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Empirical Investigations

The Challenges of Dyad Practice in Simulation Training of Basic Open Surgical Skills—A Mixed-Method Study

Zetner, Diana B. MD; Konge, Lars MD, PhD; Fabrin, Anja MD; Christensen, John B. MD; Thinggaard, Ebbe MD, PhD

Author Information
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: February 2022 - Volume 17 - Issue 1 - p e91-e97
doi: 10.1097/SIH.0000000000000560


Dyad training is a method of training, in which 2 participants collaborate to learn a task that is ultimately performed individually.1 Although not effective for all tasks, this method can benefit motivation, competition, goal setting, and peer feedback, which are important factors in motor skill learning.2 In a randomized controlled trial on dyad training versus individual training simulation-based training, qualitative analysis revealed benefits of dyad training such as being equal-level novices, observational learning, motivation, and meta-cognition.3

Benefits of collaborative learning have been explained by neuroimaging in which observation activates mirror neurons in the premotor cortex. The brain processes information in similar ways during both observational and physical practice.4,5 Studies have found that participants training psychomotor skills in pairs, alternating between physical and observational practice, perform at least as well as participants who train individually. Interestingly, dyad trainers use less time on physical hands-on practicing during training, suggesting that dyad training is more efficient than individual training.6–10 Observational practice has shown to be inferior to physical practice, but when combining observational and physical practice, performance improved compared with purely physical practice.11

Collaborative learning may also be beneficial when a task is perceived complex as learners can share the cognitive load with other trainees.12 A group of researchers have developed a theoretical model explaining when collaborative learning is effective in learning clinical skills. It is based on 3 perspectives on collaborative learning; social interaction, motor skills learning, and cognitive perspective, suggesting that all 3 perspectives are important in learning.12

Furthermore, the demand for flexibility is a challenge in surgical training. Self-regulated training is cost-effective and flexible.13 However, the social component as a motivational factor during training is lost and opportunities for supervision and feedback are limited. Dyad training could add these to off-site self-regulated training, as peer instruction may fill in this gap. Peer instruction can make it easier to relate to specific challenges not just because of the motivation of having another person present while practicing but also because the other person is at the same educational level and also struggle to learn the same task.14

Educators in clinical and simulation-based training have started to implement self-regulated training. However, we lack knowledge about the effects of implementing dyad training in self-regulated training at home. The aim of this study was to explore the effect on surgical performance and training patterns of self-regulated training in pairs versus training individually, during a basic open surgery skills course.


This study is a rater-blinded, mixed-method, simulation-based trial, examining the effect and exploring the challenges of self-regulated training in pairs versus individual training in open surgical skills. Data were collected at the Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, Denmark.15 The study was performed from August 2016 to November 2017.

The regional ethics committee determined that no approval was required for the study according to Danish legislation (H-16031885). Written and verbal informed consent was given by all participants.


Participants were medical doctors from the Capital Region and the Region of Zeeland in Denmark, who signed up for a basic open surgery skills course during the study period. Participants were excluded from the analysis if they did not complete the course (Fig. 1, study flow chart). Before enrollment, participants filled out a questionnaire to establish the level of operative experience and to collect demographic data.

Study flow chart.

Participants were randomized to either self-regulated training in pairs or individual self-regulated training. Using, randomization was performed in blocks; each class consisted of 6 to 10 participants. Generation of randomization, enrollment of participants, and assignment of participants were carried out by the corresponding author. Participants were informed that they were expected to take part in on-site training sessions but that they could decide themselves when and how much time they spent practicing.

Course in Basic Open Surgical Skills

At the CAMES, we have developed a 6-week course in basic open surgical skills aimed at junior residents about to start a career in surgery.16 The course consists of 6 weekly didactic instructions, lasting 1.5 hours each, with an experienced surgeon, expert-guided training, and self-regulated training at home. The instructions were held in a quiet environment at the simulation center. The first 2 lessons covered surgical knot tying. Sessions 3 to 5 covered 10 basic suturing techniques and instrument handling. Hemostats, use of scissors, and scalpel were demonstrated in session 6 (see Table, Supplemental Digital Content 1,, which specify all learning objectives for on-site classes) A manual was made to ensure uniformity of the course. Participants received a home training kit containing surgical instruments, sutures, skin pad, and a knotting board (Figs. 2A, B, training kit and test setup). We used a simple silicone model with only 2 layers: epidermis and subcutis, as participants trained basic suturing techniques. Participants were encouraged to use the kit to train all the techniques demonstrated at the classes at home. They decided themselves which techniques they wanted to train at home. Dyad trainees and individual trainees all trained the same techniques. Participants received verbal and written instructions on the study protocol and simulator.

