Discussion
This study determined that the approach to teaching manual clinical skills, in particular scalpel skills, appears to be consistent between university programs in Australia and New Zealand, utilising didactic-style content, demonstration, physical practice on inanimate objects and real skin, and often the use of supplementary audio-visual material. There were some differences reported between programs, mainly around the methods and processes of practice. The primary area of controversy regarded the use of inanimate objects versus real skin for practice, which was reflected in comments relating to both issues and successful strategies in teaching.
Most podiatry programs followed a traditional teaching structure when teaching scalpel skills with a didactic-style lecture or talk outlining the theoretical and explicit information relevant to using a scalpel supplemented by skill demonstration, either in real-time, streaming media or via a recorded medium such as DVD or online video. This teaching approach is consistent with evidence that observational learning together with practice is more effective for motor learning than practice alone [
12], and is supported by studies which show that similar areas of the brain activate whilst a student is observing a particular skill being performed as when they are undertaking that skill themselves [
13‐
16].
The reported mentoring relationships and strategies of students working in pairs provide an alternative avenue for such observational learning. When working in pairs, students are able to watch someone else undertake a learning process, which is believed to facilitate adaptation when they are required to perform the same action [
17‐
22]. Such observational learning provides the opportunity for students to continue to maximise learning by engaging in alternative forms of processing, whilst having a break from the cognitive demands of the skilled task [
20]. Moreover, the non-treating student can take the responsibility of engaging the patient, allowing the practising student to focus their cognitive resources and concentrate on learning and performing the skill. Working in pairs may also have an influence on the motivation and competitiveness students feel for the task, which can have a significant influence on learning outcomes and address psychological issues [
18,
20,
22,
23].
From the limited, but growing, body of literature, there is increasing evidence that simulation based practice, combined with deliberate practice is superior to traditional methods [
24] and that simulations may not need to be of high fidelity for novices [
25‐
27]. In a systematic review for medical clinical education McGaghie et al. found an effect size of 0.71 (95%CI 0.65–0.76;
P < 0.001) [
24]. However, the individual contribution of simulation versus deliberate practice was not determined. Furthermore, we should be aware of the confounding effects that feedback, motivation and other known factors may have had within the studies comprising the meta-analysis.
The findings of McGaghie et al. were supported by our findings whereby, the role of practice in teaching of manual clinical skills was highlighted by participants from all programs. Practice was often undertaken on inanimate objects and foot models, and perceived as a successful teaching strategy as it reportedly decreased students’ relative anxiety, increased engagement and provided a safer alternative than a real-life patient. Half of the programs reported using specific inanimate objects followed by wax added to some sort of base such as tape or fleecy webbing (wax impregnated materials). All except one program reported using wax on a base, with the remaining program using fleecy web only. In a majority of programs, students were paired-up and the wax was attached to the foot of their partner to enable more context-specific practice. However, there are caveats to this and a contrast of opinions There is an expectation that transfer of learning from laboratory practice to the real setting is automatic [
28]. However, the transfer of learning from one skill to another is proportional to the similarity of the skill and may depend on the environmental context [
28]. Furthermore, questions remain about how best to structure simulation interventions and the best frequency and timing for effective learning acquisition and skill retention [
25].
Conversely, participants reported that it was good to have students put into a real-life situation early as the wax does not sufficiently replicate real skin. It was felt that there is a lack of suitable models. This may be compounded by a lack of sufficient clinical exposure, particularly in the context of growing class sizes and the fact that students and teachers often rely on real patients attending the university podiatry clinic for practice exposure to a variety of conditions. It is for these reasons a combination of practice strategies was often utilised.
The differences in opinion from participants regarding open (real-life) versus closed (simulated) learning is also reflected with much controversy in the literature. This may stem from difficulty interpreting the evidence and difficulty extrapolating findings from skill acquisition research to real life application. Kneebone [
29] outlines that this may be a consequence of the limited outcome-based rather than descriptive studies, often with small sample sizes and short intervention periods.
