Improving procedural performance through warm-up and mental imagery

Abstract

Anaesthetists are expected to develop and maintain expertise in procedural skills with low or zero tolerance for error. The more complex technical skills, as required for advanced airway management or ultrasound-guided procedures, require expertise in navigation, hand-eye coordination, and visualizing distant structures. Furthermore, learning and maintaining skills on patients is no longer acceptable when alternatives exist. Reduced working hours further limit opportunities for the traditional experiential learning of advanced procedural skills.Our surgical colleagues, faced with similar issues, have responded over the last few decades with extensive research and innovation aimed at optimising procedural performance and reducing error. Simulation and skills laboratories are now required by the Accreditation Council for Graduate Medical Education American (ACGME) and the research questions have moved from does simulation work to defining the elements of skills training and pre-procedure preparation that work best in different contexts. 1 However, even our surgical colleagues have struggled to integrate simulation-based skills programs into the regular training environment. The pre-procedural warm-up, by bringing simulators into the theatre suite, may help to embed simulation practice into the standard preparation for surgery. A further approach, also the subject of recent intense research activity, is mental imagery, a structured process of mental rehearsal prior to the procedure. Warm-up and mental imagery are well established in sports and the arts prior to a performance, and increasing evidence supports their value in surgery in improving performance and reducing procedural error.In this issue, Samuelson and colleagues 2 describe a warm-up for fibre-optic intubation (FOI) for anaesthesia trainees. They randomised subjects to a control group with no warm-up and an intervention group who undertook a 5-minute warm-up using a series of cases of varying difficulty on a virtual reality bronchoscopy simulator. Subsequent performance of asleep FOI in healthy patients with no anticipated airway difficulties showed significantly better performance in the warm-up group. I could find no other studies reporting pre-procedural warm-up in anaesthesia and only one on mental imagery. 3 Of relevance, Wright and colleagues 4 reported that the rates of errors, such as administering the wrong medication or blood, inadequate depth of anaesthesia, and oesophageal intubation, decrease after the first operations of the day, suggesting that anaesthetists' performance may improve after a period of warm-up.I undertook a Medline search of the literature on warm-up and mental imagery for procedural skills and provide here a narrative review with reference to potential application in anaesthesia. Pre-procedural warm-upWarming up prior to a race or a musical performance is established practice and supported by a wealth of evidence. The similarities between athletic or artistic performance and the performance of a surgeon embarking on a comple...

Effect of a warm‐up sample on stabilizing the performance of untrained panelists in time–intensity evaluation

“…In the session in which we observed the effect of a warm-up sample, perceived intensity was significantly lower in the first trial than in subsequent trials. Several studies targeted at athletes (Cervantes & Snyder, 2011;Fradkin, Zazryn, & Smoliga, 2010;Shellock & Prentice, 1985), surgeons (Lee et al, 2012;Samuelson et al, 2016;Weller, 2016), and vocalists (Moorcroft & Kenny, 2012 reported that physical warm-up improves physical performance. Furthermore, other studies reported improvement of cognitive performance following physical warm-up (Elsworthy, Dascombe, & Burke, 2013;Hogan, Mata, & Carstensen, 2013;Pennington & Hanna, 2013) and improvement of cognitive performance following cognitive warm-up (Dinner & Duncan, 1959;Thune, 1951).…”

Rehearsal simulation for antenatal consults

“…Mental imagery practice, defined as "symbolic rehearsal of an activity in the absence of any gross-muscular movements", to rehearse a cognitive task has been reported to be limited in its effectiveness. 22 For example, mental imagery practice to rehearse for crisis management and resuscitation in anesthesia did not yield objective improvements in performance, especially in the novice. 28,29 While difficult conversations with families does not involve any procedural or hands-on skills in a traditional sense, it does involve components that are routine and recurrent, as well as aspects that require reflective, nuanced decision making.…”

“…20 Surgeons simply mentally rehearsing an impending surgery, without performing any physical simulation, also benefited from improved skills, decreased stress for the actual surgical task, and improved communication with their team. [21][22][23] If rehearsal simulation is effective for procedural skills and team communication, can it be applied to patient and family communication skills? The objective of our study was to explore how rehearsal simulations for antenatal consults affect how residents learn to engage in difficult conversations with families in the NICU.…”

Refreshing medical students’ intravenous-cannulation skills: a blinded observer three-arm randomised comparison of mental imagery, part-task trainer simulation and written instructions

“…However, when considering the effects of warm-up on the different aspects of psychomotor performance, Paschold et al 27 found that these were affected by the nature of the warm-up, the type of surgery and the expertise of the surgeon. This suggests that optimal warm-up strategies are task-specific and procedure-specific and may change with varying expertise, 19 consequently yielding conflicting results.…”

“…Several studies have investigated mental imagery in postgraduate settings,16–19 but only one small study used it during intravenous cannulation performed by undergraduate students 20. Mental imagery, due to its simplicity, could facilitate learning and skill maintenance in undergraduate medical student curricula, and release educators from the physical and temporal presence of bedside teaching.…”