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Employing cognitive task analysis supported instruction to increase medical student and surgical resident performance and self-efficacy
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Employing cognitive task analysis supported instruction to increase medical student and surgical resident performance and self-efficacy
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Content
EMPLOYING COGNITIVE TASK ANALYSIS SUPPORTED INSTRUCTION
TO INCREASE MEDICAL STUDENT AND SURGICAL RESIDENT
PERFORMANCE AND SELF-EFFICACY
by
Julia C. Campbell
A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
May 2010
Copyright 2010 Julia C. Campbell
ii
DEDICATION
This work is dedicated to my family and friends without whom I could not have
survived these past three years. To my family, I am blessed beyond words for your love
and support. To Mom and Dad, thanks for believing in me. To Aunt Veta and Uncle
Jerry, thanks for taking care of me and changing my life. To Aunt Brenda and Uncle
James, thanks for helping me start a new journey. To Denise, thanks for paving the way.
To my best friend, Andrew Jones, your calming presence has helped me through
innumerable crises. To Dr. Randy Hill, Kim LeMasters and Lori Weiss, my colleagues
who created a supportive environment in which to work and learn. To Rich DiNinni, my
colleague and friend whose quiet influence and confidence has positively impacted my
life more than he will ever know. To Matthew Trimmer, my colleague and friend whose
personal and professional support helped make this journey possible. To Tim Jones and
Lindsay Armstrong, my valued colleagues and supportive friends who allowed me to
keep my sanity while working and studying. To Dr. Matthew Hays, my colleague and
friend who went out of his way to shed light on the data management process. To Dr.
Leslie Tirapelle, my study partner and friend. It was a pleasure to share this experience
with you. To Dr. Holly Ferguson, your friendship and creative spirit made this trip an
unforgettable journey – for many. To Dr. Michele Dunbar, thank you for all of your
wonderful guidance and encouragement. To Sheba, you were always there when I needed
a friend. Finally, to Thursday Night Cohort Family 2007, I am privileged to be a part of
this group of outstanding and talented people.
iii
ACKNOWLEDGEMENTS
This dissertation would not have been possible without a few key individuals who
served as guides, mentors and friends throughout my academic journey.
To Dr. Richard Clark who went out of his way to encourage and enlighten me.
Your support and guidance helped me believe in myself. Thank you for everything!
To Dr. Kenneth Yates who convinced me three years ago upon our first meeting
to commit to pursuing the Ed.D. program. Your unwavering enthusiasm, quick humor
and limitless patience helped light the way.
To Dr. Maura Sullivan whose mentorship I will always value. Your wonderful
attitude and willingness to get in the trenches with me made my journey bearable and
enjoyable.
iv
TABLE OF CONTENTS
Dedication ii
Acknowledgements iii
List of Tables vi
Abstract vii
Chapter 1: Introduction and Review of the Literature 1
Statement of the Problem 1
Purpose of the Study 2
Review of the Literature 4
Self-efficacy and its Importance to Educators 4
Social Cognitive Theory and Self-efficacy 4
Self-efficacy and Motivation 5
Self-efficacy, Affect and Gender 7
Self-efficacy and Academic Performance 8
Overconfidence, Performance and Gender 9
Performance Feedback 10
Learning Environment and Self-efficacy 11
Self-efficacy in the Medical Domain 11
Medical Student and Surgical Resident Self-efficacy 11
Pedagogical Implications 13
Mastery Modeling and Surgical Skills Lab Instruction 14
Cognitive Task Analysis to Support Mastery Learning Instruction 15
CTA Background and History 15
Expert Instructors and the “Seventy Percent” Rule 16
Declarative and Procedural Knowledge 16
Eliciting Expert Knowledge 18
Concepts, Processes & Principles Framework 19
Instructional Design to Support Mastery Learning 20
Identifying Pass/Fail Performance Assessments 22
Evidence for CTA-Based Training 23
Systems Trouble Shooting 23
Computer Software Training 24
Surgical Skills Training 24
Cognitive Task Analysis, Self-efficacy and Performance 27
Summary 27
v
Chapter 2: Method 30
Design 30
Participants 30
Procedure and Materials 31
Chapter 3: Results 39
Experimental and Control Groups Statistical Analysis 39
Research Questions Statistical Analysis 41
Summary 46
Chapter 4: Discussion and Conclusion 47
Research Questions 47
Results Summary 52
Limitations 52
Applied Research 52
Instructional Design and Support 54
Challenges in Execution 55
Limited Time 56
Implications 56
The Role of Feedback 57
Motivation, Self-efficacy and the Medical Domain 58
Conclusion 60
References 62
Appendices:
Appendix A: Lesson Plan, Instructor Script, and Power Point Slides 72
Appendix B: Student Job Aid 80
Appendix C: Procedural Checklist 89
Appendix D: Surgical Resident Self Appraisal Inventory 90
vi
LIST OF TABLES
Table 1: Group Demographics by Education Level and Gender 40
Table 2: Group Comparison for Self Appraisal Inventory Results 44
vii
ABSTRACT
Cognitive task analysis (CTA) is a powerful tool for eliciting expert knowledge to
enhance training practices. While CTA methods have been employed successfully to
design surgical skills training to improve performance, the effects of CTA supported
instruction on self-efficacy have yet to be examined. This study explores the effects of a
CTA instructional intervention on surgical skills performance and self-efficacy beliefs for
conducting an open cricothyrotomy procedure. Self-efficacy beliefs are important for
educators to consider because they influence performance, decision making, and
motivation. Instruction focused on mastery learning, such as CTA supported instruction,
positively influences self-efficacy beliefs. The purpose of this study is to determine if
CTA instruction has an effect on self-efficacy and performance. This study compares
CTA supported instruction and expert-guided instruction used to teach medical students
and postgraduate surgical residents an open cricothyrotomy procedure at a medical
research university surgical skills lab. Education level and gender are considered for their
potential effects on self-efficacy and performance. Results indicate that CTA supported
instruction had significant positive effects on overall performance outcomes and the self-
efficacy ratings for the experimental group. Gender did not have an effect on self-efficacy
ratings; education level had significant effects on self-efficacy ratings, but not
performance. Implications for future CTA efforts and research are discussed.
1
CHAPTER 1: INTRODUCTION AND REVIEW OF THE LITERATURE
Statement of the Problem
Medical research universities have an obligation to healthcare stakeholders to
seek out and employ the best possible surgical training practices. Patient safety, limited
time and resources, and advances in educational psychology have urged the medical
community to supplement mentor based training practices with surgical skills laboratory
training (Bell, 2007; Brennan & Debas, 2004; Reznick & McRae, 2006; Wanzel, Ward &
Reznick, 2002). Cognitive task analysis (CTA) is a powerful tool for eliciting expert
knowledge to enhance training practices by providing a more complete picture of expert
knowledge, skills, steps and decisions associated with performing complex tasks (Clark
& Estes, 1996; Clark, Feldon, Van Merriënboer, Yates, & Early, 2007; Schraagen,
Chipman & Shalin, 2000). CTA methods have been employed successfully to design
surgical skills training and improve performance and decision making (Bathalon, Dorion,
Darveau & Martin, 2005; Fackler et al., 2007; Maupin, 2004; Shachak, Hadas-Dayagi,
Ziv & Reis, 2008; Sullivan et al. 2007; Velmahos et al., 2004). Previous studies
examining the effects of CTA supported instruction reference performance outcomes
alone, but these studies miss the critical role that instruction plays in influencing self-
efficacy.
Self-efficacy beliefs are judgments about whether one is capable of engaging in
tasks and reaching successful outcomes (Bandura, 1997). Educators must consider how
instruction impacts student self-efficacy beliefs because these beliefs influence
motivation, decision making and performance (Bandura, 1977, 1982, 1997, 2001).
Instruction focused on mastery learning experiences positively influences self-efficacy
2
beliefs (Bandura, 1997). Mastery learning experiences provide the learner with the
support they need, such as practice and guided feedback, to successfully complete a task.
People benefit from understanding the rules and strategies that help them manage tasks
and master procedures, but they may also need to be convinced that they have the ability
to successfully manage tasks by applying the rules in a consistent manner and
experiencing success (Bandura, 1997). Research has shown that people’s perceptions of
their abilities often vary by gender: men tend to be overconfident in their abilities and
women tend to be under confident (Barber & Odea, 2001; Jonsson & Allwood, 2003;
Moore & Healy, 2008; Pallier, 2003).
CTA is a viable option for developing instruction that helps medical students and
surgical residents master surgical knowledge and skills because CTA distills expert
declarative knowledge (what is it) and procedural knowledge (how to do it), as well as
the associated conditions that govern when and how to employ procedural knowledge
(Hamdorf & Hall, 2000; Kirschner, Sweller & Clark, 2006; Mayer, 2009; Thomas, 2006;
Wanzel et al., 2002). CTA supported instruction has had a positive impact on
performance and decision making. Will CTA supported instruction have a similar
positive effect on self-efficacy? The question is worth exploring because people with
high self-efficacy for a performing a complex task are more likely to be motivated to
persist at the task in the face of obstacles, and engage in innovative problem solving
strategies (Bandura, 1997).
Purpose of the Study
The effect of CTA supported instruction on self-efficacy has yet to be examined.
Guided by a social cognitive theory framework, this study examines the effects of a CTA
3
supported instructional intervention on performance behavior and the self-efficacy beliefs
for conducting an open cricothyrotomy procedure. The purpose of this study is to build
on previous studies that have looked at the effects of CTA instruction on performance
only (Maupin, 2004; Sullivan et al., 2007; Velmahos et al., 2004) by exploring the effects
of CTA instruction on self-efficacy for surgical performance. Replicating the
methodology of Maupin (2004) for utilizing CTA methods to create instructional support
materials and a procedural checklist, this study compares CTA supported instruction and
expert guided instruction used to teach medical students and postgraduate surgical
residents an open cricothyrotomy procedure at a medical research university surgical
skills lab. Education level and gender are considered for their potential impact on self-
efficacy and surgical performance outcomes.
The open cricothyrotomy procedure is an emergent procedure to establish an
airway after other attempts to establish an airway have failed (Schober, Hegemann,
Schwarte, Loer & Noetges, 2008). It is not a procedure that surgeons perform very often,
but because it is a last resort attempt to establish an airway, it is crucial that surgeons
master this procedure. CTA supported instruction may not only increase medical student
and surgical resident performance, but may also increase their self-efficacy for
performing this critical procedure.
4
REVIEW OF THE LITERATURE
The purpose of this section is to highlight the relationship between self-efficacy,
performance behavior and the learning environment, outline the factors that contribute
specifically to medical student and surgical resident self-efficacy, describe CTA methods,
and present research that suggests CTA supported instruction used with medical students
and surgical residents can provide mastery learning experiences that will increase
performance and self-efficacy for performing an open cricothyrotomy procedure.
Self-efficacy and Its Importance to Educators
Social Cognitive Theory and Self-efficacy
Social cognitive theory recognizes that people are not simply reacting to their
environments, but are active agents in controlling their own destinies (Bandura, 1986,
1989a, 2000, 2001). When people take action to exert control over themselves and/or
their environments, there is an interdependent relationship between people's thoughts,
actions and environmental factors. All influence each other to varying degrees depending
on the situation. Bandura’s triadic reciprocal causation is a bidirectional model in which
input from the learning environment influences people's thoughts and actions, but the
environment is also a product of human behavior as individuals continue to adapt, shape
and change the environment around them.
Self-efficacy plays a key role in determining how people think, feel and act
(Bandura, 1977, 1997). The sources that influence self-efficacy are successful learning
experiences, observed learning experiences, feedback from a competent source, and
feelings related to how people judge personal abilities and vulnerabilities. In turn, self-
efficacy beliefs inform motivation, decision making and emotional processes, and they
5
are context and task dependent (Bandura, 1997). For example, one may feel high self-
efficacy for completing math problems, but low self-efficacy for spelling. Scholarship
covers a variety of self-efficacy beliefs for: academic achievement, self regulated
learning, and emotional control. Most studies incorporate the relationship between self-
efficacy and the relationship between students' thoughts and feelings, actions, and the
learning environment.
Self-efficacy and Motivation
Feelings of perceived self-efficacy may impact motivation because the motivation
constructs of active choice, mental effort and persistence are a result of the expectancy to
do well at specific tasks, and the value one places on those tasks in terms of utility,
interest and importance (Eccles & Wigfield, 2002). Bandura (1997) argues that the
motivation to perform and the quality of the performance are dependent on people's self-
efficacy beliefs. Someone is more likely to be motivated to start a difficult task if one
feels the task is manageable based on personal abilities and experience (Bandura, 1997).
People with low self-efficacy may believe they have no control over their successes or
failures, they lower their goals, motivation suffers, and they may give up easily.
