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Context
To date, despite the relevance of manual skills laboratories in physiotherapy education, evidence on the effectiveness of different teaching methods is limited.
Medical Education
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Manual Skills
Effective teaching of manual skills to physiotherapy students: a randomised clinical trial
Abstract
Objectives
Peyton's four-step and the ‘See one, do one’ approaches were compared for their effectiveness in teaching manual skills.
Methods
A cluster randomised controlled trial was performed among final-year, right-handed physiotherapy students, without prior experience in manual therapy or skills laboratories. The manual technique of C1–C2 passive right rotation was taught by different experienced physiotherapist using Peyton's four-step approach (intervention group) and the ‘See one, do one’ approach (control group). Participants, teachers and assessors were blinded to the aims of the study. Primary outcomes were quality of performance at the end of the skills laboratories, and after 1 week and 1 month. Secondary outcomes were time required to teach, time required to perform the procedure and student satisfaction.
Results
A total of 39 students were included in the study (21 in the intervention group and 18 in the control group). Their main characteristics were homogeneous at baseline. The intervention group showed better quality of performance in the short, medium and long terms (F1,111 = 35.91, p < 0.001). Both groups demonstrated decreased quality of performance over time (F2,111 = 12.91, p < 0.001). The intervention group reported significantly greater mean ± standard deviation satisfaction (4.31 ± 1.23) than the control group (4.03 ± 1.31) (p < 0.001). Although there was no significant difference between the two methods in the time required for teaching, the time required by the intervention group to perform the procedure was significantly lower immediately after the skills laboratories and over time (p < 0.001).
Conclusions
Peyton's four-step approach is more effective than the ‘See one, do one’ approach in skills laboratories aimed at developing physiotherapy student competence in C1–C2 passive mobilisation.
Introduction
Physiotherapy education aims to prepare students to practise independently by developing complex clinical skills such as patient assessment, clinical reasoning, technical, communication and therapeutic skills.[1] The process of learning clinical skills is based upon theoretical knowledge acquired in the classroom and learning in subsequent skills laboratory sessions that prepare students for clinical rotations.[2]
A skills laboratory is defined as a unique and safe environment in which students may perform manual procedures before they encounter patients, reflect on errors and progressively improve in self-confidence and competence.[3] In skills laboratories, the learning process is structured through the use of manikin simulators,[4] practise with standardised patients[5] or practise of procedures with other students.[6] In the medical field, skills laboratories have been shown to be largely appreciated by students,[7] and to be effective in improving technical skills[8, 9] and in facilitating their transfer into clinical contexts.[10] Similarly, in physiotherapy education, skills laboratories represent promising strategies for developing clinical competence,[11] despite the fact that evidence on their effectiveness is quite limited.[12] In the field of manual therapy with reference to the acquisition of skills such as joint mobilisation, only a few studies have investigated the effectiveness of the provision of real-time visual feedback on a computer screen in terms of students’ ability to establish optimal force and demonstrate adequate performance in cervical[13] and lumbar[14] spine mobilisations, both of which are competences expected at physiotherapy entry level.[15]
The effectiveness of different teaching approaches in skills laboratories is still debated in the literature.[16] Historically, the technical skills teaching method has been based upon the paradigm of learning by doing, commonly known as the ‘See one, do one’ approach.[17] This approach assumes that trainees can become capable of performing a specific procedure after observing its performance once by an expert clinician or teacher.[18] This approach is based on the assumption that experience facilitates both learning and practical independence.[19] Nevertheless, increasing criticism of the ‘See one, do one’ approach as inadequate in maintaining required patient safety standards as a result of lack of supervision, reflection on action, performance evaluation and structured feedback has been documented.[20, 21]
In light of such criticism, Frank Doto developed a five-step model first published in the Advanced Trauma Life Support Instructor Manual[22] and published again later.[23] This was modified into a four-step model by Rodney Peyton in a technique that combined two of the steps.[24] The four-step approach has been documented as effective in laboratories for teaching procedural skills.[25] The approach consists of four teaching steps: demonstration; deconstruction; comprehension, and performance.[24] The ‘comprehension’ step represents the specific value of both the Doto and Peyton models[23, 24, 26] in that students are encouraged to: (i) reflect on information acquired in the previous step; (ii) organise their thoughts before actively verbalising them, and (iii) facilitate the integration of new knowledge with that already acquired.[27]
