Using 'Guided-Discovery-Learning' to Optimize and Maximize Transfer of Surgical Simulation
Phase: NA
Conditions: Humans, Simulation Training, Problem-Based Learning, Clinical Competence, Education, Medical, Learning, Surgical Procedure, Unspecified
Sponsor: Copenhagen Academy for Medical Education and Simulation

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Study Title:   
Using ‘Guided-Discovery-Learning’ to optimize and maximize transfer of surgical simulation 
 
Internal Short title: GDL-Efficacy 
Ethics Ref: H-18041917 
 
NCT: 03684720 
Acronym: GDLEFFICACY 
 
Date and Version No: 19.09.2018, vs.0.2 
 
Chief Investigator: 
Andreas Höier Aagesen, Bach. Med1 
Investigators:  
Ebbe Thinggaard, MD PhD,2  
Jeffrey Cheung, PhD,3 
Lars Konge, PhD, MD, Professor1 
Ryan Brydges MSc. PhD3  
Kulamakan M. Kulasegaram PhD,3 
 
Sponsors:  
Copenhagen Academy for Medical Education and Simulation, Capital Region, 
Denmark 
 
Funder: 
Application for funding is ongoing. 
 
1, Copenhagen Academy of Medical Education and Simulation, Rigshospitalet; Copenhagen, Denmark. 
2. Department of Gynecology and Obstetrics, Hvidovre Hospital, Region H, Zealand, Denmark 
3.The Wilson Centre, University Health Network and University of Toronto; Toronto, Ontario 
 
Investigators Aagesen, Thinggaard, Cheung, Konge, Brydges and Kulasegaram have no conflict of interest or financial 
ties to disclose. 
 
The reporting this study will conform to the CONSORT statement.  
 
Confidentiality Statement 
This document contains confidential information that, prior to trial registration at www.clinicaltrials.gov, must not be 
disclosed to anyone other than the Sponsor, the Investigator Team, host organization, and members of the Research 
Ethics Committee, unless authorized to do so. 
 
 

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Table of Contents 
1. 
Synopsis ........................................................................................................................... 3 
2. 
Abbreviations .................................................................................................................. 3 
3. 
Background and Rationale .............................................................................................. 3 
4. 
Objective and Outcome Measure ..................................................................................... 6 
5. 
Study Design .................................................................................................................... 6 
6. 
Participant identification ................................................................................................. 8 
7. 
Study Procedures ............................................................................................................. 8 
8. 
Statistics and Analysis ................................................................................................... 10 
9. 
Data management .......................................................................................................... 11 
10. 
Ethical and Regulatory Consideration ........................................................................... 11 
11. 
Finance .......................................................................................................................... 12 
12. 
Publication Policy .......................................................................................................... 12 
13. 
Appendix A .................................................................................................................... 13 
14. 
Appendix B .................................................................................................................... 14 
15. 
Appendix C .................................................................................................................... 15 
16. 
Appendix D .................................................................................................................... 16 
17. 
Appendix E .................................................................................................................... 17 
18. 
Appendix F .................................................................................................................... 18 
19. 
Appendix G.................................................................................................................... 19 
20. 
References...................................................................................................................... 20 
 
 
 

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1. Synopsis 
Study Title 
Using ‘Guided-Discovery-Learning’ to optimize and maximize transfer of surgical 
simulation 
Research Objective 
To explore the effect of guided-discovery-learning in transfer of surgical skills 
Study Design 
A prospective randomized study and explorative study 
Study Participants 
Students form the Medical Faculty who have not received suture-training 
Planned Sample Size 
Sixty-four participants  
Planned Study 
Period 
Twenty-four months 
Objectives 
 
To explore the effect of guided-discovery-learning vs traditional instructor lead teaching 
in the transfer of basic surgical skills. 
 
