1

Background

Orthopedic trauma is the fifth leading cause of death in the United States and the sixth worldwide. It is also the leading cause of death among the global population aged up to 45. Approximately 70 % of all trauma victims’ injuries are skeletal. Orthopedic trauma surgeries involve the use of advanced surgical systems and rely on professional, skilled trained operating room personnel (ORP) to provide uncompromising surgical care for all types of severe fractures and bony injuries. ORPs play a central role in trauma patient care management and have a significant influence on the effectiveness of the multidisciplinary team in an ever-evolving technological environment.

The unique educational program for training ORPs has been operated by AO – Arbeitsgemeinschaft für Osteosynthesefragen since 1963. Developed by an international teaching staff, the program is standardized worldwide, aiming to train personnel from across the globe in trauma care. A significant challenge faced was the implementation of the AO methodology uniformly across medical teams worldwide, particularly given the diverse linguistic, cultural, and local medical practice variations. The AOTrauma Operating Room Personnel (AOT ORP) courses address these challenges through various methodologies, with discussion groups serving as one of their key components.

Discussion groups and problem-solving, as participatory teaching methods that emphasize active student engagement, have demonstrated a 50 % knowledge retention rate. These group discussions are recognized as an innovative active learning approach due to their multisensory engagement characteristics.

Recent educational trends have promoted curricula emphasizingsmall group teaching methodologies. This approach is founded on medical scenarios and decision-making process, incorporating Problem Based Learning (PBL). ^, Small groups can engage in diverse tasks through various modalities, including problem-solving discussions, role play, and experience sharing. These group discussions effectively facilitate brainstorming while providing students opportunities to pose questions, exchange ideas, explore alternatives, and develop presentation skills among peers. The small group format focuses on treatment strategies, emphasizing skills crucial to enhancing the quality and safety of orthopedic patient care, including surgical environment preparation, equipment management, decision-making processes, potential complication awareness, and preventive measures. ^, This pedagogical approach has been demonstrated to enhance memory retention and promote advanced problem-solving capabilities.

The development of the program entailed establishing a universal basic course model, which encompassed designing practical workshops with bone model simulations, creating theoretical lectures, and developing scenario models for discussion groups. AOT ORP courses are conducted annually, with 72 courses held worldwide, including one in Israel, accommodating approximately 40 participants per course from various medical centers. Despite the substantial investment of resources and teaching efforts in these courses, a comprehensive evaluation of their effectiveness has not yet been conducted. This pioneering study will assess the impact of the AOT ORP course discussion groups on the clinical strategies and approaches adopted by nursing staff in orthopedic operating rooms. Furthermore, the study aims to determine the optimal methodologies for skill acquisition and implementation.

Research hypothesis: A significant correlation has been observed between participation in AOT ORP basic course group discussions, preceded by six-week “eLearning assessments”, completed beforehand, and enhanced care approaches and trauma patient management strategies implemented in orthopedic operating rooms.

2

Materials and methods

A prospective, empirical, quantitative, comparative study was conducted with a sample of 268 ORPs. The research group comprised147 AOT ORP basic course graduates from 2018 to 2019, distributed across three countries: Israel ( n = 72), Singapore ( n = 41), and England ( n = 34). The control group consisted of121 ORPs who were registered as future course participants, scheduled to attend after the completion ofthe study period.

This study examined the relationships between course index variables, group discussion skills, and their contribution to the clinical work of ORP, utilizing a standardized methodology across all groups. The primary research tool was an observational assessment of each discussion group, conducted with course participants before and after the educational intervention, and with the control group during the AO day. Comparative analyses were performed between the research and control groups, as well within the research group using pre- and post-course measurements. Additional comparative analyses were conducted among course participants from different countries.

Data were analyzed using Excel for initial coding and SPSS software for descriptive and inferential statistical analysis. The findings were presented through frequency distributions, means, and standard deviations of the variables. Independent samples t – test s were employed to compare study and control groups, while paired-samples t – tests evaluated pre- and post-education intervention outcomes acrossstudy groups (Israel, England, and Singapore). Independent t – tests were also utilizedfor questionnaire parameters. Multivariate analysis of variance (MANOVA) was conducted to examine relationships between questionnaire domains. Statistical significance was established at p < 0.05 for all analyses.

The observation tests used to assess the discussion groups comprised five components designed to evaluate how group participation influences the development of problem-solving approaches and trauma case management through clinical skills implementation in the operating room—while facilitating knowledge and experience sharing acquired during the course. Internal consistency reliability was assessed using Cronbach alpha before and after the educational intervention, yielding coefficientsof 0.94 and 0.93, respectively. The observation test demonstrated extremely high internal consistency with α = 0.95.

