Background

Becoming an expert surgeon entails pursuing a challenging and continuous postgraduate surgical training path. In addition to acquiring expert knowledge in diagnostics and treatments, surgical trainees must develop a high level of technical and non-technical skills. Simulation-based surgical skills training (SBST) has proven effective for developing trainees’ surgical skills [1]. Research has strengthened the evidence of skills transfer to the operating room (OR), reducing adverse events and increasing patient safety [2, 3]. However, previous literature emphasises a more holistic view of the transfer of training processes, consisting of an interplay of trainee characteristics, training design, and the work environment [4,5,6].

Different theoretical and conceptual frameworks have been developed and applied to explain learning and training processes in attaining expertise in surgery. Ericsson’s theoretical framework of deliberate practice [7, 8] has largely inspired the development of modern SBST designs, including proficiency-based training (PBT). PBT is a goal-oriented training approach that allows time for deliberate practice, accommodates individual progression pace and ensures that all trainees reach minimum performance standards [9]. PBT has proven effective for laparoscopic skills training, resulting in improved OR performances and skills retention [3, 10, 11].

Self-regulated learning (SRL) theories have been applied and investigated in medical education and simulation-based training [12,13,14]. While different theoretical frameworks exist, what they have in common is the idea that SRL is a dynamic process where the learner modulates learning experiences and adapts learning strategies to reach desired learning goals [15,16,17,18]. However, research on SRL in SBST is sparse. As pointed out by Brydges et al. (2015), SRL has largely been misinterpreted as self-learning, depicting the trainee as exclusively responsible for learning [13]. By contrast, as stated by Pintrich (1999), “self-regulated learning is neither easy nor automatic” [16]. SRL involves strategies that the learner uses and develops to regulate cognitive, affective, behavioural processes and resources throughout a learning activity. As such, SRL must be recognised as a complex and dynamic system of self-regulatory processes that should be assisted by evidence-based educational supports, especially if the goal is to promote ongoing SRL in postgraduate training [13, 19]. Previous research has demonstrated that trainees who engage in self-regulatory activities tend to learn more than those who struggle to self-regulate [17].

While previous studies have mainly focused on different structures and designs for SBST and assessing immediate and delayed transfer outcomes in the OR [2], less attention has been given to how trainees engage in and regulate their surgical training and how they transfer their training to the clinical environment. It is reasonable that much attention has concentrated on proving that SBST leads to improved OR performances. However, to advance the knowledge about trainees’ actual conditions for transfer of training from the simulated learning environment to the clinical setting, we need in-depth studies on how trainees engage in training and their perceived conditions for transfer of training. A study by Blackhall et al. (2018) explored facilitators and barriers towards engagement in home-based SBST [20]. Among key findings were that trainees did not perceive a connection between training tasks and their clinical practice and that trainees lacked motivation to engage in training because they were more focused on activities leading to career progression than on the development of their surgical skills. Moreover, engagement in simulation-based training has been shown to be complex and influenced by social and cultural factors [20,21,22].

Building on previous research, we wanted to further explore this apparent disconnect in the transfer of training by conducting in-depth interviews on how surgical trainees perceive the transfer of their training into clinical practice. Furthermore, rather than focusing on structural and psychological barriers and facilitators of training engagement, this study aimed to explore characteristics of learning processes that take place when trainees engage in surgical training. With these aims in mind, our objective was to contribute with new perspectives that may inform the development of educational interventions that support SRL and transfer of training within postgraduate surgical training.

Methods

We conducted a qualitative study using a constructivist research approach. Interviews provided insights into informants’ experiences, acknowledging that meanings, experiences and interpretations are constructed iteratively among informants, interviewers and researchers [23].

Context and sample

Informants were regularly invited on a voluntary basis among trainees participating in a six-week simulation-based laparoscopic skills training program. The training was situated and facilitated in two ways, i.e., by centralised or remote training, based on a previously published randomised comparative study investigating training patterns and performance outcomes between the two training modalities [24]. The training was structured as PBT, and training equipment was the same between groups. In comparison, the remote training group trained on their own, guided by thorough written and visual instructions and provided short written feedback on submitted task videos, while the centralised group trained for two full days with instructors present to instruct and give verbal feedback. In the previous study, we found that remote training facilitated distributed practice and that the two training modalities resulted in comparable performance outcomes [24].

