Clarity Of Instructions Research Articles

Instructional Clarity and Organization: It's Not New or Fancy, But It Matters

In higher education, it is sometimes hard to ignore the one-two doom and gloom combination of shrinking budgets and expanding accountability. But we are also in the midst of an exciting conversatio...

Cataloguing, a necessary evil: critical aspects of RDA

The Toolkit designed by the RDA Steering Committee makes Resource Description and Access available on the web, together with other useful documents (workflows, mappings, etc.). Reading, learning and memorizing are interconnected, and a working tool should make these activities faster and easier to perform. Some issues arise while verifying the real easiness of use and learning of the tool. The practical and formal requirements for a cataloguing code include plain language, ease of memorisation, clarity of instructions, familiarity for users, predictability and reproducibility of solutions, and general usability. From a formal point of view, the RDA text does not appear to be conceived for an uninterrupted reading, but just for reading of few paragraphs for temporary catalographic needs. From a content point of view, having a syndetic view of the description of a resource is rather difficult: catalographic details are scattered and their re-organization is not easy. The visualisation and logical organisation in the Toolkit could be improved: the table of contents occupies a sizable portion of the screen and resizing or hiding it is not easy; the indentation leaves little space to the words; inhomogeneous font styles (italic and bold) and poor contrast between background and text colours make reading not easy; simultaneous visualization of two or more parts of the text is not allowed; and Toolkit’s icons are less intuitive than expected. In the conclusion, some suggestions on how to improve the Toolkit’s aspects and usability are provided.

Optimizing EFL Learners’ Sensitizing Reading Skill: Development of Local Content-Based Textbook

<p>The development of local wisdom based sensitizing reading material is aimed at penetrating one of the imperishable gaps between authentic and non-authentic reading materials dispute in an EFL teaching context. Promoting EFL learners’ needs for the first semester students of English department at university level, who rarely or even never have a direct contact with native speakers, with meaningful and contextual reading textbook in an EFL setting is worth contributing. This study utilizes research and development paradigm within four stages, namely planning, development, try-out, and textbook revision. The textbook development resulted fifteen chapters containing fifteen local reading passages from various famous local tourism objects, famous public figures, cultures, traditional cuisines, and music. Each chapter encompasses eight exercises generated from the reading text itself with approximately from 400 to 600 words. Those exercises cover picture reading preview and identification, lexical sets, collocation and formation, literal, interpretive, and critical comprehension, and networking activity through interview and writing activity beyond the text. The average result of textbook validation from reading experts, English practitioners, and learners revealed the average score was 3.76 within the interval 1 to 4 and it was sorted out into ‘good’ category. Further, revisions toward grammatical error, diction, instruction clarity and picture lay out were also addressed and refined. As the textbook effectiveness toward the improvement of learners’ reading comprehension is not measured yet, so an experimental study is welcome for further research to address the issue of textbook effectiveness.</p>

From discharge to readmission: Understanding the process from the patient perspective.

Patient engagement is critical in delivering high-quality care. However, literature investigating patient perspectives on readmissions is lacking. To understand patients' beliefs and attitudes about 30-day readmissions and to elucidate areas for improvement aimed at reducing readmissions. In person survey. Academic medical center and affiliated community hospital. Patients with 30-day readmissions to medicine and cardiology services. Patient readiness, attitudes toward readmissions, discharge instructions, ambulatory resources, and follow-up care. Of 479 eligible patients approached for interviews, 230 (48%) were interviewed. Of these, 28% reported not feeling ready for discharge, and this correlated with inadequate symptom resolution, poor pain control, and concerns about self-care. Sixty-five percent remembered reviewing discharge paperwork, but over 22% could not identify critical information on this paperwork. Eighty-five percent reported having a primary doctor; however, only 56% of patients who received a contact number on discharge called a physician before returning to the hospital. One-third of patients knew where to obtain same-day care outside of the emergency room. Lastly, patients reported feeling more relieved than burdened upon readmission (7.7 [standard deviation {SD} 2.8) vs 5.9 [SD 3.4]; P < 0.001, scale of 1-10). By engaging readmitted patients we have illuminated areas for future interventions, including better symptom management and self-care planning before discharge, more clarity in discharge instructions, promoting awareness of outpatient resources, and improved alignment of patient and provider attitudes about readmissions. As the United States strives to reduce readmissions, attending to the patient perspective is critical in informing appropriate avenues for quality improvement. Journal of Hospital Medicine 2016;11:407-412. © 2016 Society of Hospital Medicine.