The inter-item correlations among the five indices of the observation test demonstrated highly significant Pearson correlation coefficients, confirming it’s construct validity. Discussion group quality was evaluated using a five-point Likert scale (1 = worst, 5 = very good), with higher scores indicating enhanced discussion quality. The discussion-group assessment index was computed by calculating the mean scores across all components.

The observation instrument, comprising five assessment components,evaluated the nature and quality of group discussions, to determine the course’s educational impact. The assessment examined five distinct competency indices: (1) orthopedic trauma management capabilities, (2) strategy development for polytrauma patient care, (3) orthopedic treatment protocol implementation, (4) participation in collaborative clinical decision-making discussions, and (5) application of newly acquired professional skills. To analyze differences in observation assessment outcomes, a paired-sample t-test were conducted.

Given the established reliability of the assessment instrument, data collection was conducted consistently across three countries (Israel, England, and Singapore) between 2018 and 2020 The observational assessment protocol consisted of two phases: an initial baseline assessment during the first discussion session, conducted without any staff intervention or guidance, followed by a post-discussion assessment where participants reconvened in a circular seating arrangement for a45-minute evaluation period.

The observation instrument on the discussion groups were conducted using standardized methodology across bothstudy and control groups in all three countries. The primary objective was to quantify changes in clinical skills related to trauma patient management among course participants compared to the control group. The observation instument evaluated the nature and quality and characteristics of small group discussions. To maintain methodological rigor and enable paired analysis, unique identification numbers were assigned to the assessment forms and systematically distributed to participants and evaluators, ensuring accurate matching of pre- and post-course data for study group participants.

The AOT ORP course includes four mandatory discussions on orthopedic trauma case management (with two optional discussions implemented according to country-specific requirements). Each discussion is conducted in small groups of maximum12 participants, facilitated by two instructors (a trauma-specialized orthopedic surgeon and an operating room personnel). he study utilized a dual assessment approach: the research group underwent pre- and post-intervention evaluations (initially during the first discussion prior to any course instruction, and again during the final course discussion), while the control group was assessed once during routine departmental trauma case discussions for comparative analysis. This methodology allowed evaluators to function as non-participating observers, enabling natural discussion flow without external guidance. Evaluators, selected from either the operating room nursing faculty AOT orthopedic surgeons completed required authorization documentation for study participation. Post-discussion, the evaluation team convened to analyze and process the collected data using standardized assessment forms with predetermined criteria to rate discussion quality across five indices for each group. This comprehensive assessment strategy enabled both longitudinal analysis of the research group’s progress and comparative analysis with the control group.

3

Results

A total of 268 ORPs from three countries (Israel, England and Singapore) were enrolled in this study between 2018 and 2019, with 121 of them serving as controls from Israel alone. Initially, means and standard deviations of five observational test indices were calculated for all groups before any intervention. The study group, which completed a six-week preparation of “eLearning assessments”, generally scored at a low-medium level, consistently surpassing the control group, which remained at a low level throughout ( Table 1 ).

To further investigate these differences, we compared the countries within the study group and found that Israel generally scored in the medium range. England and Singapore were at lower levels across all indices, though still slightly above the control group ( Table 1 ).

Next, we calculated pre- and post-course means and standard deviations for all study groups. The scores across the five observational indices showed significant improvement, increasing from the low-medium range (1.81–2.39, pre-course) to the medium-high range (2.90–3.89, post-course) following the intervention ( Table 1 ). This improvement is evidenced by the consistent increase in mean scores across all indices, with the study group’s post-intervention scores (ranging from 2.90 to 3.89) substantially higher than the control group’s scores (ranging from 1.26 to 1.72), as shown in Table 1 .

Subsequently, differences in group discussion performance among the three study groups were evaluated for statistical significance using independent samples t tests . Significant differences were found between the three countries ( Table 2 ), with Israel showing the highest mean scores both pre- ( M = 2.41, SD = 0.97) and post-intervention ( M = 3.69, SD = 0.74). Additionally, significant improvements were observed across the entire study sample ( n = 147, t =−24.93, p < 0.01), with substantial increases in mean scores from pre-intervention ( M = 2.08, SD = 0.86) to post-intervention ( M = 3.42, SD = 0.74), as demonstrated in Table 2 .

Table 2

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