Rather than a comparative research approach, the present study focused on exploring characteristic processes of engagement in surgical training and on trainees’ perceptions of transfer of training, irrespective of training mode. The study population was Danish first-year trainees in General Surgery, Urology, and Gynaecology and Obstetrics who had not previously participated in a postgraduate laparoscopic skills training program. As part of the informant selection process, a purposeful heterogeneity sampling strategy was used, which is a selection method that seeks to represent the study population as widely as possible to achieve a holistic understanding of the phenomena under investigation [25].

Data collection

From September 2019 to February 2020, informants participated in two individual interviews, each lasting 40 to 60 minutes. We conducted the first interview in the middle of the six-week training program and the second approximately two months after the program had concluded. We did this to allow time for informants to build perceptions and experiences and to capture perspectives of transfer of training both during and after the training programme. Time between interviews allow additional reflection leading to an increased level of detail in the narrative data [26, 27].

Two experienced qualitative researchers conducted the interviews using a semi-structured interview guide. We designed the interview guide with suggested open-ended questions on how trainees engaged in training and how they experienced conditions for applying trained skills into their clinical practice. The interview guide was informed by Zimmerman’s (2000) theoretical frameworks of SRL [15] and Grossman and Salas’(2011) adapted model of the transfer process [6]. Examples of questions were, “describe an optimal training situation” and “how do you see the connections between the simulation-based training and your clinical training?”. Meaning saturation was assessed continuously and reached by conducting follow-up interviews and focusing on meaning units instead of codes [28]. Interviews were audio-recorded and transcribed verbatim.

Data analysis

We conducted a thematic cross-case analysis using systematic text condensation (STC) [29]. STC includes four analytical steps. In step 1, we formed an overall impression of the data, identifying preliminary themes that served as the starting point for further analyses. In step 2, we reviewed all transcripts identifying meaning units (i.e., text fragments containing information about the research questions). Using code labels, we connected related meaning units into four thematic code groups. We repeatedly met and discussed identified meaning units and corresponding code groups. In step 3, we sorted the meaning units of each code group into subgroups. Amalgamating the content from meaning units, we reduced each subgroup into a text condensate, maintaining expressions originally used by the informants (Tables 2, 3, 4 and 5). In step 4, we interpreted and reconceptualised the data, developing descriptions elucidating the research questions. Using constant comparison, we ensured that the synthesised descriptions and concepts still reflected the validity and wholeness of the original interviews. We chose STC because it offers a transparent and collaborative approach to thematic cross-case analysis where text condensations elucidate what led to the syntheses [29]. The variety of backgrounds represented in the research group provided an opportunity to analyse and interpret emergent themes from different viewpoints and perspectives [30].

Results

Twelve informants were interviewed (Table 1) resulting in a total of 24 transcripts for analysis.

Table 1 Informant characteristics
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We identified four main themes: (1) sportification of training, (2) modes of orientation, (3) transferrable skills and (4) transfer opportunities. Our results represent overall perspectives and conceptualisations of the informants’ narrated experiences. Accompanying text condensates (Tables 2, 3, 4 and 5) illustrate multivocal narratives within the subgroups of each theme (step 3 of the analysis).

Table 2 Text condensates for subgroups within the theme ‘sportification of training’
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Table 3 Text condensates for subgroups within the theme ‘modes of orientation’
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Table 4 Text condensates for subgroups within the theme ‘transferable skills’
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Table 5 Text condensates for subgroups within the theme ‘Transfer opportunities’
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Sportification of training

Early in the analysis, it became clear that many informants viewed and spoke of surgical training in a way reminiscent of a sports activity, focusing on competition, performance, strategy, and optimisation. Several informants stated that the laparoscopic training became ‘like a sport’ to them (Table 2). A preoccupation with a competitive element seemed to facilitate commitment to training both in the simulated and clinical environment. In the simulated environment, timing and grading of training tasks were driving factors of the competitive aspect. In both training environments, the competitive aspect of training was primarily reflected as competition with oneself focusing on improving own performances in training tasks and procedures. However, some informants also found competition in an unarticulated comparison with peers within the centralised and clinical training environments. In the clinical environment, some narratives reflected a focus on comparing numbers of procedures with peers, whereas in the simulated environment informants looked to peers to compare progression pace. The competitive aspects within the simulated environment were regarded mainly as motivating and fun, whereas narratives on competitive aspects in the clinical environment were more equivocal. Timing was a particularly competitive element in the simulated training setting because the two proficiency tasks (“Peg Transfer” and “Suture with Intracorporeal Knot”) adopted from the fundamentals of laparoscopic surgery [31] were rated as grade A or B according to set time limits. While grade B was sufficient to pass the program, informants expressed a strong desire to achieve grade A to obtain a certificate with proof of excellence. Stories of trying to optimise and develop strategies for each step in the training tasks to improve speed were prevalent. For instance, an informant recalled, “Looking at those 48 seconds (the grade A time limit), you can only hold them (the pegs) for a maximum of four seconds if you want to get there. So, I try to count, so I know where I am. Then I do not have to look at that stupid clock that is counting too fast” (I-2). Likewise, in the clinical setting, narratives reflected a focus on optimising performance and time for each step in the procedures.