30 : 2: A Game Designed to Promote the Cardiopulmonary Resuscitation Protocol

Cardiopulmonary resuscitation (CPR) is a first-aid key survival technique used to stimulate breathing and keep blood flowing to the heart. Its effective administration can significantly increase the survival chances of cardiac arrest victims. We propose 30 : 2, a videogame designed to introduce the main steps of the CPR protocol. It is not intended for certification and training purpose. Driven by the 2010 European Resuscitation Council guidelines we have designed a game composed of eight mini games corresponding to the main steps of the protocol. The player acts as a helper and has to solve a different challenge. We present a detailed description of the game creation process presenting the requirements, the design decisions, and the implementation details. In addition, we present some first impressions of our testing users (25 children, five of each age from 8 to 12 years old and 12 males and 13 females). We evaluated clarity of instructions and three settings of the game: the aesthetics of scenarios, the playability, and the enjoyability of each mini game. All games were well punctuated, and there are no significantly differences between their sex. The proposed game can be a suitable tool to disseminate and promote CPR knowledge.

From ESA to ESCAPE: A conceptual model for teaching English in vocational higher education

The study develops a modified model generating a procedural guide in lesson planning construction for teaching English within the Vocational Higher Education (VHE). The work elaborates six essential elements in constructing ELT lesson plan, they are: engage, study, create, activate, practice, and evaluate, and it is so-called ESCAPE. Each element of the model represents pedagogical theories and practical approaches that constitute a guided direction and/or instruction for the construction of a practice-based teaching lesson plan. The study employed Research and Development (R&D) design through a focus group discussion (FGD) involving three experts specializing on ELT methodology, English course material development, and English curriculum development. A RASCH measurement analysis using WINSTEP and Factor Analysis using SPSS were employed in the study. The work suggests this modified model to be used in VHE and recommends further development on pedagogical theories underpinning each element, clarity of instructions, and method of implementation. Some limitations to this model were also identified.

A microanalysis of the clarity of information in physicians’ and patients’ discussions of treatment plans with and without language barriers

ObjectivePhysicians and patients discuss treatment plans. If tasks within plans are not described adequately, patients cannot adhere. We evaluated task descriptions, testing whether patient engagement and language barriers affected task clarity. MethodWe sampled 12 videotaped hospital interactions from a corpus of 497: two encounters each from six hospital physicians, interacting with one native-speaking and one non-native-speaking patient. We used microanalysis of face-to-face dialogue to assess whether the physicians and patients achieved a complete, clear description of each task’s three core information elements (who should do what and when). ResultsWe conducted detailed analysis on 78 of the 90 tasks. Core information elements were complete in 62 (0.79) and clear in 37 (0.47). Language barriers had no effect on task clarity. When native-speaking patients were engaged, tasks were clearer (p<0.05). Although non-native-speaking patients were significantly more engaged (p<0.01), their engagement had no effect. ConclusionPhysicians may be pursuing patients’ agreement, motivation, and commitment at the expense of working with the patient to be clear about what needs to be done. Practice implicationsPhysicians need to improve how clearly they present basic task information. Previous research demonstrated that even a short course can significantly improve the clarity of instructions.

Functional relevance of students’ prior knowledge and situational uncertainty during verbal interactions in vocational classrooms: evidence from a mixed-methods study