Moreover, students can subsequently have the opportunity to ‘learn through teaching’, thus increasing their ability to self-regulate during the procedure by learning through immediate feedback, monitoring improvements and failures. All of these strategies may prevent the development of a ‘mechanical performance’ that is not adaptable to different clinical settings and situations.[28] However, to date, only six studies have compared the ‘See one, do one’ and Peyton's four-step approaches as teaching methods in the learning of medical procedures by adopting a randomised controlled trial design. Four of these, involving, respectively, 94,[28] 34,[29] 84[30] and 95[27] medical students and using gastric tube insertion,[28, 29] intravenous cannulation[28, 30] and spinal manipulations,[27] documented Peyton's approach as being more effective and better able to enhance performance,[28, 30] communication skills[29] and skill speeds.[28-30] By contrast, two studies using chest compression in cardiopulmonary resuscitation involving samples of, respectively, 126 and 134 medical students documented no differences in terms of performance, but significantly higher skill speed in the groups that used the Peyton approach.[31, 32]
To date, no study has compared these two approaches in the education of other health care professionals, such as that of physiotherapists. Physiotherapists, among others, are required to demonstrate a high level of performance in technical skills that also implies the continuing acquisition of clinical data, which informs them how to apply and regulate the procedure on the basis of the individual patient's specific needs.[33, 34] Therefore, the main aim of this study was to evaluate the effectiveness of each of these approaches in physiotherapy education.
Cervical C1–C2 spine mobilisation was selected as the technical procedure to be learned for the following reasons: (i) the C1–C2 joint has been documented as showing increased prevalence and incidence of symptomatic dysfunction in patients with headaches and neck pain;[35, 36] (ii) C1–C2 spine mobilisation has been suggested as a core competence to be included in physiotherapy curricula;[37, 38] (iii) physiotherapy students and professionals are required to assess and care for patients with this dysfunction in the clinical context,[39, 40] and (iv) the procedure can be safely performed without adverse events such as cerebral blood flow reduction.[41]
Methods
Study design
A cluster randomised controlled trial designed to compare the effectiveness of Peyton's four-step approach (intervention group) and the ‘See one, do one’ approach (control group) in teaching passive cervical C1–C2 right rotation mobilisation[42] among physiotherapy students in skills laboratory settings was performed in 2014 (Fig. 1).
Figure 1.
The patient (one student) sits while the therapist (another student) stands to his right, close to the patient. The caudal (left) hand of the therapist fixes the C2 (with a thumb–index finger pinch grip on the spinous process or the thumb laterally to the spinous process) on the side contralateral to the therapist. The therapist's cranial (right) hand is positioned on the posterior arch of C1 with its fifth metacarpophalangeal joint. While the cranial hand induces C1 right rotation, the caudal hand feels the movement
Setting, participants and allocation
A Bachelors degree programme in physiotherapy based at the University of Verona (Italy) was considered. The programme was 3 years in length in accordance with national regulations. The target study population consisted of Year 3 students attending their second semester before engaging in clinical rotations designed to allow students to acquire manual competencies with patients after total knee replacement or total hip replacement. Two homogeneous rehabilitation gyms were selected as study settings.
Participants were eligible if they were: (i) final-year students; (ii) right-handed; (iii) without prior experience in manual therapy during rotations, courses or skills laboratories, and (iv) willing to participate in the study. Students with previous experience in manual therapy during clinical rotations or courses, who were left-handed, or who had discontinuous participation in learning activities (such as for health reasons or family responsibilities) were excluded.
A potential cohort of 42 students was identified. Information on the aims of the study was provided, after which student willingness to participate was ascertained through the provision of written informed consent.
A researcher generated a random allocation sequence using a random number table. The sequence was used to allocate clusters of participants to the intervention and control groups, respectively. Participants were blinded as to the aim of the study and their allocation.
