Application of a modified Peyton's four-step approach in clinical skills training for residents: a randomized controlled trial

ERCT Criteria Breakdown

• Level 1 Criteria

  • C

    Class-level RCT

    • Randomisation was performed at the individual resident level using SPSS, not at the class or school level, and the intervention is group-based teaching rather than one-to-one tutoring.
    • "One hundred and twenty residents were selected and randomly divided into an experimental group (n=60) and a control group (n=60)."
    • Relevant Quotes: 1) "One hundred and twenty residents were selected and randomly divided into an experimental group (n=60) and a control group (n=60)." (Abstract, p. 2) 2) "This study employed a prospective, single-center, randomized controlled design." (Methods, p. 5) 3) "Simple randomization was performed using SPSS software. Allocation concealment was achieved through the sealed envelope method..." (p. 7) 4) "The 60 residents in the control group were randomly and equally divided into 4 subgroups." (p. 5) and "The 60 residents in the experimental group were randomly and equally divided into 4 subgroups." (p. 6) Detailed Analysis: The ERCT 'C' criterion requires randomisation at the class level (or stronger school level), unless the intervention is one-to-one/personal tutoring, in which case student-level randomisation is acceptable. Here the unit of randomisation was the individual resident physician: 120 residents were individually randomised into two arms via simple SPSS randomisation, and each arm was then further split into subgroups. This is student-level allocation, which risks the contamination the criterion is designed to prevent (residents in the two arms are drawn from the same training programme). The intervention is a group/classroom teaching method (peer learning, video), not personal tutoring, so the tutoring exception does not apply. Criterion C is not met because randomisation was carried out at the individual resident level, not at the class or school level, and no tutoring exception applies.
  • E

    Exam-based Assessment

    • Outcomes were measured with a study-specific 11-item OSCE checklist aligned to the training syllabus, not a widely recognised standardised external exam.
    • "A 100-point scoring system aligned with the training syllabus was used for evaluation."
    • Relevant Quotes: 1) "Teaching outcomes were evaluated by assessing residents' clinical skills through objective structured clinical examinations (OSCEs)..." (Abstract, p. 2) 2) "The assessment consisted of 11 items: proper preparation of materials, aseptic technique, correct disinfection area, appropriate number of disinfection passes, proper handling of forceps, correct transfer of items, accurate cutting of sutures, proper traction on suture ends, appropriate application of dressings, correct disposal of waste materials, and adequate patient instruction. A 100-point scoring system aligned with the training syllabus was used for evaluation." (p. 8) 3) "Two consistent examiners (physicians with senior professional titles) scored all participants using the same standardized criteria." (p. 8) Detailed Analysis: Criterion E requires a standardised, widely recognised exam that was not custom-built for the study. Although the assessment is described as an OSCE (a recognised assessment format) and used "standardized criteria" applied consistently, the instrument itself is a bespoke 11-item checklist with a 100-point scale "aligned with the training syllabus" of this specific programme. It is not a named, externally validated, nationally or internationally recognised standardised examination; it was assembled by the researchers for this study and is tightly aligned to the intervention content. This is exactly the type of study-specific measure the criterion excludes. Criterion E is not met because the outcome measure is a custom, syllabus-aligned checklist rather than a recognised standardised exam.
  • T

    Term Duration

    • The final outcome was measured only one month after a very short training session, which is shorter than one full academic term.
    • "Residents from both groups were assessed on wound dressing and suture removal skills before the training, immediately after, and one month after the intervention."
    • Relevant Quotes: 1) "Residents from both groups were assessed on wound dressing and suture removal skills before the training, immediately after, and one month after the intervention." (p. 8) 2) "One month after the training, a satisfaction questionnaire on the teaching effectiveness was administered to both groups." (p. 8) 3) "The experimental group demonstrated a significantly shorter training time, with a mean of 125 minutes (SD = 12.9 minutes), compared to 200 minutes (SD = 21.6 minutes) in the control group..." (p. 12) Detailed Analysis: Criterion T requires that outcomes be measured at least one full academic term (approximately 3-4 months) after the intervention begins; short interventions are allowed but only with at least term-long follow-up tracking. In this study the training itself lasted only a matter of hours (about 125-200 minutes per arm), and the latest outcome measurement was at the one-month follow-up. One month from intervention start to the final measurement is well short of a full term. Criterion T is not met because the longest interval from intervention start to outcome measurement was only one month, which is shorter than one academic term.
  • D

