Principles and Practices of Instructional Design (ID) in surgical education - a case study on an Instructional course on Peripheral nerve surgery
Contents
Title of course: Instructional course on Peripheral nerve
surgery
An introduction
The Problem
Theoretical position and
rationale in the instructional design
Factors to be addressed
Identifying the
instructional goal
Instructional Analysis
Entry Behaviours and
Learner Characteristics
Development of the
Performance Objectives and Assessment
Instructional Strategy
Instructional Materials
Formative Evaluation
Summative Evaluation
Conclusions
References
Title of course: Instructional course on Peripheral
nerve surgery
This paper is part of the assignment for the HMID 5003: Principles and Practices of Instructional
Design (ID). The assignment will cover
the following points. It will identify a real world problem of a skill gap in
hand surgery and will use the theories of instructional design to analyse the
instructional needs in the problems and then generate solutions using
principles of ID. Based on the individual needs of the learners and entry
behaviour and characteristics, the framework will develop instructional activities
and materials allowing for effective and efficient transfer of information and
skills allowing for adequate feedback and assessment to achieve the stated
objectives of the instructions. It will include generation of appropriate tools
to evaluate the effectiveness of the whole ID framework.
The Problem
Nerve injuries are common
injuries affecting the limbs in the working population and if not treated
adequately produces significant disability and economic loss.
There are insufficient surgeons with
adequate training to treat all these patients. (There is a community and work
based need for this skill to be easily available to patients in need)
Currently there are no one-day
courses for the acquisition of microsurgical skills for a peripheral nerve
surgery. Most of the available microsurgical courses are five days long
requiring high level of expertise include mainly microvascular anastomoses
skills.
The requirement and the ability
to repair peripheral nerves in most general hospital setting is high. Most
junior doctors perform such surgery without any formal training especially in
the repair of digital nerves of the hand. This results in poor outcomes of
nerve injuries in patients. With this in
mind, we developed an animal model so that trainees will be able to acquire
very basic microsurgical skills in one day and the curriculum was developed
with this basic objective.
Theoretical
position and rationale in the instructional design
The ADDIE model and the modified version in the Dick and
Carey Model of instruction design is used in understanding the problem and
using the analysis phase to determine how instruction can solve the problem in
an effective, efficient and predictive manner and then to ensure that desirable
outcomes have been attained and gather evidence for it using the evaluation
process.
The ADDIE model is an
iterative process involved in the formulation of instructional systems to
provide training to do a particular ask and stands for the 5 phases contained
in the model (Analyse, Design, Develop, Implement, and Evaluate). According to Dick and Carey, "Components
such as the instructor, learners, materials, instructional activities, delivery
system, and learning and performance environments interact with each other and
work together to bring about the desired student learning outcomes.” I have used this model as it follows a more
behaviourist approach as the problem is one of skill acquisition of a complex
surgical procedure. It prescribes an instructional design sequence where the instruction
is broken down into small components (deconstruction of the original complex
procedure). It requires the
identification of sub-skills that should be mastered in order for learners to
acquire the intended behaviours.
Harden described ten
issues needing to be considered in formulating a new curriculum for a course or
programme of learning in medicine.
His strategies for such
a curriculum are:
1. Needs in relation to the product of a
training programme
2. Aims and objectives
3. Content
4. Organisation of the content
5. Educational strategies
6. Teaching methods
7. Assessment
8. Curriculum details communicated to
others
9. Educational climate
10. Management of the whole process
One can draw
similarities with Gagne nine events of instruction and the ADDIE model.
This has been shown in
medical education by Razavi et al (2010) who conclude that “ deconstructing the
practical skills into micro skills and tuition of those micro skills via the
separated structured educational stations is effective according to the
students’ self-ratings.”
Factors to be addressed
The steps in the model include the following:-
Identifying the instructional goal
Here desirable state of affairs by instruction should be
clearly stated. What is required is that at the end of the instructional
activities the learner should be able to comfortable and predictably suture a
digital nerve in the hand
There is a gap now
based on the personal observation of the author in his role as mentor and
surgical trainer that current junior surgeons do not have the knowledge and
skills to perform the task.
