The concept of a decentralized model of simulation (DeC-SIM) is not new (Cheung et al., 2016), however, the recent COVID-19 pandemic catalyzed vast research and development efforts in this area (Brydges et al., 2020; Dubrowski et al., 2021). Based on Ericsson’s theory of deliberate practice (Ericsson, 2004), to ensure the effectiveness and subsequent consideration of DeC-SIM as a possible adjunct to more traditional training approaches (i.e., C-SIM), the initial work should focus on creating a set of best practices for designing basic simulation elements such as instructions, scheduling and monitoring remote practice, maintaining learners’ motivation, and providing accurate feedback (Reznick and MacRae, 2006; Dubrowski et al., 2021; Ericsson, 2004). In this study, we have focused on how to structure instructions in a DeC-SIM model to a) most optimally develop procedural knowledge prior to physical practice, and b) improve learners’ performance during the initial hands-on practice.
The results of phase 1 showed that all learners improved their procedural knowledge of the suturing technique, becoming more familiar with the suturing task and the assessment tools. On the pre-test, all learners scored similarly, while on the post-test, the learners in the control group had a higher result, although this may not necessarily be interpreted as representative of a superior performance. The learners in the control group observed and assessed a set of eight error-free videos, while those in the other three groups observed and assessed videos with built-in errors; making the videos of the control group easier to assess. Overall, the shift in the ability to discern error-free and erroneous videos from pre-test to post-test implies that the observational practice was effective.
Phase 2 of this study aimed to address whether the conditions of observational practice led to different psychomotor performances on the very first attempt at hands-on practice. This was based on Miller’s model (1990) which proposes that the degree of procedural knowledge and the degree of competence, or what we refer to as the first attempt at psychomotor performance, may not always match. Although typically research shows a gap in transfer of procedural knowledge to competent performance (Witheridge, 2019), we wanted to test the opposite hypothesis - that although the various conditions of observational practice and collaboration lead to similar procedural knowledge, they may have a differential impact on initial motor performance.
The results of phase 2 suggest that collaborative, peer learning conditions lead to procedural knowledge that translates to an improved initial motor performance compared to similar practice in isolation. Furthermore, observing error-free videos vs those with errors during the observational practice, did not impact the psychomotor performance. Most importantly, however, the presence of an expert in the collaborative, peer-learning group did not affect the initial motor performance.
Collectively, our results are in support of the idea of ‘preparation for future learning' (Manzone, 2021). More specifically, these results indicate that DeC-SIM is a feasible addition to the current laboratory-based simulation learning model. For this approach to be optimal, virtual learning management systems, such as GEN, must support collaborative, peer-learning approaches (Cheung et al., 2016; Grierson et al., 2012; Welsher et al., 2018; Noerholk and Tolsgaard, 2021). One key finding stemming from the current study, is that the addition of an expert in a collaborative, peer-learning group does not impact the development of procedural knowledge or subsequent motor performance. The fact that the presence of an expert did not lead to better learning outcomes may have a practical implication for future adoption of DeC-SIM by relevant stakeholders and policymakers.
Although promising, the study has several limitations that should be acknowledged. First, the experimental design used was not orthogonal. In our context, orthogonality refers to the property of the experimental design that ensures that all conditions of practice may be studied independently. Instead, in this exploratory, pilot randomized control study, a planned comparison design approach was used. Because of the exploratory nature of this work, and the aim of testing a complex intervention, our focus was on a few comparisons of interest rather than every possible comparison. Future work will emphasize the need for more orthogonal designs. Secondly, the participants’ satisfaction with the learning environment was not assessed. According to Kirkpatrick’s model (Dubrowski and Morin 2011), the participant’s experience should be evaluated and may provide approximate levels of acceptability of the new training approach by the end point users. In addition, based on the principles of Utilization-Focused Evaluation (U-FE) (Patton, 2002) such assessment of satisfaction may also provide early evidence of the areas of improvement of the intervention. Finally, we only investigate the effectiveness of the DeC-SIM when applied to the acquisition of fundamental surgical skills by naive or novice learners. In accordance with contemporary progressive learning frameworks (Guadagnoli et al., 2012), future work should extend our current findings to more complex skills and more advanced learners.
In summary, the current results fit well with prior evidence on this topic, and suggest that junior surgical learners are effective at using video-based instructions for preparation (Dubrowski and Xeroulis, 2005), and that creating opportunities for peer-to-peer collaboration (Grierson et al., 2012; Welsher et al., 2018), with and without an expert (Cheung et al., 2016; Rojas et al., 2012) can further facilitate preparation and instructions for subsequent hands-on practice. However, to the best of our knowledge, this is the first study to include a set of instructional elements to form a complex simulation intervention that would support DeC-SIM model in the future.