Previous research has established that self-efficacy has consistently influenced
performance and academic achievement across many populations and tasks (Bandura,
1997; Zimmerman, 2000). Variables of interest for self-efficacy and motivation include
intrinsic interest for learning, self regulation for using effective cognitive strategies,
choice in activities, goals, effort and persistence. Pintrich and De Groot (1990) found a
strong positive correlation between self-efficacy and intrinsic value for learning, with
performance and the use of cognitive strategies among 173 seventh graders. The intrinsic
6
value for learning was gathered from data asking students to rate the importance of
learning English and science in terms of the interest they hold in learning these subjects,
and if they tend toward performance or mastery goals. They found that intrinsic value did
not directly influence performance, but intrinsic value was correlated strongly with self
regulation and learning strategies. Mills, Pajares and Herron (2007) studied the effects of
self-efficacy for self regulation using effective cognitive strategies for learning French.
They surveyed 303 college students taking French language courses and found that
students who expressed higher self-efficacy for using learning strategies tended to
perform better.
When students feel efficacious about their self-regulated learning, they enjoy
higher perceived self-efficacy for academic performance, and academic achievement
affects the types of goals students set for themselves. Bandura and Schunk (1981)
demonstrated that when students participated in self-directed activities to complete math
tasks and followed suggestions on whether or not to apply near term goals, long range
goals or no goals, the students who adopted proximal goals showed increased mastery
performance. Results also indicated that students acquired a sense of self-efficacy and
interest for math, and self-efficacy positively influenced performance and intrinsic
interest for math. Students also chose to engage in more difficult math problem activities.
Zimmerman, Bandura and Martinez-Pons (1992) studied the effects of parent goal
setting, student goal setting, and self-efficacy for predicting grades. Their path analysis
examined two separate but complimentary self-efficacy beliefs: student self-efficacy for
self regulated learning influenced student self-efficacy for achievement. Academic goals
were a product of both self-efficacy beliefs, and prior achievement. Prior achievement
7
predicted parent goal setting, as well as goals students set for themselves, which
predicted future academic achievement.
Mastery learning goals focus on mastering the task and individual performance
improvement in relationship to the task while performance goals are concerned with
performance when compared to others (Meece, Anderman & Anderman, 2006). As
Bandura and Schunk (1981) established, the types of goals students set for themselves are
products of self-efficacy, but also influence self-efficacy and achievement. Valle et al.
(2009) analyzed the relationship between self-efficacy, self regulated learning and
academic management behavior in terms of the types of goals students set for
themselves: high, moderate and low. The study involved 632 Spanish university students.
Their results indicated that learning goals focused on the task are positively related to
self-efficacy, self regulated learning and self regulated behavior such as time
management. A study involving 60 eleventh-grade students in the Netherlands
collaborating in a computer based environment also found that mastery goals and self-
efficacy positively influenced achievement (Sins, Van Joolingen, Savelsbergh, & Van
Hout Wolter, 2008).
Self-efficacy, Affect and Gender
Self-efficacy for controlling emotions such as anxiety may impact performance,
but may also vary by gender. Pajares & Kranzler (1995) studied 329 high school students
regarding math self-efficacy, anxiety, ability and gender as it relates to performance.
They found that ability had a direct effect on self-efficacy and self-efficacy had a direct
effect on anxiety. While there was not a significant difference between male and female
self-efficacy, females reported higher anxiety levels. Bandura, Caprara, Barbaranelli,
8
Gerbino & Pastorelli (2003) examined the self-efficacy to regulate emotions in 424
young adults over two different time periods. They tested the group within two years and
found a strong effect on academic self-efficacy and the ability to cope with social
pressures. Similar to Pajares & Kranzler (1995), Bandura et al. (2003) found a stronger
emotional effect for females as perceived empathetic efficacy was closely associated with
depression in females.
Self-efficacy and Academic Performance
People may master skills, but performance is not the best indicator of ability
because other factors (e.g. weather conditions at a sporting event) may negatively impact
performance (Bandura, 1997). Bandura stresses that performance alone does not modify
self-efficacy beliefs. Rather, self-efficacy and changes in self-efficacy are products of
individuals processing their performance results in relationship to all of the other
information available to them about the conditions of the performance. For example,
perceptions of abilities, the difficulty of the task, individual effort, if the task was
completed with or without aid, and memories of past successes or failures are all taken
into account when individuals form perceptions of self-efficacy (Bandura, 1997).
Therefore, self-efficacy rather then past performance alone is a more suitable indicator
for future performance.
Chemers, Hu & Garcia (2001) demonstrated that self-efficacy had a greater
predictive power for performance than past experiences for first-year college students.
Their longitudinal study involved 256 participants and analyzed the effects of high school
grade point average on self-efficacy and academic performance. They also compared the
effects of academic performance and expectations to factors of stress and adjustment
9
during the first year of college. The self-efficacy measure incorporated a combination of
task specific and generalized items. They found a strong correlation to high academic
self-efficacy and academic expectations, which in turn resulted in greater academic
performance. In a similar study, Majer (2009) analyzed first generation college students
to determine if academic self-efficacy would predict grade point average after one year of
college. His study involving 68 females and 28 males, found a significant relationship
between academic self-efficacy, and grade point average. Britner and Pajares (2006)
found that while social and environmental factors influenced self-efficacy, the greatest
predictors for self-efficacy were mastery learning experiences.
Overconfidence, Performance and Gender
When people are too overconfident, they may set unattainable goals for
themselves which will lead to failure (Bandura, 1986; Moore & Healy, 2008). Under
confident people will most likely engage in self-defeating behavior or avoid failure as
much as possible taking a performance avoidance approach. Bandura suggests that if
people believe they are capable of performing a task, even if it is just above their ability
level, this slight over confidence has a positive effect on self-efficacy judgments and
motivation (Bandura, 1997). Pajares & Kranzler (1995) found that a majority of high
school students expressed over confidence when assessing math ability regardless of
gender or math-efficacy. In a study involving self-efficacy and performance using
information technology (Moores & Chang, 2009), self-efficacy positively impacted
performance and subsequent performance was positively related to self-efficacy for 108
students. When overconfidence and under confidence measures were considered, under
confidence negatively impacted performance and self-efficacy.
10
Gender has also been a factor influencing self-efficacy. For example, in a study
involving 155 boys and 164 girls in middle school learning science, Britner and Pajares
(2006) found that females actually held stronger self-efficacy beliefs than males for
learning science. Higher female self-efficacy for regulated learning impacted student
performance in Caprara’s et al. (2008) longitudinal study. They followed 196 male and
216 female students from 1989 to 2004, to analyze self-efficacy for regulated learning for
Italian students. They found that self-efficacy for regulated learning declines for students
throughout their academic careers. In junior high self-efficacy for regulated learning was
significantly correlated to high school achievement and completion. Gender played a role
in self assessment of mathematic ability (Pajares, 1996). While students have a tendency
toward over confidence regarding academic ability, girls under report ability in
relationship to performance. Pajares (1996) noted that gifted girls in particular do not
report ability accurately despite performance. The tendency, however, is that men are
more likely to display more confidence than women regardless of performance in a
variety of domains (Barber & Odea, 2001; Jonsson & Allwood, 2003; Moore & Healy,
2008; Pallier, 2003). Male overconfidence is attributed to their willingness to embrace
competition as compared to women (Niederle & Vesterlund, 2006).
Performance Feedback
Feedback on performance is key to addressing over confidence and helping
people learn how to accurately self assess abilities (Moores & Chang , 2009). However,
feedback may also serve to undermine self-efficacy and performance when it highlights
negative performance. Bandura and Jourden (1991) found that feedback showing a
decline in performance in relationship to the performance of others negatively impacted
11
self-efficacy, inhibited efficient cognitive processing, and hindered performance
outcomes. Kluger and DiNisi’s (1996, 1998) feedback intervention theory describes the
connection between feedback and behavior regulation. Feedback should be focused on
bridging any gaps between behavior and desired goals or standards. Attention is required
on the part of the student to focus on the feedback if behavior is to change, but attention
is a limited resource. Therefore, it is up to the instructor to focus student attention in a
manner which regulates behavior to meet the goal or standard. When instructors provide
feedback that focuses on the individual instead of the task, they are not maximizing the
cognitive resources which should be attending to changing behavior. When feedback is
directed at the individual, it may negatively impact performance (Kluger & DiNisi,
1996).
Learning Environment and Self-efficacy
Instructors must take into account how their actions within the classroom directly
impact students’ thoughts, feelings, and actions for performing tasks. When instructors
provide training that focuses on mastery goals, they may positively affect self-efficacy,
intrinsic motivation and achievement performance. Mastery learning experiences provide
the learner with the support they need to successfully complete a task such as practice
and guided feedback.
Self-efficacy in the Medical Domain
Medical Student and Surgical Resident Self-efficacy
Surgical education advocates recognize the link between instruction that provides
mastery learning experiences and medical student and surgical resident self-efficacy.
Chalabian and Bremner (1998) suggest that surgical resident motivation and self-efficacy
12
will increase when they are provided with training opportunities to learn and master
different strategies for performing surgical tasks rather than learning many tasks at a
suboptimal level. Since the addition of surgical skills laboratory training for surgical
residents (Bell, 2007), more opportunities are available to examine the effects of
instruction on medical students, surgical interns and residents. Peyre, Peyre, Sullivan and
Towfigh (2006) demonstrated that a three-week surgical skills lab course had significant
positive effects on medical student and surgical intern self-efficacy. Peyre et al. (2006)
asked six medical students and 23 surgical interns to rate their confidence for performing
21 surgical skills, such as performing a tracheostomy or identifying surgical instruments
by name and function, prior to participating in the three-week course. Medical students
reported lower confidence for most (71%) of the 21 surgical skills prior to receiving
instruction. After participating in the course, medical students reported low confidence
for only 16% of the skills. When compared to the confidence reported by surgical interns
with and without surgical skills lab experience for performing the 21 skills, medical
students showed the greatest increase in confidence when compared to surgical interns
with and without surgical skills lab experience and medical students without skills lab
experience.
Several studies in the medical training field provide data that support the research
cited regarding the male tendency toward overconfidence in their abilities. For example,
self assessments reveal differences between male and female self-efficacy for 34 male
and 34 female medical student respondents (Lind et al., 2002). Despite female medical
students’ tendency to underestimate their abilities, they actually perform equivalent to, or
outperform, their male counterparts (Lind et al., 2002; Minter, Gruppen, Napolitano &
13
Gauger, 2005). Another study involving 134 physicians and practitioners also found a
correlation between higher reports of confidence and competence by men with poorer
performance before receiving instruction (Leopold, et al., 2005). Once participants
received instruction, female confidence levels were significantly greater than males, and
they outperformed their male counterparts on objective performance scores. Self-efficacy
did not significantly correlate with some performance scores for 113 medical students
(Mavis, 2001). However, medical students who reported higher self-efficacy were more
likely to score above the mean for OSCE. Further, self-efficacy predicted preparedness,
and preparedness and anxiety were related to performance (Mavis, 2001).
Pedagogical Implications
Appropriate feedback from the instructor will enhance performance and preserve
individual self-efficacy. Surgeon instructors at surgical skills labs must be cognizant of
the fact that female medical students and surgical residents may be underestimating their
abilities, and this must be taken into account when they provide feedback to women
(Lind et al., 2002; Minter et al., 2005). Attributions for success come into play and are
different for men and women where men tend to attribute success to skill and failure to
bad luck, and women may attribute success to good luck and failure to skill (Beyer &
Bowden, 1997). Therefore, faculty should clearly communicate to female medical
students and surgical residents that their success is based on skill and not luck (Minter et
al., 2005). Instruction that promotes medical student and surgical resident self-efficacy
for surgical performance should be a priority especially when perceiving the high
expectations for performing tasks in the operating room (Chalabian & Bremner, 1997).
14
Mastery Modeling and Surgical Skills Lab Instruction
Bandura’s mastery modeling (1997) includes demonstrating to the learner the
skills and strategies for successfully performing the task, providing guided practice so
that learners practice behavior and strategies under the direction of a competent teacher,
and then allowing learners to apply their new skills successfully in an authentic setting.
The learning environment for surgical skills labs, however, relies on expert surgeon
instructors. When experts serve as instructors in any domain, they may unintentionally
leave out basic knowledge components because they have automated the knowledge and
it is no longer available for conscious retrieval (Chao & Salvendy, 1994; Seamster,
Redding & Kaempf, 2000). Expert surgeon instructors are using didactic lecture in
combination with guided practice at the medical university which is the focus of this
study. Although this format is an effective model for instruction, experts cannot control
the amount of information they may be omitting if they rely solely on the ability to recall
procedural information which they have automated.
Information processing theory demonstrates that the instructional delivery
techniques and the supporting learning materials do make a difference in how people
learn and process information, especially when learning complex procedures (Kalyuga,
Chandler & Sweller, 2000; Luker, Sullivan, Peyre, Sherman & Grunwald, 2008; Mayer,
2009; Paas, Renkl & Sweller, 2003; Van Merriënboer, Clark & De Croock, 2002).