Generally, a step-by-step approach and strategy for improving performance and attaining proficiency in the training tasks were apparent. Informants’ narratives from the simulated setting largely resembled their accounts from the clinical setting, where they also divided procedures into sub-steps that they trained and strove to master. The step-by-step process recurred in informants’ descriptions of excellent, fluent surgical performances: “When I master each step and the transitions between the steps run smoothly, that is when I perform well. That is what I call flow” (I-7).

Modes of orientation

The text condensates in Table 3 provide insights into how informants expressed a visual orientation using actual visual inputs and mental visualisations in their planning, self-instruction and self-evaluation of training. The simulation-based training was influenced by informants’ visualisation of task performances assisted by viewing instructional videos and task demonstrations by instructors. Some sought additional instructions by searching the Internet for videos. A visual orientation was likewise present in the clinical setting, with informants using videos and inner renderings of excellent surgical performances to prepare for procedures. For example, one informant stated, “I have seen well-performed procedures, so I know what it is supposed to look like” (I-4).

Kinaesthetic learning experiences were prevalent. Informants described learning through the body, making sense of haptic input and noticing bodily movement and signals as part of their learning processes. Importantly, given the varied discourses, these findings should not be misinterpreted as an argument that the informants favoured a kinaesthetic learning approach or that it equated with broader embodied learning perspectives [32]. However, ‘learning by doing’ and experiences of internalising motor skills ‘through the body’ were salient in informants’ narratives in both training environments. For example, one informant recalled, “One or two days after (training), I was on call, and I experienced that my hands could suddenly do things (in the OR) that they could not do before” (I-3).

Informants described eliciting dialogues during their training. While informants in the centralised group could turn to the instructors for external dialogue during their training, the remote training group elicited internal dialogues for self-instruction. As one informant explained, “If I do not succeed, I stop and ask myself: ‘What can you do differently to make it easier and do it faster next time?’” (I-7). Narratives also illustrated how informants preferred their clinical supervisors to engage in explicit, instructional and reassuring dialogues in the OR: “The way I like to do it with my supervisor is to say everything I plan to do and why I plan to do it before I do it” (I-11). Moreover, informants expressed uncertainty about the unspoken: “One can get the feeling that something is unspoken ‘in the air’—that the supervisor will take over any minute because he is annoyed that nothing is happening. If I get that feeling, it is not constructive for my progress” (I-9).

To summarise, two main themes, sportification of training (i.e., competition, timing and step-by-step approach) and different modes of orientation (i.e., visual, kinaesthetic and dialogue) characterised informants’ narratives of being engaged in training. We found that these characteristics were present in both the simulated and the clinical training environment. Interpreted within the theoretical framework of SRL, these findings uncover characteristics of self-regulatory subprocesses, such as task analysis, self-control, self-observation and self-judgment within the cyclical process of self-regulated surgical training.

Transferable skills

A transferable skill is a general term for a skill that can be applied in different contexts. While many narratives centred around specific skills from the simulation-based training that trainees considered applicable in the clinical setting, others reflected how the simulation-based training influenced more generic skills, such as learning approach and training mindset.

As illustrated in Table 4, informants experienced improvements in ambidexterity and bimanual coordination in the OR due to training. In addition, several informants described improvements in their instrument handling and a general increase in their awareness of instrument selection. Interestingly, informants linked these skills to recognition in the OR. As expressed by one of the informants, “The nurses keep an eye on you. The more confident you are, the more they are on your side. If you handle things properly and know the name of the instruments, then they will hand them to you in a good way” (I-3).

Another important transfer outcome of the training program was improved visuospatial ability and hand-eye coordination. Informants referred to immediate improvements in these skills when attending laparoscopic procedures. Moreover, some informants experienced improvements in their ability to perform other endoscopic procedures (cystoscopies, colonoscopies, etc.). In addition to these noticeable and applicable improvements in skills, the training program triggered informants’ awareness of learning strategies and general approaches to training. For instance, one informant said, “I think it (the training program) has been an eye-opener on how to break learning situations down into smaller chunks” (I-11). Furthermore, the training program influenced informants’ training mindset by providing insight into their training potential. Awareness of their own skills and potential contributed to increased confidence, motivation and recognition of skills training as essential to obtaining and maintaining competencies as a surgeon.

