Instructional Protocol Research Articles

Examining the interplay of design principles in an instructional intervention for multilingual learners: the discursive mathematics protocol

We have two goals in this paper: (1) To present an iteration of an instructional protocol in mathematics designed to simultaneously promote the mathematical reasoning and learning of the mathematics register by multilingual learners (MLs) and (2) to analyse empirical data to provide evidence of the viability of the instructional protocol for MLs. Using social-constructivism as our theoretical framework, we demonstrate how the ‘Discursive Mathematics Protocol’ (DMP) builds on Pólya’s problem-solving heuristic by integrating research-based ‘language practices’ and ‘essential teaching practices’. To address the paper’s second aim, we analyse videotapes and student work from two problem-solving lessons to examine the interplay of the language practices and essential teaching practices found in the DMP and how this interplay supports students to develop their mathematical reasoning, while learning the mathematics register. This study contributes to an emerging research field that considers the interplay among instructional design principles, language and students’ mathematical learning. This research is also an important contribution to the literature for practical reasons; it demonstrates that instruction promoting language acquisition and mathematical reasoning can be integrated during problem-solving lessons and benefits MLs.

From virtual assistant to writing mentor: Exploring the impact of a ChatGPT-based writing instruction protocol on EFL teachers’ self-efficacy and learners’ writing skill

Language teaching is a highly emotional profession that can affect the teachers’ well-being and learners’ achievement. However, studies have yet to explore the potential of positive psychology interventions and artificial intelligence (AI) tools to promote the psycho-emotional aspects of second language (L2) teachers and learners. Further, studies regarding the effectiveness of AI in promoting the learners’ language skills could have been expansive. Responding to these gaps, researchers chose ChatGPT, an AI-powered chatbot capable of generating natural and coherent texts, as a potential tool to foster positive emotions and interactions between Iranian English language teachers ( n = 12) and learners ( n = 48) in the L2 writing context. We operationalized ChatGPT in a three-phased writing instruction protocol (CGWIP): (1) a planning phase, where teachers used ChatGPT to brainstorm ideas and generate outlines for each session; (2) an instruction phase, where teachers used ChatGPT to engage the learners in writing process, analyse and reflect on their drafts, and (3) an assessment phase, where teachers used ChatGPT to simulate IELTS writing exam and provided detailed and constructive feedback to the learners. We further tested the effectiveness of CGWIP on teachers’ self-efficacy and learners’ writing skills before and after a 10-week instruction program. The Independent Samples t-test results showed that CGWIP significantly enhanced teachers’ self-efficacy compared to the control group. Also, the results of One Way ANCOVA revealed that CGWIP significantly improved learners’ writing skills and that these effects persisted over time. The study implied that the protocol can nurture teachers’ efficiency by helping them in various aspects of L2 writing instruction, including brainstorming, revising, providing feedback, and assessment, which in turn, improves learners’ writing skills.

An optimized protocol for expression and purification of monomeric full-length BAX protein for functional interrogations.

Diverse developmental signals and pro-death stresses converge on the regulation of the mitochondrial pathway of apoptosis. BAX, a proapoptotic BCL-2 effector, directly forms proteolipid pores in the outer mitochondrial membrane to activate the mitochondrial pathway of apoptosis. BAX is a viable pharmacological target for various human diseases, and increasing efforts have been made to study the molecular regulation of BAX while identifying small molecules selectively targeting BAX. However, generating large quantities of monomeric and functionally competent BAX has been challenging due to its aggregation-prone nature. Additionally, there is a lack of detailed and instructional protocols available for investigators who are not already familiar with recombinant BAX production. Here, we present a comprehensive protocol for expressing, purifying, and storing functional monomeric recombinant BAX protein. We use an intein-chitin binding domain-tagged BAX-expressing construct and employ a two-step chromatography strategy to capture and purify BAX. We also provide examples of standard assays to observe BAX activation, and highlight the best practices for handling and storing BAX to effectively preserve its quality, shelf life, and function.

