and use “instruments.” This paper asks what might come into view if we take this performative language at face value and interrogate surgery from the perspective of performance science.

  • Journal article
    Sadideen H, Goutos I, Kneebone R, 2016,

    Burns education: The emerging role of simulation for training healthcare professionals

    , Burns, Vol: 43, Pages: 34-40, ISSN: 0305-4179

    Burns education appears to be under-represented in UK undergraduate curricula. However current postgraduate courses in burns education provide formal training in resuscitation and management. Simulation has proven to be a powerful modality to advance surgical training in both technical and non-technical skills. We present a literature review that summarises the format of current burns education, and provides detailed insight into historic, current and novel advances in burns simulation for both technical and non-technical skills, that can be used to augment surgical training. Addressing the economic and practical limitations of current immersive surgical simulation is important, and this review proposes future directions for integration of innovative simulation strategies into training curricula.

  • Conference paper
    Loisillier A, Granados A, Barrow A, Bello Fet al., 2016,

    Thimble end effector for palpation skills training

    , 10th International Conference on Haptics - Perception, Devices, Control, and Applications (EuroHaptics), Publisher: SPRINGER INT PUBLISHING AG, Pages: 86-96, ISSN: 0302-9743

    Interaction with force feedback haptic devices is often non-intuitive, obtrusive and unrealistic, particularly for the simulation of palpation skills training where a thimble is commonly found as an end-effector. A user will typically use two hands to steady the device and push one or more thimbles onto their fingers. New designs of thimbles, responsible for fastening the end effector of a haptic device onto the finger of the user have been explored, but do not solve the issue of introducing elements that are not present in the task being simulated. We introduce a number of design techniques, with early evaluation results for improving the way users engage, maintain connection and then disengage with thimble-connected haptic interfaces. The designs of the thimbles presented in this paper include rings and different opening shapes, which aim at creating a vacuum effect, as well as a mechanical grip around the finger of the user in order to hold it. Thimble effectiveness, as a function of low impedance on insertion and high impedance on removal, was assessed through a study which highlighted that the relationship between thimble opening size and finger circumference is a critical factor. We present results about the impact of the size of the rings on the insertion and extraction force, followed by a reflection on an improved experimental protocol.

  • Journal article
    Sadideen H, Wilson D, Moiemen N, Kneebone Ret al., 2016,

    Using "The Burns Suite" as a Novel High Fidelity Simulation Tool for Interprofessional and Teamwork Training.

    , Journal of Burn Care & Research, Vol: 37, Pages: 235-242, ISSN: 1559-047X

    Educational theory highlights the importance of contextualized simulation for effective learning. The authors recently published the concept of "The Burns Suite" (TBS) as a novel tool to advance the delivery of burns education for residents/clinicians. Effectively, TBS represents a low-cost, high-fidelity, portable, immersive simulation environment. Recently, simulation-based team training (SBTT) has been advocated as a means to improve interprofessional practice. The authors aimed to explore the role of TBS in SBTT. A realistic pediatric burn resuscitation scenario was designed based on "advanced trauma and life support" and "emergency management of severe burns" principles, refined utilizing expert opinion through cognitive task analysis. The focus of this analysis was on nontechnical and interpersonal skills of clinicians and nurses within the scenario, mirroring what happens in real life. Five-point Likert-type questionnaires were developed for face and content validity. Cronbach's alpha was calculated for scale reliability. Semistructured interviews captured responses for qualitative thematic analysis allowing for data triangulation. Twenty-two participants completed TBS resuscitation scenario. Mean face and content validity ratings were high (4.4 and 4.7 respectively; range 4-5). The internal consistency of questions was high. Qualitative data analysis revealed two new themes. Participants reported that the experience felt particularly authentic because the simulation had high psychological and social fidelity, and there was a demand for such a facility to be made available to improve nontechnical skills and interprofessional relations. TBS provides a realistic, novel tool for SBTT, addressing both nontechnical and interprofessional team skills. Recreating clinical challenge is crucial to optimize SBTT. With a better understanding of the theories underpinning simulation and interprofessional education, future simulation scenarios

  • Journal article
    Weldon S, Kneebone R, Bello F, 2016,

    Collaborative healthcare remodelling through Sequential Simulation (SqS): a patient and front-line staff perspective

