Training activity information
Details
Safely perform and report anorectal physiology investigations for patients with the following presentations:
- Faecal incontinence
- Obstructive defaecation syndrome
- Anal fissure
- Obstetric injury
- Anal fistula
- Pre- and post-surgical
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 performing anorectal manometry, rectal sensation testing, and balloon expulsion testing, and producing a high-quality report.
- Consider how the learning outcomes apply, specifically in relation to identifying expected normal and abnormal physiological findings (e.g., low squeeze pressure in incontinence, paradoxical contraction in ODS) for the specified range of conditions.
- Discuss with your training officer to gain clarity of what is expected of you in relation to patient coaching for defaecation manoeuvres, managing pain (e.g., with anal fissure), and integrating the results of multiple tests into a comprehensive report.
- What is your prior experience of this activity?
- Think about what you already know about the principles and performance of basic anorectal physiology investigations and the pathophysiology of the listed conditions.
- Consider possible challenges you might face during the activity, such as patient inability to cooperate with manoeuvres (e.g., balloon expulsion) due to pain or dyssynergia, or difficulty obtaining accurate data for specific conditions.
- 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 a patient’s pain level prevents safe continuation of the procedure (e.g., anal fissure case), or if unexpected physiological findings require immediate senior verification.
- Acknowledge how you feel about performing advanced physiological tests for a complex range of clinical presentations.
- What do you anticipate you will learn from the experience?
- Consider the specific skills you want to develop, such as advanced patient coaching techniques, real-time data acquisition adapted to complex patients, and efficient integration of multiple test findings into a high-quality report.
- Identify the specific insights you hope to gain into the physiological manifestations of various anorectal conditions as reflected in the manometric data.
- What additional considerations do you need to make?
- Consult actions identified following previous experiences of performing anorectal physiology investigations regarding technical accuracy or patient management.
- Identify important information you need to consider before embarking on the activity, such as reviewing the patient’s detailed history and local protocols specific to these complex clinical presentations (e.g., pre-surgical clearance).
In action
- Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst safely performing the anorectal physiology investigations?
- Are you encountering situations such as:
- Patient pain (e.g., due to an anal fissure) prevents safe continuation of the manometry or balloon expulsion test?
- The physiological data suggests a highly specific or unusual abnormality (e.g., complex obstructive defaecation pattern) that was not anticipated by the simple referral?
- Patient is unable to cooperate with required manoeuvres (e.g., defaecation effort) despite clear coaching, challenging the test validity?
- 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 protocol sequence or patient coaching?
- Consider the steps you are taking in the moment, such as:
- Immediately pausing the procedure and providing empathetic communication to assess the severity of the patient’s pain, adjusting the plan accordingly.
- Adapting the test to focus on alternative measures (e.g., maximum resting pressure instead of balloon expulsion) if cooperation is limited.
- How are you feeling in that moment? For instance, are you finding it difficult to adapt the protocol while maintaining data integrity? Is it affecting your confidence in obtaining diagnostically relevant data?
- What is the conclusion or outcome?
- Identify how you are working within your scope of practice. For example, are you successfully modifying the test sequence to accommodate patient limitations? Or are you needing support because the unexpected severe pain or complex finding requires clinical review before the procedure can be safely terminated or reported?
- What are you learning as a result of the unexpected development? For example, are you mastering specific patient management strategies for performing anorectal manometry in the presence of anal fissure? Or gaining insight into complex physiological trace patterns related to obstructive defaecation?
On action
- What happened?
- Begin by summarising the key steps you took when performing the anorectal physiology investigations (manometry, sensation, balloon expulsion) and reporting the findings for the specific clinical presentation.
- Consider specific events, actions, or interactions which felt important, such as how you managed patient pain (e.g., due to an anal fissure) or how you adapted patient coaching to achieve valid manometric manoeuvres (e.g., defaecation effort in ODS).
- How did you feel during this experience, e.g., did you feel focused on technical accuracy or challenged by the ambiguity of the physiological findings for the specific condition?
- Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately modifying the test protocol or terminating the procedure when patient pain prevented safe continuation.
- How has this experience contributed to your developing practice?
- Identify what learning you can take from this experience regarding performing and interpreting advanced anorectal studies.
- What strengths did you demonstrate, e.g., effective patient coaching or accurate identification of physiological findings related to the specific presentation?
- What skills and/or knowledge gaps were evident, e.g., uncertainty in interpreting complex trace patterns (e.g., high resting pressure in anal fissure) or difficulty assessing balloon expulsion parameters accurately?
- Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in safely performing and interpreting anorectal physiology investigations for a range of conditions?
- Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding whether persistent equipment artefacts or ambiguous physiological readings compromised the diagnostic quality of the study, and how you reacted to this.
- What will you take from the experience moving forward?
- Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving your interpretation methodology and report drafting for complex anorectal conditions.
- What will you do differently next time you approach performing and reporting these investigations, for instance, by proactively reviewing normal values and pathological traces for conditions like Obstructive Defaecation Syndrome (ODS) and faecal incontinence?
- Do you need to practise any aspect of the activity further, such as mastering patient coaching techniques for defaecation manoeuvres or key learning outcomes related to performing and interpreting investigations safely?
Beyond action
- Have you revisited the experiences?
- How have your subsequent experiences of interpreting endoanal ultrasound scans or reviewing patient outcomes since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, performing an investigation on a patient with chronic pain (e.g., anal fissure) forced you to re-evaluate the diligence of your patient coaching and procedural adaptation during your first attempt at this training activity.
- Considering what you understand about performing investigations safely, managing complex findings, and integrating multiple test results 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 investigation technique and report synthesis based on further learning and experiences? For example, how you proactively reviewed and integrated non-standard techniques for obtaining valid balloon expulsion data from patients with suspected obstructive defaecation syndrome, demonstrating you have adapted improvements based on further learning.
- Has discussing complex physiological trace patterns (e.g., paradoxical contraction) or the impact of procedural difficulty on data integrity 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 pain management was critical to obtaining diagnostic data refined your understanding of the critical nature of performing and interpreting anorectal physiology investigations safely.
- How have these experiences impacted upon current practice?
- How has the learning from this initial training activity, in combination with previous lower GI module experiences and multidisciplinary participation, contributed to your overall confidence and ability in performing and interpreting anorectal physiology investigations, particularly in preparing for assessments like Case-Based Discussions (CBDs)? For example, how your accumulated ability in interpreting complex manometry traces for various pathologies now enables you to confidently discuss the diagnostic rationale and findings for a patient with faecal incontinence during a CBD assessment.
- How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to investigation planning and real-time adaptation?
- 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 specialist nurse immediately when patient distress or unmanageable symptoms compromise the safety of the procedure, recognising this falls outside routine procedural execution scope.
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 3 |
Outcome
Perform and interpret anorectal physiology investigations safely in a range of anorectal conditions, identifying normal and abnormal findings, and produce high-quality reports. |