Safety was also a concern that influenced the practice strategy used with students. Practising on real patients creates a paradoxical dilemma where the public are exposed to potential risk associated with receiving treatment from inexperienced students, but with students relying on this exposure in order to gain the required experience. Further, there is controversy in the literature regarding open versus closed skill learning which adds further complexity to choices about student practice in this area, with some authors promoting research which supports open skill learning, such as a real-life clinic with a variable environment [
28,
30]. Yet Knight [
31], argues that these studies don’t take into consideration the effects of anxiety and arousal which are present particularly in learning many of the health-related clinical skills. Furthermore, Motola et al. outline that learning the whole skill at once rather than being introduced in parts may be detrimental to learning if there is an increased cognitive load [
25].
The structure of practice reported by programs did not always reflect the available evidence. Practice of podiatry-related manual clinical skills, particularly scalpel skills occurred in a massed or blocked form in some programs, whilst others used practice intermittently or spaced over an extended time. Whilst there was an early belief that intermittent or spaced practice was the superior approach for learning simple motor tasks, more recent research suggests that outcome effect sizes decrease with increasing task complexity and cognitive demands [
32]. The role of feedback, contextual interference and motivation can also have a strong influence. Interpreting studies relating to motor skill acquisition should be undertaken with care, as findings based on simple skills do not take into account the greater cognitive demand and other aspects typical of complex motor skills. Thus, we should recognise that the plethora of research designs, structure and outcomes makes interpretation and synthesis of published data to inform the teaching process quite difficult.
The practice setting and associated safety concerns were important issues recognised by participants in learning manual podiatric skills. A variation in practice environments reported between programs, such as home, supervised clinic and unsupervised clinic has the potential to vary the type and timing of feedback a student receives about their performance of a skill. For instance, the practice environment can influence whether the student receives extrinsic augmented feedback or feedback only via intrinsic mechanisms. Mars et al. [
33] found that the part of the brain responsible for error detection and correction was activated by extrinsic feedback earlier in the learning process than intrinsic feedback. Furthermore, it is commonly thought that when augmented feedback is provided too frequently, the learner becomes dependent and no longer able to perform effectively when it is withdrawn [
34]. There is debate whether this applies to complex tasks as well as simple tasks [
35]. However, it still seems that the exact timing, frequency and type of feedback can have a significant influence on task learning.
Learning may be encouraged through facilitating student autonomy. When students have autonomy over learning, when to practise and when to receive feedback, they display improved motor learning [
36‐
38]. It is believed that this may be related to motivation [
22,
39‐
41], specifically intrinsic motivation. Many of the podiatry programs attempted to do this either intentionally or unintentionally via the use of multimedia or enabling safe ways for students to practise independently.
One of the teaching-related issues in the study findings was the labour-intensive nature of teaching scalpel skills and difficulty fitting this within the University-driven workload model, potentially producing a mismatch between necessary supervision levels and the time availability and priorities of staff. The staff-student ratio specified by the Australian and New Zealand Podiatry Accreditation Council (ANZPAC) is 1:4 to 1:10 depending on associated risk [
42]. For example learning scalpel skills in a clinic environment involving novices should have a low ratio, which makes it both labour-intensive and expensive. In addition to staffing ratios, the ANZPAC recommends that 1000 clinical hours need to be achieved by students be eligible for registration. Sixty percent of these hours should be completed within internal university clinical facilities putting further pressures on university staff and workload. However, these time requirements do not specifically take into consideration the patient numbers treated, amount of pathology or variety of pathologies to which the student is exposed, or the competency of a particular student. These factors will also impact on the motor skill capability related to scalpel skills of a particular student.
It is possible that the choice to enforce a clinical time requirement to ensure registration standards are met may stem in-part from a lack of objective outcome indicators and established competencies within the teaching of manual podiatry skills. A point identified by some of the interview participants. Bradshaw [
43] reported for the nursing profession that without clearly defined competencies and prescribed assessment standards, graduating students were concerned about their practical skill competence. ANZPAC has developed a collection of competencies for the purpose of evaluating foreign podiatrists seeking registration in Australia, which at least one interviewee reported modifying for use in the undergraduate educational setting. However, it seems that further work in developing relevant podiatric competencies may be beneficial and would help address the issue of teaching consistency also identified.