2. Abbreviations 
CI 
Chief Investigator 
ICF 
Informed Consent Form 
RREC 
Regional Research Ethics Committee 
ST 
Surgical Teacher 
OSATS 
Objective Structured Assessment of Technical Skill 
CAMES 
Copenhagen Academy for Medical Education and Simulation 
 
3. Background and Rationale 
Technical skills are a core competency in surgical specialties. The level of technical skills is directly linked to patient 
outcomes and it is an absolute requirement that surgical trainees learn to master basic surgical skills. It is therefore a 
necessity that medical students also become well equipped with these skills, such as suturing. During the last decade, 
minimally invasive techniques have made their way to the operating room and improved patient outcomes. Despite 
these advances it is still necessary for surgeons to master the open surgical skills. Unexpected complication can arise in 
minimally invasive procedures that require conversion to open access surgery. Furthermore, there are procedures where 
you cannot use minimally invasive techniques. Because of the extensive use of minimally invasive surgery, it is 
becoming more difficult for doctors as well as medical students in surgical departments to gain the level of experience 
needed, to become proficient in open surgical techniques. Pre-clinical teaching and simulation training is a possible 
solution to this problem.1 For novice learners, simulation training is an opportunity to acquire fundamental skills such as 
suturing in a safe and high-feedback environment and without the difficulties of acquiring these skills in the workplace2. 
For more advanced trainees, simulation affords the practice of difficult and complex procedures which may be 
otherwise too unsafe to acquire during patient care. But, merely implementing simulation training is no guarantee of 

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educational utility, and instead thoughtful curricular integration of simulation requires considering the role and purpose 
of the simulator, the student experience, debriefing, and the intended outcomes to evaluate success.3,4  
One potential area for optimizing simulation-based training is to clarify instructors’ roles when providing guidance and 
direct supervision. One of the challenges with simulation training is the amount of resources this sort of education 
requires. Especially the amount of time a student spends interacting with an instructor. Supervision and instruction are 
key to an effective simulation-based training, and there is mounting evidence, which suggest, that we need to reconsider 
the balance between instruction and discovery, allowing for a good interaction between student and teacher, 
encouraging learning5,6 Therefore the question is; on what level should simulation-based teaching be instructor-
orientated? When teaching technical medical skills, the answer to the question, whether the training should be 
discovery-orientated or instructor-orientated has been thoroughly researched.7 Medical Education literature has long 
moved away from the question of either or, and is now more focused on, in which order discovery- and instruction-
teaching should be, to provide the best learning outcome.8,9 Recent studies has shown some positive results of guided-
discovery-learning, which in its simple form, combines both elements from discovery and instruction-based teaching.10 
Especially the ability to ‘transfer’ learning seems vastly improved, with this teaching method. Transfer tasks faced by 
learners exist on spectrum with a common challenge being new problems which are more complex or in new contexts 
but essentially require replication of previously learned skills, i.e. near transfer. While near transfer can be difficult for 
learners, even more challenging is transfer that requires they apply their previous skills and understanding to learn new 
skills or concepts, i.e. far transfer. Guided-discovery learning has been shown to especially positively impact this latter 
type of transfer task11,12.  Thus guided-discovery may promote student-autonomy and self-learning which subsequently 
enables students to take responsibility for their own future learning.11,12 
In a pilot-study completed by our research-partners at the Wilson-Centre in Toronto, Canada, they compared groups of 
discovery followed by direct discovery (DD) with instruction followed by discovery (IP). In the case of DD, the 
participants, where given the materials needed to complete a simple suture, and a finished suture to look at. After the 
discovery-phase, they were parred with an instructor who demonstrated how it was to be performed. In the IP-case they 
were first instructed on how to perform the suture, and were afterwards allowed to practice it. At the end of the course 
both groups were given a post-test of ability, and a week-later both groups were given a retention test as well as a 
transfer test. The pilot-study included 26 participants in total, divided in two groups of 13. The participants were 
randomized, and everything was filmed and scored by blinded raters after an international standard. There were no 
significant results for the immediate post-test as well as the retention test. But in the case of the transfer test, the DD-
group was far superior.  
Our study will expand on the pilot-study to provide a comparison of guided discovery to traditional instruction for the 
learning of suturing tasks in surgery, seeing if Guided-discovery-learning works in a much larger research group. Using 
a double randomized, mixed-methods experimental design, we will investigate the effect of discovery followed by 
direct instruction (DD) vs. instruction followed by practice (IP) for the acquisition and two types of transfer of surgical 
skills. To understand how and why guided-discovery learning changes the learning processes of trainees, we will also 
film and analyze the interactions of a small-subset of participants in each condition as well as conducting focus-group 
interviews. Using an exploratory approach, we will explore how discovery learning prior to direct instruction might 