Intervention
The intervention group learned the procedure through Peyton's four-step approach.[24] First, the teacher showed the mobilisation at normal speed, without commenting verbally on the procedure (Step 1: demonstration); then, the same teacher repeated the mobilisation once verbally, describing each step involved in the technique (Step 2: deconstruction). Next, the teacher repeated the mobilisation while the student guided him verbally (Step 3: comprehension). Finally, each student performed the mobilisation independently (Step 4: performance).
Each session involved a student : teacher ratio of 3 : 1.[28, 30] The procedure was applied by both teacher and students in the same subject, on a healthy volunteer student. In order to prevent teacher fatigue and adverse event(s) in the subject, the skills laboratory was offered over two consecutive days (four teaching sessions on day 1 and three on day 2) and short breaks of 15 minutes were scheduled between the sessions. Each participating student performed the last step of Peyton's four steps only once. No support (e.g. computer, blackboard) was used to remind the student of the steps of the procedure.
Control
The control group was exposed to the ‘See one, do one’ approach.[18] As suggested by Herrmann-Werner and colleagues[28] and with the aim of monitoring the difference in time required between the intervention and control groups, a conceptual introduction to the procedure was provided to students, illustrating the anatomy and biomechanics of the superior cervical spine. Subsequently, the teacher demonstrated the procedure on the same healthy volunteer student involved in the intervention group. Each step was then verbally described by the teacher as it had been performed. Students were asked to follow each step carefully in order to increase their familiarity with the procedure. However, there was no opportunity to practise the procedure in the skills laboratory sessions.[28, 30] As in the intervention group, the student : teacher ratio was 3 : 1 in each session and no support (e.g. computer, blackboard) was provided. As in the intervention group, the skills laboratory was provided over two consecutive days, with breaks of 15 minutes between sessions.
Data collection
To describe the profile of participants and to assess homogeneity between the groups, data were collected on participant socio-demographic variables (age, gender, height, body mass index [BMI], sports played and average academic grade score [AGS]). Participant learning style (visual, auditory, reading/writing or kinaesthetic [VARK]) was assessed using the Italian version of the VARK questionnaire after having obtained authorisation from Neil D Fleming (VARK Version 7.1; 2011; http://vark-learn.com). The questionnaire consists of 16 multiple-choice items with four answer options; possible scores range from 0 to 16 for each subscale. The VARK questionnaire has been reported to show adequate validity and reliability (Cronbach's alpha: 0.77–0.85).[43]
Participant self-efficacy in learning was assessed using the Italian version of the General Self-Efficacy (GSE) Scale,[44] which consists of 10 items to which the participant responds using a 4-point Likert scale (1 = strongly disagree, 4 = strongly agree). Scores on the GSE Scale range from 10 to 40; the higher the score, the greater the self-efficacy perceived by the respondent. Authorisation for use of the GSE Scale was obtained from Ralf Schwarzer; the tool represents a reliable measure of student self-evaluation.[45]
Primary outcome
The primary outcome was quality of performance. Given that no checklist was retrieved from the literature, an ad hoc checklist was developed through a Delphi procedure.[42] Specifically, five physiotherapists, experienced in both teaching and manual therapy, searched the literature for references to cervical spine mobilisation procedures. Secondly, they identified items capable of describing the expected competence. Subsequently, they agreed upon the quality of performance as expressed within each item using the terms correct, partially correct and incorrect. The 12-item checklist was then validated for face and content validity by involving another group of five physiotherapists, who were also experts in teaching and manual therapy. During the validation process, no disagreements emerged and therefore no changes in the checklist were required.
Two trained assessors used the checklist to evaluate 10 students not involved in the study. Thus, Cronbach's alpha was calculated to estimate internal consistency and McDonald's omega was estimated as general factor saturation using hierarchical factor analysis.[46] Inter-rater agreement was assessed by evaluating the intraclass correlation coefficient (ICC); Fleiss's kappa and Spearman's rho values were used as indices of agreement between raters.[47] Values between 0.61 and 0.80, and higher, indicate, respectively, substantial and almost perfect agreement.[48]
The internal consistency was adequate, both when measured as the average correlation between items with Cronbach's alpha (α = 0.82, 95% confidence interval [CI] 0.77–0.86) and when measured as a correlation of scores with the latent factor (ω = 0.82, 95% CI 0.80–0.85; correlation of scores with the factor g = 0.93). Inter-rater agreement was also high (ICC 0.97, 95% CI 0.97–0.98; Fleiss's κ = 0.97, 95% CI 0.96–0.98; Spearman's ρ = 0.98, 95% CI: 0.97–0.99).
