Aseptic Technique Training Course Teaching

Practices Based on Mastery Learning

Binlin Luo
The First Affiliated Hospital With Nanjing Medical University
Qiang Ding
The First Affiliated Hospital With Nanjing Medical University
Liling Chen
The First Affiliated Hospital With Nanjing Medical University
Junjie Du

The First Affiliated Hospital With Nanjing Medical University

Xiaozhi Wang
The First Affiliated Hospital With Nanjing Medical University
Huanhuan Chen
The First Affiliated Hospital With Nanjing Medical University
Surong Jiang
The First Affiliated Hospital With Nanjing Medical University

Research Article

Keywords: Mastery Learning, Aseptic Technique, Interns, Course Instruction

Posted Date: March 19th, 2024

DOI: https://doi.org/10.21203/rs.3.rs-4106695/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.
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Additional Declarations: No competing interests reported.

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Abstract
This research aims to explore aseptic technique training course teaching practices based on mastery
learning in the field of medical education. Aseptic techniques are indispensable in health care services,
which makes it crucial to provide training for medical students to master these skills proficiently.
Traditional teaching methods have focused primarily on theoretical knowledge, whereas mastery learning
emphasizes student engagement, autonomous study, and practical application. In designing the course,
we first establish clear learning objectives and plans, breaking the content into a series of graduated
tasks and skills. Students progressively grasp the essentials of aseptic techniques through video
demonstrations, lecture explanations, and targeted deliberate practice until they meet the minimum
standards for passing the course. Timely feedback and peer assessment are highlighted in the course,
with students' progress being evaluated through on-site practical examinations to ensure that the learning
objectives of each stage are achieved. This comprehensive assessment method helps promptly identify
and correct issues in the learning process, thereby enhancing teaching outcomes. In summary, an aseptic
technique training course based on mastery learning provides medical students with an efficient and
systematic learning approach to enhancing their ability to apply aseptic techniques in real clinical
settings, thus improving the quality and safety of clinical operations.

1. Introduction
Within the medical education domain, the mastery of aseptic techniques is crucial for ensuring patient
safety and enhancing healthcare quality[1]. Aseptic technique errors can adversely impact the safety and
efficacy of medical procedures[2]. Medical students transitioning into clinical practice often encounter
challenges such as inadequate preparation of materials, improper arrangement of items on the operating
table, and incomplete skin disinfection during aseptic technique operations. With the evolution of medical
education methodologies, mastery learning has emerged as a vital approach to fostering key skills
among medical students[3, 4]. Mastery learning, which was conceptualized by the educational
psychologist Benjamin Bloom in the 1960s, posits that, given adequate time and appropriate teaching
methods, most students can genuinely master learning content[5, 6]. The notable features of this approach
include the use of feedback-correction mechanisms, the establishment of clear mastery standards,
emphasis on student autonomy, and regular assessment during the learning process to ensure current
content mastery[4, 5, 7].

In this context, we developed an aseptic technique training course based on mastery learning to align
with the course objective of "performing bedside aseptic operations correctly and independently." By
utilizing competency-based hybrid teaching models, the course aims to ensure that each student
proficiently masters the key steps of aseptic operations through continuous feedback, competency
benchmark assessment, comprehensive pre- and postteaching scale evaluations, and personalized
teaching support.

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2. Methods
2.1 Study Subjects: Twenty-nine interns from the first cohort of the combined bachelor's- master's-
doctorate degree program in clinical medicine (Tianyuan Class) at Nanjing Medical University, comprising
19 males and 10 females with an average age of 21 ± 1.76 years, were selected for the study. All training
and assessments were conducted at the Center for Simulation in Medical Education, Nanjing Medical
University. The interns had previously participated in traditional clinical skills training courses but had not
undergone aseptic technique training based on mastery learning.

