Teaching psychomotor skills in Orthopaedics using Gagne’s model of instructional design
Abstract
Teaching psychomotor skills are one of the most important domains in undergraduate medical education, and can be exceptionally challenging, particularly if complex practical and cognitive skills are involved. We train our students in the application of plaster of Paris (POP) for the treatment of fractures by adopting Robert Gagne’s model of instructional design, which proposes a framework of instructions aimed at achieving pre-determined learning outcomes. In this model, each instructional event is characterised by teaching approaches based on established cognitive learning theories.
Here, we share our experience and outcomes of adapting Gagne’s theoretical model for psychomotor skills teaching in POP application.
Key words: Gange’s model, Psychomotor skills, POP skill teaching
Introduction
Teaching psychomotor or procedural skills is fundamental to medical education.
Ineffective instruction risks cultivating poorly-performing clinicians in an era of increased accountability, with potentially harmful and costly consequences. Designing an effective, high-quality lesson requires the application of a systematic instructional framework that fulfils all the necessary prerequisites for learning these often complex skills. There exists a number of long-standing and widely-accepted theories on psychomotor skill acquisition, which favour a graduated learning and sequential teaching approach1-4. Gagne’s model of instructional design, introduced in 1974, has been adopted by various clinical disciplines in teaching psychomotor skills effectively5-9. In Gagne’s model, specified learning outcomes are achieved through the conduct of a sequential series of events or instructions10, derived from the cognitive information-processing theory of learning and memory previously proposed by Atkinson and Shiffrin (1968)11.
Plaster of Paris (POP) application for treatment of fractures is a clinical skills procedure taught as part of orthopaedics training in our medical undergraduate curriculum. The procedure is considered technically challenging, yet it is essential that clinicians and allied healthcare workers who treat and care for fracture patients are competent in this skill. We were able to develop an engaging and meaningful approach to teaching this psychomotor skill by adopting the Gagne’s theory of instructional design. Here we describe the key components of our lesson plan, including the formation of learning outcomes and list of instructional events.
Planning of learning outcomes
The desirable outcome of instruction is the attainment of a set of goals or objectives.
This is imperative in the field of education, in which the outcomes are usually described by a range of learned human capabilities12. Gagne defined five learning outcomes encompassing the domains of verbal information, intellectual skills, cognitive strategies, motor skills, and attitudes, each representing a different class of human performance and requiring different sets of instruction. This formed the basis of our learning outcomes in POP application, starting with knowledge-based objectives and progressing towards psychomotor-based objectives.
At the end of the session, our students should be able to:
1. Recognize the indications of different types of POP application 2. Recognize the complications of POP
3. Demonstrate the skills in the application of different types of POP 4. Demonstrate professionalism in their interaction with the patient
Preparation of Clinical skills session
In his review, Osborne (1986)13 surmised that advancement in psychomotor performance is best achieved by combining the essential roles of physical practice (which requires the development of manipulative skills) with that of mental practice (which involves cognitive thinking of the correct task sequences). When applied to a
highly motivated learner led by a well-equipped teacher using the most befitting activities and with the inclusion of performance feedback, this approach ensures the highest level of psychomotor skill acquisition13. The basic premise of this is shared by Gagne, who suggests that certain “conditions of learning”, both internal and external, must be present and tailored to the specific learning domain in order to facilitate optimal learning12. While internal conditions are based on learner factors such as prior knowledge, external conditions emphasise the teacher’s role in providing effective instruction.
Gagne’s events of instruction comprise of nine steps in order – gaining the attention of the learner, informing the learner of the objectives, stimulating recall of prior learning, presenting the stimulus (i.e. content), providing learning guidance, eliciting the learner’s performance, providing feedback, assessing the learner’s performance, and enhancing retention and transfer of knowledge10. This, with the aforementioned prerequisites in mind, we structured our teaching session as described below.