A “COVID bump” in communication course evaluations: Implications for future assessment

ABSTRACT Student course evaluations (SETs) were subjects of debate among educational administrators before the COVID-19 pandemic, but recently have been examined as an indicator of student satisfaction during the transition to online instruction. The current study combines a review of SET research as well as data from multiple disciplines, including IMC, at a large US midwestern university before, during and after COVID-19 online-only instructional protocols. Slight variations in quantitative evaluations of teaching were found, with communication classes exhibiting a larger ‘COVID bump’ than other disciplines. Analysis of verbatim comments yielded insight into students changing how and on what basis they evaluated their courses. The study offers new methods of analyzing SETs, and implications for teaching and training aspiring communication professionals beyond the recent global pandemic.

Online education isn’t the best choice: evidence-based medical education in the post-epidemic era—a cross-sectional study

BackgroundThe COVID-19 pandemic led many educational institutions to shift to online courses, making blended education a significant trend in teaching. We examined the effectiveness of blended learning in an evidence-based medicine course.MethodsWe compared the examination scores of a blended learning group, an online only group, and a traditional offline group and conducted a questionnaire survey on students’ preferences for different learning modes and the reasons for their preferences. A total of 2100 undergraduate students in clinical medicine were included in this cross-sectional study. Examination results were collected, and questionnaires were administered to the study participants. We compared the mean scores and exam pass rates of the three teaching groups using ANOVA and c2test for multiple comparisons.ResultsThe blended group’s exam scores and pass rate were significantly higher than those of the offline and online groups. Furthermore, 71.6% preferred the blended teaching mode. In the survey on " learning effectiveness”, the majority of the students believed that blended education could better enhance the initiative of learning, the interest of the course, the pertinence of the learning content, the comprehension of evidence-based medical thinking, and the basic skills of evidence-based practice. Subsequently, in a questionnaire administered to a blended group of students, their foremost reason for liking online instruction was ‘flexible in time and space’ (99%), followed by ‘can be viewed repeatedly, facilitating a better understanding of knowledge points’ (98%). Their foremost reason for liking offline teaching was ‘helps to create a good learning atmosphere’ (97%), followed by ‘teachers can control students’ learning status in real time’ (89%).ConclusionsThis study explored the effectiveness of learning in evidence-based medicine courses by comparing the learning outcomes and personal perceptions of three different teaching modes. This is the first cross-sectional study in which three different teaching models are compared and discussed in an evidence-based medicine course. We also elaborate on the specific instructional protocols for each model. This study shows that using a blended education approach in evidence-based medicine courses can improve students’ learning motivation, autonomy, and satisfaction. It also enhances instructional efficiency, thereby improving students’ understanding of the course content.

How healthcare workers reacted to the different COVID-19 waves: An Italian survey

IntroductionThe COVID-19 pandemic had a huge impact on radiology departments all over the world, affecting both management and healthcare workers (HCWs). Therefore, it became challenging to guarantee high standards of diagnosis while keeping up with the workload. MethodsThe study was approved by the institutional review board. Its aim was to assess the impact of the COVID-19 pandemic over the radiology departments and HCWs through a survey. The questionnaire was available online from January to March 2022. Twelve areas of interest (sessions) were highlighted in the survey. ResultsThe number of total responders was 1376 and 73.7% of participants worked in public healthcare facilities. Comparisons between participants working in public versus private healthcare facilities were carried out using chi-square tests and Fisher tests. Within public healthcare workers, 82% affirmed having operating instruction protocols regarding confirmed or suspected COVID-19 patient CT management (p< 0.001). Private healthcare facilities had fewer CT scanners available in general (p< 0.001); in fact, only 18% of them affirmed having two or more CT scanners, and did not have CT scanners dedicated to confirmed or suspected COVID-19 patients (p< 0.001). Finally, public facilities strongly reduced (by 88%) the number of examinations booked during the first wave, compared to private healthcare facilities (p< 0.001). ConclusionThis survey showed that public facilities appeared to be better prepared from an organizational point of view than private facilities. Rescheduling the examinations booked during the first COVID-19 wave was challenging and not always possible.