Descriptive accounts of instruction in German vocational schools consistently indicate whole-class dialogue to be prevalent. We aim to extend previous research by elucidating pedagogically valuable dialogic practices that facilitate conceptual understanding, and by empirically investigating factors that promote or hinder student engagement in these practices. We focus on prior knowledge in the domain discussed, because knowledge differences count among the prime sources of heterogeneity among vocational students in Germany. However, with survey studies suggesting a decisive role of communication apprehension, we also intend to explore if feelings of uncertainty in ongoing verbal interactions moderate the knowledge–engagement relationship, while controlling for potential confounding and competing influences. The study employs a longitudinal, multi-method design. It combines video recordings of nine consecutive lessons about Economic Business Processes in two classes, preceding tests on intellectual abilities and economic literacy, questionnaire reports of teacher–student relations and instructional clarity, and Continuous State Sampling during instructional activities. Interactional features were classified by applying a fine-grained category system that distinguishes coordinating gestures as well as types and qualities of dialogic exchanges. Hierarchical regression analyses provide some evidence that getting opportunities to engage in valuable components of classroom dialogue depend on domain-specific prior knowledge. Differential teacher treatment exists in cold calling strategies and demanding follow-up techniques, even after controlling for students’ gender. Moderated regressions for effects of prior knowledge and situational uncertainty on students’ communicative behaviours indicate that advanced knowledge structures do not affect the mere quantity of a student’s verbal contributions. But they robustly predict the degree of elaboration in given answers, together with positive teacher–student-relations, and net of the influences of student gender and instructional clarity. Feelings of uncertainty neither keep students from participating in classroom dialogue nor impair the quality of their contributions. Results suggest that domain-specific prior knowledge is not an indispensable prerequisite to contribute ‘somehow’ to classroom dialogue. However, it is a decisive factor for participation and involvement in those dialogic practices that promote cognitive elaboration. Thus, when researching Matthew effects, differences concerning student engagement in pedagogically valuable features of classroom dialogue might aid in identifying how instructional communication enhances or reduces differences in learning gains.

Sustainable changes in teacher practices: a longitudinal analysis of the classroom practices of high school mathematics teachers

This study examines the effects of professional development on various aspects of teachers’ mathematics instruction. Using data collected between 2005 and 2009, we examined the extent to which the instructional practices of 49 US high school teachers who participated in content-based, sustained professional development changed over time. We found that changes in several aspects of their instructional practices followed somewhat different patterns. Teachers made statistically significant and steady changes in mathematical discourse, instructional clarity, and the development of students’ mathematical habit of mind, but not in student interactions or in the use of multiple representations.

Exploring intensive longitudinal measures of student engagement in blended learning

&lt;p&gt;In this exploratory study we used an intensive longitudinal approach to measure student engagement in a blended educational technology course, collecting both self-report and observational data. The self-report measure included a simple survey of Likert-scale and open-ended questions given repeatedly during the semester. Observational data were student activity data extracted from the learning management system. We explored how engagement varied over time, both at the course level and between students, to identify patterns and influences of student engagement in a blended course. We found that clarity of instruction and relevance of activities influenced student satisfaction more than the medium of instruction. Student engagement patterns observed in the log data revealed that exploring learning tools and previewing upcoming assignments and learning activities can be useful indicators of a successful learning experience. Future work will investigate these findings on a larger scale.&lt;/p&gt;

Testing your Tests: Reliability Issues of Academic English Exams

A testing unit or a tester when writing exam questions generally have millions of issues in mind such as, the reliability, validity, clarity of instructions, design, layout, organization, quality, and many more. However, testing units preparing tests for EAP (English for Academic Purposes) has some other concerns about their exams such as, appropriate topics for listening and reading texts, authenticity, etc. Test writers also have to consider the focus on language skills development, the full coverage of skills, effective learning tasks and the variation in the activity types for all faculties. The main purpose of the study in hand is to investigate the quality of the tests written for the freshman students of Izmir University of Economics. One of the other main purposes of the study is to evaluate the EAP tests written for this institution according to Olaofe’s (1994) eight criterion for good EAP tests.

Methodological challenges and issues of recruiting for mental health and substance use disorders trials in primary care

Background Poor recruitment to controlled trials is a frequently reported problem. Challenges related to study design, communication, participants, interventions, outcomes, and clinician workload hinder recruitment, and the effectiveness of interventions used by trialists to increase recruitment rates is unknown. Objectives To explore the methodological challenges and issues in recruiting for mental health and substance use disorder trials in primary care, and to consider how these methodological challenges can be addressed. Method The presentation will recount the authors’ experience of recruiting for cluster randomized trials in primary care. Methodological challenges, such as clarity of instruction, patient characteristics, patient-doctor relationship, effects of intervention on patients and clinic, and personal benefits for clinicians will be described. The authors will consider how these might relate to and be used for peer learning and peer support in primary care research. Conclusion The presentation will conclude with an overview of how lessons learned from past studies may be used to improve recruitment for trials of mental health and substance use disorders in primary care. Acknowledgements