1. Gaining attention
Kauffman and Mann (2014)14 described the intrinsic influence of one’s perceptions and attitudes about learning on the learning process. Having awareness of the needs and purpose of learning attaches a degree of meaningfulness to the lesson, thus prompting a desire or ‘internal motivation’ to learn and ensuring that attention of the learner is directed accordingly. To help ensure that attention is sustained, the teacher or facilitator should consider a variety of strategies such as the use of changing and/or multi-sensory stimuli, verbal questioning styles that encourage thought and debate, and non-verbal interactive demonstrations10 15.
We use a number of strategies to draw our student’s attention. To start with, all the materials required in the POP skills session are displayed to the students, some of which they have not encountered before, stimulating their curiosity. This is followed by an assessment of the student’s background knowledge of POP application by asking them questions such as essential techniques, indications, and complications of POP.
Subsequently, a brief PowerPoint presentation about POP application is shown. At this juncture, the students are made aware of the value of being proficient in this clinical skill, encouraging their readiness to learn.
2. Informing the learner of the objective
Upon being presented with the objective(s) of the lesson, students develop expectations about what is required of them and what they need to learn during the course of the lesson16, which in turn, help motivate them to complete the whole learning process. The objective(s) of the lesson must be easily understood by the learners and communicated to them in a clear and unambiguous way10. Where multiple objectives are to be achieved, the end- goal or overall purpose of the lesson relating to all of those objectives should be elaborated to the students10.
Our learning objectives for this lesson (as listed in the earlier section) are uploaded to our university’s in-house e-learning portal (TIMeS©), where it can be accessed by the students at any time before the lesson. At the start of the lesson itself, the overall goal is made clear to the students; in this instance, they must be able to perform POP application in the treatment of an uncomplicated fracture under minimal clinical supervision.
3. Stimulating recall of prerequisite learning
Learning a new psychomotor skill often builds on the learner’s prior knowledge, which is critical to the learning process and needs to be readily accessible to the learner.
Recollection of relevant prior knowledge is facilitated by asking the learner recall-based questions10. All of our students have been taught about bone physiology, injury and remodeling, and how to evaluate and manage bony fractures in theory. Additionally, they have observed POP application in the outpatient fracture clinic. To stimulate recall and put our POP lesson into context, we ask the students recall questions relating to the aforementioned topics, such as basic POP knowledge including the POP application
procedure previously observed in the clinic. Thus, the lesson is adjusted to the learner’s needs.
4. Presenting the stimulus Material
The content of the lesson or instructional event, the so-called stimulus, must be presented to the student in the appropriate format using a variety of media, encompassing all learning objectives, and ideally including a range of examples for the teaching of new concepts10. The learner should not only be able to recall the new information taught to them, but must also be able to utilise it for problem-solving. It is important to note, however, that working memory has a relatively limited capacity for information processing and storage, according to cognitive load theory17. Thus, in order to optimise learning of new concepts and procedural skills for POP application in our students, we incorporate oral and visual/pictorial components into our teaching, while limiting the duration of each component to no more than ten minutes at a time. This method of presenting new information systemically in ‘chunks’ and providing basic rules by which the learner can apply to solve a variety of problems, allows for better learning of more complex tasks which require higher cognitive processing loads17. Following the teaching session, the students discuss and reflect on what they have learnt.
5. Providing learning guidance
Knowledge can be effectively acquired through observation and emulation14, processes which are integral to the learning of psychomotor skills. Memorisation of each procedural step is aided by focusing on their meaningful aspects, a process which utilises the neurocognitive strategy of semantic encoding10. We demonstrate the procedure live with our students on a volunteer, while providing a brief explanation of each step of the process. The students are taught in groups of no more than five. The appreciation that there are different types of learners with varying capabilities signifies the importance of adapting the amount of guidance provided for the learners’ needs.
Those who require more guidance, are aided by viewing pre-recorded video clips of our demonstration uploaded to our e-learning portal (TIMeS©), which they can access at
any time after the lesson. This provides a form of adaptive learning that caters to both
‘quick’ and ‘slow’ learners while minimising any feelings of dissatisfaction or frustration induced by the pace of teaching.