2.2 Aseptic Technique Training Course Based on Mastery Learning: Before the course commenced, a
clinical operation self-confidence and psychological safety questionnaire was administered to all interns.
The key to mastery learning lies in assessing whether interns meet the requirements for clinical-facing
patient operations using a checklist. The mastery learning strategy employed in this course module is
outlined in Figure.1, including (1) baseline testing (pretest); (2) clear learning objectives; (3) simulation-
based teaching sessions (with prerecorded instructional videos); (4) effective assessment tools with
predefined minimum passing standards for passing (formulated through discussions by the senior
teaching team in the Department of Surgery); (5) strategies and forms for effective feedback (detailed
checklists and evaluation instructions), focusing on deliberate practice to meet passing standards; (6)
postcourse skill testing to assess mastery levels, followed by course refinement based on test results; and
(7) continued deliberate practice for interns who did not pass until they met the minimum standards for
passing. The checklists and assessment forms used in the study are illustrated in Figure.2, 3 and
Figure.4, 5.

2.3 Specific Implementation Process of the Course: Prerecorded instructional videos on the "Preparation
of Treatment Room Items" and "Preparation of Bedside Aseptic Operation Areas" were distributed to each
intern, who was required to study the content of the videos, self-assess knowledge points and erroneous
operations based on pretest data results, and learn how to correct and improve their performance. One
week later, teaching sessions were conducted by instructors at the well-equipped medical simulation
education center, where interns were organized into teams for practical operations, with deliberate
practice sessions added to the schedule. The instructors provided immediate feedback during the interns'
operations, while the interns engaged in peer monitoring and operation improvement. The setup for the
deliberate practice rooms was consistent with the testing conditions. Following the course, all interns
were surveyed again using questionnaires. Details of the survey questions can be found in Figure.6.

2.4 Data analysis: Statistical analyses were performed using SPSS 24.0 software. Continuous variables
conforming to normal distributions are expressed as the means ± standard deviations (χ ± s), and the t
test was used for intergroup comparisons. P < 0.05 was considered to indicate statistical significance.

3. Results
3.1 Research Subjects’ Pre-Training Status
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Despite having previously received traditional clinical skills training, 29 interns still encountered issues
with incorrect aseptic technique operations, such as improper unpacking of sterile packaging,
unfamiliarity with basic aseptic operation preparation procedures, lack of familiarity with sterile
instrument usage, and indifference toward aseptic operation concepts (Figure.7). A pretraining survey on
clinical operation confidence and psychological safety was conducted among the 29 interns, revealing
common psychological experiences such as "not knowing what to do," "feeling at a loss," and "fear of
making mistakes."

3.2 Pre-Test Results

Table.1 shows that there were varying degrees of issues among the 29 interns involved in aseptic
operations. Inadequate item preparation, incorrect opening of sterile packs, inability to place items
correctly in sterile areas, and incomplete skin disinfection were the most common operational problems.
The proportion of non-execution in hand sanitization operations reached 41.4%, while the error rate in
disinfecting operation area skin procedures was as high as 100%.
3.3 Post-Test Results
All 29 interns successfully completed the aseptic technique training course and completed the first post
test after self-assessing their learning goals. Table.2 shows that 23 interns passed the minimum
standard test without any difficulties. The six interns who did not meet the minimum standard underwent
another practice session, self-assessed their learning goals, and completed the second post test. Table.3
shows that all the interns passed the minimum standard assessment. Confidence assessments in clinical
aseptic operations were conducted before and after the interns participated in the aseptic technique
training course. Figure.8 shows a significant improvement in interns' confidence levels after completing
the aseptic technique training course based on mastery learning.
3.4 Course Feedback Evaluation
In the analysis of factors contributing to increased intern confidence, "ample practice" was considered the
most helpful in boosting confidence, with approximately 39.1% (9 individuals) of students stating that
they gained confidence from this factor. The next most common theme was "instructional videos," with
approximately 34.8% (8 individuals) stating that it helped build confidence. In contrast, "teacher
feedback" and "pretest experiences" had smaller impacts on confidence enhancement. Only 13% of the
students (3 individuals) indicated that "teacher feedback" positively influenced their confidence, while
only approximately 8.7% of the students (2 individuals) believed that "pretest experiences" enhanced their
confidence. These data suggest that in this simulated course, the impact of practical exercises and
instructional videos on student confidence is more significant than that of teacher feedback and prior
testing experience.