Transfer opportunities

The informants were very preoccupied and reflective about their opportunities to perform in the clinical setting. Viewing the training program as an entry ticket, the informants regarded it as a useful argument for being allowed to perform in the OR: “Now I can say ‘I have been on this course, now I want to use my hands.’ As I said, it is an entry ticket to the fun stuff” (I-3).

Remarkably, at the same time, informants mentioned a lack of attention and recognition of their participation in the training program in their clinical work environment and were convinced that no supervisor would ever request their course diploma or bother about their training grades. Some informants described referring and hinting to their clinical supervisors about their course participation to argue for more procedural involvement. The informants had a general perception that creating opportunities to perform in the OR requires outreach and being visible. An informant explained, “You have to be skilled. You have to make yourself visible in everything you do. And you have to show them that you really want it. Otherwise, you will not get it. I have heard many times that ‘education is something you take. It is not something you get’” (I-11).

As illustrated in Table 5, the relational aspect was prominent in informants’ narratives on transfer of training. In particular, informants perceived their relationship with the clinical supervisor as decisive for their opportunities to perform in the OR. Difficulties in decoding this relational aspect were prominent, and informants described different strategies for navigating day-to-day interactions with their supervisors, trying to create opportunities to perform by obtaining mutual confidence and respect. Strategies ranged from purposefully seeking out well-known supervisors to asking peers for advice on how to approach certain supervisors.

Furthermore, organisational factors such as work planning and priorities were described as typical barriers to the transfer of training. For instance, an informant stated, “It is not taken into account in the work planning in any way—that I should be prioritised for attending in the OR after the training program” (I-5). Informants were frustrated about this lack of coherence between the training course and the clinical work and saw much potential for increased transfer outcomes in optimising this aspect.

Discussion

Surgery and skills training has previously been compared to other high-performance domains [33, 34]. This study substantiates this comparison by finding that trainees’ narratives on engaging in surgical training were reminiscent of accounts from engaging in a sports activity. Sportification can have two separate meanings. Firstly, it can refer to applying sports elements (e.g., rules, training regimes, performance standards, time regulations) in a non-sport activity. Secondly, it can refer to viewing, organising and regulating a non-sport activity in a way that resembles sports [35]. In the present training programme, elements and structures (e.g., grades, timing, proficiency levels) resembled sports elements. We found that the informants generally viewed, regulated and engaged in surgical training in a manner reminiscent of a sports activity (i.e., the second definition of sportification). They embraced competition and comparison of performances with themselves and others as an inevitable training regime. Furthermore, they accepted the external regulation of rules, exercises and proficiency criteria that rewarded or possibly induced a competitive mindset within the SBST program. These findings are perhaps not surprising since sports play a prominent role in popular culture and society in general [36, 37].

According to Zimmerman (2000), SRL involves three cyclical phases: forethought, performance and a self-reflection phase [15]. Our findings demonstrate characteristics of how trainees modulated and adapted their learning approaches during training. Trainees did this by sportification and by the presented different modes of orientation in training. We argue that the scaffolding of the PBT program supported trainees’ goal orientation and self-regulatory training processes. Written and visual instructions provided stepwise process goals that supported trainees’ self-instruction and visual orientation (imagery) in the performance phase. Our findings also suggest that further application of kinaesthetic learning principles may contribute to this phase, which is supported by a previous study [38] and aligns with established theories of skills acquisition [7, 39]. Opportunities for video reviewing and written summary feedback from instructors assisted trainees in the self-reflection and forethought phases. Correspondingly, a recent metanalysis advocates applying sport psychology techniques to improve clinical skills of health professionals [40]. Interestingly, we found that the self-regulatory learning processes in both the simulated and the clinical environment mirrored some of these sports psychology techniques, namely imagery, self-talk and goal setting. These findings raise questions about how instructional designers and clinical and educational coordinators may support and benefit from trainees’ self-regulatory processes in ways that transcend training environments. Future research should explore how simulation-based training can support ongoing SRL in clinical practice and, in turn, investigate how that affects the transfer of training.