Learning experience of Chinese nursing students in an online clinical English course: Qualitative study

The low English proficiency of Chinese nurse/nursing students affects their performance when they work in English-speaking countries. However, limited resources are available to help them improve their workplace English, i.e. English used in a clinical setting. To this end, it is essential to look for an appropriate and effective means to assist them in improving their clinical English. The objective of this study is to evaluate the learning experience of Chinese nursing students after they have completed an online clinical English course. Focus group interview was used to explore their learning experience. 100 students in nursing programs at Tung Wah College were recruited. The inclusion criteria were: (1) currently enrolled in a nursing program; and (2) having clinical experience. Eligible participants self-registered for the online English course, and were required to complete the course within 3 months. After that, semi-structured interviews were conducted on students whom completed the whole and less than half of the course. One of the researchers joined each of the interviews as a facilitator and an observer. Thematic analysis was used to analyze the data. Finally, 7 themes emerged from the interviews: technical issues, adequacy of support, time requirement, motivation, clarity of course instruction, course design, and relevancy of the course. Participants had varied opinions on the 2 themes: motivation and relevancy of the course. Overall, results of this study suggest that the online English course helped students improve their English. Factors which support their learning are interactive course design, no time constraint, and relevancy to their work/study. Factors which detracted from their learning are poor accessibility, poor technical and learning support and no peer support throughout the course.

The development of individual cognitive stimulation therapy (iCST) for dementia.

BackgroundAdopting a systematic approach to the development of an intervention, supported by robust theoretical, empirical, and clinical rationales represents best practice. The Medical Research Council (MRC) provides a framework for a systematic step-wise approach to the evaluation of complex interventions. This study describes the development phase of the individual cognitive stimulation therapy (iCST) for dementia trial, within this framework.MethodsIn the preclinical phase, a recent Cochrane Review of cognitive stimulation for dementia and the current literature on individual cognitive stimulation interventions were examined to establish an evidence base. In addition, people with dementia, carers, and care staff were consulted regarding the acceptability of iCST, and a panel was put together to advise the team on the adaptation of group cognitive stimulation therapy (CST). Phase I (modeling) involved consultations with service users and experts in a series of focus groups, interviews, an online survey, and a consensus conference. Finally, Phase II field testing of the intervention was carried out.ResultsTwo drafts of the materials were produced before a final version ready for use in the main randomized controlled trial (RCT). Key changes between the drafts included: editorial amendments to improve the clarity of instructions, emphasize the person centeredness of the approach, and reduce the overall length of the introduction section; the simplification of academic terminology and activities deemed “too difficult”; adjustments made to the monitoring-progress forms and session rating scale to enhance user-friendliness; the addition of a “Getting started” section; amendments made to the content of the toolkit; and clearer distinction made between the level of difficulty of activities.ConclusionThe rigorous development of the intervention was beneficial as the feasibility of the intervention was explored both in theory and practice, and consulting with service users ensured that materials were appropriately tailored to their needs. A Phase III RCT is currently being conducted to determine the effectiveness of iCST.

Student perceptions of effective instruction and the development of critical thinking: a replication and extension

This study utilized data from the Wabash National Study of Liberal Arts Education to test the robustness of research conducted by Pascarella et al. (J Coll Stud Dev 37:7–19, 1996) that explored the relationship between student perceptions of exposure to organized and clear instruction and growth in critical thinking skills among college freshmen. To accomplish this, we created fully-specified models that included statistical controls for an array of potential confounding influences such as, student race, sex, pre-college critical thinking ability, pre-college tested academic ability, parental educational degree attainment, pre-college academic motivation, and a measure of interaction with high school teachers. Net of these influences, our findings generally replicate those uncovered by Pascarella et al. (J Coll Stud Dev 37:7–19, 1996) which suggest that student perceptions of organized instruction are positively associated with gains in critical thinking. Perceptions of instructional clarity, however, failed to exert a statistically significant influence on the dependent variable. Lastly, the results of our analyses suggest the effect of student perceptions of organized instruction on critical thinking affects students similarly, regardless of tested academic preparation (ACT or equivalent score), sex, or pre-college critical thinking levels.

Unit of measurement used and parent medication dosing errors.