4. Discussion

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In modern medical education, strategies are shifting toward outcome-oriented models, with the objective
of cultivating medical professionals with high clinical competence[8]. This transition is supported by
policy documents such as the State Council's Opinion on Deepening Medical Education Collaboration
and Further Promoting Medical Education Reform and Development, which emphasizes the importance
of deepening medical education system reform and specifies the requirements for improving medical
students' ability to solve practical clinical problems. Faced with this challenge, a consensus is emerging
in contemporary medical education: it is crucial to introduce medical students to clinical practice earlier
and to do so more efficiently[9, 10]. The transition from basic theoretical learning to clinical apprenticeship
marks a shift in medical identity, which for students is often rapid, challenging, and may even involve a
loss of direction[11, 12]. However, the optimal timing for medical students to start clinical exposure and the
most effective methods to use to learn and improve clinical skills remain unanswered questions[13].
Various medical schools are exploring solutions through practical experience, but there is still a lack of
sufficient scientific research support in this field.

Nanjing Medical University's integrated clinical medicine program (Tianyuan Class) is designed for
students with exceptional learning and comprehension abilities in clinical specialties. However, as
indicated by the pretest results, even Tianyuan Class students exhibit various errors when facing complex
real clinical scenarios and issues with aseptic technique operations. Using Tianyuan Class students as
research subjects, this study designed a simulated course module content and teaching plan titled "Basic
Aseptic Operation Pass-through Practice" to explore the construction of a mastery learning course based
on simulation, focusing on addressing the "transition crisis" between the early clinical learning stage and
the clinical training stage for medical students. The results of two posttests showed that the aseptic
technique training course based on mastery learning enabled all 29 interns to master the aseptic
technique training.

Mastery learning is an educational strategy of which the ultimate goal is to ensure that all learners
achieve the same level of skill mastery, not only reaching the allowable competency level within the set
training time but also involving repeated deliberate practice until all learners reach the predetermined
competency level (with the addition of requirements regarding the minimum standard for passing)[3, 14].
In mastery learning, continuous feedback and assessment are crucial for interns to understand and
correct errors[15]. Teachers provide timely, specific feedback to help interns understand areas in which
they excel and those in which they need improvement. Incorporating techniques such as video
demonstrations and simulation training into the course helps interns better understand and simulate
aseptic technique operations, ensuring that each intern has sufficient practical opportunities to apply the
knowledge learned in actual clinical practice. Additionally, by analyzing real cases and conducting
scenario simulations, teachers can enable interns to apply theoretical knowledge to practice and
understand the importance and application of aseptic techniques in actual clinical settings. Furthermore,
teamwork plays an important role in aseptic technique learning. Through group discussions and peer
assessments, knowledge and skills are shared, allowing interns not only to learn from others but also to

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practice communication and collaboration skills in a team environment, which are crucial for successful
teamwork in future clinical settings.

This course module emphasizes the application of mastery learning in aseptic technique training, which
means that teaching should focus not only on imparting theoretical knowledge but also on practical skill
development. Teachers should design step-by-step learning modules to ensure that each intern fully
masters each step before proceeding to the next learning stage. Furthermore, this course module is low-
cost, easy to replicate, and effective, providing a bridge for medical students from the early clinical
learning stage to the clinical training stage. This module can be adapted to many different groups of
medical students, serve as a prerequisite for other medical simulation education modules that require
correct use of aseptic techniques, and it can also be used in residency training programs to help interns
transition to the resident stage and adapt to new environments.

The aseptic technique training course based on mastery learning mainly demonstrates the following
effects: (1) enhancing students' grasp of aseptic concept: after adopting teaching practices based on
mastery learning, repeated stimulation and feedback in the process of deliberate practice quickly
transform students' theoretical understanding of aseptic principles into a framework that may be applied
to practical thinking; (2) deepening students’ understanding of aseptic principles: as a basic norm for
surgical operations, aseptic principles pervade every clinical scenario, and simulating actual clinical
environments helps students understand theoretical knowledge; and (3) increasing classroom interest
and cultivating a habit of active inquiry: traditional teaching is often rigid and dull, involving low levels of
student interest and shallow memorization processes, while this teaching method reduces the distance
between teachers and students, attracting student attention, stimulating the desire for active inquiry,
encouraging active thinking and problem solving in the interactive process, and cultivating the ability for
autonomous learning.

