Received: 8 September 2020 Revised: 1 December 2020 Accepted: 20 December 2020

DOI: 10.1111/vsu.13585

ORIGINAL ARTICLE - RESEARCH

Influence of instructor-to-student ratio for teaching

suturing skills with models

Julie A. Hunt DVM, MS | Stacy L. Anderson DVM, MVSc, PhD, DACVS-LA |

Dawn Spangler DVM | Robert Gilley DVM, MA, PhD, DACVS

Lincoln Memorial University College of

Veterinary Medicine, Harrogate,
Abstract
Tennessee Objective: To evaluate the influence of instructor to student ratio on the effec-
tiveness and efficiency of teaching suturing skills to veterinary students.
Correspondence:
Julie A. Hunt, LMU-CVM, 6965 Study design: Prospective randomized study.
Cumberland Gap Pkwy, Harrogate, TN Sample population: Second-year veterinary students (N = 121).
37752.
Methods: Students were randomly divided into three groups to participate in
Email: [email protected]
four 2-hour skills laboratory sessions in which suturing of the subcutaneous
tissue was taught by using a simple continuous pattern, suturing of the skin
was taught by using continuous patterns, suturing of the skin was taught by
using interrupted patterns, and suturing of hollow organs was taught by using
inverting patterns. For each laboratory, the groups were taught by using
instructor-to-student ratios of 1:6, 1:8, and 1:10 on a rotating basis. Students
were surveyed at the end of each laboratory, and underwent individual perfor-
mance assessments at the end of each laboratory session and again at the end
of the semester in an objective structured clinical examination (OSCE).
Results: For each of the four in-laboratory assessments and the OSCE, no dif-
ference in performance was detected between groups. When they were sur-
veyed, students in all groups reported that there was an adequate number of
instructors in the laboratory and that they received help in a timely fashion
when help was requested (median for all groups = agree).
Conclusion: For students with prior surgical skills education and with the use
of prelaboratory instructional videos, teaching at the 1:10 instructor-to-student
ratio was efficient and effective.
Clinical significance: Good educational outcomes may be reached with a
1:10 instructor-to-student ratio or, potentially, fewer instructors, depending on
the educational aids present in the laboratory and students' prior level of
experience.

1 | INTRODUCTION practice.8 One fundamental tenet of deliberate practice is

that timely, specific feedback must be provided to the
Surgical skills models are effective training tools for vet- learner. For adequate feedback to be delivered when low
erinary students learning to perform live surgery.1-7 fidelity models are used, there must be an adequate num-
Learning with models occurs as a result of deliberate ber of instructors in the room to observe students and

Veterinary Surgery. 2021;1–8. wileyonlinelibrary.com/journal/vsu © 2021 The American College of Veterinary Surgeons 1
2 HUNT ET AL.