An algorithm-based active cleansing protocol can reduce the bowel preparation time for screening colonoscopy: A propensity score matching study.

Methods that minimize the time for on-site bowel preparation before colonoscopy are needed. We prospectively validated that a novel algorithm-based active cleansing (ABAC) protocol could reduce the time for preparation compared with the conventional method. This was an open-label, multicenter, prospective comparative study from April to October 2021. The study compared the bowel preparation time for colonoscopy between patients instructed with the ABAC protocol and control groups. Patients in the ABAC protocol group as well as the control group were administered 2000 mL of polyethylene glycol (PEG) within 2 hours. After the first two hours, patients in the protocol group voluntarily took 300 ml of the solution without the instruction of nursing staff depending on the number of defecations in the first 2 hours. The intervention and control groups were adjusted for background characteristics by propensity score matching (PSM). After adjustment by PSM, 174 patients in each of the two groups were included in the final analysis. In the intention-to-treat analysis, the preparation time was significantly shorter in the intervention group than that in the control group (126.3 ± 32.7 min vs. 144.9 ± 39.9 min, P = 0.018). The proportion of additional PEG intake was significantly higher in the intervention group (16 [9.2%] vs. 6 [3.4%], P = 0.047). The number of defecations was also higher in the intervention group than in the control group (7.8 ± 2.5 vs. 6.3 ± 2.2, P = 0.001). Simple active instruction protocol is effective to reduce on-site bowel preparation time and nursing staff labor for colonoscopy.

Protocol-Guided Teaching in Junior-Secondary Physics Education: An Analysis of the Learning Protocol for the Velocity Instruction Based on Real-World Circumstances

Protocol-guided teaching is a student-centered instructional model in which the teacher creates the learning protocol prior to the lesson in order to direct students toward active and autonomous learning. A well-structured learning protocol is essential for the effective application of this instructional paradigm. This article evaluates the significance of protocol-guided instruction in junior secondary physics education by analyzing the learning protocol for velocity instruction. Protocol emphasizes situation-based learning and the inquiry chain method.

Effect of Low-Tech Augmentative and Alternative Communication Intervention on Intentional Triadic Gaze as Alternative Access by School-Age Children With Multiple Disabilities.

Students with multiple disabilities who are beginning communicators require augmentative and alternative communication (AAC) to communicate during school and participate in its academic and social aspects. Triadic gaze is a method for accessing low-tech AAC that minimizes physical demands on access for students with limited mobility, such as students with multiple disabilities. Thus, this study evaluated an instructional protocol for teaching triadic gaze as a low-tech AAC access method for students with multiple disabilities. Three students with multiple disabilities who were beginning communicators participated in a multiple baseline across participants design with three phases: baseline, treatment, and generalization and maintenance. Participants engaged in instruction around using triadic gaze to communicate by making selections on an eye gaze board. Visual analysis showed that all three participants acquired the use of triadic gaze as a method of accessing low-tech AAC in response to instruction. Effect size estimations suggested instruction was effective. The participants also demonstrated that the newly acquired skill generalized to interactions with familiar communication partners after instruction ended. These findings show that instruction can be effective in teaching triadic gaze as a low-tech AAC access method for students with multiple disabilities. Future research should explore the effects of using this access method on communicating across school contexts.