    Documented Control Group

    • The control group is clearly documented with baseline demographics, sample size, baseline scores, and the traditional teaching it received.
    • "As shown in Table 2, there were no statistically significant differences between the two groups in terms of demographic characteristics, years of residency training, educational background, residency specialty, or surgical clinical experience."
    • Relevant Quotes: 1) "The 60 residents in the control group were randomly and equally divided into 4 subgroups. Instructors used the traditional Peyton's Four-Step Teaching Approach to train the four subgroups in wound dressing and suture removal skills in batches." (p. 5) 2) "As shown in Table 2, there were no statistically significant differences between the two groups in terms of demographic characteristics, years of residency training, educational background, residency specialty, or surgical clinical experience." (p. 9) 3) Table 2 reports the control group's gender (Male 34 (56.7%), Female 26 (43.3%)), age (25.9 +/- 1.57), residency duration, degree, specialty, and surgical clinical experience. (p. 10) 4) Table 4 reports control-group baseline (pre-course) score 54.23 +/- 5.56 alongside the experimental group 53.97 +/- 7.08. (p. 12) Detailed Analysis: Criterion D requires the control group to be well documented, including demographics, baseline performance, and the conditions it experienced. The paper provides a dedicated control column in Table 2 with full baseline demographic and background characteristics, states the group size (n=60), describes that the control group received the traditional Peyton four-step training in the same skills, and reports control-group baseline OSCE scores in Table 4. This allows readers to confirm baseline comparability. Criterion D is met because the control group's demographics, size, baseline scores, and treatment are clearly documented.

• Level 2 Criteria

  • S

    School-level RCT

    • This is a single-center trial with randomisation at the individual resident level, not at the school or institution level.
    • "This study employed a prospective, single-center, randomized controlled design."
    • Relevant Quotes: 1) "This study employed a prospective, single-center, randomized controlled design." (p. 5) 2) "One hundred and twenty residents were selected and randomly divided into an experimental group (n=60) and a control group (n=60)." (Abstract, p. 2) 3) "Simple randomization was performed using SPSS software." (p. 7) Detailed Analysis: Criterion S requires randomisation at the school (institution/implementing unit) level. This trial was conducted at a single centre (The First Affiliated Hospital of Yangtze University, Jingzhou), and randomisation occurred at the level of individual residents, not schools or institutions. No multiple schools/sites were randomised. Criterion S is not met because randomisation was at the individual level within a single institution, not at the school level.
  • I

    Independent Conduct

    • Although outcome scorers and the statistician were blinded and external to the team, the authors who designed the modified method also implemented the trial and performed the analysis and conclusions.
    • "All outcome assessments were performed independently by physicians not involved in the research team."
    • Relevant Quotes: 1) "Outcome assessors and the statistician were blinded to group assignment. Due to the nature of the interventions, neither the instructors nor the resident participants could be blinded to the teaching method used." (p. 7-8) 2) "All outcome assessments were performed independently by physicians not involved in the research team." (p. 8) 3) "To address these shortcomings, this study innovatively incorporates structured peer-assisted learning and a video recording component into the foundational Peyton's four-step model." (p. 4) 4) Author contributions: "B.-Y. Liu and S.-F. Xiang: Conceptualization, data curation, and manuscript writing; J.-J. Xiang and B.-L. Xiao: Statistical analysis and data interpretation; Y.-M. Sun and Y. Ren: Study design and critical revision of the manuscript." (p. 15) Detailed Analysis: Criterion I requires the study to be conducted independently from the authors who designed the intervention, to reduce bias in implementation, analysis and reporting. There is a genuine element of independence here: the outcome (OSCE) assessments were performed by physicians not involved in the research team, and the outcome assessors and statistician were blinded to allocation, which reduces measurement bias. However, the modified teaching method was designed by the authors, and the same author team conceived the study, curated the data, performed the statistical analysis and data interpretation, and formulated the conclusions. Unlike the standard's examples (where the intervention provider/developer did not participate in data collection, analysis or conclusions, or where the trial was led by an independent body such as a government), here the intervention designers led the overall conduct, analysis and interpretation. Blinded independent scoring alone does not establish independent conduct of the study as a whole. Criterion I is not met because the intervention designers themselves designed, ran, analysed and interpreted the trial, with only the outcome scoring delegated to blinded external assessors.
  • Y