provide feedback. However, guidelines for instructor-to- skills laboratory sessions, each approximately 2 hours in
student ratios for surgical skills training have not been duration. Sessions focused on instrument handling (two
reported in veterinary medicine. In a single study in session), hand ties (one session), instrument ties (two ses-
human medical education, Dubrowski and MacRae9 sions), and interrupted skin sutures (one session, specifi-
sought to determine the ideal instructor-to-student ratio cally simple interrupted and cruciate sutures). All skills
for teaching undergraduate medical students to place sur- training sessions were completed by using models. Stu-
gical sutures. They reported an ideal instructor-to-student dents had been previously assessed on two objective
ratio of 1:4. However, they tested ratios of only 1:2, 1:4, structured clinical examinations (OSCE), one per semes-
and 1:12, so, without further investigation, it could be ter, and had passed those examinations to continue to
concluded with accuracy that the optimum ratio is some- their second year of veterinary school.
where between 1:4 and 1:12, which is a wide range. That
study remains the only published report of instructor-to-
student ratios in surgical skills training in any health 2.2 | Laboratory sessions
professions discipline. Nonsurgical tasks that require a
high degree of accuracy, such as skills performed Students were randomly divided into three even groups by
by osteopathic doctors, paramedics, and in cardiopulmo- using a spreadsheet formula. Students participated in four
nary resuscitation, have traditionally been taught at clinical skills laboratory sessions during the study to learn
instructor-to-student ratios ranging from 1:4 to 1:8.10-13 suturing skills. These skills were subcutaneous layer sutur-
The ideal ratio varies according to the task and learner's ing with a simple continuous pattern with buried knots;
level of prior experience. Determining the ideal ratio opti- continuous skin sutures consisting of a Ford interlocking
mizes the learning experience without wasting valuable pattern and an intradermal pattern; interrupted skin
teaching resources. sutures including vertical mattress, horizontal mattress,
The objective of this study was to evaluate three cruciate, and near-far-far-near patterns; and inverting
instructor-to-student ratios, 1:6, 1:8, and 1:10, for teach- suture patterns consisting of Cushing, Lembert, and
ing suturing skills with models to second-year veterinary Utrecht patterns. These laboratory sessions took place in
students. We chose to investigate suturing skills because weeks 7, 8, 9, and 13 of the semester, respectively. The
these are fundamental surgical skills that must be taught groups were assigned to laboratory sessions with an
to all veterinary students prior to the performance of instructor-to-student ratio of 1:6, 1:8, or 1:10 on a rotating
almost every type of surgery in small or large animals. basis, so that each group had at least one laboratory ses-
We selected these ratios to evaluate because they fell sion at each ratio. Determination of instructional effi-
between the values of 1:4 and 1:12 previously researched ciency was based on the instructor-to-student ratio; using
by Dubrowski and MacRae9 and would help to elucidate a reduced number of instructors, or a higher instructor-to-
the value at which educational outcomes begin to decline student ratio, was considered to be more efficient. Labora-
for suturing tasks. We hypothesized that an instructor-to- tory instructors were veterinarians with at least 3 years of
student ratio of 1:8 would be the optimum ratio for the experience teaching surgical skills to veterinary students.
instruction of surgical skills. Students were required to attend every laboratory ses-
sion as a part of their clinical skills course. Each session
was taught by using a surgical skills model. The subcuta-
2 | MATERIALS AND METHODS neous and skin suture laboratory sessions were taught by
using the LMUterus spay model (Lincoln Memorial Uni-
2.1 | Participants and ethics versity, Harrogate, Tennessee), which had a three-layer
outer covering consisting of a silicone body wall layer, a
This study was approved by the Lincoln Memorial Uni- foam subcutaneous layer, and a silicone skin layer. Each
versity Institutional Review Board. A convenience sample layer contained a four-way stretch powermesh layer that
of 121 second-year graduate veterinary students signed held sutures, and the entire covering was wrapped
informed consent forms and were enrolled in the study; around a base made of wood and polyvinyl chloride
all students who wanted to participate were enrolled. In (PVC). The inverting patterns laboratory session replaced
the absence of published data that could be used to per- the outer covering with thin silicone over a mesh
form a sample size calculation, we selected our sample pantyhose layer, securing the covering onto the same
size after reviewing the results of Dubrowski and wood and PVC LMUterus base. For each laboratory, stu-
MacRae,9 which provided evidence of statistically signifi- dents were required to review materials on the online
cant differences among three groups among a sample of learning platform, including instructional videos, before
108 students.9 After completing their first year of veteri- coming to the laboratory. At the start of the laboratory,
nary school, students had participated in six surgical the instructor who served as the laboratory leader would
HUNT ET AL. 3

give introductory remarks and then give a demonstration 3 | RESULTS

of the task while highlighting important steps or
common errors during the laboratory. 3.1 | In-laboratory assessment scores