“At the end of this workshop you will be able to confidently
in the sheep hoves model
•
Place a 9/0 needle through the perineurium of
the cut fascicle
•
Co apt the two ends accurately based on the
micro structure
•
Tie the knot of the suture sufficiently tight to
bring the ends together
•
without causing tension or redundant nerve
material at the suture site
•
Plan and place the sutures circumferentially
around the repair site without crowding of sutures “
Instructional Analysis
Here we need to determine the skills
involved in reaching the above mentioned goal. Once that has been clearly
identified by procedural analysis, Next the effective means of knowledge,
information and skill transfer required for the learning. (Information
processing and Task Analysis).
Entry Behaviours and Learner Characteristics
Here we determine which of the
required learning skills and acquired prior knowledge and skills the learners
bring to the learning task including spatial orientation and personality
traits.
All learners would be expected to
have attended a basic surgical course and have some experience in handling
micro instruments. They must be able to perform fine manipulative procedures
using high magnification. They must be able to pay attention to fine details
and have patience, perseverance and manual dexterity.
Development of the Performance Objectives and Assessment
Here we translate the needs and
goals into specific and detailed learning objectives. It ensures that the
instruction is related to its goals and targets the instructional planning and guides in the development of performance
assessment. As the overall objective is to have an observable outcome at the
end of the instruction (ability to suture the divided nerve in the sheep hooves
model), the Criterion-Referenced performance assessment will be used to
evaluate the effectiveness of the instructional program. This will also provide
documentation for credentialing and appraisal process as part of the total
performance management in the work place.
Instructional Strategy
Here we develop the instructional
activities which will relate to the accomplishment of the objectives
As the goal is the transference of
psychomotor skill the best medium for the deliverance of the instructional
activities will be hands on workshop.
Thus Gagne 9 events of instruction become
an ideal framework to design and develop the course.
|
Instructional
Event
|
Internal
Mental Process
|
|
1. Gain attention
|
Stimuli activates receptors
|
|
2. Inform learners of objectives
|
Creates level of expectation for
learning
|
|
3. Stimulate recall of prior learning
|
Retrieval and activation of short-term
memory
|
|
4. Present the content
|
Selective perception of content
|
|
5. Provide "learning
guidance"
|
Semantic encoding for storage
long-term memory
|
|
6. Elicit performance (practice)
|
Responds to questions to enhance
encoding and verification
|
|
7. Provide feedback
|
Reinforcement and assessment of
correct performance
|
|
8. Assess performance
|
Retrieval and reinforcement of content
as final evaluation
|
|
9. Enhance retention and transfer to
the job
|
Retrieval and generalization of
learned skill to new situation
|
Gain
attention
The announcement for this course creates
the attention by stating that it will be hands on workshop with a high faculty
to student ratio and there will be emphasis on practical sessions on the sheep
hoof model. It shows a clear outcomes and the community need for the skill.
Relevance
Most trainees in these specialities will be
exposed to injuries of peripheral nerves and involved in their management and
will be required to manage these surgically. The opportunity to therefore apply
these skills in their day to day practice will augment their skill acquisition
process
Inform
learners of objectives
The
course aim and objectives will be clearly stated as follows:-
The instructional objective and goal
“ At the end of this workshop you will be
able to confidently suture a cut nerve less than 3 mm in diameter without
tension and with precise co-aption using the sheep hooves model using 9/0 micro
sutures placed uniformly around the cut ends ,with micro instruments and an
operating microscopes “
Stimulate
recall of prior learning
Associating new information with prior
knowledge facilitate the learning process.
Thus a review of anatomy of the nerve and
repair process in the lecture series allows for learners to encode and store
information in long-term memory when there are links to prior knowledge. This
is facilitated by interactive session during the lecture where they are quizzed
on prior basic knowledge of anatomy and then the formal lecture add on to this
knowledge base.
Present
the content
This event of instruction is where the new
content is actually presented. Here the lecture on anatomy and biology of nerve
healing and the methods of repairing nerves are presented to the learner.
The sequence of the lectures are sequenced
in order and interposed with practical skill sessions.
Content
The content will include the handling of
micro-instruments and the use of the microscope.
basic inanimate exercises have been
included to get familiarisation of the microscope and instruments and in the
handling of microstructures under magnification.