Instruction informed by CTA may include an instructor script, student job aid and
procedural checklist. In addition, evaluating performance based on a standardized
procedural checklist developed from the job aid may reduce instructor subjectivity.
Instruction and evaluation procedures informed by CTA may also help mitigate the
15
effects of education level or gender which influence self-efficacy toward performing
specific tasks.
Cognitive Task Analysis to Support Mastery Learning Instruction
The following section describes the function of CTA to elicit expert knowledge
and inform instructional practices, and presents evidence for CTA supported instruction
for performance improvement.
CTA Background and History
Cognitive Task Analysis is an overarching term to describe any number of
information gathering and interview strategies to capture expert decision making and
cognitive processes (Clark et al., 2007; Schraagen et al., 2000). The broad theoretical
framework for CTA is shaped by task analysis, a product of European schools of thought
developed in the late 1800s to inform industrial psychology, and assist in the training of
the industrial workforce (Schraagen et al., 2000). Clark’s and Estes’s (1996) seminal
article argued that task analysis alone could no longer support the training needs for a
global and information centric workforce, and that CTA supported training is better
suited for training complex task and problem solving skills in current work environments.
Performance improvement in general, regardless of the training domain, is the
ultimate goal for conducting a CTA (Schraagen et al., 2000). Employing CTA techniques
provides a means to illustrate a more complete picture of the necessary steps and thought
behind performing complex tasks. The methods for conducting CTAs continue to evolve
given advances in cognitive science and training simulation (Clark & Estes, 1996; Clark
et al., 2007; Crandall, Klein & Hoffman, 2006). Oftentimes, practitioners will mix CTA
methods to capture as much qualitative and quantitative data as possible (Crandall et al.,
16
2006; Yates, 2007). Practitioners of CTA look to experts to provide insights into the most
efficient and desirable approach to solving problems (Clark, Pugh, Yates, Early &
Sullivan, 2008).
Expert Instructors and the “Seventy Percent” Rule
When experts serve as instructors in any domain, they may unintentionally leave
out information that students must master when learning procedural skills (Hamdorf &
Hall, 2000; Kirschner et al., 2006; Mayer, 2009; Thomas, 2006; Wanzel et al., 2002).
Experts may omit basic knowledge components because they have automated the
knowledge and it is no longer available for conscious retrieval (Chao & Salvendy, 1994;
Seamster et al., 2000). Expert automation is a boon to problem solving and a bane to
instruction because the characteristics inherent to a domain expert are the same things
that make the expert an inadequate teacher (Brown & Cocking, 2000; Kirschner et al.,
2006). When experts describe a familiar task, they may omit up to 70 percent of the
critical declarative and procedural knowledge information that novices need to perform a
task (Chao & Salvendy, 1994; Hoffman, Crandall & Shadbolt, 1998), and are usually not
even aware that they are leaving out this information (Sullivan et al., 2008). This
phenomenon is known as the “70 percent rule”, and it applies to declarative and
procedural knowledge. Novices need to understand not only procedural skills, but also
whether or not to perform the procedure, under what conditions the procedure must be
modified, and standards by which they must be held.
Declarative and Procedural Knowledge
In order to understand the usefulness of CTA strategies to create instruction that
supports mastery learning experiences, it is helpful to break the teaching and learning
17
process into its most basic components of knowledge: declarative and procedural. The
relationship between knowledge components should shape how the expert information is
gathered, interpreted and applied. This section defines the knowledge types and how they
are employed using the Concepts Processes and Principles (CPP) (Clark et al., 2007)
technique.
Declarative knowledge is conscious knowledge, is hierarchical in nature, and
serves as the basic foundation for understanding one’s environment (Anderson, &
Lebiere, 1998). Declarative knowledge is used to address problems or change one’s
environment. When declarative knowledge is activated and practiced, it becomes non
conscious procedural knowledge exhibited in behavior (Anderson & Lebiere, 1998).
Merrill (2002) describes declarative knowledge as facts concepts, processes and
principles. Examples of declarative knowledge include domain specific concepts such as
the definition of a procedure, the definition of domain principles, and the equipment
required to perform a procedure. Concepts are organized as chunks (Anderson, &
Lebiere, 1998), and the working memory can typically hold up to five to seven chunks at
one time for a short time.
Procedural knowledge is employed to execute actions and behaviors geared
toward a specific goal (Maupin, 2004). Novices gain procedural skills by practicing the
procedure given a response under appropriate conditions (Anderson & Lebiere, 1998;
Bandura, 1997). Through consistent practice and adjustment to feedback conceptual
knowledge is converted to procedural skills (Bandura, 1986, 1997), and finally
automation of these procedural skills. Automation is desired because performance
becomes more efficient and cognitive processes are freed up to attend to other
18
information (Seamster et al., 2000). All too often, however, declarative knowledge is
emphasized more than procedural knowledge during training (Clark & Elen 2006; Yates,
2007).
Maupin (2004) presents a flow chart of knowledge development (Clark, 1995)
that initiates with declarative knowledge that is factual and conscious thought.
Declarative knowledge includes concepts such as names of people, places, objects and
events, aids in the classification and organization of ideas, and principles that encompass
cause and effect rules. From concepts, classification procedures develop allowing one to
use concepts based on how they are ordered as sequences of decisions, actions or
examples. Principles include declarative knowledge related to experiences that help one
determine cause and effect relationships, make inferences regarding future events, and
modify one’s actions or thoughts. Construction procedures are principles in action that
are shaped by sequences of actions and decisions in order to change one’s environment
(Maupin, 2004, p. 13).
Eliciting Expert Knowledge
Although there are numerous methods and goals for conducting a CTA, central to
all CTA methods is the elicitation and interpretation of expert knowledge. The word
“elicit” is quite appropriate as used by many scholars because the CTA does involve
drawing out expert automated knowledge and decision making processes (Clark et al.,
2007; Crandall et al., 2006; Schraagen et al., 2000). Practitioners also follow general
guidelines to execute a CTA as outlined by Clark, Van Merriënboer, Yates and Early
(2006). The emphasis for eliciting expert knowledge is to indentify declarative and
procedural knowledge representations required to complete a complex task. Yates (2007),
19
however, found that practitioners have emphasized declarative more than procedural
knowledge when conducting CTAs. For this reason, the CPP framework is better suited
to elicit procedural knowledge in combination with declarative knowledge, and identify
the conditions that inform decisions and actions.
Concepts, Processes & Principles (CPP) Framework
The CTA framework informing this study is Concepts, Processes & Principles
(Clark et al., 2007) because it is suited to instructional design for training (Maupin,
2004). The CPP protocol for conducting a CTA explicitly focuses on drawing out expert
concepts, processes and principles that are employed and modified to fit various
conditions (Clark et al., 2008). For example, the interviewer may ask the expert to define
any domain specific terminology and provide examples. The expert will be asked to
describe processes in terms of step-by-step tasks or operations of equipment. Process may
include both cognitive functions, such as the thought processes that occur when
performing the task, or employing materials or equipment required to reach a goal. Clark
et al. (2008) describe processes as a means to provide context for relationships regarding
how things work together to resolve a given problem. Describing cause and effect
relationships, or principles that govern a given domain, help the expert relay what caused
the problem and how to modify solution strategies based on principles and various
conditions.
The information for the CPP protocol is reported in terms of an overall goal, the
conditions as defined by indications and contraindications, a list of equipment, and a list
of tasks and steps required for each task listed in the order in which they should be
completed. Under each step, if applicable, if/then statements highlight conditions for
20
taking specific actions. Experts are also asked to describe indications and
contraindications for performing the task, and standards for performance. Ideally, at least
three Subject Matter Experts (SMEs) are interviewed. One of the products of this
approach is an expert mental model that presents a gold standard for the most efficient
and effective means to solve a specific problem (Clark et al., 2007).
Instructional Design to Support Mastery Learning
Once the expert knowledge has been unpacked using CTA, the information must
be interpreted and presented in a useful format such as a student job aid or instructor
script. Merrill’s first principles of instruction (2002) and Pebble-in-the-Pond model
(2007) describe instructional design to support training for real world tasks by stressing
how learner knowledge may be developed in a sequential manner that is structured
around solving a whole task (Merrill, 2007). Merrill’s first principles of instruction
include the task-centered principle, the activation principle, the demonstration principle,
the application principle, and the integration principle (Merrill, 2006).
Under each principle is a set of rules. For example, the task centered principle is
based on the observation of real world tasks and its outcome. Students should be
presented with the concepts and principles required to complete the task. The activation
principle includes activating student prior knowledge through recall of previous
experiences similar to the task at hand. The demonstration principle posits that learning
will take place when students see skills demonstrated, when demonstrations are
consistent with repetition and with curriculum, when guidance is available, and when
relevant media are available. The application principle suggests that learners must be able
to apply knowledge and skills through consistent practice, and appropriate feedback and
21
coaching should decrease as novices gain experience. The integration principle asks
students to reflect upon and use their new knowledge as well as demonstrate they have
mastered the new knowledge. See, for example, Merrill (2002, 2006, 2007). Merrill’s
first principles informed the development of the Guided Experiential Learning (GEL)
course design (Clark, 2004). The GEL course structure will guide the development of
instruction to be implemented in this study.
The GEL course structure model follows a format designed to maximize how
people process information. The GEL model provides steps, actions and decisions that
will be informed by the CTA to teach surgical residents an open cricothyrotomy
procedure. These steps include: introduction and course goal, reason for the course,
course overview, and a carefully sequenced lesson structure, selecting the appropriate
media, and an evaluation plan. The introduction and course goal provide an overview of
the course, and describe the utility and value of the course. The course overview
introduces the relationship and sequence of the knowledge and procedures required, and
describes the strategies to be implemented to acquire the procedural and declarative
knowledge. The lesson structure has subcomponents that will be informed by the CTA
process. These include: an overview of how this information fits into the overall content,
concepts, processes and principles, a demonstration of the procedure, and directed
feedback during practice of the procedure (Clark, 2004).
The CPP (Clark, et al., 2007) method for organizing the expert knowledge in a
sequence of tasks and subtasks based on expert concepts, processes, and domain
principles aids in the development of a GEL course. Instructional materials include job
aids, instructor script and PowerPoint slide presentation. Conditional “if this/then this”
22
statements help to illustrate domain principles that guide knowledge application. For
example, the instructional material should include a description of any relevant
definitions and equipment needed, the task and its procedures, a list of indicators and
contraindicators, a list of tasks and related subtasks, demonstrations of the procedure, and
opportunities for the student to practice. See for example, Maupin (2004) and Clark et al.
(2008).
Identifying Pass/Fail Performance Assessments
Providing assessments measures for complex tasks may be difficult because the
greater the complexity of the task based on a real world scenario, the more ambiguous the
answer (Merrill, 2006). Merrill describes a complex task as a task which cannot be
performed the same way every time due to varying conditions in the environment.
Performance measures must account for levels of sophistication for the problem solving
solution as students acquire greater experience. Merrill suggests three methods for
providing scaled measurements for complex tasks. For example, it may be possible to
provide a series of whole tasks that increase in difficulty, and then rate performance
based on how many whole tasks are completed versus presenting questions that are
limited in scope. If it is impossible to break the complex task into smaller subtasks, then
provide coaching only when the student is unable to succeed. Increase coaching if the
student is unable to move forward. Finally, if the problem lends itself to stages that
contribute to the final solutions, evaluate students at these stages.
The CPP framework for conducting a CTA is applicable for identifying scaled
assessment measures because the information is gathered using scenarios of varied
difficulty, experts are asked to provide standards for performance, and the information is
23
reported as a sequence of tasks (Clark et al., 2007). Using the CTA data, a rubric for
performance for each task may be created as proposed by Merrill. Students would be
rated on how well they were able to progress through each task rather than on being
scored on isolated operations within each task (Merrill, 2006). If all tasks required to
meet a specific goal are equal in complexity, Merrill suggests offering coaching when
students are unable to progress, and the student is rated on based on the amount of
coaching received. Finally, for tasks that require that learners acquire a level of expertise
before moving to the next step, performance is based on the steps completed in
relationship to that step’s associated level of expertise.
Evidence for CTA-Based Training
Systems Trouble Shooting
Schaafstal and Schraagen (2000) developed CTA supported instruction for Naval
weapon engineers to help improve performance trouble shooting and maintain
communication, weapons and sensor systems. After performing a CTA based on
techniques that highlight knowledge and skills, tasks and cognitive processes, they found
performance deficits were due to the fact that novice technicians were not learning a
process for approaching problem solving in a goal directed manner, and they were not
learning processes for how the equipment operated. They introduced a supplemental
training course and tested it with 21 novice technicians who had completed current
instruction and 11 participants who completed the one week CTA supported training
course. Results were that despite the fact that the experimental group did not score
significantly higher than the control group on the knowledge test, the experimental group
scored much higher on all other measures during the trouble shooting scenarios. Using
24
the same knowledge test and trouble shooting scenarios, students taking the shorter
course were able to solve 95 percent of the problems, and scored higher on reasoning and
system knowledge.