For the subcutaneous closure laboratory, 99 (81.8%) stu-

2.3 | Assessment dents received a passing GRS (scores 4-6) on their in-
laboratory assessment. The groups taught at 1:6, 1:8, and
Four of the more experienced laboratory instructors, each 1:10 instructor-to-student ratios each had median GRS of
with at least 5 years of experience teaching and assessing 5, with no difference in distribution of scores (P = .311).
surgical skills, were selected to be raters in all four of the For the continuous skin suturing laboratory, 89 students
laboratory sessions. They met together for 30 minutes (73.6%) received a passing in-laboratory-assessment GRS.
prior to each laboratory to review the content and scoring The groups taught at 1:6 and 1:10 instructor-to-student
of the assessment. Students were scored according to a ratios each had a median GRS of 4, while the group taught
rubric (Appendix A) with a six-point global rating score at a 1:8 ratio had a median GRS of 5; however, there was
(GRS) in which 1 = very poor, 2 = poor, 3 = borderline no difference in distribution of scores (P = .965).
satisfactory, 4 = satisfactory, 5 = good, and 6 = excellent. For the interrupted skin suturing laboratory, 114
Because the raters were also instructors in the laboratory, students (94.2%) earned a passing GRS for their in-
it was not possible to blind them to the instructor-to- laboratory assessment. Groups taught at 1:6, 1:8, and 1:10
student ratio. After completion of each laboratory ses- instructor-to-student ratios all had a median GRS of 5; there
sion, students filled out a brief, anonymous survey asking was no difference in the distribution of scores (P = .332).
about their experience in the laboratory and their satis- For the inverting suture laboratory, one student was
faction with their instruction (Appendix B). All students absent, and 116 students (96.7%) received a passing GRS
were provided with LMUterus models to take home and on their in-laboratory assessment. Groups taught at 1:6,
encouraged to practice their skills outside of scheduled 1:8, and 1:10 instructor-to-student ratios each had a
laboratory time, either at home or in the clinical skills median GRS of 5; there was no difference in the
practice laboratory. An optional 3-hour review laboratory distribution of their scores (P = .475; Table 1).
was offered prior to the OSCE.
During week 18 of the semester, students participated
in a 12-station OSCE, which counted as 30% of their final 3.2 | Objective structured clinical
grade in their clinical skills course. The OSCE included examinations scores
an inverting Lembert pattern suturing station based
directly on the laboratory session in the study. The OSCE Two students were excluded from analysis of OSCE
station was scored by using a checklist and six-point scores; one student had an excused absence for the
GRS. The station also included a short list of student OSCE, and the other student had been absent from the
actions that would trigger mandatory station failure inverting suture laboratory. Among the remaining
(Appendix C). Instructional effectiveness was assessed 119 students, 112 (94.1%) received a passing GRS (scores
via student performance in the in-laboratory assessments 4-6). Students taught at a 1:6 instructor-to-student ratio
and the OSCE. The ideal instructor-to-student ratio was for the inverting suture laboratory received a median
deemed to be the one that was most efficient in terms of GRS of 5, while students taught at 1:8 and 1:10 ratios
instructor use with no loss of instructional effectiveness. received a median GRS of 6; there was no difference in
distribution of GRS among groups (P = .553).

2.4 | Statistical analysis

3.3 | Student surveys
Global rating scores from in-laboratory assessments
and the OSCE were tested for normality by using All groups of students reported that they made significant
Shapiro–Wilk, found to be nonparametric in distribution, improvement in the laboratory sessions (median of agree)
and are described by using median and compared by and that there was an adequate number of instructors pre-
using Kruskal-Wallis H tests. Survey responses were con- sent in the laboratory (median of agree). Students in the
sidered to be ordinal data, described by using median, 1:6 instructor-to-student-ratio group strongly agreed that
and compared by using Kruskal-Wallis H tests. Survey they received the timely assistance of an instructor when
data were pooled from all laboratories for analysis. Signif- they required it, while students in the 1:8 and 1:10 ratio
icance was set at P ≤ .05, and all analyses were per- groups agreed that they received timely assistance; there
formed in SPSS version 26 (IBM, Armonk, New York). was no difference between groups' responses (P = .091).
4 HUNT ET AL.

