DISCUSSION
COMPLICATIONS
The most important finding of this study was that those who trained in a team exhibited superior nontechnical skills, performing the operations more efficiently, and with fewer technical errors when compared with those who trained alone. The use of iVR simulation to facilitate the delivery of this training seems to be feasible and highly effective.The association between good teamwork skills and improved patient safety is now well established.A second benefit of the team training was increased efficiency, with a 33% reduction in overall procedure time recorded. This may also have a beneficial effect on patient safety; there is now a substantial body of evidence linking prolonged operation times to an increased risk of developing significant complications.One explanation for the association between superior nontechnical skills and reduced intraoperative error could be related to flattening hierarchical gradients, allowing all team members to communicate freely, making operations safer and less error-prone.The concept of interprofessional education (IPE) has evolved recently to introduce this training at an early career stage. Multiple studies support this idea with data suggesting training medical students and technicians together leads to superior nontechnical skills development, better interprofessional relations, and superior patient outcomes.Although there is a paucity of data using iVR in a collaborative approach, it has demonstrated success in training surgeons and scrub technicians individually. One of its advantages over other forms of high-fidelity simulation training is that it does not require significant resources or equipment. Headsets can now be purchased for <$500 and are easily transportable.There are several important factors to consider when applying this data and moving forward. The iVR training program utilized in the present study delivered substantial benefits when used for team training, however was time-intensive. In time-pressured health care systems, implementing a 5-session team iVR curriculum may not be practical, which questions whether these benefits can be obtained over a shorter time period. The authors feel the main reasons for the team groups' superior performance, were related to familiarity, collective PS, and ability to communicate freely without the barriers of work-based hierarchy. This allows teams to work better together and complete the sequence of steps with greater accuracy while being more efficient. However, individual role technical ability was not influenced by team training. There were no differences seen in component orientation (acetabular anteversion and inclination) between groups. This could be because there is little teamwork involved in the surgeon orientating the components. These aspects of the training could potentially be taught separately from a team training focussed intervention, to maximize efficiency.Another important consideration is whether the benefits seen could be delivered in an alternative medium. The iVR team training allowed participants to gain teamwork skills organically through repetitive practice. However, it may be possible to expedite the development of these skills using targeted teamwork interventions. Classroom or simulation-based team training has been utilized in a number of studies with encouraging results. CRM training, which originates in the aviation industry, focuses on improving nontechnical skills. A study by McCulloch et alThis study has several limitations. First, although baseline scores were similar between groups, the novice scrub technician group was a diverse mix of student nurses, medical students, newly qualified scrub technicians, and anesthetic assistants. Although the primary outcome was related to overall team performance and not role-specific, this may have introduced some bias and limited how these results can be generalized to the wider population of scrub technicians. In addition, although randomized, when comparing team and solo surgeon groups, those in the team group had marginally more years of residency experience. Although this was not statistically significant, this group also had higher baseline knowledge scores which could have biased the final assessment results. To mitigate a preexisting knowledge discrepancy, we provided an introductory presentation to all participants; however, we did not repeat the baseline assessment to ensure knowledge parity had been achieved. Second, the real-world assessment was conducted in a simulated setting on a high-fidelity model and focused on one operation. This means we cannot comment on how this performance would translate into a real operating room or across different surgical disciplines. Third, although the iVR training modules were identical between solo and team-trained groups, the solo participants were provided with a perfect avatar playing the counterpart role. This could have introduced some bias in their ability to retain information. Finally, as this was a simulated study, the true impact of this intervention on patient safety in the real-world is as yet unknown; this could form an interesting area for future research.