Computer Software Training
Merrill (2002) conducted a study that compared instruction for teaching
spreadsheet skills. The groups for comparison were one receiving guided training, one
receiving no training (discovery learning), and one receiving training supported by
instructional design that emphasized Merrill’s four principles and incorporating CTA
techniques based on the GEL course design (Clark, 2004) described previously. Study
participants included 49 participants for the CTA supported instruction, 49 participants
for the guided training group, and 30 participants for the discovery learning group. The
guided training group received instruction through an e-learning course that allowed for
practice and offered feedback. The discovery learning group did not receive instruction.
All groups were presented with three real world spreadsheet tasks to complete. The
average group scores were 89 percent for the CTA supported group, 68 percent for the
guided e-learning group, and 34 percent for the discovery learning group. Results for
Merrill’s study indicated that not only did CTA supported group outperform the guided
training and discovery learning group, but also completed the spreadsheet tasks more
quickly (Merrill, 2002).
Surgical Skills Training
In the medical field, Crandall and Getchell-Reiter (1994), Maupin (2004),
Velmahos et al. (2004), and Sullivan et al. (2007) laid the groundwork for establishing
the validity of CTA techniques to support training for neo natal nurses, surgical interns
25
and residents. Crandall and Getchell-Reiter incorporated CTA techniques based on Klein
Calderwood, and MacGregor’s (1989) Critical Decision Method (CDM) in order to
determine how experienced nurses were able to diagnose sepsis in its early stages. The
CDM process organizes expert interviews to focus on goals, options, cues, context and
situational awareness. After 19 nurses were interviewed, symptoms and indicators for
sepsis, such as a change in skin color and limp limbs that were not described in training
literature, were identified and included in following instructional material.
Maupin’s (2004) and Velmahos et al.’s (2004) study focused on comparing CTA
based instruction to traditional behavior task analysis based instruction to teach surgical
interns placement procedures for central venous catheters (CVC). Participants included
12 in the experimental group and 15 in the control group. Using the CPP model, two
surgeon experts were interviewed to determine all necessary concepts, processes and
principles required to perform the CVC procedure. The data gathered from the CTA
interviews was used to develop a lesson and training support manual.
All participants received a pre-test to determine a knowledge baseline of the CVC
procedures. The experimental group received the CTA training which included a three-
hour instruction combined with task practice on a model. The CTA supported course
included an overview of the CVC based on indications and contraindications, a
demonstration of the procedure on the artificial model, and practicing the procedure on
the model. The control group learned the CVC procedure based on the mentor
methodology of see-one-do-one-teach-one.
Both the experimental group interns and the control group interns were then
evaluated after two-and-a-half months performing the procedure on patients. The
26
evaluation included observation of the procedure that was then rated using a 14-step
checklist. The experimental group, which had a lower mean score than the control group
on the baseline performance test, scored on average 12.6 out of 14 while the control
group scored on average 7.5. The experimental group completed all tasks at a higher
percentage rate than the control group, and significantly outperformed the control group
in 5 out of the 12 categories. The greatest discrepancy in performance between the two
groups was the task to occlude ports of the catheter after placement (7 percent for the
control group and 92 percent for the experimental group). Also of note is that the
experimental group scored 100 percent in 5 of 12 categories and 92 percent in 5 out of 12
categories.
Sullivan et al. (2007) compared CTA instruction to traditional mentor based
instruction teaching residents to perform percutaneous tracheostomy placement. The
CTA involved the identification of five tasks comprising 7 to 10 steps in each task, data
from video taped procedures by three experts, the creation of the cognitive demands table
outlining decision points, error issues and consequences, and strategies for preventing
errors. This information was utilized to create course material illustrating each step of the
procedure. Participants included second-, third- and fourth-year postgraduate residents.
Nine participants comprised the experimental group and 11 participants comprised the
control group. All were asked about their familiarity with the procedure. The
experimental group received the CTA instruction that included practicing the procedure
on a model. The control group completed the traditional based instruction one week
following. All residents were allowed to practice the procedure as often as they wished.
The two groups were tested directly after the control group received instruction. Groups
27
were evaluated based on technical competence and decision making using think aloud
strategies. Results indicated that the experimental group significantly outperformed the
control group. Sullivan et al. (2007) do note, however, that the limitations of the study are
that the procedure tested is fairly simple, the study group is small, the experts represented
only one institution, and tools which lacked validity.
Cognitive Task Analysis, Self-efficacy and Performance
Experiments using CTA supported instruction for Central Venous Catheter
placement (Velmahos et al., 2004) and percutaneous tracheostomy procedure (Sullivan,
et al., 2007) resulted in increases in skills and knowledge acquisition as well as increases
in performance. Increased knowledge and skills may not only improve performance, but
may also increase self-efficacy. The CTA supported instruction may be successful in
increasing performance and perhaps self-efficacy because it provides a complete picture
of knowledge and skills required to succeed, and it provides a checklist for the expert to
gauge and standardize evaluation.
Summary
A review of the educational research literature provides evidence for the
importance of providing mastery learning experience to positively influence self-efficacy
for performing tasks. A review of medical education research provides evidence that
surgical skills lab instruction may positively influence medical student and surgical intern
self-efficacy for performing specific tasks. This review also suggests that gender played a
role at times: males tended to be overconfident about their abilities and females tended to
be under confident about their abilities when compared to actual performance. A review
of cognitive task analysis (CTA) research confirmed that CTA is a viable method to
28
improve instruction and performance by eliciting expert knowledge associated with the
action steps and decisions steps for a given procedure. CTA instruction seems to support
Bandura’s (1997) mastery modeling teaching strategies that may positively influence
self-efficacy.
Analyzing CTA supported instruction as an effective means to enhance medical
student and surgical resident self-efficacy is a natural extension and complement to
previous work using CTA to increase surgical skills performance (Maupin, 2004;
Velmahos et al., 2004; Sullivan et al., 2007). While expert instructors at surgical skills
labs may be implementing effective instructional strategies, such as didactic lecture
followed by a demonstration and guided practice, CTA supported instruction may
enhance these practices as demonstrated by student performance conducting and self-
efficacy for performing an open cricothyrotomy procedure. For the purposes of this
study, the control group instruction will be referred to as "expert guided instruction," and
the experimental group instruction will be referred to as "CTA supported instruction".
Because the effects of CTA supported instruction on self-efficacy have yet to be
examined, this study analyzes the effects of a CTA instructional intervention to determine
if CTA supported instruction will positively influence the performance and self-efficacy
beliefs of the experimental group compared to the control group. Gender and education
level are considered for their potential effects on self-efficacy and performance. The
performance and self-efficacy of two groups executing an open cricothyrotomy procedure
after receiving expert guided instruction or CTA supported instruction will be used to
address the following questions:
29
(1) Will type of instruction have an effect on medical student and surgical
resident performance conducting an open cricothyrotomy procedure?
(2) Will type of instruction have an effect on medical student and surgical
resident self-efficacy?
(3) Will gender have an effect on performance?
(4) Will gender have an effect on self-efficacy?
(5) Will education level have an effect on performance?
(6) Will education level have an effect on self-efficacy?
30
CHAPTER 2: METHOD
Design
This study incorporated a stratified randomized sampling design to accommodate
for the varying degrees of education levels among the participant population: third-year
medical students, second-year postgraduate residents and third-year postgraduate
residents. Random sampling was applied within each subgroup to create the experimental
and control groups. The focus of this study was the effects of a CTA supported
instructional intervention on self-efficacy and performance for an open cricothyrotomy
procedure. The CTA supported instructional module included an instructor script,
PowerPoint presentation and student job aids. The remaining elements of instruction,
including didactic lecture, guided practice, and evaluation performing an open
cricothyrotomy on an inanimate model remained the same for both groups. Gender and
education level were considered variables that could have effects on self-efficacy and
performance. The dependent variables were scores on the procedural checklist when
being evaluated performing an open cricothyrotomy on an inanimate model, and scores
on the 14-item self appraisal score to measure self-efficacy for the procedure. This study
design and supporting materials were approved by the medical research university’s
Institutional Review Board.
Participants
All third-year medical students on the surgery clerkship, second-year postgraduate
surgical residents and third-year postgraduate residents at a medical research university
were recruited to participate in this study.
31
Procedure and Materials
Phase 1: The CTA procedure. The CPP protocol for conducting a CTA follows
five steps (Clark et al., 2008): 1. Identify tasks and collect preliminary knowledge, 2.
Identify required knowledge to perform the tasks and subtasks, 3. Interview multiple
SMEs, 4. Analyze and verify the data, and 5. Format the results for instruction.
Step 1: Preliminary research related to the open cricothyrotomy procedure was
conducted.
Step 2: The researcher identified the knowledge types associated with the open
cricothyrotomy procedure.
Step 3: Six expert trauma surgeons participated in CTA interviews. Experts
answered questions regarding the overall goal of the procedure, they listed the necessary
equipment required, described the major steps of the procedure, the indications and
contraindications for performing the procedure, outlined conditions for each decision
step, and identified the standards required for successfully performing an open
cricothyrotomy procedure. They also included any new concepts that medical student and
surgical residents may not know as well as highlighted the problem areas for novices,
such as not being able to recognize the indications for performing the procedure or not
being familiar with the equipment. Interviews were recorded through note taking and
with digital audio recorders.
Step 4: The audio recordings of six interviews were transcribed and transcripts
coded in accordance with the CPP protocol to create the CTA report. At least two raters,
and sometimes three raters, coded each transcript. Raters reviewed each line of the
transcript to tally declarative and procedural knowledge as well as action steps and
32
decision steps. Disagreements were resolved through consensus, and inter rater reliability
average was 96 percent. Raters also created flowcharts of the procedure to verify all
action steps and decision points. Once consensus was reached, a master transcript was
created for each expert and then used to develop a CTA report. The CTA report identified
the goal of the procedure, ordered the major steps and subtasks supporting each step,
identified the necessary equipment, listed the indications and contraindications for
performing the procedure, identified decision points associated with various conditions,
and standards indicating successful completion.
Each of the six expert surgeons received an email with a draft of his or her CTA
report and the flowchart attached in a word document. All six surgeons were instructed to
use track changes to provide additional information or make corrections to the CTA
report or comment on the flowchart. Once they had reviewed their CTA reports, the
surgeons emailed the CTA reports and flowcharts back with comments and/or changes. A
master draft of the CTA report and flowchart compiling all expert information into one
report was developed. All six surgeons were asked to review the master draft CTA report
to provide additional information or make corrections. Five surgeons provided input. The
report was updated and became the gold standard for conducting an open cricothyrotomy
procedure according to five experts.
Step 5: The gold standard CTA report served to inform the development of the
CTA supported instructional module, including the instructor script, PowerPoint
presentation and student job aid. All materials were created following the training
guidelines produced by Clark et al. (2008) and the GEL course structure model (Clark,
2004). The instructor script, PowerPoint presentation, student job aid and procedural
33
checklist were reviewed by a second year post graduate surgical resident who was not
participating in the study to identify any issues with the materials. The resident also
assisted by demonstrating the procedure on the inanimate model. Pictures from the
demonstration were included in the PowerPoint slides and job aid to illustrate some of the
major steps of the open cricothyrotomy procedure. (See Appendix A for the instructor
script, and Appendix B for the student job aid).
Phase 2: Instrumentation development. The gold standard CTA report served
to inform the development of the baseline performance test, the procedural checklist and
the self appraisal scale. To help ensure internal validity for the baseline performance test
instrument, the control and experimental groups were randomly subdivided without the
participants’ knowledge. Parallel forms of the baseline performance test instrument were
developed based on two different emergency medical scenarios. Each participant was
evaluated according to the scenario received on the baseline performance test. Each
baseline performance test consisted of six question open ended questions for a total of 17
possible points. The points for the baseline performance test were based on all possible
expert answers for each question. For example, given a specific scenario, participants
were asked how to prepare the patient. One scenario included a cervical spine injury
which would result in the decision to position the patient differently than the scenario
without the cervical spine injury. Participants could have responded with one or more
answers to each question on the baseline performance test. They received points for every
correct response that corresponded to the gold standard for the open cricothyrotomy
procedure.
34
The procedural checklist was created from the gold standard and emphasized the
action steps of the open cricothyrotomy procedure. The 17-step procedural checklist
contained tasks to be performed in order. Instructors evaluated participants performing
the procedure on an inanimate model. For each step on the checklist, instructors marked
“Correct”, “Incorrect” or “Not done”. The checklist also included a question that asked if
all items were performed in the correct order, and if not, which items were not performed
in the correct order. There were 19 possible points on the checklist.