TABLE 1 Results of the performance assessments

Suture pattern ITS ratio GRS 1, n (%) GRS 2, n (%) GRS 3, n (%) GRS 4, n (%) GRS 5, n (%) GRS 6, n (%)
Subcutaneous 1:6 0 0 10(25) 8(20) 19 (48) 3(8)
1:8 0 1(3) 6(15) 11(28) 21 (53) 1(3)
1:10 0 1(2) 4(10) 9(22) 22 (54) 5(12)
Continuous skin 1:6 1(3) 4 (10) 7(18) 9(23) 12 (30) 7(18)
1:8 0 2(5) 9(23) 9(23) 15 (38) 5(13)
1:10 0 1(2) 8(20) 12(29) 16 (39) 4(10)
Interrupted skin 1:6 0 0 3(8) 8(20) 24 (60) 5(13)
1:8 0 0 1(3) 8(20) 23 (58) 8(20)
1:10 0 1(2) 2(5) 9(22) 26 (63) 3(7)
Inverting patterns 1:6 0 0 1(3) 12(31) 25(64) 5(13)
1:8 0 0 2(5) 10(25) 24 (60) 4(10)
1:10 0 0 1(2) 8(20) 25 (61) 7(17)
OSCE station - 1:6 0 1(3) 2(5) 8(21) 12 (31) 18 (46)
inverting pattern 1:8 0 0 2(5) 5(13) 11 (28) 21 (54)
1:10 1(3) 0 1(3) 5(13) 9 (23) 23 (58)

Abbreviations: GRS, global rating score; ITS, instructor-to-student;

TABLE 2 P values

P
Skills Assessment value
In-lab assessment, subcutaneous suture pattern, GRS .311
In- lab assessment, continuous skin suture pattern, .965
GRS
In-lab assessment, interrupted skin suture pattern, .332
GRS
In-lab assessment, inverting suture pattern, GRS .475
OSCE assessment - inverting suture pattern, GRS .553
Student survey - my skills improved significantly .511
during this lab
Student survey - an instructor observed me .036*
sufficiently
Student survey - I was able to get instructor .091
assistance in a timely fashion
Student survey - the lab had an adequate number of .056
instructors
F I G U R E 1 Student survey responses to the prompt “An *P <. 05
instructor observed me sufficiently to tell if I was doing the skills Abbreviations: GRS, global rating score; OSCE, objective structured clinical
correctly,” where 1 = strongly disagree; 2 = disagree; 3 = neutral; examination; lab, laboratory.
4 = agree; 5 = strongly agree. For each group, a bold line represents Hunt JA, Anderson SL, Spangler D, Gilley R. Influence of instructor-to-
student ratio for teaching suturing skills with models. Veterinary Surgery.
the median, a solid blue box demonstrates the middle 50% of the
2020;00:000-000. https://doi.org/10.1111/vsu.13585
values, a vertical line shows the range, and open circles represent any
outlying values
there was a difference in the distribution of student
Students in all groups reported that an instructor observed responses among groups (P = .036). Specifically, although
their performance sufficiently to determine whether they the median values were equivalent, student responses in
were doing the skills correctly (median of agree); however, the 1:6 instructor-to-student-ratio group were clustered
HUNT ET AL. 5