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change participants’ interactions with instructors and task compared to their interactions during initial direct instruction. 
We will seek to uncover which exploratory approach or approaches provide the best qualitative data. This part is 
elaborated and investigated in a separate additional protocol. 
We hypothesize that: 
1) Participants in the DD condition will be better able to transfer their knowledge to learning a new skill (i.e., 
preparation for future learning).  
2) Participants in the DD condition will have equivalent performance to IP on post-test, but a similar or slightly 
improved performance on transfer of suturing skill to a more complex task (near-transfer). 
3) Participants in the DD condition will interact differently with instructors and will use their learnings from the 
discovery phase to scaffold their learning during the direct instruction phase as well as interacting differently 
with the task at hand. 
 
PERSPECTIVES  
Faculty instructors are a limited resource in formal simulation-based training during post-graduate training. The rise of 
structured learning activities such as surgical boot camps and the emphasis on greater feedback and support for trainees 
means that instructor time is at a greater premium than ever before. Instructors must take time away from their busy 
clinical and workplace-based education activities in order to teach. Not only does this cost the healthcare system, the time 
commitment can reduce willingness to participate in education. Additional costs may be incurred by programs that must 
offer financial incentives for instructors. This trade-off between education and clinical work occurs in all academic 
postgraduate programs. Given the cost and investment required to recruit faculty for training, research is needed to 
maximize the efficiency of faculty involvement13. Our work directly contributes to this goal by identifying how instructor 
guidance is most helpful to trainees. Guided-discovery may be one approach to reducing the cost of training and instructor 
time in both post-graduate as well as pre-graduate learning courses18.  
 
Post-graduate training also requires that trainees develop autonomy and are able to learn new skills or concepts effectively 
(Scholar role; Competency 1, Enabling 1.1, 1.2)19,20. Further, Medical Expert19,20 (Competency 3, Enabling 3.1, 3.4) 
stresses trainees’ abilities to transfer their training when faced with uncertainty and or complexity in future scenarios. 
Guided-discovery may be an effective organizing principle for educational design that can achieve these competencies 
across a wide range of disciplines and training environments. Our proposal would thus establish evidence of efficacy for 
guided-discovery for these competency roles.  
 
 
 
 
 
 
 

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4. Objective and Outcome Measure 
 
Objective 
Outcome measure 
Primary outcome: 
To examine the effect of Guided-discovery-learning on 
far transfer of simple surgical skills 
 
Secondary outcome:  
To examine the effect of Guided-discovery-learning on 
near-transfer of simple surgical skills 
To examine the primary learning-efficiency of the two 
types of teaching. 
To examine the effects on the different types of transfer 
for the intervention and control groups.  
 
Explorative outcomes:  
To examine the difference in interaction between 
students receiving Guided-discovery, and those that 
didn’t. 
To examine the difference in student interaction and 
approach to the task. 
 
To examine different explorative approaches for 
examining the mechanics behind Guided-discovery 
 
To examine how students, experienced the training. 
 
Difference in the two groups OSATS-scores on a far-
transfer test evaluated by blinded raters  
 
 
Difference in the two groups OSATS-scores on a near-
transfer test evaluated by blinded raters  
Difference in OSATS-scores between immediate post-
test. 
Difference in OSATS-scores between near-transfer and 
far-transfer-tests. 
 