Scores for each item on the checklist could range from 2 (correct performance) to 1 (partially correct performance) and 0 (incorrect performance). A trichotomous scale such as a standard 3-point Likert scale was preferred in view of its ability to detect inter-rater differences.[49] Thus, total scores on the checklist could range from 0 (substantially incorrect performance) to 24 (completely correct performance). An English translation of the full checklist with descriptions of items is provided in Table S1 (online).
Student performance was recorded using a high-definition digital camcorder (Legria HF G25; Canon, Inc., Tokyo, Japan). During the video-recording, each student worked with the subject-student while the teacher recorded the performance. The student was allowed to perform the technique only once; classmates waited in another room with a faculty supervisor who controlled potential interaction regarding C1–C2 joint mobilisation. In both groups, performances were recorded immediately after the teaching session (acquisition phase: T1), at 1-week follow-up (retention phase: T2) and at 1-month follow-up (retention phase: T3). No additional educational intervention was provided at the follow-ups. Performances were measured in the same setting, with the same student simulating the patient. Recordings were digitally processed and randomly submitted to assessors. At the end of data collection processes, feedback regarding the quality of performance was offered individually to all students in both groups.[2]
Secondary outcomes
Three secondary outcomes were measured: time to teach the technique; time to perform the technique, and student satisfaction with the approach used. Time to teach and time to perform were calculated in minutes by analysing the length of time on the video-recording (both measured from the time of picking up the first item to the time at which the teacher or student announced the end of the procedure).[28] Student satisfaction was explored using a seven-item scale developed by the authors.[29, 30] The scale asked for the level of agreement with the statements: (i) teacher feedback was understandable; (ii) instructions were easy to follow; (iii) instructions were helpful; (iv) instructions were too short; (v) the method was motivating; (vi) (intervention group only) Step 3 of Peyton's approach was helpful, and (vii) (intervention group only) the division of teaching into four steps was helpful. Responses were given using a 5-point Likert scale on which 1 = completely disagree and 5 = completely agree; therefore higher scores indicated a higher degree of student satisfaction.
Teachers and assessors
Two teachers were involved in the study. Both were right-handed physiotherapists and experienced in skills laboratory teaching of manual therapy (each had 6 years of experience). Each teacher was trained in only one method in order to prevent contamination during the sessions.[28] The toss of a coin was used to randomly allocate the two teachers. The intervention group teacher undertook a briefing prior to the sessions, in accordance with Peyton's approach.[24] Both teachers received a detailed sheet regarding students’ learning goals, the duration of the session and the steps required by the approach. Teachers were blinded to the study outcomes.
The primary and secondary outcome assessments were performed by three evaluators.[27] Each was experienced in both manual therapy and teaching (average of 11 years of experience). Assessors were blinded to the aims of the study and the allocation of participants. With the aim of ensuring validity, assessors were preliminarily trained in performance evaluation; the assessors evaluated the recorded performances independently and then compared the measurements obtained. No disagreement emerged between assessors.
Statistical analysis
A power analysis revealed that 36 students were needed for this study. The expected difference of means for normalised data was 0.6, which is a difference representing a medium or large effect using Cohen's d.[50]
Researchers who performed statistical analyses were blinded to the allocation sequence. Given the small sample size, only non-parametric tests were used to compare baseline variables. The Wilcoxon test was used to assess differences between groups to evaluate the effectiveness of the intervention. Both execution times and checklist scores were analysed using a 2 × 3 analysis of variance (anova) with the factors Group (intervention versus control) by Time (T1, T2 and T3), both for the average score and for each item. Each value was reported as the mean ± and standard deviation (SD). A p-value of < 0.05 was considered to indicate a difference of statistical significance. Moreover, for each item, Bonferroni correction was applied to compensate for the likelihood of incorrectly rejecting a null hypothesis (e.g. making a type I error) by testing each individual hypothesis at a significance level of 0.0042. The entire statistical analysis was performed in the R Statistical Environment.[51]
Results
Participants
Of the potential cohort of 42 students, 39 were included (21 in the intervention group; 18 in the control group) as reported in Fig. 2. After assessment for eligibility, three students were excluded as a result of health problems that threatened the possibility of their attending the skills laboratory sessions and follow-ups.