Although the primary purpose of this exploratory study was not comparative, we did notice slight differences between the two different training groups. While the remote training group only had themselves to compete with, some informants from the centralised training group also mentioned a competitive orientation towards peers. The same was true for the orientation towards dialogues during training; the remote training group elicited an inner dialogue, while the centralised group relied more on conversations with the instructors who were present. These findings add to research suggesting that trainees in a proctored and grouped training setting somewhat rely on observing and mirroring peer performances and receiving concurrent feedback from instructors [14]. Similarly, we found that trainees engaging in remote laparoscopic training also viewed and regulated their training in ways resembling those of a sports activity. Despite being unable to interact with instructors and peers concurrently, they used similar modes of orientation in their training. These findings add to research that investigated the effect of different types of instructor feedback and the value of video instructions in basic surgical skills training [41,42,43].

Trainees had ambiguous perceptions and experiences of transfer of training to the clinical environment. On the one hand, they reported applicable performance improvements from training and viewed the program as an ‘entry ticket’ to the OR. On the other hand, they struggled for opportunities to transfer and expressed difficulties navigating the relational aspects and overcoming organisational barriers for transfer of training. Previous SBST studies have primarily focused on training design and on establishing evidence for transfer of training by demonstrating performance improvements in the OR after training [2]. As mentioned above, established models of the transfer process emphasise that the actual conditions of transfer are influenced by two other main factors, namely trainee characteristics and the work environment [4,5,6]. Even though an investigation of trainee characteristics (e.g., cognitive ability and motivation) from a psychological perspective was outside the scope of this study, we generally found the first-year trainees to be adept and highly motivated individuals. Evidence from various training domains emphasise that transfer climate, support, opportunity to perform and post-training follow-up in the work environment critically influence the conditions of transfer [4,5,6]. We found that trainees did not experience adequate support and recognition of their participation in SBST in the clinical work environment. In transitioning from the simulation-based training setting to the clinical setting, trainees experienced lack of timely opportunities to intensify relevant surgical activities, partly due to what they experienced to be inadequate work planning. The findings of a previous study by our research group support the idea that these experiences reflect reality [44]. Further studies that focus on the influence of the clinical work environment on the transfer of training process are recommended.

Strengths and limitations

This study contributes to existing knowledge of surgical training by providing insights into the more specific characteristic processes of surgical training engagement and transfer of training. Our study was informed by well-established theories on SRL and transfer of training. This theory-informed research approach allowed us to draw from existing knowledge from the outset of the study while at the same time using the theories as lenses for analysing and interpreting new insights from our specific subject field based on narrative data [45]. On the other hand, a robust theoretical outset may limit the researchers’ receptiveness to other perspectives. We tried to overcome this limitation by bracketing our preconceptions and undertaking a collaborative approach to the analysis [29].

By conducting two interviews separated in time, we allowed informants to develop and elaborate on their experiences, contributing to an in-depth understanding of the subject matter. Sharing sample population with a comparative study harbours the risk that this would divert focus from our intended research objectives. However, the present study served a different purpose, and research questions and methods differed substantially from our previous work [24]. We did not find that the informants’ narratives reflected a substantial focus on allocated training groups or the derived consequences thereof. However, we might arguably have identified more differences if a further comparison of the two training modalities had been the focus of the present study.

The extent to which the findings and conclusions drawn from this type of study applies to other contexts is always disputable. The purpose of this exploratory study was to contribute to further understanding SRL processes and perspectives of transfer in the transition between simulation-based and clinical surgical training. As such, the findings may have utility across contexts, where similar training situations and transitions exist.

Conclusions

In developing postgraduate training initiatives, instructional designers should consider how to support learning processes and the transfer of training into clinical practice. Knowledge of educational supports and factors influencing the transfer process is essential in this endeavour and understanding trainees’ perspectives is key. Further studies that address the supervisor and organisational perspectives are warranted.

The insights from our study suggest that instructional designers may leverage the sportification of training in motivating engagement and supporting trainees in self-regulatory training processes that transcend training environments. In addition, our findings substantiate how educational supports affect trainees’ self-regulatory learning processes.

We have elaborated on the complexity of the transfer process in finding that trainees struggle in aligning their expectations with the actual clinical opportunities and in navigating relational and organisational transfer aspects in the clinical work environment. Accordingly, we argue for adopting a more holistic approach to the transfer of surgical training that focuses not solely on training design and methods but acknowledges that transfer occurs before, during and after training and should be supported at every stage. In that endeavour, instructional designers should collaborate closely with clinical training coordinators to ensure that supportive measures for transfer are in place in both training environments and to better align training opportunities with clinical work planning.