 
Using whole-room angle video recordings to observe the 
student-teacher interactions.  
 
Using task-focused video recordings to observe student-
task interaction. 
 
Using think aloud video-recordings for select students. 
 
Using focus group interviews 
 
5. Study Design 
The study is a randomized experimental study comparing guided-discovery-learning to traditional instructional 
learning. The study will be performed at CAMES, including n=64 pre-clinical students from the Medical Faculty of 
Copenhagen University. Part 1 of this study is an experimental design with two phases that will test the efficacy of 
guided discovery: Phase 1 will be a learning phase with the experimental manipulations, and Phase 2 will take place one 
week later and be outcome assessment for near- and far transfer. Part 2 of this study will be an observational analysis of 
films of a sub-set of participants in the DD and IP conditions in order to establish differences in learning behaviors 

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between both conditions and possible mechanisms for guided-discovery learning.  The analysis will compare how 
participants interact with the task in each learning condition including documenting activities in each phase and 
interactions with instructors.  
For Phase 1, participants will be enrolled and randomly allocated to either the DD or IP groups. Each group consists of 
8 participants. Participants will be randomized and the method of teaching allocated on the date of teaching. This will 
ensure generalization and ease of statistical analysis. In the DD group, participants will be given an example of a 
completed simple interrupted suture and their own skin pad, and suturing kit. They will then attempt to replicate the 
suture using the equipment and their own knowledge over 30 minutes. During the same period of time, the IP group will 
be taught using an instructor. The instructor will provide two demonstrations and explanations of the simple interrupted 
suture following which the participants will attempt the suture individually on their own skin pads and suturing kit (see 
Appendix A for Instructor directions; modifications will be made by an experienced surgical instructor on our team ST). 
The instructor will be told to provide feedback and guidance to the participants as well as answer any questions that 
participants may have. After the initial time, the DD group will be paired with an instructor who will provide two 
demonstrations and explanations of the suture and then interact with participants as they attempt the suture. The IP 
group will practice the suture without any further instructor guidance. At the end of the teaching session, all participants 
will complete a post-test requiring them to complete two simple interrupted sutures. Afterwards participants willing will 
be interview in short focus-group interviews. This entire session is expected to last 2 hours including consent and setup 
time.  
After a 1-week delay, participants will return for Phase 2 for the tests of near- and far transfer. Each group will again be 
randomly allocated a transfer task. Two transfer tasks will be used in this study: To test Hypothesis 1, (the impact on 
transfer to future learning), participants will be taught the interrupted vertical mattress suture. To ensure equivalency of 
design and to prevent biasing in favor of one group, all participants will be taught didactically, which will involve 
viewing a 15-minute video designed by an expert surgeon on our team (ST) to teach the novel suturing task. 
Participants will then be given 20-30 minutes to practice the suture following which they will perform two vertical 
matrass sutures on a typical skin pad. To test Hypothesis 2 (the impact on transfer of learning to a more complex 
version of the initial task) participants will perform two simple interrupted sutures on a suturing pad representing in an 
abdominal simulator with the added contextual change of different instruments and suture. In both groups, participants 
willing, will afterwards be recorded for a ‘Think-Aloud’ interview, in which they describe their approach to the suturing 
task out-loud.  This phase is expected to last 1.5 hours. (See Appendix B for flow chart). All the interviews, Focus and 
Think-Aloud, as well as the observational filming will be investigated further and expanded upon in a separate 
additional protocol, which focuses on the qualitative data.  
 
 

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Outcomes, Measures, and Data Collection 
Transfer Tasks 
We chose our transfer task based on transfer theory15 which stresses the spectrum of possible applications of learning. 
Transfer to a complex variation of the skill, in this case, the simulated organ tissue in an abdominal trainer, is expected 
to create significant contextual barriers for participants to successfully enact their mental representation of the simple 
interrupted suture16. Whilst also including different instruments and suture, the haptic feedback and force required to 
complete the task are significantly different from the previous learning while the essential schema for the suture is 
preserved. Similarly, the vertical mattress suturing task involves the fundamental skills of suturing which participants 
will have developed from prior learning but creates new motor and perceptual patterns which must be scaffolded and 
developed from the initial learning experience. It will also require participants to engage any learning using their own 
self-regulation and capacity11, 12.  
 