Despite the identified lack of agreed skill competencies, the most commonly employed assessment method reported was the use of clinical examination in the form of a single examination or as an ongoing requirement for students to be signed-off on particular aspects of competency. Ongoing assessment was more commonly reported to be associated with evaluating a minimum skill threshold rather than grading performance. This potentially has the added benefit of invoking less anxiety in the students, thereby facilitating greater safety for both the students and patients concerned. Also, through the use of an ongoing competency checklist, poor performers can be identified easier and earlier, providing a greater opportunity for remedial strategies to be used.
Motivational states are influential to the learning of complex skills [
22] and were identified as a student-related issue in this study. The defining feature of intrinsic motivation is that it needs to be driven by the individual themselves, not just by the educators or other external mechanisms. There are also other student-related psychological aspects which may impact on motor learning, including high levels of anxiety and decreased confidence or self-efficacy. Evidence consistently demonstrates a high correlation between an individual’s self-efficacy, motivation and subsequent performance [
44]. Self-efficacy has been linked with motivation [
44‐
46] and anxiety [
44‐
48], itself affecting performance. A number of participants outlined the need to avoid negative comments and instead provide positive comments in an attempt to positively reinforce or increase a student’s self-efficacy. Self-efficacy may mediate anxiety and the effect it has on performance [
48,
49]. A number of reported experiments found that self-efficacy was the major predictor of anxiety, even more than the individual’s susceptibility to anxiety [
49]. There are consistent findings that managing perceived self-efficacy is of greater benefit than merely managing anticipatory anxiety in avoidance behaviour [
49], and therefore may be a more suitable method of managing students learning scalpel use.
A student’s ability to reach a sufficient level of dexterity was identified as an issue in this study with the suggestion that a screening test could be useful, similar to that used by dental programs in North America [
50,
51]. However, the importance of screening was not universally agreed by participants. Research undertaken on a number of pre-entry skill aptitude tests for study programs have been shown to have poor correlation or non-significant outcomes between the test and success in the program, associated learning, or subsequent performance [
50‐
56]. This is clearly an area for future research, including consideration of the student perspective.
A number of remedial strategies were discussed to manage poorly performing students, which were targeted at increasing practice and improving dexterity. Participants reported strategies of increasing practice time, increasing exposure to relevant conditions, increasing educator input and feedback, providing reassurance or building the confidence of the student or by pairing struggling students with stronger students to maximise upon the benefits of observational learning discussed earlier. Dexterity is considered a skill which may be learnt over time rather than being entirely innate. There has been little research into the best ways to improve dexterity, particularly in health professionals, and therefore does not address the dilemma where students have a need for increased exposure and practice which may increase the risk to the patients or students.
There are limitations in the use of semi-structured interviews to investigate the teaching approach in podiatry programs. Despite an overall feeling that a particular point is relevant or important, participants may not think of it at the time of the interview or may prioritise other points. Therefore, the findings from this study cannot be considered a ranking of issues nor an exhaustive indication of the breadth of all relevant issues. Furthermore, participants are likely to be influenced by their most recent exposures or experiences and therefore have a specific bias. Furthermore, other intrinsic and extrinsic factors may influence their answers including their years and breadth of experience teaching scalpel skills, or even time pressures they may have faced at the time of the interview. As the interviews were undertaken specifically on podiatry programs within Australia and New Zealand, the findings may not be generalisable beyond this setting.
On occasion, there were small inconsistencies reported between participants from the same university, for example with the motor practice arrangements as shown in Table
2. All views were reported; however, this may reflect a lack of standardised rules regarding scalpel skill teaching within some programs
This study highlights the need for further research into practical skill instruction, in particular scalpel skills in the podiatric student population, the use of simulation and practice arrangements (including temporal aspects) and their translation to real-life practice. To build upon the evidence provided in this article an investigation of the impact on staff or the perception of students regarding issues in scalpel skill learning would be beneficial. Furthermore, a quantitative evaluation of the scalpel skills relating to methods of instruction or those facing the identified issues would be useful for further progress.