A, Training kit. B, Test setup.

Intervention: Dyad Practice

Participants were paired at the first on-site training session and practiced in pairs during on-site training sessions held at the CAMES. They were instructed to practice with their partner and to receive all feedback from the expert in pairs. They were informed how to give constructive feedback and were encouraged to give each other feedback during training as well as to divide time equally among them. They trained at the same table to ensure that they practiced in pairs at the CAMES. Participants were instructed to actively observe their partner while practicing and to discuss their performance and any difficulties that they encountered. Testing was done individually.

Control: Individual Training

Participants randomized to train individually were instructed to do all the training individually. They were instructed not to practice with others when practicing at home and to receive individual feedback from the expert during the expert-guided training. During training sessions at the CAMES, they sat at separate tables.

Outcome Measures

Surgical Skill Assessment

Participants' suturing skills were assessed before and after the course.16 The test consisted of 5 basic tasks performed on a simulated skin model (Figs. 2A, B, training kit and test setup for pictures of equipment and test setup; see Text Document, Supplemental Digital Content 2,, examination test for details and instructions to the test). All tests were video recorded. An expert, a doctor with specialty degree in thoracic surgery, rated participants' surgical performance using the Objective Structured Assessment of Technical Skills (OSATS) Global Rating Scale. The OSATS is an assessment tool, supported by validity evidence, for the evaluation of general surgical skills.17,18 We modified the global rating scale by removing 2 items on the scale, because no assistant was available during testing and because it was not possible to estimate tissue damage on silicone pads on videos (see Table, Supplemental Digital Content 3,, Modified OSATS Global Rating Scale).16 The rater was blinded to the randomization. To ensure blinding, only the participants' hands were visible on the video, and sound was deleted.

Training Log

Participants were asked to keep a training log with details of time spent on training and number of training sessions. The training log contained information on which type of task was practiced and whether the training was performed in pairs or individually. In addition, time spent in the operation room, assisting, or performing open surgery was registered. We also measured number of participants completing the course and attendance at the on-site classes.

The primary outcome was differences in pretest and posttest OSATS scores. Secondary outcomes were time (in minutes) spent on self-regulated training, number of self-regulated training sessions, number of dyadic training sessions at home, and number of tasks performed per trainee during self-regulated training (hands-on time).


Participants were asked to fill out a questionnaire at the end of the course (see Questionnaire, Supplemental Digital Content 4,, Questionnaire Dyad Training and Questionnaire; see questionnaire, Supplemental Digital Content 5,, Questionnaire Individual Training). Two questionnaires were designed, one for dyad trainees and one for individual trainees. Questions related to the course in general were the same in the 2 questionnaires. Questions were a combination of yes/no questions, 5-point Likert scale, and commentaries. Data were analyzed using conventional content analysis.19 Themes were identified by reading commentaries and highlighting repeated or similar statements. The first author performed the primary analysis identifying themes. Two authors afterward went through the results and agreed on the analysis.

Statistical Analysis

A multilevel model with mixed effects (fixed effect of randomization and random effect of assigned class and pairs) was used to establish whether there was a significant level of difference in pretest and posttest OSATS scores, time (in minutes) spent on self-regulated training, number of self-regulated training sessions, number of dyadic training sessions at home, attendance at the on-site classes, and number of tasks performed per trainee during self-regulated training (hands-on time). Differences in baseline scores was calculated using Student t test, as participants were not randomized at the baseline test. Pearson correlation was used to establish whether there was a correlation between improvement of surgical skills (OSATS score) and number and time spent in the operation theater. A statistical software package was used (SPSS Version 20.0; IBM, New York), and P values of less than 0.05 were considered statistically significant.

Sample Size

The required sample size was calculated based on data from 32 participants completing the course in December 2015 to March 2016. The intervention group was expected to improve by 2 points on the OSATS score compared with the control group. Setting an α value at 0.05 and a β value at 0.20, 27 participants were required in each group. We aimed to include 40 participants in each group to account for the high risk of dropouts in a nonmandatory 6-week-long course. Dropouts from the trial were not included in the data analysis, but a separate analysis was performed to explore the effect of dropouts on findings.