Because self-efficacy is context and task dependent, it follows that self-efficacy
scales that target specific tasks (e.g. making a vertical incision two centimeters long in
the right location) are more accurate than scales attempting to measure general feelings of
competence (e.g. performing well under pressure) (Bandura, 1997, 2006; Pajares, 1996).
The self appraisal scale for this study was developed to focus on specific behavioral tasks
of the open cricothyrotomy procedure within the individual’s power to control, which
helped to ensure content validity (Bandura, 2006). Bandura recommends constructing a
self appraisal scale that asks individuals whether they can do specific tasks right now
prompting people to judge their current perceived capabilities for successfully performing
a given task. The respondents for this study rated their confidence based on a 10-point
Likert scale with 0 indicating “Cannot do at all”, 5 indicating “Moderately certain I can
do”, and 10 indicating “Certain I can do”. This range of responses, according to Bandura,
allowed individuals to gauge their strength of confidence with greater accuracy than a
limited response range such as a 5-point Likert scale. The self appraisal scale included 14
items. (See Appendix C for the procedural checklist and Appendix D for the self
appraisal scale). In an effort to ensure the reliability and validity of self appraisal scale for
35
the open cricothyrotomy procedure, two expert surgeons who participated in the CTA
interviews reviewed the instrument. Additionally, a second-year post graduate surgical
resident who was not participating in the study reviewed the self appraisal scale to
identify any issues with the instrument.
Phase 3: Participant recruitment. Potential participants for the study were
contacted two weeks before the study and provided a flyer with information describing
the study. Potential participants were also welcome to join the day of the study.
Participants provided demographic information, education level and answered questions
regarding past experience with the open cricothyrotomy procedure.
Phase 4: Instructor variables. Due to limited time, the decision was made to use
two instructors rather than one instructor for the two conditions. The two surgeon
instructors had comparable levels of teaching experience. Both were second year trauma
critical care fellows and received equivalent outstanding teaching evaluations. It should
be noted, however, that the control group instructor has more years of experience as a
surgeon. The surgeon instructor leading instruction for the control group did not
participate in any of the CTA interviews and did not review any of the CTA instruction
module materials. Instead, the control group instructor used the PowerPoint presentation
normally used during her lecture, and was provided with an inanimate model in order to
demonstrate the procedure after instruction. The surgeon instructor leading instruction for
the experimental group did participate in the CTA interviews and reviewed the CTA
instruction module materials (the instructor script, PowerPoint presentation and student
job aid) one week prior to the study. Three surgeons, including the instructor, assisted
36
with evaluations in the control group, and two surgeons, including the instructor, assisted
with the evaluation in the experimental group.
Phase 5: Execution. The day before the study, the third-year medical participants
who had confirmed were randomly divided into the control and experimental groups.
New participants who arrived the day of the study were randomly divided on site. The
study was conducted over a three-hour period in two classrooms at a surgical skills lab at
a medical research university. Each classroom included a projector for the PowerPoint
presentation as well as an inanimate model to demonstrate the procedure. Each room
included digital video recorders in order to record each session. Before the students and
residents arrived, the five surgeon instructors assisting with the study were briefed on the
procedures for the study and their responsibilities during the evaluation using the
procedural checklist.
When the students and residents arrived, they were assigned to their rooms,
proceeded to their rooms, and were given an envelope that had the baseline performance
test attached to the outside of the envelope with a paperclip. The procedural checklist and
the self appraisal inventory were inside the envelope. Participants were instructed not to
open the envelope until after they had received instruction, practiced the procedure and
were ready to be evaluated. Participants in the control group learned the open
cricothyrotomy procedure through didactic lecture and observing a demonstration on an
inanimate model. Participants in the experimental group learned the procedure through
similar techniques with the difference being an instructional module informed by CTA
including an instructor script, PowerPoint presentation, and student job aid.
37
After receiving either CTA supported instruction or expert guided instruction,
participants in the experimental group received a job aid to assist them performing the
procedure during practice. Participants in the control moved to a location that allowed
them to practice the procedure on an inanimate model. Instructors were asked to allow
students and residents a 30-minute guided practice session performing the open
cricothyrotomy procedure on an inanimate model. Seven participants in the control group
were not able to practice due to time constraints. Participants in both groups were
evaluated performing an open cricothyrotomy on an inanimate model with a procedural
skills checklist. Three surgeons evaluated individuals in the control group and two
surgeons evaluated individuals in the experimental group. All materials were collected.
The baseline performance tests were graded by two raters who reached consensus on
every item for 100 percent inter rater reliability. Data were entered into Microsoft excel,
and then imported into SPSS data analysis software.
Phase 6: Data analysis plan. The independent variables for analysis include type
of instruction (expert guided instruction or CTA supported instruction), gender, and
experience level (third-year medical student, second- and third-year postgraduate surgical
residents). The independent variables were dummy coded according to the following
format. For type of instruction, 0 = expert guided instruction of the control group and 1 =
CTA supported instruction. For gender, 0 = Male and 1 = Female. For experience level,
second- and third-year postgraduate students were combined due to their small numbers.
Experience level dummy coding was 0 = third-year medical students and 1 = second- and
third-year postgraduate students. The dependent variables are performance based on
38
scores from the procedural checklist and self-efficacy based on the total score from the
self appraisal scale.
To answer question 1 regarding the effects of type of instruction on performance,
an independent samples t-test compared the effects of CTA supported instruction or
expert guided instruction on participant total score on the procedural checklist. To answer
question two regarding the effects of instruction on self-efficacy, an independent samples
t-test compared the effects of type of instruction to participant total score on the self
appraisal scale. To answer question three regarding the effects of gender on performance,
and independent samples t-test compared the effects of gender on participant total score
on the procedural checklist. To answer question four regarding the effects of gender on
self-efficacy, an independent samples t-test compared the effects of gender on the self
appraisal scale. To answer question five an independent samples t-test compared the
effects of education level on performance. To answer question six, an independent
samples t-test compared the effects of education level on total self-efficacy scores.
39
CHAPTER 3: RESULTS
This study compared a CTA supported instruction module informed by expert
surgeon interviews to expert guided instruction at a surgical skills lab for third-year
medical students and post graduate surgical residents learning how to perform an open
cricothyrotomy. Expert guided instruction served as the control group condition and
included didactic lecture, demonstration and guided practice. The intervention for the
CTA supported instruction, which served as the experimental group condition, included
the same procedures as the expert guided instruction in addition to an instructor script,
PowerPoint slide presentation and student job aid created from CTA methods. Data were
collected from students who completed a baseline performance test, participated in either
the control group (expert guided instruction) or experimental group (CTA supported
instruction), participated in guided practice, were evaluated with a procedural checklist
while performing the procedure on an inanimate model, and finally, completed a self
appraisal inventory.
The anticipated results were that students receiving CTA supported instruction
would significantly outperform the control group on the procedural checklist and would
report higher self-efficacy ratings than students in the expert guided instruction control
group. Gender and education level were considered for their potential effects on
performance and self-efficacy.
Experimental and Control Groups Statistical Analysis
There were 33 participants in total. The experimental group included 12
participants, seven of whom were male and five of whom were female. The education
level breakdown for the experimental group included seven third-year medical students,
40
two second-year postgraduate residents and three third-year postgraduate residents. The
control group consisted of 21 participants with 14 males and 7 females. There were 19
participants who were third-year medical students, one participant was a second-year
postgraduate resident and one participant was a third-year postgraduate resident. For a
breakdown of gender by group and education level, see Table 1.
Table 1
Group Demographics by Education Level and Gender
Experimental Group Control Group
Education
Level
Males Females Males Females
Third-Year
Medical
Students
4 3 13 6
Second-Year
Postgraduate
Residents
3 0 1 0
Third-Year
Postgraduate
Residents
0 2 0 1
To gauge experience level, participants were asked if they had ever observed,
assisted with or performed an open cricothyrotomy procedure previously. One participant
in the control group reported observing two procedures. One participant in the
experimental group reported performing one open cricothyrotomy, assisting with one and
observing one. One participant in the experimental group reported performing one open
cricothyrotomy, assisting with five and observing ten. All other participants reported that
they had not performed, assisted with or observed the procedure.
41
Research Questions Statistical Analysis
Raw data were input into an Excel spreadsheet and then imported into Statistical
Package for the Social Sciences (SPSS) 14.0 for analysis. A p-value < .05 was
determined as statistical significance. Because the self appraisal scale was created for this
study, a reliability analysis was conducted which resulted in a Cronbach’s alpha score of
.90. The next section presents statistical analyses and results for the experimental and
control groups regarding performance scores and self-efficacy ratings to address the
following questions:
(1) Will type of instruction have an effect on medical student and surgical
resident performance conducting an open cricothyrotomy procedure?
(2) Will type of instruction have an effect on medical student and surgical
resident self-efficacy ratings?
(3) Will gender have an effect on performance?
(4) Will gender have an effect on self-efficacy?
(5) Will education level have an effect on self-efficacy?
(6) Will education level have an effect on self-efficacy?
Baseline performance test. The 17-point baseline performance test helped to
determine whether or not there were significant differences between the participants prior
to receiving any instruction. For the baseline performance test, the mean score for the
experimental group prior to instruction was 5.4 (SD = 1.68) and the mean score for the
control group prior to instruction was 5.6 (SD = 1.69). An independent samples t-test
revealed no significant differences between the experimental and control group based on
baseline performance test scores prior to receiving instruction: t(23) = -0.88, p = 0.39.
42
Question 1: Will type of instruction have an effect on medical student and
surgical resident performance conducting an open cricothyrotomy procedure?
The first question was concerned with whether or not medical students and
surgical residents receiving CTA supported instruction would outperform their
counterparts receiving expert guided instruction. Participants were evaluated on their
performance of an open cricothyrotomy procedure on an inanimate model. Their
performance scores on the 17-item procedural checklist were compared. An independent
samples t-test revealed that type of instruction had significant effects on participant
performance. The mean score on the procedural checklist for the experimental group was
17.75 (SD = 2.34), and the mean score for the control group was 15.14 (SD = 2.48): t(25)
= 3.01, p = .006. The answer to the first question is that type of instruction received had a
significant positive effect on participant performance for the CTA supported instruction
group, which outperformed participants in the expert guided instruction group.
Question 2: Will type of instruction have an effect on medical student and
surgical resident self-efficacy ratings?
The second question asked whether medical students and surgical residents who
receive CTA supported instruction will report higher self-efficacy ratings than their
counterparts who receive expert guided instruction. Participants in the control and
experimental groups completed a 14-item self appraisal scale (140 possible points) after
being evaluated performing the open cricothyrotomy procedure on an inanimate model.
The self appraisal mean score for the experimental group was 126.10 (SD = 16.90) and
the self appraisal score for the control group was 110.67 (SD = 16.81). An independent
samples t-test revealed that there were significant effects on the self appraisal inventory
43
based on the type of instruction received: t(18) = 2.38, p = 0.029. The answer to question
two is that CTA supported instruction had a significant positive effect on self appraisal
scores. The group that received CTA supported instruction reported higher self-efficacy
for performing an open cricothyrotomy procedure. For a breakout of response by group
question, see Table 2.
44
Table 2
Group Comparison for the Self Appraisal Inventory Results
Scale:
0 “Cannot Do At All” to
10 “Certain I can Do”
Self Appraisal
Inventory Item
Experimental
Group
Mean Score
(N = 10)
Control Group
Mean Score
(N = 21)
p-value
1. Recognize the indications for
when to perform the procedure.
9.00 7.33 0.03
2. Recognize the contraindications for
when not to perform the procedure.
9.00 5.14 < 0.01
3. Prepare yourself using universal
safety precautions.
10.00 8.67 0.01
4. Prepare the necessary equipment
to perform the procedure.
9.60 9.05 0.10
5. Choose the appropriate tube
for the procedure.
8.60 8.24 0.56
6. Put the patient in the
optimal position.
9.20 8.62 0.19
7. Visualize the anatomic
landmarks.
8.80 8.86 0.93
8. Identify the location to make
the incision.
9.00 8.86 0.83
9. Make the necessary
incisions.
9.00 8.24 0.30
10. Place the tube inside
the opening correctly.
9.20 7.38 0.01
11. Recognize the indicators for
successful performance.
9.60 8.52 0.01
12. Perform the procedure in an
emergency situation.
8.30 7.24 0.24
13. Perform the procedure
in 5 minutes or less.
8.50 7.29 0.14
14. Perform the procedure without
making any major mistakes.
8.30 6.50 0.03
45
Question 3: Will gender have an effect on performance?
The third question was concerned with whether or not female medical students
and surgical residents would perform at the same level as their male counterparts. An
independent samples t-test compared overall male (N = 21) performance to overall
female (N =12) performance on the procedural checklist. Gender did not have a
significant effect on performance on the procedural checklist between male performance
(M =16.43, SD = 2.82) and female performance (M = 15.50, SD = 2.5): t(25) = 0.98, p =
0.90. The answer to question three is that males and females displayed similar
performance.