more positively, while the 1:8-ratio group had responses are higher compared with long-term retention scores, the
over a wider spread, including some students who believed opposite was seen in this study. This likely resulted from
that their skills were not adequately observed. Student students practicing their skills outside of scheduled labo-
responses from the 1:10 instructor-to-student-ratio group ratory sessions in preparation for the OSCE, which was
were clustered positively, similarly to the 1:6-ratio group worth 30% of their course grade.
(Figure 1, Table 2). Although educational outcomes were similar among
groups on all five performance measures, and survey
results were nearly identical for the groups, there was
4 | DISCUSSION one statistically significant difference in survey
responses. Specifically, almost all of the students in the
Developing clear guidelines on instructor-to-student ratio 1:6 instructor-to-student ratio group believed that they
optimizes the use of instructor resources in the educa- were adequately observed, while some of the students in
tional setting. However, there had previously been no the 1:8 group believed that they were not adequately
research in veterinary education on instructor-to-student observed. This could have been a type 1 error because
ratio in teaching clinical skills. Existing medical educa- the same students reported that they felt there was an
tion research has provided evidence for recommending adequate number of instructors in the laboratory, and
an instructor-to-student ratio of 1:4 for teaching suturing the 1:10 instructor-to-student ratio group believed that
skills after testing only ratios of 1:2, 1:4, and 1:12.9 We they were adequately observed. However, if this repre-
identified 1:10 as the best instructor-to-student ratio sents a real difference, the reader can be reminded that
among those tested for teaching suturing skills to second- student satisfaction with the feedback process in veteri-
year veterinary students during 8 hours of surgical skills nary and human medicine has at times been disappoint-
training sessions with models. Although Dubrowski and ing.16 In addition, there can be a mismatch between
MacRae9 found reduced learning outcomes at a 1:12 what students perceive faculty are providing and what
instructor-to-student ratio, we saw equivalent learning faculty perceive they are providing in terms of
outcomes at a 1:10 ratio. This difference may have feedback.17,18
resulted from the video-recorded resources that were pro- This study had several limitations. Suture patterns are
vided to our students in the laboratory or from our veteri- typically taught early in students' progress toward surgi-
nary students' prior surgical skills training. This prior cal competence and may be followed by laboratories in
training consisted of 12 hours of surgical skills laborato- which students combine these skills into an entire surgi-
ries in instrument handling, knot tying, and suturing cal procedure in a model, such as an ovariohysterectomy
during the previous year, while students in the or castration. Students subsequently move on to live sur-
Dubrowski and MacRae9 study had no previous formal gery supervised by licensed veterinarians. One limitation
surgical skills training. Novices typically require more of this study is that the instructor-to-student ratio
feedback and guidance during instruction compared with required for practicing suturing skills practice with
students who have some experience, which may explain models may not match the ratio required for supervising
why their results differed from ours. model surgery or live surgery, so educators should not
Learning a psychomotor skill such as suturing generalize this study's findings to that setting until addi-
involves perceiving an on-going visual and tactile input tional experimental data are available. In particular, if
and creating a monitored, manual motor output in instructors want to monitor students closely for errors in
response.14 Students learn suturing skills cumulatively, aseptic technique, additional instructors may be required.
through deliberate practice with specific instructor feed- The ideal ratio is also influenced by what other resources
back.8 The provision of feedback has been identified as the students are using in the laboratory. Students in this
the single most important factor contributing to the suc- study had access to online video recordings of the suture
cess of simulation-based training in medical education.15 patterns on their learning management system and were
However, low-fidelity models themselves do not provide encouraged to view these recordings in the laboratory on
feedback; it must be provided by the instructor, which their tablets or smartphones to augment the instructors'
requires an adequate instructor-to-student ratio. The vast guidance. Had these videos not been available, additional
majority of our students passed both their in-laboratory instructors may have been required. The instructor-to-
(74%–97%) and OSCE station (94%) assessments, provid- student ratio required for effective instruction may vary
ing evidence that adequate practice and feedback were under different circumstances.
present in all groups for both short- and long-term learn- Another limitation is that students were not asked
ing to take place. Although most reports of simulation- about whether they had extracurricular surgical experi-
based research studies describe initial passing rates that ence and, if so, excluded from the study; however, the
6 HUNT ET AL.

study size (N = 121) was likely sufficiently large to not RE FER EN CES
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Author Contributions Hunt JA, DVM, MS: Study Osteopath Assoc. 2012;112(4):182-187.doi:112/4/182 [pii]
design, enrollment of students, laboratory leadership, 11. United States Department of Transportation National Highway
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Responder/FR_1995.pdf. Accessed January 22, 2021.
MVSc, PhD, DACVS-LA: Study design, institutional
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Emma Wilson, RVT for assisting with data collection. 15. Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL,
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CONFLICT OF INTEREST tions that lead to effective learning: A BEME systematic review.
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01421590500046924.
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A P P E N D I X A : G R A D I N G R U B R I C F O R A N I N - L A BO R A T O RY A S S E S S M E N T O F
I NTE RR UP T ED SK I N SU TU RE S