6. Eliciting the performance
At this stage, which the students seemingly find most enjoyable, active participation is expected, aiming to bridge the theory-practice gap. The students practice their POP application on each other in small groups. Indirect guidance is provided by giving the students a procedural checklist, starting with consent-taking, followed by a brief summary of the procedure, the application steps, and finally, the complications related to POP application. This constitutes the longest session of the event and the students are encouraged to practice the procedure in turns until they feel confident in their abilities.
7. Providing feedback
Feedback and reflection allow for integration and reinforcement of new knowledge and skills18. Effective feedback facilitates reflective practice. While feedback focuses on improving the learner’s psychomotor skills, reflection encourages personal, emotional, and psychological development in the context of learning those skills18. We observe the student’s performance and provide immediate error correction and feedback where needed. By correcting any mistakes at the earliest opportunity and allowing the students to redress their practice thereafter, we can avoid erroneous actions from being retained.
Reflective practice is encouraged, for example, by asking the students to think about what they have accomplished with their learning event, how they feel about the prospect of performing the procedure on patients, and what steps might they take to increase their confidence.
8. Assessing the performance
In order to determine whether the expected learning outcomes have been satisfactorily achieved, we assess the students’ proficiency in their POP application skills via a formative and summative assessment at the end of their orthopaedic posting. Their psychomotor skills are evaluated in the form of an objective structured clinical examination (OSCE) station comprising of a brief clinical scenario instructing the students to demonstrate POP application to either the upper or lower limb, by cast or slab.
Gagne (1992)10 emphasizes the importance of validity in the assessment process.
Validity is established by how accurately the performance reflects the learning outcomes, and knowledge that the learner’s performance truly reflects their learned capabilities (and that their actions have not occurred, say, by chance alone) 10. To help ensure the validity of our assessment, our clinical scenarios are adapted to minimize guesswork and encourage the use of clinical reasoning and judgement in addition to their psychomotor skills in performing the procedure. For example, we may provide a scenario in which an elderly woman has fallen over on an outstretched hand, causing injury to her wrist, resulting in a ‘dinner-fork’ deformity on examination. The student is then shown an X-ray of the patient’s wrist and asked to suggest a diagnosis. They must then decide on the most suitable method of POP application and proceed to demonstrate its application. At the end of the performance, the students are briefly quizzed on topics from the knowledge domain of our learning outcomes.
9. Enhancing retention and Transfer
The simplest approach to perfecting psychomotor skills follows the proverbial saying that ‘practice makes perfect’. Attaining a high level of proficiency through repeated practice during the initial learning stage is associated with better retention and transfer of those skills13 19. Our clinical skills lab is available for self-directed practice by students on a daily basis, allowing them opportunities for further practice, even after an extended period of time from their initial instruction. Moreover, we use of a variety of clinical vignettes requiring different problem-solving approaches during our instruction process,
further enhancing knowledge retention10 and aiding the transfer of skills to the clinical setting.
Discussion
The main challenge of teaching almost any psychomotor clinical skill is ensuring the successful retention and transfer of said skills. While repeated practice, use of logbooks, and revision sessions help ensure proficiency and retention15, the ability to recall a discrete series of complex motor tasks (such as that of POP application) is significantly more difficult than continuous or repetitive motor skills19. Skill transference to the clinical setting is yet another challenge as the students may have limited opportunities to practice on real patients. Addressing these obstacles should be prioritised when planning the teaching sessions.
We find that the use of Gagne’s instructional model highly suited to the teaching of POP application skills in our medical undergraduate programme. Moreover, the use of a dedicated clinical skills lab for our sessions allows for a more structured and comprehensive teaching plan, and more conducive learning environment compared to the ward or outpatient clinic. Small group teaching has its clear merits, at the very least it encourages student participation and one is able to address their individual needs more effectively. Unsurprisingly, our students find these psychomotor skills sessions highly enjoyable and much more engaging than the traditional talk-and-chalk approach.