Reliable assessment of pain behaviour in adults with profound intellectual and multiple disabilities: The development of an instruction protocol

Persons with profound intellectual and multiple disabilities (PIMD) are vulnerable when it comes to experiencing pain. Reliable assessment of pain-related behaviour in these persons is difficult. Aim To determine how pain items can be reliably scored in adults with PIMD. We developed an instruction protocol for the assessment of pain-related behaviour in four phases. We used videos of 57 adults with PIMD during potentially painful situations. The items were assessed for inter-rater reliability (Cohen's kappa or percentage of agreement). The developed instruction protocol appeared to be adequate. Twelve items had satisfactory inter-rater reliability (n= 9: .30-1.00; n= 3: 85%-100%). Calibrating and adjustments to the instructions and item set appeared to be crucial to reliably score 12 items in adults with PIMD. Further research should focus on creating an assessment instrument based on these reliably scored items.

Remote Delivery of the Fugl-Meyer Assessment for the Upper Extremity: A Pilot Study to Assess Feasibility, Reliability, and Validity

ObjectiveTo develop a remote protocol for the upper extremity Fugl-Meyer Assessment (reFMA) and assess the reliability and validity with in-person delivery. DesignFeasibility testing. SettingRemote/virtual and in-person in participants’ homes. ParticipantsThree triads of therapists, stroke survivors, and carepartners (N=9) participated in Phases 1 and 2. Twelve different stroke survivors participated in Phase 3. InterventionThe FMA was administered and received remotely using the instructional protocol (Phases 1 and 2). Pilot testing with the delivery of the reFMA remotely and the FMA in-person occurred in Phase 3. Main Outcome MeasuresFeedback for refinement and feasibility of obtaining the reFMA (including the System Usability Scale) and the FMA scores remotely and in-person to assess reliability and validity of the reFMA. ResultsThe reFMA was refined to incorporate feedback and suggestions from users. Interrater reliability between 2 therapists evaluating the FMA remotely was found to be poor with little agreement. For criterion validity, only 1 out of 12 (8.3%) total scores were in agreement between the in-person and remote assessments. ConclusionReliable and valid remote administration of the FMA is an important aspect of telerehabilitation for the upper extremity after stroke, but further research is needed to address current protocol limitations. This study provides preliminary support for the need for alternative strategies to improve appropriate implementation of the FMA remotely. Possible explanations for the poor reliability are explored and suggestions for improvement of the remote delivery of the FMA are provided.

P305 Normal reference ranges and cut-off values for considering and performing endoscopy using the Sentinel CaliaGold® Calprotectin assay

Abstract Background Fecal calprotectin, a calcium-binding protein, is used as a sensitive marker for gastrointestinal mucosal inflammation. It is a simple, non-invasive test that can be used to differentiate irritable bowel syndrome (IBS) from inflammatory bowel disease (IBD), where there can be significant overlap in clinical symptoms. Recently, Sentinel Diagnostics launched a new CALiaGold® pierce Tube in combination with a new latex immunoassay for calprotectin measurement on the SENTiFIT® 270 analyzer. The aim of the study is to evaluate the current used normal reference range for calprotectin &amp;lt;60 µg/g*) and the current used cut-off values for considering and performing an endoscopy in case of IBD (considering endoscopy: calprotectin 60-250 µg/g*, performing endoscopy: calprotectin &amp;gt;250 µg/g*). Methods Patients received the CALiaGold® pierce Tube (Sentinel, ref. 1151300) along with the instruction protocol for stool collection at home. Within two days after fecal sampling, calprotectin was measured with the corresponding Quantitative Calprotectin latex immunoassay (Sentinel, REF 115100) on the SENTiFIT® 270 analyzer. Endoscopies were performed within one month around the fecal collection. Results of the endoscopies were registered and interpreted by the gastroenterologist. Calprotectin results were classified according to the clinical diagnosis. Results In total 438 symptomatic patients participated in the study (163 men, age 18-83 and 275 female, age 18-90): 239 with active inflammatory bowel disease, 43 with IBD in clinical remission, 43 with IBS, 17 with other intestinal diseases and 96 controls without identified intestinal disease. The normal reference range for calprotectin was established as &amp;lt;70 µg/g (= p5 positive samples) and the cut-off for performing endoscopy as &amp;gt;355 µg/g (= p95 negative samples). The range 70-355 µg/g calprotectin can be used for considering an endoscopy. Using the new reference range, sensitivity and specificity was calculated as 92% and 93%, respectively. The negative predictive value (NPV) and positive predictive value (PPV) were calculated as 88% and 95%. Using the routinely used reference range (&amp;lt;60 µg/g calprotectin) a 95% sensitivity, 86% specificity, 90% NPV and 92% PPV was established. Conclusion In case of stool collection at home with the CALiaGold® pierce Tube, the Sentinel CaliaGold® Calprotectin assay is highly sensitive in detecting mucosal inflammation. To differentiate between IBS and IBD, it is recommended to adjust the cut-off for differential diagnosis to 70 µg/g calprotectin. In case of IBD monitoring, it is recommended to adjust the cut-off for endoscopy to &amp;gt;355 µg/g calprotectin to reduce the risk of relapse. * Ref.: Nederlandse Vereniging van Maag-. Darm- en Leverartsen, oktober 2015

