title: Peyton's four-step approach: differential effects of single instructional steps on procedural and memory performance - a clarification study.
abstract: BACKGROUND
  Although Peyton's four-step approach is a widely used method for skills-lab training in undergraduate medical education and has been shown to be more effective than standard instruction, it is unclear whether its superiority can be attributed to a specific single step.
  
  
  OBJECTIVE
  We conducted a randomized controlled trial to investigate the differential learning outcomes of the separate steps of Peyton's four-step approach.
  
  
  METHODS
  Volunteer medical students were randomly assigned to four different groups. Step-1 group received Peyton's Step 1, Step-2 group received Peyton's Steps 1 and 2, Step-3 group received Peyton's Steps 1, 2, and 3, and Step-3mod group received Peyton's Steps 1 and 2, followed by a repetition of Step 2. Following the training, the first independent performance of a central venous catheter (CVC) insertion using a manikin was video-recorded and scored by independent video assessors using binary checklists. The day after the training, memory performance during delayed recall was assessed with an incidental free recall test.
  
  
  RESULTS
  A total of 97 participants agreed to participate in the trial. There were no statistically significant group differences with regard to age, sex, completed education in a medical profession, completed medical clerkships, preliminary memory tests, or self-efficacy ratings. Regarding checklist ratings, Step-2 group showed a superior first independent performance of CVC placement compared to Step-1 group (P<0.001), and Step-3 group showed a superior performance to Step-2 group (P<0.009), while Step-2 group and Step-3mod group did not differ (P=0.055). The findings were similar in the incidental free recall test.
  
  
  CONCLUSIONS
  Our study identified Peyton's Step 3 as being the most crucial part within Peyton's four-step approach, contributing significantly more to learning success than the previous steps and reaching beyond the benefit of a mere repetition of skills demonstration.
authors.affiliation: Department of Nephrology, University of Heidelberg Medical Hospital, Heidelberg, Germany.
authors.forename: Markus
authors.initials: M
authors.lastname: Krautter
authors.affiliation: Department of General Internal and Psychosomatic Medicine, University of Heidelberg Medical Hospital, Heidelberg, Germany.
authors.forename: Ronja
authors.initials: R
authors.lastname: Dittrich
authors.affiliation: Department of General Internal and Psychosomatic Medicine, University of Heidelberg Medical Hospital, Heidelberg, Germany.
authors.forename: Annette
authors.initials: A
authors.lastname: Safi
authors.affiliation: Department of Nephrology, University of Heidelberg Medical Hospital, Heidelberg, Germany.
authors.forename: Justine
authors.initials: J
authors.lastname: Krautter
authors.affiliation: Department of General Internal and Psychosomatic Medicine, University of Heidelberg Medical Hospital, Heidelberg, Germany.
authors.forename: Imad
authors.initials: I
authors.lastname: Maatouk
authors.affiliation: Department of General Internal and Psychosomatic Medicine, University of Heidelberg Medical Hospital, Heidelberg, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Moeltner
authors.affiliation: Department of General Internal and Psychosomatic Medicine, University of Heidelberg Medical Hospital, Heidelberg, Germany.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Herzog
authors.affiliation: Department of General Internal and Psychosomatic Medicine, University of Heidelberg Medical Hospital, Heidelberg, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Nikendei
keywords: Peyton’s four-step approach; procedural skills; skills-lab training