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• Journal article
  Plumptre I, Mulki O, Granados A, Gayle C, Ahmed S, Low-Beer N, Higham J, Bello Fet al., 2017,

  Standardizing bimanual vaginal examination using cognitive task analysis.

  , International Journal of Gynecology & Obstetrics, Vol: 139, Pages: 114-119, ISSN: 1879-3479

  OBJECTIVE: To create a standardized universal list of procedural steps for bimanual vaginal examination (BVE) for teaching, assessment, and simulator development. METHODS: This observational study, conducted from June-July 2012 and July-December 2014, collected video data of 10 expert clinicians performing BVE in a nonclinical environment. Video data were analyzed to produce a cognitive task analysis (CTA) of the examination steps performed. The CTA was further refined through structured interviews to make it suitable for teaching or assessment. It was validated through its use as a procedural examination checklist to rate expert clinician performance. RESULTS: BVE was deconstructed into 88 detailed steps outlining the complete examination process. These initial 88 steps were reduced to 35 by focusing on the unseen internal examination, then further refined through interviews with five experts into 30 essential procedural steps, five of which are additional steps if pathology is suspected. Using the CTA as a procedural checklist, the mean number of steps performed and/or verbalized was 21.6 ± 3.12 (72% ± 10.4%; range, 15.9-27.9, 53%-93%). CONCLUSION: This approach identified 30 essential steps for performing BVE, producing a new technique and standardized tool for teaching, assessment, and simulator development.

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• Book chapter
  Kneebone RL, Nestel D, Bello F, 2017,

  Learning in a simulated environment

  , A Practical Guide for Medical Teachers, Editors: Dent, Harden, Hunt, Hodges, Publisher: Elsevier, Pages: 92-100, ISBN: 9780702068911

  This highly regarded book recognises the importance of educational skills in the delivery of quality teaching in medicine. The contents offer valuable insights into all important aspects of medical education today.

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• 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.

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• 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.

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• 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.

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• 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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• Conference paper
  Mulki O, Plumptre I, Granados A, Ahmed S, Low-Beer N, Higham J, Bello Fet al., 2016,

  Bimanual vaginal examination: Using innovation through cognitive task analysis to standardise practise and enhance teaching

  , Publisher: Wiley, Pages: 205-205, ISSN: 1470-0328
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• Journal article
  Powell P, Sorefan Z, Hamilton S, Kneebone R, Bello Fet al., 2016,

  Exploring the potential of sequential simulation.

  , The Clinical Teacher, Vol: 13, Pages: 112-118, ISSN: 1743-498X

  CONTEXT: Several recent papers have highlighted the need for better integrated care to improve health care for children and families. Our team spent a year exploring the potential of 'Sequential Simulation' (SqS) as a teaching tool to address this need with young people and multidisciplinary teams. SqS allows the simulation of a series of key events or 'crunch points' that come together to represent the patient journey, and highlights the impact of individuals on this journey. The pilot SqS was based on an adolescent with asthma - a common condition that requires excellent multidisciplinary care with the patient at the centre. INNOVATION: The SqS was designed using transportable sets and audio-visual equipment to create realism. Actors were employed to play the roles of the young person and mother and health professionals played themselves. The SqS was run at different events with varied audiences, including young people, health professionals and teachers. It was used to explore the difficulties that can arise during a patient journey, the importance of communication throughout, and to highlight the significance of each individual in the patient experience. RESULTS: The SqS was met with enthusiasm and felt to be an innovative and effective way of promoting better teamwork and communication. It was well received at a school asthma education event for pupils and community teams, demonstrating its varied potential. The year was the first step in the introduction of this exciting new concept that has the potential to help promote better integrated care for paediatric patients and their families. Our team spent a year exploring the potential of 'Sequential Simulation' as a teaching tool [to provide better integrated care].

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