5. Conclusion
The aseptic technique training course based on mastery learning integrates various teaching methods
and strategies, focusing more on each student's learning process and depth of understanding, thus
adapting to the individual differences and learning needs of students, rather than simply facilitating
students to complete the course content. Moreover, by employing step-by-step learning processes,
personalized pathways and continuous feedback and assessment can be provided.

Declarations
Author Contribution
BL Luo. Q Ding. and XZ Wang. HH Chen. wrote the main manuscript text and SR Jiang. LL Chen. JJ Du.
prepared figures 1-3. All authors reviewed the manuscript. BL Luo and Qiang Ding contributed equally to
this paper.

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Tables
Table.1 Pre-Internship Assessment Results

Assessment Item Not Performed Performed Performed Correctly

n(%) Incorrectly n(%) n(%)

Wearing Mask and Cap 1 (3.4) 4 (13.8) 24 (82.8)

Hand Sanitization 12 (41.4) 4 (13.8) 13 (44.8)

Verifying Patient Information and 2 (6.9) 2 (6.9) 25 (86.2)

Site

Preparing Items 1 (3.4) 28 (96.6) 0

Opening Sterile Packs 1 (3.4) 22 (75.9) 6 (20.7)

Placing Items in Sterile Area 1 (3.4) 28 (96.6) 0

Resanitizing Hands, Wearing 2 (6.9) 25 (86.2) 2 (6.9)

Sterile Gloves

Disinfecting Operation Area Skin 0 29 (100.0) 0

Laying Sterile Towel 1 (3.4) 10 (34.5) 18 (62.1)

Table.2 First Post-Internship Assessment

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 Assessment Item Not Performed Performed Performed Correctly
n(%) Incorrectly n(%) n(%)

Wearing Mask and Cap 2 (6.9) 1 (3.4) 26 (89.7)

Hand Sanitization 0 0 29 (100)

Verifying Patient Information and 0 0 29 (100)

Site

Preparing Items 1 (3.4) 0 28 (96.6)

Opening Sterile Packs 0 2 (6.9) 27 (93.1)

Placing Items in Sterile Area 0 2 (6.9) 27 (93.1)

Resanitizing Hands, Wearing 0 4 (13.8) 25 (86.2)

Sterile Gloves

Disinfecting Operation Area Skin 0 10 (34.5) 19 (65.5)

Laying Sterile Towel 0 1 (3.4) 28 (96.6)

Table.3 Second Post-Internship Assessment

Assessment Item Intern Intern Intern Intern Intern Intern

1 2 3 4 5 6

Wearing Mask and Cap 0 2 2 2 2 0

Hand Sanitization 2 2 2 2 2 2

Verifying Patient Information and Site 2 2 2 2 2 2

Preparing Items 2 2 0 2 2 2

Opening Sterile Packs 2 1 2 1 2 2

Placing Items in Sterile Area 2 2 2 1 1 2

Resanitizing Hands, Wearing Sterile 1 2 1 1 1 2

Gloves

Disinfecting Operation Area Skin 2 1 1 1 1 1

Laying Sterile Towel 2 2 2 1 1 2

Pass/Fail Status Fail Fail Fail Fail Fail Fail

Note: 0 indicates not performed; 1 indicates performed incorrectly; 2 indicates performed correctly.

Figures
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Figure 1

Course Process of Applying Mastery Learning, Emphasizing Deliberate Practice and Minimum Standards
for Passing

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Figure 2

Mastery Learning Checklist-Bedside Sterile Area Preparation Mastery Learning Checklist

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Figure 3

Mastery Learning Checklist-Checklist for Mastery Learning of Bedside Sterile Operating Area Preparation
Guidelines for Completion

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Figure 4

Student Confidence Assessment Scale-Simulation Skill Training Experience Questionnaire (Pre-Test)

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Figure 5

Student Confidence Assessment Scale-Simulation Skill Training Experience Questionnaire (Post-Test)

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Figure 6

Course Implementation Process

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Figure 7

Common Errors in Medical Skills Knowledge

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Figure 8

Student Confidence Assessment Results

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