Adopting the milliliter as the preferred unit of measurement has been suggested as a strategy to improve the clarity of medication instructions; teaspoon and tablespoon units may inadvertently endorse nonstandard kitchen spoon use. We examined the association between unit used and parent medication errors and whether nonstandard instruments mediate this relationship. Cross-sectional analysis of baseline data from a larger study of provider communication and medication errors. English- or Spanish-speaking parents (n = 287) whose children were prescribed liquid medications in 2 emergency departments were enrolled. Medication error defined as: error in knowledge of prescribed dose, error in observed dose measurement (compared to intended or prescribed dose); >20% deviation threshold for error. Multiple logistic regression performed adjusting for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease; site. Medication errors were common: 39.4% of parents made an error in measurement of the intended dose, 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a nonstandard instrument. Compared with parents who used milliliter-only, parents who used teaspoon or tablespoon units had twice the odds of making an error with the intended (42.5% vs 27.6%, P = .02; adjusted odds ratio=2.3; 95% confidence interval, 1.2-4.4) and prescribed (45.1% vs 31.4%, P = .04; adjusted odds ratio=1.9; 95% confidence interval, 1.03-3.5) dose; associations greater for parents with low health literacy and non-English speakers. Nonstandard instrument use partially mediated teaspoon and tablespoon-associated measurement errors. Findings support a milliliter-only standard to reduce medication errors.

Rigor, Grades, Support, and the Amount of Time Students Spend Outside of Class: A Comparison of Full- and Part-time Faculty in an Entertainment and Music Business Program

IntroductionWhile there are few reliable data on exact proportions of full-time and part-time faculty in entertainment and music business programs, MEIEA (Music and Entertainment Industry Educators Association) institutional data suggest entertainment and music business programs have historically relied heavily on part-time (adjunct) professionally-oriented faculty for delivery of their programs (MEIEA 2014). Additional study of full- and part-time faculty between 1987 and 2003 revealed a steady increase in the percentage of part time faculty in four-year, higher education institutions; specifically, increases in fine arts and business were 7.5% and 6.2% respectively (NEA Update 2007). Given that music and entertainment industry programs in the United States are typically housed in either a department of fine arts or business, the increase in the number of part-time faculty may impact student perception of course rigor, anticipated and earned final grades, faculty accessibility and support, and the amount of time students spend outside the classroom preparing for class. Most institutions utilize some form of course evaluation that measures these points, with the intent of improving course content and instructional practices. Most often, those data are generated by students via questions that may suggest conclusions about instructional clarity, helpfulness of the faculty, relevance of homework assignments, and so on. Rigorous course content often defined as being demanding, with time spent outside the classroom preparing. Studies also suggest students tend to over-estimate the amount of time they spend preparing for class, and students expect higher grades for more classes, and students' anticipated grades are often greater than their actual final grades. In addition, it also widely assumed that faculty members who were more and supportive award higher grades than those who were less accessible and less supportive, and part-time faculty award higher grades than their full-time counterparts.This study used nine matrices to three semesters of faculty course evaluations and surveys in order to examine the relationship between perceived course rigor, anticipated and earned final grades, faculty accessibility and support, and the amount of time students spent outside the classroom preparing for class. Finally, this relationship was compared between full- and part-time instructors.Literature ReviewRigor has been simply defined as the degree or amount of time that students spend in learning that requires higher order thinking (Bogess 2007). Blackburn (2008) expands upon this by claiming that instructional rigor is an environment in which each student expected to leam at high levels, each student supported so he or she can leam at high levels, and each student demonstrates learning at high levels. More specifically, Wagner (2006) defines the outcomes of rigorous instruction as creating a 'jury-ready' populace who can analyze an argument, weigh evidence, recognize bias (their own and others), distinguish fact from opinion, and be able to balance the sometimes competing principles of justice and mercy. After plotting course outcomes against Bloom's revised Taxonomy Table, Wagner concluded that college- and career-ready students should be able to and evaluate conceptual knowledge and apply underlying procedures for concluding a verdict-hence, the result of a rigorous curriculum.In 2005, Higgins, Hall, Baumfield, and Moseley examined twenty individual studies of students' academic achievement in secondary schools and its relationship to cognitive rigor. They found substantial evidence that indicated higher cognitive rigor was associated with greater academic achievement. A study conducted by Meyer, Spencer, and French (2009), concluded that student perception of academic rigor often influenced by the information received from close, interpersonal sources, such as family members and close friends. …

Pre-operative fasting - a patient centered approach.

