• Ryan Brydges, Parvathy Nair, Irene Ma, David Shanks, and Rose Hatala.
• Department of Medicine, University of Toronto, Toronto and The Wilson Centre, University Health Network, Toronto, Ontario, Canada. ryan.brydges@utoronto.ca
• Med Educ. 2012 Jul 1;46(7):648-56.

ObjectivesSimulation training offers opportunities for unsupervised, self-regulated learning, yet little evidence is available to indicate the efficacy of this approach in the learning of procedural skills. We evaluated the effectiveness of directed self-regulated learning (DSRL) and instructor-regulated learning (IRL), respectively, for teaching lumbar puncture (LP) using simulation.MethodsWe randomly assigned internal medicine residents in postgraduate year 1 to either DSRL ('directed' to progress from easy to difficult LP simulators during self-regulated learning) or IRL (in groups of four led by an instructor). All participants practised for up to 50 minutes and completed a pre-test, post-test and delayed (by 3 months) retention test on the simulator. Pairs of blinded trained experts independently rated all videotaped performances using a validated global rating scale and a modified version of a validated checklist. Participants provided measures of LP experience and self-reported confidence. We analysed the pre-post (n = 42) and pre-post-retention performance scores (n = 23) using two separate repeated-measures analyses of variance (anovas) and computed Pearson correlation coefficients between participants' confidence and performance scores.ResultsInter-rater agreement was strong for both performance measures (intra-class correlation coefficient > 0.81). The groups achieved similar pre-test and post-test scores (p > 0.05) and scores in both groups improved significantly from the pre- to the post-test (p < 0.05). On retention, a significant interaction (F(2,42) = 3.92, p = 0.03) suggests the DSRL group maintained its post-test performance, whereas that in the IRL group dropped significantly (p < 0.05). Correlations between self-reported confidence and post-test performance were positive and significant for the DSRL group, and negative and non-significant for the IRL group.ConclusionsBoth IRL and DSRL led to improved LP performance immediately after practice. Whereas the IRL group's skills declined after 3 months, the DSRL group's performance was maintained, suggesting a potential long-term benefit of this training. Participants in the DSRL group also developed a more accurate relationship between confidence and competence following practice. Further research is needed to clarify the mechanisms of self-regulated learning and its role in simulation contexts.© Blackwell Publishing Ltd 2012.

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