Despite its strengths, however, there are downsides to our approach in teaching POP application skills. A simulated learning environment cannot fully replicate the clinical setting, which the students must eventually familiarise themselves with. Therefore, we encourage them to practice their POP skills on consenting patients in the outpatient clinic under supervision as soon as they feel confident in their basic skills. Small group teaching may not be feasible where there are fewer qualified faculty staff able to teach this specialised skill. Moreover, the cost of POP consumables and related equipment for
teaching and regular practice may be too much of a financial burden for many clinical schools to bear.
To the best of our knowledge, the OSCE is the ideal instrument to assess psychomotor skills. However, care needs to be taken in setting the questions in order to discourage compartmentalisation and avoid cultivating assessment-driven learning. From the assessment, it should be apparent that students are able to draw upon their learned skills and apply them to novel (simulated) clinical scenarios, an indication that the learning process has been successful.
Conclusion
We discussed our experience in using Gagne’s model in teaching psychomotor skills, applying robust learning theories that underpin each instructional event to ensure effectiveness of learning in our students. We have found this to be a rewarding experience and preferable to using the often-quoted, traditional methodology of “See one, do one, teach one” in clinical skills teaching. Gagne’s model is easily adaptable and applicable to a wide-range of psychomotor skills in both simulated and clinical settings.
References
1. Fitts PM. Factors in complex skill training. In: Glaser R, editor. Training research and education. Pittsburgh: University of Pittsburgh Press, 1962.
2. Fitts PM, Posner MI. Human performance. Oxford, England: Brooks/Cole, 1967.
3. Gentile AM. A Working Model of Skill Acquisition with Application to Teaching. Quest 1972;17(1):3-23.
4. Harrow AJ. A Taxonomy of the Psychomotor Domain: A Guide for Developing Behavioral Objectives. New York: David McKay Co., 1972.
5. Belfield J. Using Gagne's theory to teach chest X-ray interpretation. The Clinical Teacher 2010;7(1):5-8.
6. Cheung L. Using an Instructional Design Model to Teach Medical Procedures. Med Sci Educ 2016;26:175-180.
7. Khadjooi K, Rostami K, Ishaq S. How to use Gagne's model of instructional design in teaching psychomotor skills. Gastroenterol Hepatol Bed Bench 2011;4(3):116-9.
8. Ng JY. Combining Peyton's four-step approach and Gagne's instructional model in teaching slit-lamp examination. Perspectives on Medical Education
2014;3(6):480-485.
9. White C, Rodger MWM, Tang T. Current understanding of learning psychomotor skills and the impact on teaching laparoscopic surgical skills. The Obstetrician &
Gynaecologist 2016;18(1):53-63.
10. Gagné RM, Briggs LJ, Wager WW. Principles of Instructional Design. 4th ed. New York: Holt, Rinehart and Winston Inc, 1992.
11. Atkinson RC, Shiffrin RM. Human memory: a proposed system and its control processes. New York: Academic Press, 1968.
12. Gagné RM. The conditions of learning and theory of instruction. 4th ed. New York:
Holt, Rinehart and Winston, 1985.
13. Osborne ECFpdM. Teaching Strategies for Developing Psychomotor Skills. NACTA Journal 1986;30(1):54-57.
14. Kauffman DM, Mann KV. Teaching and learning in medical education. How theory can inform practice. 2nd ed. Chicester: Wiley-Blackwell, 2014.
15. Buscombe C. Using Gagne's theory to teach procedural skills. Clin Teach 2013;10(5):302-7.
16. Driscoll MP. Psychology of Learning for Instruction. Boston: Allyn and Bacon, 2000.
17. Sweller J. Cognitive load theory, learning difficulty, and instructional design.
Learning and Instruction 1994;4(4):295-312.
18. Branch WT, Jr., Paranjape A. Feedback and reflection: teaching methods for clinical settings. Acad Med 2002;77(12 Pt 1):1185-8.
19. Fischman MG, Christina RW, Vercruyssen MJ. Retention and Transfer of Motor Skills: A Review for the Practitioner. Quest 1981;33(2):181-194.