The whole process of the complex skill
acquisition for microsurgical nerve repair has been deconstructed to allow for
piecemeal skill acquisition with immediate feedback and sequential assessment
to ensure successful acquisition of skills.
Organisation Of The Content
The content will be organised by a top down
approach using the needs of a practising on call surgeon to meet this basic
skills to be able to practice on a day-to-day basis.
The sequential modular approach to basic
skill acquisition ensures the familiarity with the new working environment
under magnification of the microscope and the use of fine instruments prior to
handling of nerve tissue.
Following the lectures the workshop is
conducted by explaining each skill by order and then demonstrated on the sheep
hoof model. The candidates then perform this activity until comfortable prior
to moving on to the next step.( extract from program)
Practical 1 Instrument handling
You should be able
• To
hold and manipulate a jewellers forceps, micro needle holder and scissors
comfortably.
• Care
for the fine tips of the micro instruments
• Mount
and dismount a 9/0 needle on the needle holder
• Manipulate
a suture with a jewellers forceps
Practical 2 Micro suturing practices
You should be able
• Place
a 9/0 needle at various angles through a cut in the rubber glove
• Co
apt the two ends accurately based on the micro structure ensuring fascicle to
fascicle coaptation
• Tie
the knot of the suture sufficiently tight to bring the ends together without
causing tension or escaping fascicles at the suture site
• Plan
and place the sutures circumferentially around the repair site without crowding
of sutures
Practical 3 Fascicular Repairs
You should be able
• Place
a 9/0 needle through the perineurium of the cut fascicle
• Co
apt the two ends accurately based on the micro structure
• Tie
the knot of the suture sufficiently tight to bring the ends together without
causing tension or redundant nerve material at the suture site
• Plan
and place the sutures circumferentially around the repair site without crowding
of sutures
This hierarchal model provides the
procedural – decision relations.
Learning-Prerequisite. This knowledge structure arranged components
in a hierarchy indicating that a component lower in the hierarchy must be known
before a component higher in the hierarchy can be learned i.e. the handling of
instruments before fascicular repair
Procedural-Decision. In this structure alternative procedures are
identified and the learner must consider a number of factors (conditions) in
order to make a decision about which alternative is appropriate in a given
situation. This was utilized in the interactive final session where different
cases using images of cases, will be put forward to the candidates to assess
how they would manage the case.( An image of a badly crushed digit with untidy
laceration of tendon and nerves with
skin loss and candidates were asked their management plan). This was done at the end of the workshop to
assess the knowledge acquisition from the workshop.
We have developed the program through
student centred approach to delivering the content. We integrated Basic
surgical skills with that of highly trained microsurgical skills and introduced
the sequential manner but first introducing the microscope and then the
handling of micro-instruments prior to the exercise on the nerve tissue.
It includes elective components for those
who have completed the basic skills in the form of nerve grafts and allow time
for those that have not obtained the basic skills for remedial practice
sessions.
The whole course is designed and delivered
using a systematic approach and with targeted objectives in a timely fashion
with predictable learning outcomes.
Provide
"learning guidance"
To help learners encode information for
long-term storage, additional guidance was provided along with the presentation
of new content. The use of case studies was employed to guidance on the
principles of nerve surgery.
The high faculty to trainee ratio will
provide the climate of trust and comfort for the trainees to learn. The use of
the animal model provides the student with confidence and life like simulation
to learn this skill in a relaxed and timely fashion. The availability of the
elective component reinforces the flexible student centred learning
environment.
Elicit
performance (practice)
In this event of instruction, the
candidates practice the new skill of nerve repair on the sheep model. Each
candidates performance will be observed by a faculty member and immediate
remedial steps will be instituted. The task will be repeated till they were
comfortable before moving to the next step. This provided an opportunity for candidates
to confirm their correct understanding, and the repetition further increases
the likelihood of retention.
Flexible
As it is modular in nature it can allow for
more advance students to omit the basic practical and concentrate on the more
advance nerve grafting techniques.
Provide
feedback
As candidates practice the skills, the
faculty provides specific and immediate feedback of their performance as part
of formative feedback.