Student Task
Place a horizontal mattress suture followed by a vertical mattress skin suture. Place the sutures adjacent to each other as for a small
animal skin closure.
Guidelines for accepted technique
Suture handling: Remove the suture from the packet by grasping the needle with the needle drivers. Suture should not drop below
table level or outside of what could reasonably be expected to be a draped area on a canine patient (approximately 2 feet square).
When tying knots, the student should hold the needle in between their thumb and index finger or place the needle just below the base
of the palm (not in the palm) and gather their suture in 1-2 large loops with the working end extending from the top of their hand.
Suture should only be gathered when tying knots and not with every stitch.
Instrument handling: Hold ringed instruments using ring finger and thumb. Tripod, palmar, and modified palmar grips are acceptable
for needle drivers. Thumb forceps should be held in the nondominant hand and put into resting position while knots are being tied.
Forceps should be held as an extension of the thumb and index finger. The middle finger may come alongside in order to stabilize the
instrument, but the student should not consistently have 4 fingers (thumb, index, middle, and ring) on the forceps as this leads to
tissue trauma. Thumb forceps should not be held within the palm (‘palmed’) while being actively used.
Tissue handling: Students can gently pick up or evert skin to facilitate suturing but should not aggressively pull on tissue or peel tissue
layers back from each other.
Horizontal mattress: Start on the side opposite and take a bite approximately 4-5 mm back from the cut edge. Student may or may not
come up in the center before taking a bite 4-5 mm on the near side. Regrip the needle in the drivers so that the needle is pointing away
from them (backhanding the needle) and take a bite away from themselves, approximately 8-10 mm away from the first bite, first
through their near side, 4-5 mm back from the cut edge, and then coming through the far side, 4-5 mm back from the cut edge. The
suture ends will be tied using square throws.
Vertical mattress: Start on the side opposite and take a bite approximately 8-10 mm back from the cut edge. Come up in the center and
regrip the needle to take another bite 8-10 mm back from the cut edge on the near side. Reverse the direction of the needle in the
drivers (backhanding) and take a bite away from themselves, in the same line as the first bite, ~4-5 mm back from the cut edge on
their near side, and then coming through the far side, 4-5 mm back from the cut edge. The suture ends will be tied using square
throws.
Tension: Edges should be apposed but not overlapping or excessively tight. There should not be gapping of more than 1-2 mm between
the tissue edges.
Acceptable Variations
Using a surgeons throw for the first throw is acceptable as long as the suture tension is appropriate.
Global Score

6 5 4 3 2 1
Excellent Good Borderline satisfactory Borderline unsatisfactory Poor Very Poor
8 HUNT ET AL.

Mandatory failure (GRS 1-3)

Student does not complete the task within time allowed
Student throws multiple half-hitches without tying a full square knot (2 throws) on top of them, or knots are otherwise of poor quality
Student makes no effort to gather suture while tying knots
Student demonstrates significant, consistent instrument handling deficits
Abbreviations: GRS, global rating score.

A P P EN D I X B : P O S TL A B O R A TO R Y S TU D E N T SU R V EY

Please answer the questions using the following scale:

A = strongly agree, B = agree, C = neutral, D = disagree, E = strongly disagree

1. My skills improved significantly during this laboratory: A B C D E

2. An instructor observed me sufficiently to tell if I was doing the skills correctly: A B C D E
3. I was able to get instructor assistance in a timely fashion when I asked for help: A B C D E
4. The laboratory had an adequate number of instructors: A B C D E

A P P EN D I X C : O S C E ST A TI O N - L EM B ER T S U T U R E P A T T E R N S C O R I N G RU BR I C

Checklist

Yes No
Student performed the following: (1) (0)
1 Started first knot at or before the start of the incision
2 Buried first knot correctly
3 Took proper perpendicular bites to extend Lembert pattern the length of
the incision
4 Made no gaps in pattern (leak proof seal)
5 Made final knot at or past the end of the incision
6 Buried second knot correctly
7 Tied square throws or recognized half-hitches and placed a full square
knot on top of them
8 Demonstrated proper instrument handling
9 Demonstrated acceptable tissue handling
10 Gathered and controlled suture adequately
11 Demonstrated safe sharps management
Global Rating Score

1 2 3 4 5 6
Very Poor Poor Borderline unsatisfactory Borderline satisfactory Good Excellent
Mandatory failure (GRS 1-3)
Student does not complete the correct task within the time allotted
Student backhands the entire pattern/most of the pattern
Student places incorrect bites and/or ties over a superficial suture and as a result, neither of the knots bury
Student throws multiple half-hitches without tying a full square knot (2 throws) on top of them, or knots are otherwise of poor quality
Student demonstrates significant, consistent instrument handling deficits
Abbreviations: GRS, global rating score; OSCE, objective structured clinical examination.