Blinded raters will evaluate participants’ suturing performances using a 5-point global rating scale taken from the OSATS 
tool which has previously demonstrated high inter-rater reliability across multiple contexts and good evidence of 
association with changes in trainee skill17(see Appendix C for scale). We will use a repeated measures analysis to account 
for the multiple attempts.  
 
6. Participant identification 
6.1 Study Participants 
Participants will be students primarily at the Medical Faculty of Copenhagen University who haven’t received surgical 
education yet. Eighty participants will be included split into two groups. Both groups will be taught, filmed and tested at 
CAMES.  
6.2 Inclusion and exclusion criteria  
Participants are students currently attending a Danish bachelor at a Medical Faculty and who are willing and consent to 
participation in the study. Participants who have received prior suturing education are excluded from participating in the 
study.  
 
7. Study Procedures 
7.1 Recruitment 
Participants will be recruited from the Medical Faculty of Copenhagen University, Zealand, Denmark. Everyone 
recruited will be given an information leaflet. (Appendix D) 
 
 

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7.2 Informed Consent 
Participants must personally sign and date the ’Informed Consent Form’ (appendix E) before they can participate in the 
study. Both written and verbal versions of the consent form and Participants information will be presented to 
participants, including everything that is to happen to the participants throughout the study. This included the known 
side effects and risks, associated in participating in the study. It will be clearly stated, that the participants are under no 
obligations to complete the study, and can withdraw at any time, without giving a specific reason for their withdrawal. 
Participants will be allowed as much time, as they wish to consider the information. Written Informed Consent will then 
be obtained by means of participant dated signature and dated signature of the person who presented and obtained the 
Informed Consent. The person who obtained the consent must be suitably qualified and experienced and have been 
authorized to do so by the Chief/Principal Investigator. A copy of the signed Informed Consent will be given to the 
participant. The original signed form will be retained at the study site in a locked cupboard which only the chief 
investigator has access to. 
 
7.3 Randomization 
Randomization 
 
The study is a double randomized study. Participants will be randomized using en-bloc randomization sequence in 
groups. After enrollment participants will be assigned a group and a date for teaching. And the groups will then be 
randomized, and assigned a teaching method, which will be revealed on the date of teaching. Each group will then again 
be randomized to either to a near-transfer or a far-transfer group for the second phase of the study.  
 
Groups range from A through H, making 8 groups in total. All groups assigned an uneven number will be allocated the 
intervention, whereas groups assigned an even number will be allocated the control. Furthermore, the 4 groups in the 
control and the intervention will be randomly assigned to a new number. Groups assigned an uneven number will be 
allocated the near-transfer group, and groups assigned an even number will be allocated the far transfer group. 
 
For the recording and rating of the test each participant will assigned an identification number (A_1, B_1 etc) which 
will correspond to an identification key-number in the video (eg. 18920, 32, 564). The conversion key will be stored by 
the principle investigator and only he will have access to it, thus allowing the raters to score the participants blinded. 
 
All randomization will be done using www.random.org and disclosed by an external party.  
  
7.4 Definition of End of Study 
The end of study is after the last of the groups has finished their transfer test in the second week. Any participant, who 
hasn’t shown at any of the teaching days, will be considered as having dropped out of trial.  