Figure 2.
Flow diagram of the phases of randomisation according to CONSORT (Consolidated Standards of Reporting Trials)[65]
Table 1 shows that the majority of participants across both groups were male (intervention group, n = 12; control group, n = 9) and were homogeneous in age (mean ± SD age: 23.89 ± 3.01 years versus 25.11 ± 5.71 years), BMI (mean ± SD BMI: 22.25 ± 2.07 kg/m2 versus 21.91 ± 2.16 kg/m2) and involvement in sport activities (number of students: 19 versus 15). With regard to academic performance, AGS values were similar (mean ± SD: 26.52 ± 1.44 versus 26.77 ± 1.67) and students also reported homogeneously higher scores in the kinaesthetic learning style (mean ± SD score: 4.81 ± 1.08 versus 4.44 ± 1.38) as measured by the VARK scale. Students were also homogeneous in GSE Scale scores (mean ± SD: 22.67 ± 2.06 versus 22.17 ± 1.95).
| Baseline variables | Intervention group (n = 21) | Control group (n = 18) | p-value |
|---|---|---|---|
| |||
| Gender (male : female) | 12 : 9 | 9 : 9 | 0.901a |
| Age, years, mean ± SD | 23.86 ± 3.01 | 25.11 ± 5.71 | 0.988a |
| Height, cm, mean ± SD | 174.33 ± 9.56 | 174.67 ± 9.88 | 1.000a |
| BMI, kg/m2, mean ± SD | 22.25 ± 2.07 | 21.91 ± 2.16 | 0.704a |
| Sport activity, yes : no, n | 19 : 2 | 15 : 3 | 0.704a |
| AGS, mean ± SD | 26.52 ± 1.44 | 26.77 ± 1.67 | 0.615a |
| VARK scale score, mean ± SD | |||
| Visual | 3.48 ± 0.81 | 3.39 ± 0.78 | 0.773a |
| Aural | 3.67 ± 0.66 | 3.50 ± 0.71 | 0.386a |
| Reading/writing | 4.38 ± 1.07 | 4.39 ± 1.09 | 0.953a |
| Kinaesthetic | 4.81 ± 1.08 | 4.44 ± 1.38 | 0.440a |
| GSE Scale score, mean ± SD | 22.67 ± 2.06 | 22.17 ± 1.95 | 0.427a |
Primary outcome
As Table 2 shows, the average quality of performance was higher in the intervention group (mean ± SD: 20.06 ± 3.08) than in the control group (mean ± SD: 16.61 ± 3.72); this difference is statistically significant as a function of cluster (F1,111 = 35.914, p < 0.001). For some items (‘Undress the patient’, ‘Let the patient sit’, ‘Sideways position of the physiotherapist’, ‘Sideways stabilisation of the patient's trunk’, ‘Perception of the end feeling’, ‘Patient's final position’, ‘Physiotherapist's final position’), no statistically significant differences emerged.