Question 4: Will gender have an effect on self-efficacy?
An independent samples t-test revealed that gender did not have a significant
effect on self appraisal scores reported by males (M = 115.95, SD = 16.62) and females
(M = 115.09, SD = 21.4): t(17) = 0.12, p = 0.91. The answer to the third question is that
female medical students did not express lower confidence than males.
Question 5: Will education level have an effect on performance?
An independent samples t-test revealed that education level did not have a
significant effect on performance based on the procedural checklist scores for males (M =
15.85, SD = 2.82) and females (M = 17, SD = 2.16): t(12) = -1.7, p = 0.27. The answer to
question five is that medical students and surgical residents exhibited similar
performance based on the procedural checklist when performing the open cricothyrotomy
procedure.
46
Question 6: Will education level have an effect on self-efficacy?
This question addressed whether or not third-year medical students would report
lower self-efficacy than second- and third-year postgraduate surgical residents. An
independent samples t-test reported a mean self appraisal score for second and third-year
medical students as 112.12 (SD = 18.10) and a combined mean self appraisal score for
second- and third-year surgical residents as 130.33 (SD = 8.60), and revealed significant
effects on self-efficacy ratings according to education level: t(17) = -3.61, p = 0.002. The
answer to the sixth question is that experience level influenced how third-year medical
students and second- and third-year postgraduates reported self-efficacy for performing
the task. Third-year medical students rated self-efficacy significantly lower than second-
and third-year postgraduate residents.
Summary
Results indicate that CTA supported instruction had significant positive effects on
the performance outcome and the self appraisal ratings for the experimental group.
Gender did not influence performance or self-efficacy ratings. Experience level did not
influence performance, but significantly influenced self-efficacy. See the Discussion
section for a more detailed account of outside factors which may have contributed to
these results.
47
CHAPTER 4: DISCUSSION AND CONCLUSION
The results of this study indicate that the type of instruction received had
significant effects on participant performance and self-efficacy. Gender did not have
significant effects on self-efficacy or performance, but participant education level had
significant effects on self-efficacy. This section discusses these results, study limitations,
and implications for future research.
Research Questions
Question 1: Will type of instruction have an effect on medical student and
surgical resident performance conducting an open cricothyrotomy procedure?
CTA supported instruction had a significant positive effect on participants’
procedural performance in the experimental group based on a procedural checklist
evaluation of them conducting an open cricothyrotomy procedure on an inanimate model.
This result is expected because the experimental group CTA supported instruction was
closely aligned with the steps of the procedure in the order they appeared on the
checklist. This result also is consistent with previous research: when medical students and
surgical residents receive instruction that is informed by expert surgeon input, is based on
mastery learning, and is organized in such a way that helps them efficiently organize and
process important action and decision steps for procedures, they will outperform their
colleagues who are not provided with the same instructional support materials (Luker et
al., 2008; Maupin, 2004; Sullivan et al. 2007; Velmahos et al., 2004).
In order to improve future training, instructors may want to refer to those
procedural steps on the checklist that showed greater discrepancies between the two
groups. Instructors should also take note of lower performance scores for the entire group
48
of participants. For the experimental group, 75 percent of the participants performed the
steps in the correct order, and 48 percent of participants in the control group performed
the steps in the correct order. This result speaks to the utility of CTA to provide step by
step actions for conducting a procedure.
Some of the between group differences are due to the fact that nine participants in
the control group used the endotracheal tube to perform the procedure. Choosing to use
alternate equipment that was not intended for this study accounts for some of the
differences between the group scores on items related to testing the tracheostomy tube,
and assembling the pieces of the tracheostomy tube after inserting the tube. Providing
uniform equipment for all participants should have been a priority for the researcher.
Group differences may also be due to the fact that seven participants in the control group
did not have time to practice the procedure due to time constraints. The researcher was
informed of this fact after evaluation had taken place. Controlling for variables that may
affect participant performance is a priority for future similar efforts.
Question 2: Will type of instruction have an effect on medical student and
surgical resident self-efficacy ratings?
CTA supported instruction had a significant positive effect on self appraisal
scores for the experimental group. Since the experimental group reported greater
confidence for the items “Placing the tube inside the opening correctly,” “Recognizing
the indications for performing the procedure correctly,” and “Perform the procedure
without making any major mistakes,” it is possible that the CTA supported instruction
covered these items more thoroughly than the control group instruction. It is not
surprising that the control group did not report equal self-efficacy ratings for placing the
49
tracheostomy tube correctly because this was not specifically highlighted by the control
group instructor in the slides or lecture. Of note for the control group is that the
instructional materials highlighted how to recognize contraindications, which were listed
on the slide as a learning objective. However, contraindications were not covered
anywhere else in the instruction because they were omitted by the instructor during the
control group lecture. We do not know if this information was excluded because the
instructor had automated this knowledge or simply did not remember to include it. A post
interview with the instructor would have been helpful to confirm the reason for leaving
out this information.
The control group reported higher self-efficacy than the experimental group for
performing the procedure without making any major mistakes. This is an important
differentiation between the groups because greater confidence for performing the
procedure may affect future performance conducting the procedure in a live setting.
Interviews with students and residents would contribute overall to these finding so
that participants would have an opportunity to communicate in their own words what
concepts or steps in the procedure were most challenging, and what suggestions they may
have for improving instruction.
Question 3: Will gender have an effect on performance?
Gender did not have an effect on performance which supports previous research
in the medical education field that females perform at the same level as their male
counterparts (Lind et al., 2002; Minter et al., 2005). This result suggests that regardless of
type of instruction, females are performing at the same levels as males, a positive finding
for this surgical skills lab.
50
Question 4: Will gender have an effect on self-efficacy?
Females did not express lower confidence than males. This result does not support
previous research related to differences in male and female reports of self confidence
(Barber & Odea, 2001; Jonsson & Allwood, 2003; Moore & Healy, 2008; Pallier, 2003).
This result also does not support research in the medical domain regarding male
overconfidence and female under confidence (Mavis, 2001; Minter et al., 2005).
However, the fact that females were not reporting lower self-efficacy than males is an
encouraging result for the surgical skills center in general. This result may indicate that
females are experiencing education in a supportive environment (De Saintonage & Dunn,
2001), and receiving feedback that emphasizes success due to skill versus luck (Beyer &
Bowden, 1997). Because this result does not support previous research in the medical
domain, further research is recommended to determine what environmental factors are
influencing female self-efficacy particularly at this surgical skills center. Qualitative
research using focus groups would be valuable to explore this finding further.
Additionally, the design for the self appraisal may need to be adjusted in order to
account for changes in self-efficacy, possibly related to feedback and performance. One
of the issues with the current design is the self appraisal occurred only after performance
on the procedural checklist. This decision was made because it did not make sense to
assess self-efficacy regarding the specific tasks of a procedure prior to learning the
procedure. It would be interesting, however, to have students complete the self appraisal
scale just after instruction, perform the procedure, and then complete the same self
appraisal scale to determine if there were any differences in pre and post procedure scores
between the experimental and control groups.
51
Question 5: Will education level have an effect on performance?
Education level did not have a significant effect on performance. This result is
unexpected due to the number of postgraduate surgical residents in the experimental
group (five out of 12 participants) compared to the control group (2 out of 19
participants). This study could be improved by attending to the demographics and
numbers of participants in the control group and experimental group.
Question 6: Will education level have an effect on self-efficacy?
Self-efficacy was significantly lower for third-year medical students when
compared to second- and third-year post graduate surgical residents. This result may be
supported by the literature if second- and third-year postgraduates have had past
successful learning experiences that will influence self-efficacy (Bandura, 1997). As
mentioned, past performance alone, however, is not the best indicator of future successful
performance (Bandura, 1997; Bandura & Lock, 2003). This results does not support the
research of Peyre et al. (2006) which demonstrated that medical students had greater self-
efficacy for specific surgical tasks than interns after completing a three-week training
course. Time may be a factor that plays a role in self-efficacy development for novices. It
is interesting that unequal distribution of second and third-year postgraduates influenced
self-efficacy but not performance. More research is needed to explore this result. Focus
groups would be helpful in determining the differences between these groups and if these
difference affect self-efficacy.
52
Results Summary
The purpose of this study was to build on previous studies that have looked at the
effects of CTA instruction on performance only (Maupin, 2004; Sullivan et al., 2007;
Velmahos et al., 2004), and explore the effect on CTA instruction on self-efficacy. This
study provides a baseline for establishing the relationship between CTA supported
instruction and self-efficacy and adds to the knowledge base of CTA supported training
to improve performance, because it is the first to examine the effects of CTA instruction
on self-efficacy. One of the major contributions of this study is that it covers new ground
related to the influence of CTA supported instruction on motivation and self-efficacy of
surgical residents and students.
Limitations
Applied Research
Conducting research in a dynamic environment with multiple instructors
introduces variables that are difficult to control. It was not feasible to coordinate a
meeting with five surgeons in order to brief them on the study logistics. Therefore, the
instructors were briefed right before the two classes began the morning the study was
conducted. There were two different instructors, so the study cannot rule out the
possibility that instructors may have influenced the outcome of the experiment with their
teaching techniques, rapport with students, etc. Further, both instructors introduced
material beyond the scope of the study, and therefore interfered with the validity and
reliability of the study’s measures. The researcher was not prepared for the control group
instructor to include two different open cricothyrotomy techniques during instruction, and
allow students to practice with and be evaluated on different equipment from the
53
experimental group. Instructors in the experimental and control groups spent time
introducing information beyond the procedural checklist during guided practice.
One way to control for multiple instructors, and also create CTA supported
instructional materials that could be easily distributed, would be to make a video that
provided the instruction and visual demonstration of the procedure. Luker et al. (2008)
successfully created interactive media to teach the flexor tendon repair using CTA
methods. Repeating the current study with multiple instructors who would be tasked with
teaching both expert guided instruction and CTA supported instruction would provide
opportunities to analyze how instructors interact with the CTA instructional materials,
and possibly help to control for the differences in teaching techniques.
The dynamic nature of the classroom also made it difficult to control the behavior
of the participants. For example, many participants were given an envelope with the
baseline performance test paper clipped to the outside of the envelope, and they were
directed not to open the envelope until after receiving instruction. Many participants in
both the control and experiment groups, however, did not hear the instructions or did not
follow them. Even when participants in the experimental group were reminded not to
review the materials prior to being evaluated, they did not follow directions. Students
who reviewed the information prior to being evaluated may have been influenced by the
materials, which was likely reflected in their scores on the procedural checklist.
Although the students in the experimental group were given a handout of the
PowerPoint slides, no one took notes, either on the slide handouts or in his or her own
notebooks. Experimental group participants received a job aid handout for them to use
during guided practice, but none were observed using the job aid hand out while
54
practicing the procedure, despite being reminded by the researcher to refer to the handout
during practice. Some participants in the experimental group did not practice but instead
socialized or sent text messages on their cell phones. Given these observations, the
researcher should not have distributed the self appraisal scale and procedural checklist
prior to the students receiving instruction, and the researcher should have communicated
more clearly to the instructors and to the students what was expected of them.
Instructional Design and Support
While the instructional materials were designed following a Guided Experiential
Learning model (Clark, 2004), the experimental group instructor did not follow a GEL
model in terms of delivery. The instructor for the experimental group, although he was
provided with a script, diverted from the script and asked students questions to encourage
more interaction. It would have been helpful to provide a brief training session on the
GEL model. The researcher should have provided the instructor with a description of the
processes and procedures he was expected to follow.
Another option would be to align the experimental group’s slide presentation as
close to the control group’s slide presentation as possible. For example, the experimental
group may have benefited from seeing the illustrations of the anatomy and examples of
how to stabilize the trachea with the non dominant hand. Conversely, the control group
may have benefited from receiving the information arranged hierarchically with the
overall goal, indications, contraindications, equipment, and step-by-step actions and
decisions.
The materials for the experimental group were created from the CTA interviews,
but did not include input from any of the surgeon instructors. There was also
55
misinformation in the PowerPoint slides and student job aid, and the instructor should
have been given more lead time to review the instructional materials to avoid including
erroneous information on them. Involving instructors in developing the instructional
materials from the outset may also influence instructor self-efficacy because they will
have exercised some control over this component of instruction (Jesus & Lens, 2005;
Skaalvik & Skaalvik, 2007). Surgeon instructor individual self-efficacy and collective
efficacy is an area for future research. These expert surgeons may feel efficacious in the
emergency room, but may not experience the same self-efficacy for teaching in the
classroom. Much of the empirical research on collective efficacy is related to public
school teachers and supports the concepts introduced by Bandura (1993) that teacher self
efficacy is task and context dependent, and is directly related to student achievement
(Ciani, Summers, Easter, & Sheldon, 2008; Goddard, 2002; Goddard, Hoy, & Hoy,
2000).
