title: The benefit of repetitive skills training and frequency of expert feedback in the early acquisition of procedural skills.
abstract: BACKGROUND
  Redundant training and feedback are crucial for successful acquisition of skills in simulation trainings. It is still unclear how or how much feedback should best be delivered to maximize its effect, and how learners' activity and feedback are optimally blended. To determine the influence of high- versus low-frequency expert feedback on the learning curve of students' clinical procedural skill acquisition in a prospective randomized study.
  
  
  METHODS
  N = 47 medical students were trained to insert a nasogastric tube in a mannequin, including structured feedback in the initial instruction phase at the beginning of the training (T1), and either additional repetitive feedback after each of their five subsequent repetitions (high-frequency feedback group, HFF group; N = 23) or additional feedback on just one occasion, after the fifth repetition only (low-frequency feedback group, LFF group; N = 24). We assessed a) task-specific clinical skill performance and b) global procedural performance (five items of the Integrated Procedural Performance Instrument (IPPI); on the basis of expert-rated videotapes at the beginning of the training (T1) and during the final, sixth trial (T2).
  
  
  RESULTS
  The two study groups did not differ regarding their baseline data. The calculated ANOVA for task-specific clinical skill performance with the between-subject factor 'Group' (HFF vs. LFF) and within-subject factors 'Time' (T1 vs. T2) turned out not to be significant (p < .147). An exploratory post-hoc analyses revealed a trend towards a superior performance of HFF compared to LFF after the training (T2; p < .093), whereas both groups did not differ at the beginning (T1; p < .851). The smoothness of the procedure assessed as global procedural performance, was superior in HFF compared to LFF after the training (T2; p < .004), whereas groups did not differ at the beginning (T1; p < .941).
  
  
  CONCLUSIONS
  Deliberate practice with both high- and low-frequency intermittent feedback results in a strong improvement of students' early procedural skill acquisition. High-frequency intermittent feedback, however, results in even better and smoother performance. We discuss the potential role of the cognitive workload on the results. We advocate a thoughtful allocation of tutor resources to future skills training.
authors.affiliation: General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Düsseldorf, Germany. hansmartin.bosse@med.uni-duesseldorf.de.
authors.forename: Hans Martin
authors.initials: HM
authors.lastname: Bosse
authors.affiliation: Department of General Internal and Psychosomatic Medicine, University of Heidelberg Medical Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany. jonathan-mohr@gmx.com.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Mohr
authors.affiliation: Department of General Internal and Psychosomatic Medicine, University of Heidelberg Medical Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany. beate.buss@web.de.
authors.forename: Beate
authors.initials: B
authors.lastname: Buss
authors.affiliation: Department of Nephrology, University of Heidelberg, Heidelberg, Germany. markus.krautter@med.uni-heidelberg.de.
authors.forename: Markus
authors.initials: M
authors.lastname: Krautter
authors.affiliation: University Department of Medicine, Department of Internal Medicine IV, Endocrinology and Diabetology, Angiology, Nephrology and Clinical Chemistry, University of Tübingen, Tübingen, Germany. pweyrich@hotmail.com.
authors.forename: Peter
authors.initials: P
authors.lastname: Weyrich
authors.affiliation: Department of General Internal and Psychosomatic Medicine, University of Heidelberg Medical Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany. wolfgang.herzog@med.uni-heidelberg.de.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Herzog
authors.affiliation: Department of General Internal and Psychosomatic Medicine, University of Heidelberg Medical Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany. jana.juenger@med.uni-heidelberg.de.
authors.forename: Jana
authors.initials: J
authors.lastname: Jünger
authors.affiliation: Department of General Internal and Psychosomatic Medicine, University of Heidelberg Medical Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany. christoph.nikendei@med.uni-heidelberg.de.
authors.forename: Christoph
authors.initials: C
authors.lastname: Nikendei
mesh_terms: D002983:Clinical Competence; D004504:Education, Medical, Undergraduate; D005260:Female; D000068156:Formative Feedback; D006801:Humans; D007441:Intubation, Gastrointestinal; D059032:Learning Curve; D008297:Male; D008348:Manikins; D011214:Practice, Psychological; D011446:Prospective Studies; D020377:Self Efficacy; D000066908:Simulation Training / Q000379:methods*; D055815:Young Adult