| Item | Mean ± standard deviation score | |||||||
|---|---|---|---|---|---|---|---|---|
| Intervention group (n = 21) | Control group (n = 18) | F-value | ||||||
| T1 | T2 | T3 | T1 | T2 | T3 | Group | Time | |
| ||||||||
| A Undress the patient | 1.94 ± 0.25 | 1.86 ± 0.35 | 1.67 ± 0.48 | 1.83 ± 0.38 | 1.67 ± 0.48 | 1.50 ± 0.51 | F1,111 = 3.944 | F2,111 = 5.094 |
| B Sit the patient down | 1.76 ± 0.43 | 1.62 ± 0.49 | 1.52 ± 0.50 | 1.56 ± 0.50 | 1.44 ± 0.60 | 1.33 ± 0.58 | F1,111 = 3.791 | F2,111 = 1.874 |
| C Lateral position of the physiotherapist | 1.70 ± 0.46 | 1.57 ± 0.50 | 1.48 ± 0.50 | 1.57 ± 0.57 | 1.39 ± 0.60 | 1.28 ± 0.56 | F1,111 = 2.924 | F2,111 = 2.302 |
| D Lateral stabilisation of the patient by the physiotherapist | 1.81 ± 0.40 | 1.71 ± 0.46 | 1.57 ± 0.50 | 1.67 ± 0.48 | 1.57 ± 0.50 | 1.44 ± 0.50 | F1,111 = 2.517 | F2,111 = 2.433 |
| E Detection of C2 | 1.89 ± 0.32 | 1.81 ± 0.40 | 1.52 ± 0.50 | 1.39 ± 0.49 | 1.28 ± 0.45 | 1.22 ± 0.42 | F1,111 = 28.892a | F2,111 = 3.919 |
| F Fixation of C2 | 1.91 ± 0.30 | 1.81 ± 0.40 | 1.57 ± 0.50 | 1.44 ± 0.50 | 1.33 ± 0.48 | 1.22 ± 0.42 | F1,111 = 27.261a | F2,111 = 4.057 |
| G Detection of C1 | 1.95 ± 0.22 | 1.71 ± 0.46 | 1.52 ± 0.50 | 1.44 ± 0.50 | 1.33 ± 0.48 | 1.28 ± 0.45 | F1,111 = 20.501a | F2,111 = 4.590 |
| H Fixation of C1 | 1.95 ± 0.22 | 1.76 ± 0.43 | 1.57 ± 0.50 | 1.39 ± 0.49 | 1.28 ± 0.66 | 1.17 ± 0.61 | F1,111 = 26.736a | F2,111 = 3.621 |
| I Right rotation of C1 | 1.86 ± 0.35 | 1.71 ± 0.46 | 1.52 ± 0.50 | 1.39 ± 0.60 | 1.22 ± 0.63 | 1.11 ± 0.66 | F1,111 = 20.325a | F2,111 = 3.080 |
| L Perception of the end feel | 1.71 ± 0.46 | 1.43 ± 0.59 | 1.24 ± 0.69 | 1.37 ± 0.62 | 1.28 ± 0.56 | 1.06 ± 0.63 | F1,111 = 4.279 | F2,111 = 4.544 |
| M Final position of the physiotherapist | 1.78 ± 0.42 | 1.62 ± 0.49 | 1.43 ± 0.50 | 1.44 ± 0.74 | 1.39 ± 0.76 | 1.28 ± 0.74 | F1,111 = 4.420 | F2,111 = 1.851 |
| N Final position of the patient | 1.79 ± 0.41 | 1.52 ± 0.50 | 1.38 ± 0.73 | 1.56 ± 0.50 | 1.56 ± 0.50 | 1.17 ± 0.77 | F1,111 = 1.635 | F2,111 = 4.616 |
| Total score | 22.05 ± 2.13 | 20.14 ± 2.50 | 18.00 ± 3.16 | 18.06 ± 3.25 | 16.74 ± 3.77 | 15.06 ± 3.69 | F1,111 = 35.914a | F2,111 = 12.911a |
In both groups, the quality of performance deteriorated over time (F2,111 = 12.911, p < 0.001), with no statistically significant difference between clusters (F2,111 = 0.275, p = non-significant [NS]).
Secondary outcomes
Time required for teaching did not differ significantly (W = 25.5, p = NS) between the intervention (mean ± SD time: 46.28 ± 2.36 minutes) and control (mean ± SD time: 44.50 ± 1.04 minutes) groups.
Time required for students to perform the procedure immediately after teaching, and at 1 week and 1 month was shorter in the Peyton's four-step approach group (mean ± SD time: T1, 283.76 ± 27.99 seconds; T2, 257.09 ± 29.08 seconds; T3, 235.71 ± 17.17 seconds) than in the ‘See one, do one’ group (mean ± SD time: T1, 387.44 ± 30.63 seconds; T2, 340.72 ± 14.25 seconds; T3, 320.11 ±13.48 seconds). This difference was statistically significant as a function of group (F1,111 = 434.110, p < 0.001) and of time (F2,111 = 58.866, p < 0.001).