Challenges in Execution
The study design using two different scenarios within groups could have been
more flexible in execution. While an attempt was made to prepare as much as possible
before the day of the study by organizing packets for those participants who signed up
ahead of time, the rigidity of this approach did not allow the researcher to readily adapt to
accommodate for new participants arriving the morning of the study. Some participants
did not report to the surgical skills lab to be assigned to a group, but instead followed
their normal instructor, who happened to be observing the control group instructor.
Therefore, there were disproportionate numbers in the control group versus the
experimental group.
56
Limited Time
The biggest limitation to this study was time. It is difficult to make generalized
conclusions based on a three-hour experience. Surgeons are busy people and it is
understandable if developing the ideal training module is not a top priority. Conducting
CTA interviews is time consuming, coding the documents and creating the instructional
media are also time consuming. However, CTA in conjunction with valid instructional
design methods has proven its effectiveness in increasing performance, in both this study
and others. Future research should focus on strategies for streamlining the CTA process.
For example, can technology be implemented to automate CTA processes and
procedures?
This study was limited by insufficient time and resources. It would have been
beneficial to audit a semester at the surgical skills center to provide a gap analysis that
would help identify any existing training gaps (Clark & Estes, 2002). This step would not
only inform the CTA supported instruction, but it would allow for the observation of
multiple classes with multiple instructors and thus could provide a better picture of some
of the training challenges that might be within the instructor’s control. Future research
may include a gap analysis and focus groups including instructors and students.
Implications
Given the limitations of this study, future research should focus on refining and
improving the self appraisal instrument by testing it on a larger population of medical
students and surgical residents. It is also helpful to investigate the optimum time and
conditions for administering the instrument in relationship to instruction and performance
evaluation. This study provides a baseline for establishing the relationship between CTA
57
supported instruction and self-efficacy, and future research may also examine self-
efficacy as a mediating variable for performance when comparing types of instruction.
While this study provides some evidence for the effects of CTA supported
instruction on self-efficacy for surgical performance, future research must focus on
examining the role of CTA instruction on self-efficacy for surgical performance on more
complex surgical procedures. Peyre et al. (2006) noted that even after a three-week
surgical skills course, self-efficacy remained low for students when they were rating
more complex procedures. Because CTA methods and CTA supported instruction are
designed to provide training for more complex tasks, a replication of this study targeting
a surgical procedure that is complex and performed often would be a valuable
contribution. Furthermore, future research efforts should focus on the effects of CTA
instruction on self-efficacy and performance over a longer period of time. For example,
replicating Peyre et al.’s (2006) work, it would be interesting to explore introducing CTA
supported instruction into a three-week surgical skills course for medical students and
surgical interns. Measuring self-efficacy prior to the course and after the course
comparing CTA supported instruction with expert guided instruction may yield
informative results.
The Role of Feedback
One unintended discovery during the course of this study is that further attention
should be paid to the timing and delivery of feedback from surgeon instructors to students
and residents during lecture and while they are performing a procedure. Feedback
techniques were identified as an issue in the experimental group during lecture and
during guided practice. During instruction, when one student responded incorrectly,
58
negative feedback was directed at the individual rather than the task. For example, when
a student reported the wrong answer, the instructor told her that she should know better
because of her education level. Also, while students in the experimental group practiced
performing the procedure, the instructors introduced more new information rather than
focusing on providing feedback. Since one of the factors that influences self-efficacy is
verbal feedback from a respected source (Bandura, 1997), inattention to the detail of
when and how to deliver effective feedback to students may lead to negative results in
both performance and self-efficacy (Bandura & Locke, 2003; Kluger & DiNisi, 1996,
1998).
In this study, the researcher’s assumption that instructors were familiar with the
term “guided feedback” as well as the techniques for how to apply guided feedback was
an error. Cognitive task analysis can support future research by defining guided feedback
for surgical skills lab instruction, and focusing on the processes for implementing guided
feedback most efficiently for students conducting procedural tasks. Nicol and
MacFarlene-Dick (2006) offer a model for formative feedback that will encourage self-
regulated learning. Their seven principles describe strategies that promote clear
communication of learning goals and standards as well as timely and directive feedback
that will help the student correct and self assess.
Motivation, Self-efficacy and the Medical Domain
Due to the nature of medical education and the unique opportunity it provides for
teaching and learning, more research should focus on motivation in the domain of
surgical education as well as how CTA can be implemented to teach other processes such
as efficiently using tools of the job (Fackler et al., 2009) and improving communication
59
between supporting staff and patients (Shachak et al., 2008). For example, how does the
environment, such as the emergency room, influence motivation when active choice is
removed due to the emergency nature of the job, but persistence and mental effort may
mean the difference between life and death? Can CTA help identify strategies and
procedures that expert surgeons use to cope before, during and after an emergency
procedure? Can these strategies be documented and presented in way that novices can
learn what to expect and how to cope with emergency surgical procedures? These
questions are ideal for future CTA research to address.
60
CONCLUSION
This effort may positively impact instructional techniques for teaching an open
cricothyrotomy procedure at a surgical skills lab. The medical research university
collaborating on this study now has a CTA report that documents and integrates how five
expert surgeons perform an open cricothyrotomy procedure. This document can be
leveraged to refine future instructional materials. The CTA report includes other
information beyond the decisions steps and actions for the procedure. It also describes,
from an expert’s perspective, where novices tend to run into issues when trying to learn
the procedure. Another important aspect of this study is the creation of the procedural
checklist. This checklist is a powerful example of how expert automated decisions and
action steps can be distilled into a tool that can be used for standard evaluation of surgical
residents and medical students. The PowerPoint slides and student job aid created for
this effort can be used in their current state, or refined if needed. The bigger picture,
however, is that providing surgeon instructors with access to these materials offers
surgeon instructors examples of how they might approach teaching a procedure and what
kind of support novices will need in order to efficiently learn the procedure, maximize
performance and self-efficacy for performing the procure.
Developing common learning support media with an instructor script is a step in
the right direction to help standardize the information being presented in surgical skills
labs regardless of who is in the instructor role. When surgeon instructors are open to
collaborating with educational psychologists, they can draw from proven adult training
practices and motivational theory grounded in research to improve how they deliver
instruction for teaching surgical procedures. Because expert surgeons may find
61
themselves playing the role of instructor at some point in their professional careers, they
also have a learning curve in understanding their limitations as an instructor inherent to
their expert status.
The surgeon instructor’s role is to help maximize the way people learn by
providing a complete picture of the concepts, processes and procedures for a given task.
When surgeon educators are informed about how people process information, and begin
to implement the processes for effective instruction, guided practice and feedback, they
will create a training culture that supports mastery learning experiences for medical
students and surgical residents. Adopting instructional processes geared toward mastery
learning will positively impact medical student and surgical resident self-efficacy and
performance.
62
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APPENDIX A
LESSON PLAN, INSTRUCTOR SCRIPT, AND POWER POINT SLIDES
Lesson Overview
Instructor Activities Student Activities Estimated
Time
• Hand out PowerPoint
presentation.
• Overview of Open
Cricothyrotomy: Slides 2 – 4
• Describe procedure: Slides
5 –18
• Receive PowerPoint
handout.
• Receive verbal & visual
presentation from
instructor
• Observe & ask questions
20 minutes
• Demonstrate procedure on
anatomical model
• Receive verbal & visual
presentation from
instructor
• Observe & ask questions
15 minutes
• Hand out Job Aid
• Provide Guided Practice
• Review Problems: Slide 20
• Receive Job Aid
• Part task and whole task
practice of the procedure
• Receive feedback on
practice
20 minutes
• Evaluate resident and student
performance: Slide 21
• Receive checklist
evaluation
30 minutes
73
Power Point Slides
Slide 2: Course Objectives
• Introduce the Lesson Goal:
You will learn the open cricothyrotomy which is performed to establish a
definitive airway in an emergency situation when oral tracheal intubation
fails.
We will review the step-by-step procedure.
I will demonstrate the procedure on an anatomical model.
You will practice the procedure on an anatomical model.
After practice, you will be evaluated performing the procedure on an
anatomical model.
Side 3 Indications and Contraindications:
• The indications for the procedure are:
Loss of airway
Multiple attempts at oral tracheal intubation fails
Facial injuries make it impossible to maintain an airway
• The contraindications for the procedure are:
Able to establish an oral endotracheal
You do not know how to do the procedure
You do not have a scalpel and a tube
Children under 10 years of age
Patient has advanced directive not to be resuscitated
74
Side 4 Procedure Overview:
• The 4 major Tasks for the Open Cricothyrotomy are:
1. Prepare: equipment, patient, and self
2. Make incisions and open airway
3. Place tube in airway
4. Confirm placement and secure the tube
• The procedure should take from 1 minute to under 5 minutes.
Slide 5: Scenario:
• Explain: I’m going to describe an incident in which I had to perform an open
cricothyrotomy. Together we will review the steps required to successfully
perform the procedure.
Scenario: Instructor, convey an incident in which you had to perform the open
cricothyrotomy procedure describing how you used the following steps:
1. Prepare: equipment, patient, and self
2. Make incisions and open airway
3. Place tube in airway
4. Confirm placement and secure the tube
Slide 6: Task 1 – Preparation: Equipment
Locate and prepare equipment. A full list of equipment is on the last page of your
handout. At a minimum you will need:
Cricothyrotomy Kit
Blade
Tracheostomy tubes – sized 6.5 mm, 7 mm, and 7.5 mm
Rolled towel
75
Obtain assistance if possible
• Position lights
• Prepare the tracheostomy tube – INSTRUCTOR DEMOSTRATES:
Test for working cuff using 10 cc syringe:
Blow up cuff
Deflate cuff.
Pull inner cannula out of the tracheostomy tube and put the obturator into the
tracheostomy appliance.
Assemble CO2 monitor onto bag.
Slide 7: Task 1 – Preparation: Patient
• Position patient into supine position with patient’s arms at their side.
IF patient is at risk for C-Spine injuries, THEN:
Provide C-spine immobilization to secure patient neck from moving OR
Keep patient in a neutral position.
IF patient has no C-spine injuries, THEN place a rolled towel underneath
patient shoulders to open up neck.
• Prepare the neck with chlorhexidine or betadine and drape the patient. Local
anesthetic is unnecessary.
Slide 8: Task 1 – Preparation: Self
• Prepare self by donning universal safety precautions; scrubbing hands is
unnecessary because of time constraints.
• Position self:
IF you are right-handed, THEN position yourself to the patient’s right
side.
IF you are left-handed, THEN position yourself to the patient’s left side.
Slide 9: Task 2 – Make Incision and Open Airway: Identify Incision Location
• Use non-dominant hand to hold the trachea
• Identify incision location
76
Use dominant hand to palpate through the skin
Feel for cricothyroid membrane and thyroid cartilage (Adam’s Apple),
either by going inferior to the Adams’s apple or by going three four
fingers up from the sternal notch.
Slide 10: Task 2 - Make Incision and Open Airway: Vertical Incision
• Make a vertical incision
1.5 cm to 2.5 cm in length in the area between the
thyroid cartilage and cricothyroid cartilage centered over the top of the
cricothyroid membrane.
• Bluntly dissect down past the soft tissue to expose thyroid cartilage and
cricothyroid cartilage.
Slide 11: Task 2 - Make Incision and Open Airway: Confirm Location
• Retract the area
IF you have an assistant THEN have the assistant hold the skin flaps open
using a Kelly hemostat.
IF you do not have an assistant THEN push straight back with your fingers
to open the incision.
• Once through the skin and soft tissues, use your finger to feel again to
confirm cricothyroid membrane location.
IF the incision is not over the cricothyroid membrane or the incision is too
small THEN extend the incision before continuing.
Slide 12: Task 2 - Make Incision and Open Airway: Transverse Incision
• Make a transverse [horizontal] incision
Across cricothyroid membrane or
Penetrate the cricothyroid membrane with the sharp end of your blade.
• Spread the cricothyroid opening 5-10 mm to fit tube by:
Inserting and twisting the blunt end of scalpel or
Inserting and expanding a Kelly hemostat inside of the opening.
77
Using your finger is not recommended to avoid injury from cutting
yourself on sharp fragments.
Slide 13: Task 2 - Make Incision and Open Airway: Confirm Location
• Standard: Incision location is correct if you:
Encounter a gush of air and/or
Observe a small opening.
• IF you get bleeding, THEN apply pressure to stop the bleeding but continue
procedure
Slide 14: Task 3 - Place the tube in airway
• Recommended: Lift the airway up to facilitate the insertion of the appliance
by:
Inserting the trachea hook
Turning the hook towards the lower or upper part of the tracheal incision,
and
Pulling the hook up towards yourself
Slide 15: Task 3 - Place the tube in airway
• Approach the hole perpendicularly:
Place the tube inside opening,
Twist the tube downwards and
Insert the entire length of tube.
• IF the tube does not go in easily or you get a lot of subcutaneous emphysema
THEN remove the tube and try again.
