Friday, 11 March 2016

Principles and Practices of Instructional Design (ID) in surgical education - a case study on an Instructional course on Peripheral nerve surgery


Title of course: Instructional course on Peripheral nerve surgery. 1
An introduction. 1
The Problem.. 2
Theoretical position and rationale in the instructional design. 2
Factors to be addressed. 3
Identifying the instructional goal 3
Instructional Analysis. 4
Entry Behaviours and Learner Characteristics. 4
Development of the Performance Objectives and Assessment 4
Instructional Strategy. 4
Instructional Materials. 9
Formative Evaluation. 9
Summative Evaluation. 10
Conclusions. 10
References. 10

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.


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.


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.

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.


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.


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.

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