Student satisfaction with regard to the teaching approach used was higher in the intervention group (mean ± SD: 4.31 ± 1.23) than in the control group (mean ± SD: 4.03 ± 1.31); this difference was statistically significant (W = 65, p < 0.001). Specifically, as reported in Table 3, agreement with the statement ‘Instructions were easy to follow’ was significantly higher (W = 133.50, p < 0.05) in the intervention group (mean ± SD: 4.91 ± 0.30) than in the control group (mean ± SD: 4.61 ± 0.50).
| Item | Satisfaction score, mean ± SD | W-value | |
|---|---|---|---|
| Intervention group (n = 21) | Control group (n = 18) | ||
| |||
| The teacher's feedback was understandable | 4.48 ± 0.51 | 4.33 ± 0.49 | 162.00 |
| Instructions were easy to follow | 4.91 ± 0.30 | 4.61 ± 0.50 | 133.50a |
| Instruction was helpful | 4.81 ± 0.40 | 4.67 ± 0.49 | 162.00 |
| Instruction was too short | 1.48 ± 0.51 | 1.67 ± 0.77 | 208.50 |
| Instruction method was motivating | 4.95 ± 0.22 | 4.89 ± 0.32 | 177.00 |
| Commenting on the procedures while the tutor performed them was helpful | 4.71 ± 0.46 | NA | NA |
| Dividing the session into watching, listening, commenting on and doing was helpful | 4.86 ± 0.36 | NA | NA |
Discussion
Findings
To the best of our knowledge, this is the first study to evaluate the effectiveness of two different skills laboratory teaching approaches in physiotherapy students. Participants were mainly male, young, of normal weight and engaged in sports activities, in line with the student profile already documented in the literature.[13, 14] Participants were characterised by a kinaesthetic learning style, and thus preferred practical exercises, examples and cases[43] as in the skills laboratories. Moreover, they also reported moderate scores on the GSE Scale, thereby indicating a general sense of perceived self-efficacy that may facilitate the goal setting, investment of effort and persistence[45] required in learning processes.
In the present findings, the intervention group showed a higher level of performance. Specific improvements were noted in fine characteristics of manual skills (e.g. identification and fixation of cervical spine level) that require high levels of sensory and motor coordination.[34] However, in neither group did participants achieve completely correct performance during the skills laboratories, possibly because joint mobilisation is not included among the learning outcomes expected at undergraduate level[27] and the participating students were being exposed to the acquisition of this complex competence for the first time.[52]
Analyses of the effect of the teaching method as a function of time showed that performance declined in both groups: the lack of practice and repetition of the technique[53, 54] may have worsened performance. However, the group using Peyton's four-step approach demonstrated better performance than the ‘See one, do one’ group after both 1 week and 1 month. Among medical students, similar findings on the effectiveness of Peyton's approach, in both the short and long terms, have been reported.[27-30] By contrast, the superiority of the approach was not confirmed recently in cardiopulmonary resuscitation chest compression.[32] Nevertheless, this latter study was affected by several limitations: for example, it was statistically underpowered by its small sample size, and chest compression was not a new procedure for the majority of participants, who had received previous training in this skill.[32]
The effectiveness that emerged in both performance quality and its retention at 1 month may be attributable to the third step of Peyton's approach (comprehension), which constitutes the main difference between the approaches: in this phase, students are given the opportunity to develop a mental representation of the skill without any body movement.[26, 29] Moreover, this step implicates motor imagery processes that can activate the same neural circuits of the primary motor cortex involved in the performance of the skill, thereby facilitating the training process.[55] In addition, students encouraged to reflect on an action may increase their metacognitive abilities,[56, 57] learning processes[28, 30] and expertise.[58-60] The third step of Peyton's approach promotes the active participation of the student in the learning process, and provides an opportunity to structure self-regulating learning[61, 62] by describing the performance to the trainer and observing potential errors in the skill. The student is encouraged to become responsible for his or her learning and to take the initiative,[63, 64] and this may increase performance.