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8. Statistics and Analysis 
8.1 Description of Statistical Methods 
To examine the effects of guided-discovery-learning contra traditional instructional learning, the following outcomes 
will be measured: 
• 
Difference in OSATS scores between the control and intervention groups far-transfer-test 
• 
Difference in OSATS scores between the control and intervention groups near-transfer-test 
• 
Difference in OSATS scores between the groups post-test. 
• 
Difference in OSATS scores between the groups development from post-test to transfer-test. 
To establish whether there is a significant level of difference in the above-mentioned measurements, students t-test will 
be used. A statistical software package will be used to calculate these (SPSS vs. 25.0, Chicago, IL). 
Analysis 
 
Analysis of the experimental data will be through a mixed-effects linear models with participants as random and 
instructional condition as fixed factors. We will conduct separate analysis for each hypothesis. For hypothesis 1, we will 
analyze post-test and near-transfer test scores through a multivariate model (repeated MANOVA or similar depending on 
model fit and sampling adequacy)18 with the expectation of a significant interaction indicating differences between groups 
at near-transfer but not on post-test. To address hypothesis 2, we will analyze performance on the vertical mattress suture 
using a univariate model (ANOVA). Where appropriate, covariates for performance such as post-test performance will 
be included to account for individual skill difference and to increase statistical power. A mixed-effects model will also 
compare participants’ near- and far-transfer test scores across both conditions.  
 
The qualitative data analysis is described in more detail in the additional protocol 
 
8.2 The Number of Participants 
Learners:  
We will recruit n=64 pre-clinical students from the Medical Faculty of Copenhagen University. We are targeting 
undergraduate students, rather than surgical residents, because we want novice learners, and we believe it is worthwhile 
to establish efficacy of our intervention group using simpler tasks which can be feasibly studied.  We based our sample 
size on the previous pilot-study which suggests that detecting a large effect on a global rating scale (Hedges g of >0. 
with an alpha of 0.05 and power of 80% requires at least 13 participants per group with additional participants recruited 
for potential loss to follow-up24 for a total of 16 per group. Participants will receive a certificate showing completed 
suturing course, as an honorarium to compensate for their time in the study. 
 
Instructor and Raters: 
We will recruit one 2nd year post-graduate surgical trainees to serve as an instructor. We will recruit an instructor who 
has some experience in teaching or coaching undergraduate students. Additionally, participant performance on the post- 

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and transfer tasks will be assessed by a blinded rater who will receive video-tapes of all relevant participant 
performances. 
 
 
9. Data management  
9.1 Access to Data 
Direct access will be granted to authorized representatives from CAMES monitoring and/or audit of the study to ensure 
compliance with regulations. All the written consent forms, other paperwork and video files will be locked in a 
cupboard at PhD office at CAMES and only the chief investigator will have direct access to it. Associates of the study, 
can be granted access through the chief investigator, as they are needed for the study  
 
9.2 Data Recording and Record Keeping 
Data will be collected and entered by the principle investigator. It will be entered in a pre-formatted form and stored in 
a database under password protection. 
 
10. Ethical and Regulatory Consideration 
10.1 Declaration of Helsinki 
 
The Investigator will ensure that this study is conducted in accordance with the principles of the Declaration of 
Helsinki.  
 
10.2 Approvals 
The study will be reported to the Danish Data Protection Agency in Region H and all data will meet the criteria set forth 
by the General Data Protection Regulation. According to Danish law it is not a requirement for the study to be 
submitted to the Regional Research Ethics Committee (RREC) for approval.  
 
10.3 Participant Confidentiality  
The study staff will ensure that the participants’ anonymity is maintained.  All documents will be stored securely and 
only accessible by study staff and authorized personnel. The study will comply with the Data Protection Act, which 
requires data to be anonymized as soon as it is practical to do so.  
 

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11. Finance 
11.1 Funding 
Application for funding is ongoing. Training facilities will be provided by the Copenhagen Academy for Medical 
Education and Simulation. Further application for funding is ongoing 
 
12. Publication Policy 
 
The Investigators will be involved in reviewing drafts of the manuscripts, abstracts, press releases and ay other 
publications arising from the study.  Authors will acknowledge the source of funding. Authorship is determined as;  
1st Andreas Höier Aagesen, 2nd Ebbe Thinggaard, 3rd Jeffrey Choung, 4th Lars Konge, 5th Ryan Brydges, 6thKulamakan 
M. Kulasegaram 
 
In accordance with the ICMJE guidelines, other contributors will be acknowledged. 
 
