Training activity information
Details
Intubate the anorectum with an anorectal manometry catheter and confirm the correct positioning
Type
Entrustable training activity (ETA)
Evidence requirements
Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion.
Reflection at multiple timepoints on the trainee learning journey for this activity.
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
- What does success look like?
- Identify what is expected of you in relation to safely and successfully intubating the anorectum with the manometry catheter and accurately confirming the correct anatomical positioning.
- Consider how the learning outcomes apply, specifically in relation to performing the investigation safely, ensuring calibration is correct, and demonstrating sensitivity to the patient’s comfort during intubation.
- Discuss with your training officer to gain clarity of what is expected of you in relation to the correct technique for insertion, the anatomical landmarks for positioning, and how to recognise correct positioning on the manometry tracing.
- What is your prior experience of this activity?
- Think about what you already know about performing intubations or similar procedures. Are you familiar with the different types of anorectal manometry catheters?
- Consider possible challenges you might face during the activity, such as patient discomfort leading to resistance, difficulty advancing the catheter, or incorrectly recognising tracing cues that confirm positioning.
- Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if you encounter significant resistance during intubation or if the tracing fails to confirm correct positioning after initial troubleshooting attempts.
- Acknowledge how you feel about undertaking this intimate and practical procedure.
- What do you anticipate you will learn from the experience?
- Consider the specific skills you want to develop, such as safe and effective catheter insertion technique, confirming correct positioning using technical tracing cues, and applying adaptation strategies to minimise patient discomfort.
- Identify the specific insights you hope to gain into how patient anatomy might affect intubation technique, and the importance of pre-intubation checks, such as performing the catheter calibration.
- What additional considerations do you need to make?
- Consult actions identified following previous experiences of performing physical procedures or technical setup.
- Identify important information you need to consider before embarking on the activity, such as reviewing the specific intubation technique used in your department, ensuring the catheter is calibrated correctly before intubation, and reviewing DRE findings that might affect intubation.
In action
- Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst inserting the manometry catheter?
- Are you encountering situations such as:
- Significant anatomical resistance or patient discomfort makes catheter insertion difficult, challenging the safety and smooth execution of the procedure?
- Initial manometry readings or anatomical landmarks conflict, making it challenging to confirm the correct positioning of the catheter, compromising data quality?
- The catheter or equipment malfunctions during the intubation process, requiring immediate technical troubleshooting?
- How are you reacting to the unexpected development?
- How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to insertion angle, lubrication, or tracing verification technique?
- Consider the steps you are taking in the moment, such as:
- Immediately pausing insertion and offering reassurance or adjusting technique to minimise patient discomfort
- Troubleshooting equipment connections or re-checking anatomical landmarks to confirm correct positioning
- How are you feeling in that moment? For instance, are you finding it difficult to maintain technical precision while focusing on patient comfort? Is it affecting your confidence in confirming correct anatomical positioning using the initial readings?
- What is the conclusion or outcome?
- Identify how you are working within your scope of practice. For example, are you successfully troubleshooting minor issues and confirming correct positioning on the trace? Or are you needing support because the inability to confirm correct positioning or a persistent equipment malfunction requires senior technical intervention?
- What are you learning as a result of the unexpected development? For example, are you mastering a more efficient technique for troubleshooting minor equipment issues? Or gaining insight into correlating insertion depth with tracing cues to confirm placement?
On action
- What happened?
- Begin by summarising the key steps you took when applying lubrication, inserting the anorectal manometry catheter, advancing it to the correct depth, and using the pressure recording system to confirm accurate anatomical positioning.
- Consider specific events, actions, or interactions which felt important, such as how you managed the fine motor control required for insertion to minimise patient discomfort, or how you correctly identified the high-pressure zone corresponding to the anal sphincter on the manometric trace.
- Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately withdrawing and slightly adjusting the catheter direction when initial resistance was encountered, ensuring smooth and safe intubation.
- How did you feel during this experience, e.g., did you feel focused on achieving technical precision or concerned about ensuring the recording apparatus was functioning correctly?
- How has this experience contributed to your developing practice?
- Identify what learning you can take from this experience regarding the technical procedure of intubation and the necessity of real-time confirmation using manometric data.
- What strengths did you demonstrate, e.g., successful application of lubrication to ensure smooth insertion?
- What skills and/or knowledge gaps were evident, e.g., difficulty distinguishing between technical artefact and subtle pressure readings when confirming placement?
- Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved?
- Has your practice improved in efficiently confirming the catheter positioning using technical landmarks?
- Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding whether persistent pressure instability indicated a technical malfunction rather than physiological variation, and how you reacted to this.
- What will you take from the experience moving forward?
- Identify the actions you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to refining the fine motor skills required for safe catheter insertion and rapid trace interpretation for positioning.
- What will you do differently next time you approach intubating the anorectum, for instance, by proactively performing a systematic pre-intubation check of the recording system to eliminate technical variables?
- Do you need to practise any aspect of the activity further, such as reading the real-time pressure trace to confirm correct anatomical positioning or key learning outcomes related to confirming correct equipment positioning?
Beyond action
- Have you revisited the experiences?
- How have your subsequent experiences of performing the full investigation or analysing results since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, identifying tracing artefacts caused by slight catheter movement during patient manoeuvres, forced you to re-evaluate the initial positioning verification and stability checks you applied during intubation during your first attempt at this training activity.
- Considering what you understand about anatomical verification, accurate positioning, and how poor placement contributes to inaccurate data now, were the actions or considerations you identified after your initial reflection on this training activity sufficient?
- How have you since implemented or adapted improvements in your intubation technique and technical verification process based on further learning and experiences? For example, how you proactively ensured precise confirmation of the high-pressure zone on the manometric trace to confirm correct placement prior to commencing the study.
- Has discussing difficult intubations or situations where positioning was challenging to confirm or the impact of inaccurate positioning on data quality with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a case where inaccurate positioning required repeating the procedure, refined your understanding of the critical nature of meticulous pre-study setup and technical verification.
- How have these experiences impacted upon current practice?
- How has the learning from this initial training activity, in combination with subsequent practical procedure experiences, contributed to your overall confidence and competence in intubating the anorectum, applying anatomical knowledge, and verifying technical steps, particularly in preparing for assessments like Direct Observations of Practical Skills (DOPS)? For example, how your accumulated ability in confirming correct anatomical positioning now enables you to confidently proceed directly to data acquisition during the practical assessment.
- How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to procedure execution and technical verification? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Training Officer or technical support immediately when a problem with the catheter prevents confirmation of the correct position, compromising data integrity, recognising this falls outside routine technical troubleshooting scope.
- Looking holistically at your training journey, how has this initial intubation experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to performing the investigation safely and recognising problems and artefacts? For example, how this foundational experience has supported your development in practicing safely by providing the necessary knowledge base for the subsequent learning outcomes focused on analysing the results accurately.
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 1 |
Outcome
Describe the requirements of anorectal physiology investigations including indications and contraindications, and take a patient history. |
| # 5 |
Outcome
Perform, analyse and report anorectal physiology investigations in a range of patient conditions adapting the procedure to answer the scientific question and to meet the patient’s needs. |
| # 6 |
Outcome
Perform routine maintenance and calibration of anorectal manometry equipment, recognising problems and artefacts which may result in an inaccurate study being performed. |
| # 7 |
Outcome
Apply and adapt their approach to the patient’s individual tolerance, personal experience and anxieties, demonstrating sensitivity to the emotional implications of intimate and invasive investigations on a patient’s wellbeing. |