Slide 16: Task 3 - Place the tube in airway
• Once tube is in place:
Hold the tube,
remove the obturator,
attach 10cc syringe and inflate the cuff and
place the inner cannula into the tube.
78
Slide 17: Task 4 – Confirm Placement and Secure Tube
• Connect bag and CO2 monitor to patient
Bag patient while ventilator is set up.
Check for CO2 return
CO2 monitor should change from purple to gold
• IF you are not getting CO2, THEN
Make sure the patient did not die
Recheck the tube’s position
Extend your incision
Look back into the incision and make sure you have identified your
landmarks.
Slide 18: Task 4 - Confirm Placement and Secure Tube
• Confirm successful placement with the following indicators:
Look for increased oxygen saturation levels
Check for bilateral breath sounds with stethoscope and confirm that chest
is rising and falling.
Optional: Conduct a bronchoscopy or chest x-ray.
• Suction area out once saturation levels have increased (mid 90’s).
• Place a tracheostomy collar around the neck
• Suture the collar with 3.0 or larger nylon sutures.
Slide 19: Guided Practice
• Hand out job aids.
• Explain: Using your job aids, you will perform the open cricothyrotomy
procedure on the anatomical model. You will have some time to practice, and
then an instructor will observe you performing the procedure without the job aid.
79
• Allow students and residents to practice performing the open cricothyrotomy
procedure on an anatomical model. Provide feedback.
• After students have practiced, but before they are evaluated, explain some of the
problems/complications.
Slide 20: Problems/Complications
• Explain: Some of the potential problems/complications associated with this
procedure are:
Deciding when to do this procedure. Novices decide that the patient needs
an airway too late – or perform the procedure too slowly – because they
start looking for other causes.
Lack of experience using equipment.
Attempting to insert wrong size tube.
If the patient’s neck is short or the patient is obese, it is more difficult to
locate the anatomy
Hematoma or a neck injury may distort the anatomy
Bleeding
Misidentifying landmarks
Too small of an incision into the membrane
Too large of an incision which can transect the larynx
Letting go of the anatomy with the non-dominant hand and losing site of
where to place the tube
Inserting the tube into the wrong passage
Slide 21: Evaluation
• Explain: After guided practice, you will be evaluated performing the open
cricothyrotomy procedure without using the job aid.
80
APPENDIX B
STUDENT JOB AID FOR OPEN CRICOTHYROTOMY
Open Cricothyrotomy Procedure
Objective: The Open Cricothyrotomy procedure is a procedure performed to establish a
definitive airway in an emergency situation when oral tracheal intubation fails.
Open Cricothyrotomy Task List:
81
Equipment
o Tracheostomy Kit / cricothyrotomy kit
Tracheostomy tube
Cricothyroid cannula
Tracheostomy hook
Trachea tape
Tracheostomy collar
10 cc Syringe
Airway extender / extension tubing
o Blade/Knife/Scalpel
o Surgical tray
o Sutures
o 4x4 gauze
o Clamp or Kelly hemostat
o Small retractor– optional
o Chlorhexidine or betadine
o Drapes
o Rolled towel
o Lighting
o Suction
o Universal barrier precautions: Eyewear, Hat, Mask, Gown, Sterile gloves
o Pulse oximeter
o CO2 detector
82
o Bronchoscope
o Stethoscope
o Chest x-ray
o Recommended: Assistant to provide retraction/apply pressure
o Ambu bag
o Ventilator / oxygen source / airway team
83
Task 1: Prepare equipment, patient, and self
Step Actions and Decisions
1.1 Locate and prepare equipment.
1.2 Locate:
• Cricothyrotomy Kit
• Blade
• Tracheostomy tubes –
sized 6.5 mm, 7 mm,
and 7.5 mm
1.1.2 Prepare the
tracheostomy tube(s)
• Test tracheostomy for working cuff by testing with a 10cc syringe,
blowing up balloon cuff, deflating balloon cuff.
• Pull inner cannula out of the tracheostomy tube and put the obturator
into the tracheostomy appliance.
• Go to step 1.1.3
1.1.3 Assemble CO2 monitor onto bag
1.3 Obtain assistance if possible
1.4 Position lights
1.5 Position patient
1.5.1 Position patient into supine position with patient’s arms at their side.
Cricothyrotomy Kit
84
• IF patient is at risk of C-Spine injuries, THEN provide C-spine
immobilization to secure patient neck from moving or keep patient in a
neutral position. Go to step 1.5.
• IF patient has no C-spine injuries, THEN go to step 1.4.2.
1.5.2 Place a rolled towel underneath patient shoulders to open up neck.
1.6 Prepare self by donning universal safety precautions; scrubbing hands is
unnecessary because of time constraints.
1.7 Prepare the neck with chlorhexidine or betadine and drape the patient. Local
anesthetic is unnecessary.
1.8 Position self for the procedure.
• IF you are right-handed, THEN position yourself to the patient’s right
side.
• IF you are left-handed, THEN position yourself to the patient’s left side.
Task 2: Make incisions and open airway
Step Actions and Decisions
2.1 Use non-dominant hand to hold the trachea still
2.2 Identify the location to make the incision by using the dominant hand to palpate
through the skin and feel for cricothyroid membrane and thyroid cartilage
(Adam’s Apple), either by going inferior to the Adams’s apple or by going three
to four fingers up from the sternal notch.
85
2.3 Make a vertical incision 1.5 cm to 2.5 cm in length in the area between the
thyroid cartilage and
cricothyroid cartilage centered
over the top of the
cricothyroid membrane.
Bluntly dissect down past the
soft tissue to expose thyroid
cartilage and cricothyroid
cartilage.
2.4 Retract the area.
• IF you have an assistant THEN have the assistant hold the skin flaps
open using a Kelly hemostat.
• IF you do not have an assistant THEN push straight back with your
fingers to open the incision.
2.5 Once through the skin and soft tissues, use your finger to feel again to confirm
cricothyroid membrane location.
• IF the incision is not over the cricothyroid membrane or the incision is
too small THEN extend the incision before continuing to step 2.6.
• IF this incision is in the correct location THEN go to step 2.6
Vertical Incision
86
2.6 Make a transverse [horizontal]
incision across cricothyroid
membrane or penetrate the
cricothyroid membrane with
the sharp end of your blade.
2.7 Spread the cricothyroid
opening 5-10 mm to fit tube
by:
• Inserting and twisting the blunt end of scalpel
or
• Inserting and expanding a Kelly hemostat inside of the opening. Using
your finger is not recommended to avoid injury from cutting yourself on
sharp fragments.
Standard: Incision location is correct if you encounter a gush of air and/or
observe a small opening.
• IF you get bleeding, THEN apply pressure to stop the bleeding but
continue to step Task 3.
• IF you do not get bleeding THEN continue to Task 3.
Task 3: Place tracheostomy tube in airway
3.1 Recommended: Lift the airway up to facilitate the insertion of the appliance by
inserting the trachea hook, turning the hook towards the lower or upper part of
the tracheal incision, and pulling the hook up towards yourself.
Horizontal Incision
87
3.2 Approach the hole perpendicularly place the, tube inside opening, twist the tube
downwards and insert the entire length of tube.
• IF the tube does not go in easily or you get a lot of subcutaneous
emphysema THEN remove the tube and repeat step 3.2.
• IF the tube insertion is successful THEN go to step 3.3
3.3 Hold the tube, remove the obturator, attach 10cc syringe and inflate the balloon
cuff and place the inner cannula into the tube.
Task 4: Confirm placement and secure the tube
Step Actions and Decisions
4.1 Connect bag and CO2 monitor
to patient and bag patient
while ventilator is set up.
4.2 Check for CO2 return.
• IF you are not getting
CO2, THEN
o Make sure the
patient did not die
o Recheck the tube’s position
o Extend your incision
o Look back into the incision and make sure you have identified
your landmarks.
• IF you are getting C02 THEN go to step 4.3
4.3 Ventilate the patient.
Bag the patient while ventilator is set up.
88
4.4 Confirm successful placement with the following indicators:
• Look for increased oxygen saturation levels
• Check for bilateral breath sounds with stethoscope and confirm that
chest is rising and falling.
• Optional: Conduct a bronchoscopy or chest x-ray.
4.5 Suction area out once
saturation levels have
increased (mid 90’s).
4.6 Place a tracheostomy collar
around the neck and then
suture the collar with 3.0 or
larger nylon sutures.
4.7 STOP
Place the tracheostomy collar around
the neck and suture the collar.
89
APPENDIX C
SURGICAL SKILLS SIMULATION AND EDUCATION CENTER
OPEN CRICOTHYROTOMY PROCEDURAL CHECKLIST
Scenario 1: A 54-year old female presents to the emergency room after she was struck in the face
with a baseball bat. Her airway is compromised and she has major maxillofacial injuries.
Endotracheal tube intubation was attempted but not successful.
Task:
Not Done (N) Or
Incorrect (I)
Done
Correctly
Comments
1. Correct reasons for performing procedure
N I 1
2. Prepare required equipment:
a. Test tracheostomy tube for working cuff
b. Pull inner cannula out of the tube and put
obturator into the appliance.
c. Assemble CO2 monitor onto bag
N I
N I
N I
1
1
1
3. Correct patient position
N I 1
4. Prepare patient
N I 1
5. Prepare self and position self
N I 1
6. Stabilize trachea with non-dominant hand
N I 1
7. Identify incision location
N I 1
8. Make vertical incision (1.5 – 2.5 cm)
N I 1
9. Retract area with retractor and confirm cricothyroid
location by touch
N I 1
10. Make transverse incision across cricothyroid
membrane
N I 1
11. Spread the cricothyroid opening 5-10 mm
N I 1
12. Insert tube inside opening
N I 1
13. Remove obturator, inflate the cuff and place inner
cannula into tube
N I 1
14. Connect patient to CO2 monitor and check for Co2
return
N I 1
15. Confirm tube placement
N I 1
16. Suction area
N I 1
17. Secure tube
N I 1
Total:
Were all tasks performed in the correct order? Yes No
If no, which were performed out of order? ____________________________________________________
90
APPENDIX D
SURGICAL RESIDENT SELF APPRAISAL INVENTORY
Please rate the following statements to the best of your knowledge.
If you had to perform an open cricothyrotomy right now, how confident are you that you can
succeed in performing the following skills associated with the procedure? Rate your degree of
confidence.
0 1 2 3 4 5 6 7 8 9 10
Cannot Moderately Certain
Do At All Certain I Can Do I Can Do
Confidence
(0 – 10)
1. Recognize the indications for when to perform the procedure. _____
2. Recognize the contraindications for when not to perform the procedure. _____
3. Prepare yourself using universal safety precautions. _____
4. Prepare the necessary equipment to perform the procedure. _____
5. Choose the appropriate tube for the procedure. _____
6. Put the patient in the optimal position. _____
7. Visualize the anatomic landmarks. _____
8. Identify the location to make the incision. _____
9. Make the necessary incisions. _____
10. Place the tube inside the opening correctly. _____
11. Recognize the indicators for successful performance. _____
12. Perform the procedure in an emergency situation. _____
13. Perform the procedure in 5 minutes or less. _____
14. Perform the procedure without making any major mistakes. _____
Abstract (if available)
Abstract
Cognitive task analysis (CTA) is a powerful tool for eliciting expert knowledge to enhance training practices. While CTA methods have been employed successfully to design surgical skills training to improve performance, the effects of CTA supported instruction on self-efficacy have yet to be examined. This study explores the effects of a CTA instructional intervention on surgical skills performance and self-efficacy beliefs for conducting an open cricothyrotomy procedure. Self-efficacy beliefs are important for educators to consider because they influence performance, decision making, and motivation. Instruction focused on mastery learning, such as CTA supported instruction, positively influences self-efficacy beliefs. The purpose of this study is to determine if CTA instruction has an effect on self-efficacy and performance. This study compares CTA supported instruction and expert-guided instruction used to teach medical students and postgraduate surgical residents an open cricothyrotomy procedure at a medical research university surgical skills lab. Education level and gender are considered for their potential effects on self-efficacy and performance. Results indicate that CTA supported instruction had significant positive effects on overall performance outcomes and the self-efficacy ratings for the experimental group. Gender did not have an effect on self-efficacy ratings
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Asset Metadata
Creator
Campbell, Julia C.
(author)
Core Title
Employing cognitive task analysis supported instruction to increase medical student and surgical resident performance and self-efficacy
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Education (Leadership)
Publication Date
04/14/2010
Defense Date
02/08/2010
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
cognitive task analysis,OAI-PMH Harvest,self-efficacy
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Clark, Richard E. (
committee chair
), Sullivan, Maura E. (
committee member
), Yates, Kenneth A. (
committee member
)
Creator Email
campbell@ict.usc.edu,juliacampbell2003@yahoo.com
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-m2921
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(contributing entity),
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Tags
cognitive task analysis
self-efficacy