We enrolled 101 participants in the study, and 97 were included in the analysis (intervention, n = 45; control, n = 52; Fig. 1, study flow chart). Four participants were excluded. One participant, who was randomized to dyad practice, decided to leave the course just before the first lecture because of a job opportunity. This participant's partner was excluded as well, because she trained alone but was randomized to dyad practice. Another participant was excluded because she left the course because of illness. The last participant was excluded because of not showing up for the final test. Most participants were first-year residents (postgraduate year 1, n = 40) or interns (postgraduate year 2, n = 27) and were employed at a surgical department (n = 70). See Table 1 for participant demographics.

TABLE 1 - Participants
Individual Dyad Total
Sex Female 34 32 66
Male 18 13 31
Level of experience First-year resident 24 16 40
Intern 17 10 27
Specialty training 1 4 5
Other* 10 15 25
No. operations performed (at baseline) Supervised 40.2 30.1 70.3
As assistant 56.3 56.1 112.4
Employment Surgical department 37 33 70
Medical department 6 3 9
General practice 4 4 8
Emergency department† 1 2 3
Other‡ 4 3 7
Previous experience with surgical simulation(s) Yes 33 30 63
No 19 14 33
*PhD student, maternity leave, unclassified, and unemployed.
†Expected to start in a surgical department after finishing the course.
‡Psychiatry, PhD student, maternity leave, and unemployed.

Quantitative Data

We found no statistical differences between dyad training and individual training in the OSATS score from pretest to posttest. Dyad trainees improved on average (intercept estimate) 7.23 [median = 7.0, interquartile range (IQR) = 6.0–9.5 (weighted average)], with individual trainees improving 0.293 points lower [median (IQR) = 7.0 (4.25–9.0), P = 0.881]. Figure 3 illustrates the increase in OSATS score for the intervention and control group. Furthermore, there was no statistical difference in OSATS baseline scores between the dyad and individual trainees [mean (SD) = 8.6 (3.29) points vs. 9.21 (2.7) points, respectively, P = 0.395].


No statistical difference was found in time (in minutes) spent on self-regulated training between the intervention and control group [intercept estimate = 493 vs. 418, median (IQR) = 395 (298–525) vs. 475 (360–475), P = 0.668.]

A statistically significant difference was observed in number of off-site training sessions; the dyad trainees trained fewer times than the individual trainees [intercept estimate = 7.23 vs. 12.1, median (IQR) = 12 (9–17) vs. 7 (5–10), P ≤ 0.001]. Dyad trainees thereby trained for longer time intervals than individual trainees. Dyad trainees spent on average 68 minutes per training session and individual trainees spent on average 36 minutes per training session. We found no difference between the intervention group and the control group in number of tasks performed during off-site training [intercept estimate = 889 vs. 1032, median (IQR) = 842.5 (594.5–1409.25) vs. 1032.5 (358–1150.25), P = 0.622; Table 2, quantitative results].

TABLE 2 - Quantitative Results
Dyad Individual P
Difference in OSATS score from pretest to posttest 7.23 6.94 0.881
Time spent on self-regulated training, min 493 418 0.668
No. off-site training sessions 7.3 12.1 <0.001
No. tasks trained per off-site training session 889 1032 0.622

Five of the 45 participants allocated to dyad practice reported that they trained individually in addition to training with their partner. Three of these 5 participants reported training 1 time individually at home and 2 reported that they trained 2 times individually at home. None of the participants, who were randomized to train individually, trained with others during the course.

Nine participants failed the final test and were offered re-examination. Four of the 9 participants who failed were allocated to the intervention group and 5 allocated to the control group. Only 1 participant did not complete the course after re-examination. Data from the re-examination were not included in the statistical analysis.

Of the 97 participants, 94 attended all on-site classes. The remaining 3 participants attended 5 of the 6 on-site classes. Two of these 3 participants were dyad trainers and 1 trained individually. There was no statistically significant difference in attendance at on-site classes between dyad trainees and individual trainees (P = 0.50).

We found no statistically significant difference in previous operative experience (number of surgical procedures performed under supervision).

We found no correlation in number of operations performed or assisting (Pearson correlation = −0.295), nor time spent assisting performing surgery during the course, and an increase in OSATS score (Pearson correlation = −0.313). Demographic data did not reveal any heterogeneity between dyad and individual trainees.