    Year Duration

    • Follow-up lasted only one month, far short of 75% of an academic year, and the prerequisite term-duration criterion T is not met.
    • "One month after the training, a satisfaction questionnaire on the teaching effectiveness was administered to both groups."
    • Relevant Quotes: 1) "Residents from both groups were assessed on wound dressing and suture removal skills before the training, immediately after, and one month after the intervention." (p. 8) 2) "At 1-month post-training, a clinical skills assessment and a teaching satisfaction questionnaire were administered to trainees in both groups." (p. 8) Detailed Analysis: Criterion Y requires outcomes to be measured at least 75% of a full academic year (roughly 7 months or more) after the intervention begins, and it is conditional on criterion T being met. The maximum follow-up here was one month after a short training session, which is far below a year, and criterion T (term duration) was already not met. Per the standard, if T is not met, Y is not met. Criterion Y is not met because tracking lasted only one month, nowhere near a full academic year, and the prerequisite T is not satisfied.
  • B

    Balanced Control Group

    • Both arms received training in the same skills with no extra time or budget given to the intervention group (which in fact used less instructor time), and the added video/peer components are integral to the method tested.
    • "The experimental group demonstrated a significantly shorter training time, with a mean of 125 minutes (SD = 12.9 minutes), compared to 200 minutes (SD = 21.6 minutes) in the control group (P < 0.001)."
    • Relevant Quotes: 1) "The experimental group received training using the modified Peyton's four-step approach, while the control group received training using the traditional Peyton's four-step approach." (Abstract, p. 2) 2) "There was a significant difference in training time between the two groups. The experimental group demonstrated a significantly shorter training time, with a mean of 125 minutes (SD = 12.9 minutes), compared to 200 minutes (SD = 21.6 minutes) in the control group (P < 0.001; Fig 3)." (p. 12) 3) "To address these shortcomings, this study innovatively incorporates structured peer-assisted learning and a video recording component into the foundational Peyton's four-step model. This modified approach not only reduces direct instruction time..." (p. 4) Detailed Analysis: Criterion B asks whether the intervention and control conditions received comparable time, budget and resources, so that any effect can be attributed to the intervention itself rather than to extra inputs. Here both groups received training on the same two skills (wound dressing and suture removal) using the same core four-step framework. The modification consists of restructuring (peer learning, mutual supervision, centralised feedback) plus a smartphone video-recording component; these are integral, defining features of the teaching method being tested, not separable add-on resources. Crucially, the intervention group did NOT receive extra instructional time or budget - it actually used substantially LESS instructor time (125 vs 200 minutes). There is therefore no unmatched extra time/budget advantage for the experimental group; if anything the control group received more direct instruction time. Applying the decision tree: no extra time/budget was given to the intervention group, and the distinguishing components are integral to the method being tested, so the balance requirement is satisfied. Criterion B is met because the intervention added no unmatched time or budget (using less instructor time than the control), and the peer-learning and video-recording elements are integral to the teaching method under evaluation.