Prolonged pre-operative fasting can be an unpleasant experience and result in serious medical complications. The Royal College of Nursing guidelines state a minimum fasting period of six hours for food and two hours for clear fluids, prior to elective anaesthesia or sedation in healthy patients. We audited the Moorfields South Pre-operative Assessment Unit fasting instruction policy to ensure it is clear and in accordance with national guidelines.A questionnaire assessing the clarity and accuracy of fasting instructions and patient hydration was employed to survey patients undergoing elective anaesthesia or sedation in July 2013 (first cycle) and September 2013 (second cycle). The fasting instruction policy and patient information leaflet were reviewed; they state “nothing to eat or drink from midnight” for morning surgery and “nothing to eat or drink from 7AM” for afternoon surgery.The 10 patients surveyed in the first cycle reported that the instructions they were given were clear. 70% expressed subjective dehydration and 40% showed clinical evidence of dehydration. The patients had not been encouraged to drink clear fluids up till two hours before surgery. Patients fasted for unnecessarily prolonged periods, the longest of which was 17 hours.Our interventions were: delivering a teaching session to update staff of current pre-operative fasting guidelines, producing a patient information leaflet that was correct, reader-friendly and comprehensive and displaying posters as a reminder of the updated fasting instruction policy.The 12 patients surveyed in the second cycle had been encouraged to drink clear fluids up till two hours before surgery. A dramatically reduced 25% expressed subjective dehydration and 25% showed clinical evidence of dehydration. The longest fasting period was reduced to eight hours.We encourage all hospitals to adopt a patient centered approach to pre-operative fasting, dispelling the “nil my mouth for eight hours” policy, to improve patient wellbeing and satisfaction.

Life or death decision making: Qualitative analysis of death penalty jurors

The relationship between capital jury instructions and imposition of the death penalty in the United States is analyzed through 36 semi-structured interviews collected as part of the archives of the national Capital Jury Project (CJP) at the School of Criminal Justice at the State University of New York in Albany. Former capital jurors expressed confusion, frustration, or ambivalence in areas of instruction clarity and procedural integrity. Specifically, jurors reported significant degrees of confusion as to the clarity of the instructions and the verbiage used to define their role and the exact parameters guiding both their sentencing decision and findings of fact. Moreover, a discrepancy was found in the degree to which statutory aggravation influenced decision making as opposed to mitigating testimony, calling into question both the constitutionality of the death penalty and its compliance with legal precedent. The article concludes with a discussion of the relevance these findings have for forensic social workers working in capital cases including implications for policy and practice.

Optimizing study design for interobserver reliability: IUGA–ICS classification of complications of prostheses and graft insertion

Results of interobserver reliability studies for the International Urogynecological Association-International Continence Society (IUGA-ICS) Complication Classification coding can be greatly influenced by study design factors such as participant instruction, motivation, and test-question clarity. We attempted to optimize these factors. After a 15-min instructional lecture with eight clinical case examples (including images) and with classification/coding charts available, those clinicians attending an IUGA Surgical Complications workshop were presented with eight similar-style test cases over 10 min and asked to code them using the Category, Time and Site classification. Answers were compared to predetermined correct codes obtained by five instigators of the IUGA-ICS prostheses and grafts complications classification. Prelecture and postquiz participant confidence levels using a five-step Likert scale were assessed. Complete sets of answers to the questions (24 codings) were provided by 34 respondents, only three of whom reported prior use of the charts. Average score [n (%)] out of eight, as well as median score (range) for each coding category were: (i) Category: 7.3 (91 %); 7 (4-8); (ii) Time: 7.8 (98 %); 7 (6-8); (iii) Site: 7.2 (90 %); 7 (5-8). Overall, the equivalent calculations (out of 24) were 22.3 (93 %) and 22 (18-24). Mean prelecture confidence was 1.37 (out of 5), rising to 3.85 postquiz. Urogynecologists had the highest correlation with correct coding, followed closely by fellows and general gynecologists. Optimizing training and study design can lead to excellent results for interobserver reliability of the IUGA-ICS Complication Classification coding, with increased participant confidence in complication-coding ability.