Qualitative Data

In total, 73 participants filled out the questionnaire (28 of 45 dyad trainees and 45 of 52 individual trainees). Overall, the participants reported a high personal outcome of the course. Individual trainees rated a mean of 4.84 and dyad trainees rated a mean of 4.54 on a 5-point Likert scale. In general, participants who were randomized to dyad training reported that they perceived dyad training to be beneficial. Participants reported the following as beneficial: having a sparring partner, receiving feedback, corrections, increased motivation, as well as more structured training sessions and having fun. Please see Table 3, qualitative results (eg, quotes).

TABLE 3 - Qualitative Results
Theme Examples
Feedback from peers “It was beneficial to have one to spar with, especially if you were unable to recall what was demonstrated at the lecture.”
“We were able to support each other and correct each other's mistakes.”
“It is much more detailed when your training partner demonstrates.”
Motivation and structure “We practiced every week, which I might not have been inclined to do if I trained individually.”
“You have a responsibility to you partner to train before the next lecture.”
“I wanted to be just as good as my partner.”
“In a way the partner aided in a way the expert could not, because we are on the same level, and we faced the same challenges.”
Challenges in off-site dyad training “Sometimes it was difficult to coordinate schedules, and you have different learning paces.”

Feedback From Peers

The most frequent reported benefit of dyad training was the opportunity to ask someone for help and corrections of wrong techniques. Most dyad trainees (18/28) also reported that their partner was able to assist them in their training in a way that the expert and student assistant could not, because the partner was available all the time and because the partner provided more detailed demonstrations and instructions than the expert.

Motivation and Structure

Of the 28 dyad trainees who filled out the questionnaire, 17 reported that dyad training increased motivation. Dyad trainees reported that it was beneficial to schedule training with a partner, because it kept them motivated to train, and that training with a partner contributed to a more structured training. Participants also reported that motivation was increased because of competition and that it was a benefit to train with someone on their own level. Furthermore, the trainees reported that it was beneficial for them to have a partner, as they shared experiences from the clinic.

Challenges in Off-site Dyad Training

A major disadvantage reported by the dyad trainees was that it was difficult for the trainees to coordinate training sessions, because of busy working schedules. Dyad trainers also reported on concerns about limited training time, less spontaneous training, and different learning paces.


Despite performing a large study with sufficient power, we found no statistically significant differences between dyad training and individual training of open surgical skills in improvement of skills measured by the OSATS, time spent on off-site self-regulated training, nor number of tasks performed during off-site self-regulated training. We found a statistically significant difference in the number and duration of training sessions. Participants training in dyads had fewer and longer training sessions. In our qualitative analysis, dyad trainees reported on benefits such as increased supervision and motivation. However, it was difficult for dyad trainees to coordinate training sessions.

We included 97 doctors in this study, which is considered a large sample size in medical educational research.20 With a difference in improvement between the groups of only 0.293 points, the sample size may not have been large enough to detect a statistical difference. Nonetheless, even if a statistical difference was identified, we find that a difference of less than 2 OSATS points is insufficient to have any practical relevance.

The participants' surgical skills were tested individually in both groups. This might have been an advantage for the individual trainees, as the setting for both training and testing was similar. The dyad trainees did not have the opportunity to prepare themselves for the test individually, as they were asked to train with a partner during the entire course.

Participants chose their partner themselves. Most commonly, they chose partners that worked at the same hospital or lived near them, but as there were a maximum of 10 participants per class, this was not always possible. Most of the participants lived or worked within 15 km from the simulation center. One participant lived 110 km away; however, this participant still rated 5 out of 5 when asked whether he thought that dyad training had been beneficial for him. This participant and others reported that they have changed their mind about dyad training after the course.

In this study, trainees were encouraged to observe each other and give feedback. However, as most of the training was off-site self-regulated training, it was not controlled if they followed these instructions. If trainees in our study did not spend time on observation and feedback, they might not have benefitted from dyad training. Medical students who trained clinical skills in dyads have expressed concern about dyad training because of less hands-on training.21 We found that 5 of 45 dyad trainees decided to train individually in addition to training in pairs, which may indicate that some dyad trainees were concerned about less hands-on training.

Finally, dyad trainees may have benefitted of dyad training, as they most likely have spent a short amount of time each session socializing. They potentially received the same improvement as individual trainees, spending less time on actual hands-on training.

