Peyton’s method and modifications
Peyton’s Four Step approach (1998) is the most popular and tested method of skills instruction. And most people haven’t heard of it. The steps are straight forward and easily mastered.
2. The teacher repeats the procedure, this time describing all necessary sub-steps (“Deconstruction”)
3. The student has to explain each sub-step while the teacher follows the student’s instructions (“Comprehension”)
4. The student performs the complete skill on his/her own (“Performance”).
The four step approach has been shown superior to standard instruction using demonstrations and repeated substeps in terms of student performance and student acceptance. Step 3 appears to be key with much of the success related to this step.
Nikendei et al (2014) were able to expand this model to small group teaching using the following modification to ensure all students were able to perform the skill, received feedback and maintained step 3:
The Tutor performs Steps 1 and 2 of Peyton’s Four-Step Approach to all Trainees
B – Comprehension, Tutor’s Performance and Observation
The Tutor performs Step 3 following the instructions of Trainee 1, while all other Trainees are observing
C – Comprehension, Trainee’s Performance and Observation
Trainee 1 performs Step 3 following instructions of Trainee 2, while the other Trainees are observing
D – Tutor and Peer Feedback
Trainee 1 receives feedback by Peer Trainees, followed by Tutor feedback
E – Circulation
Parts C and D are repeated in turn until the last Trainee has performed Step 3 following thein structions of a Trainee
F – Completion and Conclusion
Finally, the last Trainee performs Step 4, followed by Peer and Tutor feedback.
Provide detailed instructions
Giving students as much information as possible on how to perform a skill improves performance. Unfortunately, many times instructors are unable to break down the steps of a skill as they have become proficient and the skill no longer requires that level of processing. Think about tying your shoelaces or hopping on a bike and starting to ride. Describe the steps. Now try to perform that skill following only those steps. Usually there are quite a few key components missing!
Developing these steps often takes significant effort; cognitive task analysis has been shown effective in both veterinary and human medicine. Using videos, descriptions and questions, the steps can be identified. Once identified, they can be better taught.
Axt et al showed that breaking down the steps of a laparoscopy procedure into a limited number of essential key steps (nodal points) improved learning and internalization of the skill. Having a list of such steps not only helps with practice in lab but with mental rehearsal.
Encourage attempts (and errors)
Instruction about the most common errors and how to avoid them improved acquisition of surgical skills. Encouraging or focusing on errors during training can improve performance, retention and transfer of procedural skills. With error-focused training, learners experience common errors, how to correct them and how to avoid them during training rather than during practice.
Choice is good
Most veterinary students will be highly intrinsically motivated to learn related skills. However, for some basic skills, motivation may be limited, particularly for those who have training as veterinary technicians. In these instances, any form of choice (station, partner, activity, form or reporting) can help improve attitudes.
Resources
Ikudome et al. The Effect of Choice on Motor Learning for Learners With Different Levels of Intrinsic Motivation. J Sport Exercise Physio 2019, 41:159-166.
Axt et al. Evaluation of self-educational training methods to learn laparoscopic skills – a randomized controlled trial. BMC Medical Education (2018) 18:85
Rossettini et al. Effective teaching of manual skills to physiotherapy students: a randomised clinical trial. Medical Education 2017: 51: 826–838
Gardner AK et al. Embracing Errors in Simulation-Based Training: The Effect of Error Training on Retention and Transfer of Central Venous
Catheter Skills. J Surg Educ (2015) 72(6):e158-162.
Sullivan et al. The Use of Cognitive Task Analysis to Reveal the Instructional Limitations of Experts in the Teaching of Procedural Skills. Acad Med 2014:89(5):811-816.
Read E and Baillie S. Using Cognitive Task Analysis to Create a Teaching Protocol for Bovine Dystocia. JVME 2013:40(4):397-401.
Krautter et al. Effects of Peyton’s Four-Step Approach on Objective Performance Measures in Technical Skills Training: A Controlled Trial. Teaching and Learning in Medicine (2011) 23:3, 244-250
Rogers et al. A role for error training in surgical technical skill instruction and evaluation. Am J Surg 2002:183:242-245.
Walker M, Peyton R. 1998. Teaching in theatre. In:Peyton R, editor, Teaching and learning in medical practice. Rickmansworth, UK: Manticore Europe Limited. p. 171–180.