• Level 3 Criteria

  • R

    Reproduced

    • This specific modified-Peyton wound-dressing/suture study has not been independently replicated; cited related studies are prior work in different contexts, not replications of this trial.
    • "In recent years, some scholars have introduced and modified the Peyton teaching approach, achieving favorable educational outcomes [3-7]."
    • Relevant Quotes: 1) "In recent years, some scholars have introduced and modified the Peyton teaching approach, achieving favorable educational outcomes [3-7]." (p. 3-4) 2) References [3-7] cover different modifications and contexts (e.g., endotracheal intubation, maternal ACLS, newborn life support, echocardiography, video-based surgical skills) by other author teams, cited as prior literature rather than replications of this study. (pp. 16-17) Detailed Analysis: Criterion R requires that this specific study (its central design and claim) be independently replicated by a different team in a different context and published in a peer-reviewed journal. The paper cites earlier related modified-Peyton studies as background, but these are antecedent works in other clinical domains, not replications of this particular trial (modified Peyton with peer learning and video recording for wound dressing and suture removal in residents). An internet search (Google Scholar, PubMed, Springer/BMC) conducted on 2026-07-10 identified numerous other Peyton and modified-Peyton trials by other teams (e.g., flipped- classroom ultrasound zoning, video-modified spinal/ neurological examination, surgical suturing with PDCA), but none replicate this specific study; this paper is a 2026 article in press and no independent reproduction was found. Criterion R is not met because there is no independent peer-reviewed replication of this specific study; the cited works are prior, different studies and no reproduction was located online.
  • A

    All-subject Exams

    • Only a single skills domain (wound dressing and suture removal) was assessed, and criterion E is not met, so the all-subject exam requirement cannot be satisfied.
    • "Residents from both groups were assessed on wound dressing and suture removal skills..."
    • Relevant Quotes: 1) "Residents from both groups were assessed on wound dressing and suture removal skills before the training, immediately after, and one month after the intervention." (p. 8) 2) "A 100-point scoring system aligned with the training syllabus was used for evaluation." (p. 8) Detailed Analysis: Criterion A requires that all main subjects be measured using standardised exam-based assessments, and it is conditional on criterion E being met. The study assessed only one narrow skills domain (wound dressing and suture removal) via a custom checklist, and did not assess other subjects. Furthermore, criterion E (standardised exam) was not met, which by rule means criterion A also cannot be met. Criterion A is not met because only a single skill domain was assessed with a non-standardised instrument, and the prerequisite criterion E is not satisfied.
  • G

    Graduation Tracking

    • Participants were tracked only to one month post-training with no graduation follow-up, and the prerequisite year-duration criterion Y is not met.
    • "At 1-month post-training, a clinical skills assessment and a teaching satisfaction questionnaire were administered to trainees in both groups."
    • Relevant Quotes: 1) "At 1-month post-training, a clinical skills assessment and a teaching satisfaction questionnaire were administered to trainees in both groups." (p. 8) 2) "Although the sample size met the statistical requirements, large-scale, multicenter, and long-term studies are still needed to further validate the generalizability of our findings." (p. 14) Detailed Analysis: Criterion G requires tracking participants through to graduation from their educational stage, and it is conditional on criterion Y being met. This study tracked residents only to the one-month follow-up and the authors themselves note that long-term studies are still needed. There is no graduation or end-of-residency tracking, and the prerequisite Y is not met. An internet search on 2026-07-10 for subsequent or follow-up publications by the same author team (Liu, Xiang, Xiao, Sun, Ren) tracking this cohort to graduation found no such papers. Criterion G is not met because follow-up stopped at one month with no graduation tracking, no follow-up publication was found, and the prerequisite criterion Y is not satisfied.
  • P

    Pre-Registered

    • No pre-registration is reported; the paper explicitly states the clinical trial number is not applicable, with only ethics-board approval described.
    • "Clinical trial number: Not applicable."
    • Relevant Quotes: 1) "Clinical trial number: Not applicable." (p. 16) 2) "The protocol was approved by the hospital's Ethical Review Board." (p. 5) 3) "This study obtained ethical approval from the Institutional Review Board of Jingzhou First People's Hospital (Approval Code: KY202321)." (p. 16) Detailed Analysis: Criterion P requires the full study protocol to be pre-registered on a public registry before data collection begins, with hypotheses and analysis plans. The paper provides only ethics-committee approval, which is not a pre-registration, and explicitly states that a clinical trial number is "Not applicable." No registry platform, registration ID, or registration date is given, so there is no registry entry to verify. Criterion P is not met because there is no public pre-registration of the protocol; only ethics approval is reported and the clinical trial number is stated as not applicable.