.
Assess
performance
Upon completing the various step by step
modules on nerve repair, the candidates were given a typical nerve injury in the
sheep hoof. They will be required to perform a full repair based on all the
components learned earlier. They were than assessed on their performance. On
successful completion of this exercise they were provided a certificate of
satisfactory completion.
Criterion-Referenced Test criteria were
used to assess the competency that as already mentioned during the instructions
of the individual steps.
Enhance
retention and transfer to the job
As most of the participants are in clinical
practice and have the opportunity to treat patients with nerve injuries, they
are encouraged to provide feedback to the course organisers on how it affected
their practice.
Effective and
efficient instructional strategy
The animal model chosen closely resemble the digital nerve
of the hand and thus makes the simulation life like. The complex procedure has
been deconstructed to basic steps allowing for a graduated skill acquisition.
The faculty will be available for immediate assessment of each step and
allowing for remedial learning. There is a clear end point of skill acquisition
where the candidate and faculty can clearly see the results of the training.
Instructional Materials
We will provide all course material online via our Moodle
site for the candidates to obtain the knowledge component prior to attending
the workshop. This will include step by step instructions of the curriculum. To
appeal to different learning modalities, a variety of media will be used,
including text, graphics, workbook and video.
We are currently
working on instructional digital videos to accompany the course material.
Eventually we can focus on psycho motor skill acquisition at the workshop with
little didactic components saving time and focussing on hands on learning.
Lectures using PowerPoint and a handbook will be developed
to deliver the knowledge base of the content. This will be provided off line
and on line using a Moodle website. This will allow for students to do their
reading and knowledge acquisition prior to the workshop. More time thus will be
available for skill acquisition at the workshop. The knowledge obtained can be
evaluated by a pre workshop MCQ and discussion.
The skills of basic microsurgery for nerve repair will be
delivered through and animal model that closely resembled the human digits of
the hand. A high faculty to student ratio will be maintained to provide for the
one to one teaching of the skill. It will be a safe and realistic environment
to learn these suturing skills. Introduction will be provided for by a “master”
demonstrating the technique via video
and TV as the operative area will be too small to allow for direct observation.
Formative Evaluation
This allows for evaluating, reviewing and improving
instructional materials. This allows effective instruction delivery and can be
done via one on one evaluation during the worshop.
In this course, the high faculty to student ratio allows for
adequate opportunity to assess the effectiveness of the materials in delivering
the knowledge and the workshop in transferring skills.
Student evaluation of the materials and delivery can be
assessed via interviews and questionnaires at the end of the program. Any
weakness in the instructional assets can be evaluated and revised.
Summative Evaluation
This is performed to study the effectiveness of system as a
whole in achieving the overall objectives.
This can be done by performing a post course survey and
measure the change in behaviour in students and if they have used the skills in
their clinical practice as part of their reflective practice in the work place.
Conclusions
In this paper the author has drawn on the theories on ID to
analyse the learning gap in a group of junior surgeons in the performance of nerve
repair in the wok place. Using the revised ADDIE and the Dick and Carey model,
the author has used the framework to analyse the instructional goals and needs
and formulated strategies to bridge the gap by developing the instructional
events for delivery of the learning in the form of an intensive course to
transfer knowledge and skills using a high fidelity simulated animal model
using Gagnes 9 events in instruction.
The author has used the framework to develop instructional resources to
meet the overall learning objectives.
References
Akbulut, Y.; Anadolu
M.A.(2007). Implications of Two Well-Known Models for Instructional
Designers in Distance Education: Dick-Carey versus Morrison-Ross-Kemp. , Turkish
Online Journal of Distance Education, 8 Number: 2 Article: 5
Razavi et al , (2012) Station-based deconstructed
training model for teaching procedural skills to medical students: a
quasi-experimental study , Advances in
Medical Education and Practice 1 p17–23
Reznick, R. K., & MacRae, H. (2006). Teaching
Surgical Skills — Changes in the Wind. New England Journal of Medicine, 355(25),
2664–2669.
Harden, R. M. (1986). Ten questions to ask when planning
a course or curriculum. Medical education, 20(4), 356–365.
No comments:
Post a Comment