 

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13. Appendix A 
 
Instructor Template and Script for Phase 1 Teaching 
Today we will learn a simple interrupted suture.  
Begin by selecting a 3-0 nylon suture. Open the packet, and grasp the needle of the suture with the suture driver. 
Position the needle so that it sits right at the tip of the needle driver and such that the needle driver grasps the needle ½ 
to 2/3 of the way from the sharp end to the blunt end of the needle. Suture have “memory”, meaning they will stay 
curled up and difficult to work with after removing them from the package. Pull gently on the suture material in a 
constant manner for a few seconds to reduce the coiling. 
With the suture driver in your dominant hand and the toothed Addson forcep in your non-dominant hand begin the 
procedure for the interrupted simple suture. Start by elevating the skin gently on one side of the wound. Pronate your 
hand to position the needle 5-10mm from the wound edge, and 90 degrees to the plane of the skin. Supinate your hand 
you pierce the epidermal and dermal layers to curve the needle through and into the wound. Continue to supinate to 
bring the full needle through the skin. Next elevate the other side of the wound. Enter at the same depth (under the 
dermal layer) as you exited on the opposite side. Supinate aiming to have the needle exit the skin the same distance 
from the wound edge you entered on the opposite side. Release the needle driver and grasp the needle outside the skin. 
Continue to supinate to curve the needle completely out of the skin. Pull the suture through leaving a short trail and 
prepare for an instrumented tie. 
At this point the long tail of the suture should be closest and the short farthest from you an opposite sides of the wound. 
Place your needle driver between the two tails. Loop the long tail around the needle driver and towards the short tail 
twice, this produces a surgeons know. Grasp the short tail with the needle driver and pull through the loop, cross your 
hands as you pull the not tight to lay it down flat. Place the needle driver back between the two tails. Again loop the 
long tail towards the short tail, which should now be on opposite sides than previous. Continue this process until at least 
3 throws are completed. 
Grasp the short tail in the suture driver when completed tying the knot. Pass the needle driver and long end of the suture 
into your non-dominant hand. Grab the straight Mayo scissors in your dominant hand and cut both suture tails at least 
1cm in length. 
 
 
 
 
 
 
 
 
 

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14. Appendix B 
Study Design – Flow Chart 
 

15 
 
15. Appendix C 
 
Objective Structured Assessment of Technical Skills (OSATS) 
OSATS is a validated assessment tool for grading overall technical proficiency for open surgical skills.  Below are the 
performance anchors and rating scale for the OSATS tool. Each scale is scored 1 - 5, which means the total score could 
range from 8- 40. 
 
 

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16. Appendix D 
 
Study Title: “Using ‘Guided-Discovery-Learning’ to optimize and maximize transfer of surgical simulation” 
 
We want to ask, if you wish to participate in a scientific study. 
It is voluntary to participate, and you can at any time and without giving a specific reason, take back your informed 
consent. 
 
The Study will be carried out at: 
Copenhagen Academy for Medical Education and Simulation (CAMES) 
Rigshospitalet / Copenhagen University. 
Blegdamsvej 9 
2100 København Ø 
 
The study objective is to explore the effect of guided-discovery-learning vs traditional instructor lead teaching in the 
transfer and retention of basic surgical skills. 
 
As participant in the study, you will either be allocated to a control group or and intervention group. The study will take 
place over 2 weeks, where you will participate on a single every week for about 1 ½ to 2 hours. In both groups you’ll in 
the first week be taught simple suturing technique. On the same day, you’ll perform a post-teaching test. A week later 
you’ll be undertaking a retention-test much like the one you’ll meet on the 8th semesters OSCE-examine. Afterwards 
you’ll be asked to perform a new suture technique without prior teaching to test your abilities to transfer learning.  
 
The control-group will be taught using traditional principles whereas the intervention group will be taught after the 
guided-discovery-principle. It is and exclusion criteria if you have received prior suture training in the form of a SAKS-
course or through the university (7th semester and henceforth).  
 
