In this study, we aimed to gain insight into current and ideal Dutch urological skills training and presented the outline of the D-UPS program, including the assessment of design characteristics that may increase its acceptability. The results of this study show that Dutch residents in urology currently learn their practical skills ‘by doing’, according to the classic master-apprentice model. Ideally, they would prefer to practice certain procedures on simulation models first, especially in endourology. The acceptability of implementing the newly developed D-UPS program is high. Residents and program directors think this program would provide all residents in urology with a nationwide uniform foundation for training urological techniques. Design characteristics that increase acceptability of the D-UPS/related practical skills training programs are discussed in the next paragraphs.
One of the expected difficulties in implementing the skills training program was ‘materials’. Residents and program directors expressed the belief that practical skills training is only useful if residents practise on realistic, i.e. high fidelity models. This is contradictory to the present outline of the D-UPS program, in which low fidelity models are preferred. In the decision of which simulator to use for skills training it is of paramount importance that the simulator can serve the goal of training. In the development of the D-UPS program, first the learning objectives for training a certain skill were defined and subsequently a suitable simulator was sought. If possible the choice was for a simulator of low fidelity. This was not only to limit the cost, but also to simplify logistics and because for certain basic skills no high fidelity models are available. In the literature it is confirmed that, especially for training basic skills, low fidelity simulators can be of great value. Matsumoto et al. compared the effectiveness of a strictly didactic training in ureteroscopy with training on a low fidelity model and on a high fidelity model [22]. They showed that training on the low fidelity model had the same degree of benefit as training on the high fidelity model, and both had a significantly higher degree of benefit than the didactic session alone. Since the first eight training sessions focus on basic urological procedures, low fidelity simulators could be suitable. However, when it comes to training more advanced skills sometimes high fidelity simulators, e.g. virtual reality simulation, will be needed. For successful implementation of practical skills training using low fidelity models, it will be of great importance that residents and program directors understand the value of these training models. McDougall et al. designed a 4-year curriculum for urology residency training, with frequent training sessions using mainly low fidelity models [14]. Although this study included only 8 residents so far and evaluation is ongoing, initial results are encouraging. Most participants stated that this 4-year curriculum provided a better learning experience than the curriculum without structured skills training. Furthermore, while residents and program directors in our study expected one-hour training sessions to be insufficient for some parts of practical skills training, McDougall and colleagues found that acceptance of a weekly hour of training was high [14]. In their study, the majority of residents indicated that one hour of training was sufficient and provided new clinical information.
Another important expected obstacle, according to residents and program directors in our study, was the logistic integration of practical skills training into the working week. Structured scheduling was suggested as a condition for successful implementation. The importance of scheduling training sessions and making them obligatory was emphasized by Chang and colleagues, who examined the effectiveness of voluntary training in a simulation laboratory as part of the surgical curriculum [23]. They showed that voluntary use of a surgical simulation laboratory resulted in minimal participation in the curriculum.
Another expected difficulty in implementation was motivation, in particular the motivation of program directors. This concern is in line with the findings of Stefanidis et al., who described the implementation of a proficiency-based laparoscopic skills curriculum in a general surgical residency program and found that this can only be achieved successfully if dedicated faculty and scheduled training time are ensured [24]. Hence, one of the key success factors for implementation is motivating program directors for their educational role in urology skills training programs.
A remarkable finding was the significant difference in views on the current availability of structured practical skills training in the local teaching hospitals. This was mentioned as current practice by 12 % of residents versus 44 % of program directors. A possible explanation for this difference could be that residents and program directors have different perceptions of the definition of practical skills training, or that some of the residents started their residency only recently, and might not yet have been involved in practical skills training.
To our knowledge, the D-UPS program would be the first curriculum in Europe that provides yearly repetitive practical skills training in the local hospital setting, including the use of the local equipment. The first step in the development and implementation of a new curriculum is the performance of training needs analysis and the establishment of acceptability, which was evaluated in this study. Although the results of this study describe the Dutch situation, which limits generalizability, the outline of the D-UPS program could serve as a blueprint for skills training in other surgical specialties in the Netherlands. Moreover, extrapolation to European countries would be possible, especially those countries with similar residency programs, since up till now there have been limited initiatives for non-patient related skills training curricula.
Where possible, existing validated simulation training is incorporated in the D-UPS program, to avoid duplication and expense. For example, the tasks used in the basic laparoscopy training of the D-UPS program are derived from the validated European Basic Laparoscopic Urological Skills program [21]. Other possibilities should be further explored.
We acknowledge that validation of the curriculum is of paramount importance in the process of innovating educational programs. However, this is a multi-year process and is considered to be the endpoint of the implementation process. In the process towards this validation it is important to inform colleagues in the field of curriculum development regarding the ongoing developments, since they might profit from the outline of this program an our findings on design characteristics that increase the acceptability of implementing practical skills training in a non-patient-related setting.
The use of a questionnaire and interviews is relatively subjective and might have led to socially desirable answers. To counter this effect, the interviews were moderated by an independent educational expert, and anonymity was guaranteed. Furthermore, residents and program directors were interviewed in separate groups to ensure freedom and safety in expressing opinions. As in any qualitative study, investigator objectivity is a limitation [25]. This issue was countered by having 25 % of the transcripts coded by two researchers separately.