    , BMJ Simulation & Technology Enhanced Learning, Vol: 2, Pages: 78-86, ISSN: 2056-6697

    Background The Department of health funded an initiative to pioneer new approaches that would create a more integrated form of care.Local problem In order to receive funding, local Clinical Commissioning Groups were required to engage a range of stakeholders in a practical approach that generated the development of an integrated model of care.Intervention Two sequential simulation (SqS) workshops comprising 65 and 93 participants, respectively, were designed using real patient scenarios from the locality, covering areas of general practice, community health and adult social care. Workshops were attended by a diverse group of stakeholders. The first workshop addressed current care pathways and the second modelled ideal care pathways generated from the data obtained at the first workshop.Methods Discussions were captured through video recording, field-notes and pre and post questionnaires. Data was collated, transcribed and analysed through a combination of descriptive statistics and thematic analysis.Results The questionnaires revealed that attendees strongly agreed that they had had an opportunity to contribute to all discussions and raise questions, concerns and ideas (100%). Pre and post knowledge of current and new models of care was vastly improved. The opportunity to share information and to network was valued, with the SqS approach seen as breaking professional barriers (100%).Conclusions Simulation can be used as a tool to engage stakeholders in designing integrated models of care. The systematic data collection from the diverse ideas generated also allows for a much-needed ‘ear’ to those providing the solutions, as well as a legitimate and balanced perspective.

  • Journal article
    Weldon S, Ralhan S, Paice L, Kneebone R, Bello Fet al., 2016,

    Sequential simulation of a patient journey

    , Clinical Teacher, Vol: 14, Pages: 90-94, ISSN: 1743-4971

    Objectives: To develop an intervention for educating pharmacists(community and hospital) about integrated care and their role in implementingit.Methods: We developed a sequential simulation derived from a patient’sjourney, the key scenario featuring a community pharmacist. The scenarioswere designed with input from pharmacists and patients, and emphasized theeffect operating in silos can have on the patient.Evaluation: Evaluation was by questionnaire, field notes and analysis ofvideo material. 21/37 (56.7%) participants responded to the questionnaire.19/21 expressed that they felt the event was a good or excellent educationalexperience, and had improved their confidence in their capability to improvepatient care. 19/21 said their knowledge and understanding of integrated carehad been enhanced. The sequential simulation was appreciated as a way ofvisualizing integrated care, with 19/21 describing it as good or excellent.Further themes were identified through video-analysis and field note analysis.Conclusion: Sequential Simulation is a novel and practical approach topresent current care pathways, aiming to generate a mutual focus, createparticipant empathy and bring the conventionalities of integrated care to life.We consider this approach helpful in preparing frontline staff to participate in integrated care.

  • Journal article
    Korzeniowski P, Barrow A, Sodergren M, Hald N, Bello Fet al., 2016,

    NOViSE: a virtual natural orifice transluminal endoscopic surgery simulator

    , International Journal of Computer Assisted Radiology and Surgery, Vol: 11, Pages: 2303-2315, ISSN: 1861-6410

    Purpose: Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a novel technique in minimally invasive surgery whereby a flexible endoscope is inserted via a natural orifice to gain access to the abdominal cavity, leaving no external scars. This innovative use of flexible endoscopy creates many new challenges and is associated with a steep learning curve for clinicians. Methods: We developed NOViSE - the first force-feedback enabled virtual reality simulator for NOTES training supporting a flexible endoscope. The haptic device is custom built and the behaviour of the virtual flexible endoscope is based on an established theoretical framework – the Cosserat Theory of Elastic Rods. Results: We present the application of NOViSE to the simulation of a hybrid trans-gastric cholecystectomy procedure. Preliminary results of face, content and construct validation have previously shown that NOViSE delivers the required level of realism for training of endoscopic manipulation skills specific to NOTES Conclusions: VR simulation of NOTES procedures can contribute to surgical training and improve the educational experience without putting patients at risk, raising ethical issues or requiring expensive animal or cadaver facilities. In the context of an experimental technique, NOViSE could potentially facilitate NOTES development and contribute to its wider use by keeping practitioners up to date with this novel surgical technique. NOViSE is a first prototype and the initial results indicate that it provides promising foundations for further development.

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