Information about the test: 
To be able to compare the two groups suturing ability you will be filmed carrying out the suture. This will be a camera 
recording you will you perform the suture in a test situation. These recordings will be anonymized, so that blinded 
raters can score the procedure in an international context. 
 
Information about the teaching: 
Your teaching session will take place at CAMES in the Teilum building. Throughout the first week, there will be 
recordings of the teaching session in chosen groups, so we can compare the teacher/student interaction in each group. 
The recordings will be transcribed for their verbal communication and anonymized, afterwards they will be analyzed. 
 
Besides contributing to the study, you will also receive a diploma stating completed course and achieved ability of 
simple suturing. Throughout the participation, there will be refreshments and food. Before participating you’ll be asked 
to sign a informed consent form, but you are always welcome to withdraw from the study. 
 
If you any questions, you are always welcome to contact us: 
 
Andreas Höier Aagesen 
Asminderødgade 7,2tv 
2200 København N 
andreas.hoier.aagesen@gmail.com 
tlf: 30274904 
 
 
Best regards, 
 
Andreas Höier Aagesen 
 
 

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17. Appendix E 
 
Informed consent for participation in a health-science scientific study.  
 
Study Title: “Using ‘Guided-Discovery-Learning’ to optimize and maximize transfer of surgical simulation.” 
 
Declaration from participant:  
I have received sufficient written and verbal information, and I know enough about the objective, method, pros and cos 
to give my consent to participating in the study. I know it is voluntary to participate, and that I can always withdraw my 
consent without losing my present and future rights to treatment. I give my consent to participate in the study, and I 
have received a copy of this consent form, as well as a copy of the written information about the study for personal use. 
 
Participant’s name: ________________________________________________________ 
 
Date: _______________ 
 
 
Signature: _______________ 
 
 
 
Declaration from study responsible investigator: 
I declare, that the participant has received written and verbal information about the study.  
It is my belief that sufficient information has been given to the participant, so that he/she can make an informed 
decision about whether or not to participate for the study. 
 
Name of the study responsible investigator: _______________ 
 
Date: _______________ 
 
 
Signature: _______________ 
 
 
Project identification: () 
 
 

18 
 
18. Appendix F  
 
Informed consent for dissemination of study data for use in academic purposes.  
 
Study Title: “Using ‘Guided-Discovery-Learning’ to optimize and maximize transfer of surgical simulation.” 
 
Declaration from participant:  
I have received sufficient written and verbal information, and I know enough about the objective, method, pros and cos 
to give my consent to dissemination of the study data. I know it is anonymized, and that I can always withdraw my 
consent without losing my present and future rights to treatment. I give my consent to dissemination of the study data, 
and I have received a copy of this consent form, as well as a copy of the written information about the study for 
personal use. 
 
Participant’s name: ________________________________________________________ 
 
Date: _______________ 
 
 
Signature: _______________ 
 
 
 
 
Declaration from study responsible investigator: 
I declare, that the participant has received written and verbal information about the dissemination of the study data.  
It is my belief that sufficient information has been given to the participant, so that he/she can make an informed 
decision about whether or not to consent to the dissemination of the study data. 
 
Name of the study responsible investigator: _______________ 
 
Date: _______________ 
 
 
Signature: _______________ 
 
 
Project identification: () 
 
 
 
 

19 
 
19. Appendix G 
 
Open-ended questionnaire concerning benefits and drawbacks of teaching. 
 
Questionnaire regarding teaching of basic suture techniques    
 
1. What did you see as the biggest 
challenges of today’s teaching session?  
 
2. How did you overcome these 
challenges? 
 
3. What worked well with your 
interactions with your instructor? 
 
4. What didn’t work well with your 
interactions with your instructor? 
 
5. How did you experience the teaching 
session as a whole? 
 
  
 
6. Other comments? 
 
 
 
 
 
 
 

20 
 
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