In this study we investigated the feasibility of using a video-assisted 4-SA during student training and evaluated how it might affect the students’ performance in exams.
The objective test performance after the video-assisted 4-SA was similar to that after a conventional 4-SA and hence the video-assisted 4-SA did not improve the objective test performance. Our results are therefore similar to those of Sopka et al. who studied a media-assisted 4-SA for training basic life support (BLS) and showed that media-assisted 4-SA was equivalent to traditional 4-SA in teaching BLS .
The global performance assessed by the examiners was significantly improved by the use of the video-assisted 4-SA. Educational psychology might offer an explanation for this improvement in the global performance scores. Although favorable learning conditions had been created in both groups by the multiple repetitions, there was a change of media in the study group; from video in steps one and two to instructor in steps three and four. This has been shown to enhance knowledge acquisition .
Videos can be used to show moving images and spoken language and, in addition, a multitude of effects such as superimposed text, animation or slow-motion clips. An optimal observation point can be provided for all viewers so that important details become and remain visible. Even difficult-to-illustrate situations can thus be reproduced with the help of videos. In addition, the videos can be made available to the students before the begin of the course to promote a type of “blended learning” . In our study we used text overlays in the second step of the video-assistet 4-SA. Vester  was the first to describe the 4 different learning styles. According to Vester these include the auditive, the visual, the haptic and the intellectual learning type. In this regard, the visual learning type could benefit from changing the acoustic explanation in the control group to the visual overlay in the study group. On the other hand, there is no solid evidence to confirm Vester’s theorie of learning, which has been critiqued in the past .
Although there are some pedagogic arguments in favor of a 4-SA, no scientific study has shown an objective advantage of the method. Orde et al. compared the 4-SA to traditional two-step methods (2-SA; “see one, do one”) for teaching the insertion of a laryngeal mask airway. The 2-SA required less time and the performance of the participants was adequate . In another study, Greif et al., who compared the 4-SA and traditional teaching methods for teaching needle cricothyrotomy, came to similar conclusions. Leaving out steps two and three of the 4-SA did not result in a difference of the time required to complete a cricothyrotomy or the number of repetitions required before the participant considered himself adequatelytrained . Furthermore, Jenko et al. compared a 2-SA and a 4-SA for teaching chest compression and showed no difference in the results of the two teaching methods . However, in these three studies the skill that was taught and evaluated may be considered simple and one-dimensional, at least in the teaching model that was applied in the course [5, 6, 13]. Moreover, teaching the structured clinical care of a trauma patient is a complex process, and to our knowledge there are no studies comparing the 2-SA with the 4-SA in the teaching of complex skills.
The conventional 4-SA is not only time consuming and personnel-intensive but also requires well-qualified instructors to guarantee a consistent level of teaching quality independent of the person teaching. In our study, the teaching video has demonstrated the potential to markedly reduce personnel requirements without negatively affecting student performance compared to the 4-SA with two instructors. Importantly, the video-assisted 4-SA was able to reduce the personnel requirements for each one two-week module by a full one man-day, while simultaneously providing an identical presentation of the subject matter. This calculation is limited to our 4 SA with two instructors. Interestingly, the number of negative free-text comments in the evaluation diminished, and an increase in the number of positive comments on the module on trauma management was noted after our study began. In particular the differing presentation styles and priorities of individual instructors in steps one and two of the 4-SA, which were often criticized before starting the study, were standardized with the help of the videos. Moreover, the differences in the presentation styles in the control group were also reduced since the instructors began using the videos to prepare their own lessons as the videos were available to the faculty instructors before the study began to prepare for the course.
The subjective assessment of the students’ relative knowledge increase differed during the two study semesters. It is important to keep in mind that this subjective assessment depended partly on the extent of the participants’ prior knowledge, which was not determined before the course, and thus the resulting relative increase in knowledge must be interpreted with caution. Our study results offer no explanation for the differing results.
One shortcoming of our study is that there was no objective pre-evaluation determining the previous experience of the individual participants and that there was no longitudinal follow-up. Furthermore, we did not collect data for demographic differences between the study groups except for gender. This information potentially could have been useful in assessing the results of the relative increase in knowledge, and in detecting potential differences in the persistence of the imparted knowledge depending on the teaching method. A further limitation of the study was that due to organizational factors it was not possible to maintain the same interval between intervention (course) and data acquisition (OSCE).