Distributed Learning

Our qualitative analysis revealed that dyad trainees found it difficult to coordinate training sessions because of distance and working schedules. This may have resulted in trainees training fewer times but in longer time intervals. Studies indicate that spacing training sessions over several times, referred to as distributed practice or spaced repetition, is more effective on motor skills learning than massed practice.22,23 If it was difficult or inconvenient for dyad trainees to coordinate training sessions, it might have had a negative impact on their performance outcome. Studies indicate that trainees do not train as much as recommended, and it is possible that a structured training program or clear goal setting is needed to ensure distributed practice in self-regulated training.24–26 The ideal time interval between training sessions has not been established.27 In our study, dyads trainees reported that they found dyad training beneficial in providing structure to training, and that dyad training improved their motivation to train in between lectures. Participants decided themselves when and how often they wanted to train and how they structured training sessions. However, because of the difficulties in coordinating training, a combination of dyad training and individual training may be more beneficial. More studies are needed to understand the barriers of off-site self-regulated training in dyads, and future studies may benefit from imposing a structured self-directed training program.


In this study, the participants trained for 6 weeks using a combination of on-site expert-regulated lectures and off-site self-regulated training. To our knowledge, this is the first study exploring the effect of dyad training of clinical skills in a course spanning over several weeks. Therefore, our results cannot be compared with previous studies exploring the effect of short on-site training sessions. Data on how trainees perceive dyad versus individual training in different training setting and in different phases of training may aid in the understanding of when and how dyad training is effective in simulation-based medical education.

A limitation of the study is that we only used 1 rater. Initially, we did have 2 raters. However, a systematic error was found in one of the rater's ratings. Therefore, we decided to ask only 1 rater to rerate the entire dataset.

From the social interaction perspective, learners may benefit from observation of a peer as they reproduce and imitate actions and adjust errors. Furthermore, self-efficacy and motivation may improve. In this study, we used mainly objective measurements, such as logbook data to analyze training patterns. A qualitative analysis was made based on a questionnaire. Previous studies in computer-based learning found that high motivational score is correlated to higher scores in anatomical questions.28,29 In our study, dyad trainees reported on increased motivation, but no scores on motivation and fun were made. In addition to measuring clinical skills in different stages, it may also be relevant to measure when trainees perceive a task as difficult, how they interact, if they had fun, and how their motivation is affected in different stages of training. Qualitative methods such as interviews may provide deeper understanding of when and how dyad training is beneficial or not.

Collaborative learning may be more effective in the beginning of the learning process or when training complex tasks, where the cognitive load may be high. The effectiveness of collaborative learning, however, may decrease with time as the cognitive load decreases with practice and repetition. This is explained by reduction in hands-on time and the cost of communication that may outweigh the benefits of collaborative learning in the later stages of training.12 We only monitored participants' clinical skills before and after the course; hence, we were unable to establish if dyad training had an effect on the participants' skills at different points throughout the course. Cognitive load may have been high in the beginning of the course, and participants may have benefitted from dyad training in this stage. In future studies, it would therefore be interesting to explore the correlation between the effect of dyad training and cognitive load and whether the effect of dyad training decreases over time.

In the surgical setting, the patient safety relies on both the operator's surgical skills and cooperation between the surgeon, surgical assistant, nurses, and anesthesiologist. This has increased focus on training and assessment of both technical and nontechnical skills, such as teamwork and communication.30 Nontechnical skills may have improved in our intervention group as dyad training encourages communication and feedback. However, we only assessed technical skills in a simulated setting. An improvement in nontechnical skills would therefore not have been detected. In future studies, it would be interesting to explore whether dyad training leads to an improvement in transfer of skills to the operation room, including assessment of the interaction between the surgeon and the assistant in the operating room.


No differences were found between dyad trainees and individual trainees in improvement of basic surgical skills from pretest to posttest measured using the OSATS. However, during the 6-week course, dyad trainees trained fewer times but in a longer time interval compared with individual trainees. As a distributed training pattern is recommended when training motor skills, this may have had a negative impact on the effectiveness of training. Dyad trainees reported benefits, such as having a sparring partner, receiving feedback, corrections, increased motivation, as well as more structured training sessions and having fun. However, coordinating training sessions was difficult. Future studies should focus on clarifying how and when dyad training is effective, if dyad training of surgical skills may have an impact on nontechnical skills, and whether dyad training has effects on skills on real patients.


The authors thank Søren Grimstrup for statistical assistance. The authors also thank Ethicon, Surgical Care, and Johnson & Johnson for providing equipment (knot-tying station, suturing kit, and instruments) for the start-up of the course. The authors thank the Copenhagen Academy for Medical Education and Simulation for providing training facilities.


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collaborative learning; dyad training; off-site training; open surgery; self-regulated training; simulation training; peer teaching

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