With regard to secondary outcomes, time for teaching did not differ significantly between the groups as documented in previous studies,[28-30] and this may encourage teachers to move from the ‘See one, do one’ to Peyton's approach in skills laboratories,[25] given that in view of the greater learning outcomes, such a shift makes no impact on time requirements. In addition, students may be encouraged to learn through the Peyton approach given that the time required to perform the procedure was significantly lower immediately after teaching, after 1 week and after 1 month. Satisfaction scores were significantly higher in the intervention group, mainly because students evaluated the instructions given as being easy to follow, as already documented by Krautter and collegues.[29] Further, at the overall level, the skills laboratory experience in manual therapy was appreciated by all students, as has been documented previously.[7] The quality of teaching delivered, the teacher's leadership, the short and helpful instructions offered, and the motivating context all contributed to improving the value of the skills laboratories.[2]
Limitations
The study is affected by several limitations. Firstly, only 39 participants, as suggested by the sample size calculated a priori, were involved. However, despite the small sample size, the calculated effect size was high and potential confounding factors were equally distributed between the groups. Moreover, with the aim of increasing homogeneity across participants and given that right rotation in the mobilisation procedure is performed with the right hand, only right-handed physiotherapy students were included. Left-handed students may report worse performance as a result of lower dexterity rather than the effect of a specific teaching approach; therefore, our findings can be transferred only to right-handed physiotherapy students and future studies investigating the effects of skills laboratory sessions among left-handed students are strongly recommended. Secondly, the instrument used for the evaluation of competence as the primary outcome was developed specifically by the research team for the purposes of the present study: despite promising findings for face and content validity processes, further studies to evaluate the psychometric properties of the checklist are recommended.
Thirdly, baseline passive cervical C1–C2 mobilisation without participation in any teaching sessions was not evaluated; this decision was made for ethical purposes (the safety of the healthy volunteer acting as patient) and in order to avoid any change in the performance of students included. Practising a skill, even without previous training, may modify performance given that practical experience changes motor task performance.[54] Moreover, the intervention group performed the technique once more than the control group, and this may have increased the effect of the intervention. However, this limitation is intrinsic to the teaching approach,[24] as highlighted previously.[28-30]
Finally, although the study was performed in a period during which students were not involved in clinical practice and although we asked them not to perform the procedure outside the study sessions until the end of the study follow-up, we cannot exclude the possibility that they practised the technique by themselves or talked about the study together.
Conclusions
The effectiveness of Peyton's four-step approach in enhancing performance is superior to that of the ‘See one, do one’ approach in physiotherapy students’ training in C1–C2 passive mobilisation in the short, medium and long terms. Peyton's approach is also capable of reducing the time required for students to perform the procedure, both at the end of the skills laboratories and over time, and achieves greater student satisfaction. The time required by teachers is homogeneous between the ‘See one, do one’ and Peyton approaches, which thus encourages the adoption of the Peyton method in times of faculty shortages.
We suggest that further studies designed to test the effectiveness of Peyton's approach in teaching other procedures to physiotherapy students and involving larger sample sizes should be carried out to increase the evidence available.
Contributors
GR contributed to the conception and design of the work, the interpretation of data and the drafting of the paper. AR and AP contributed to the interpretation of data and the drafting of the paper. SC contributed to the conception of the work and to the drafting of the paper. MV contributed to the analysis of data and the drafting of the paper. FB and LF contributed to the acquisition of data and to the drafting of the paper. MT contributed to the conception and design of the work and to the interpretation of data. All authors contributed to the critical revision of the paper and approved the final manuscript for publication. All authors have agreed to be accountable for all aspects of the work.
Acknowledgements
the authors thank Maria Gabriella Landuzzi, Department of Human Sciences, University of Verona, Via Lungadige Porta Vittoria, 41, 37129 - Verona, Italy, for her valuable support in the structuring of this research.
Funding
none.
Conflicts of interest
none.
Ethical approval
this study was approved by the Vicenza Province's Clinical Experimental Ethics Committee (proposal no. 1684; year of proposal 2014; experiment no. 59/14; approval no. 963, approved 22 December 2014). This work was carried out in accordance with the Declaration of Helsinki, including, but not limited to, the anonymity of participants being guaranteed and the informed consent of participants being obtained.