College Students Improvised Ideas during Physics Laboratory Activities

This study aims at checking college student-teachers’ transferability ideas from physics laboratory activities to improvised materials. We employed undergraduate students from the University of Rwanda College of Education to carry it out during their laboratory experiments session. Since these students are future secondary teachers, we first observed them performing Ohms Law, Faraday law, Wheatstone bridge, and Compass magnet experiments. We followed them, asking them to compare how they could improvise from what they did at school whenever there were no conventional materials. We found that students face challenges in performing provided experiments even if the instructional protocols are provided and receive laboratory technician support. These students could also not imagine how they could improvise these experiments. These results were caused by the fact that they do not possess improvisation skills, and few experiments were provided to them. In this regard, the author recommends that college lecturers not only increase laboratory experiments but also instruct their students by reflecting on their future careers.

Applied Research Note: Interest, engagement, and motivation - a tool to evaluate extension programming

The objective of our study was to evaluate and describe participant interest and engagement in the inaugural offering of the Shell Egg Academy. We randomly selected eight lecture-based sessions (23-44 participants/session) across 37 total offerings and evaluated participant engagement, interest, and motivation. A questionnaire was administered immediately following each session and contained Likert-style questions to evaluate interest, motivation, and self-reported engagement. Sessions were recorded and reviewed using the Behavioral Engagement Related to Instruction protocol. This study is one of the first to describe participant interest, motivation, and engagement as tools to assess Extension programs.

Life Quality of Children Affected by Cleft Lip Palate and Alveolus (CLPA).

The aim of this study was to investigate the quality of life of children and adolescents affected by cleft lip, palate and alveolus (CLPA) in the Italian population after a tailored treatment dental program. A prospective study was conducted with subjects of both genders at the University Hospital of Pisa, Italy. This study included 32 patients (11 females and 21 males, mean age: 9.8 ± 2.1 years old) affected by CLPA (test group); a tailored oral hygiene instruction protocol was adopted in the test group since early age (6.1 ± 0.9 years old) after corrective surgery and regular dental hygiene appointments were scheduled. Moreover, a control group of 32 patients (11 females and 21 males, mean age: 10.1 ± 2.2 years old) without CLPA was included; control subjects were first-visit patients, matched for age and sex, who had not received a specific dental hygiene program before. The OHIP-14 (Oral Health Impact Profile) questionnaire was applied for the evaluation of the quality of life of patients of both groups and the questions were presented directly to the patients. Moreover, the DMFT (Decayed, Missed and Filled Teeth) index was measured. A statistical analysis was performed and the level of significance was set at: p < 0.05. The OHIP-14 scores presented significant differences between the two groups (p < 0.05); the test group exhibited a lower mean OHIP-14 score in comparison to the control group. The DMFT score was significantly lower in the test group in comparison to controls (p: 0.001, p < 0.05). The quality of life and DMFT score of children and adolescents affected by CLPA, after a tailored treatment dental program, were better than that of the subjects of the control group.

Efficacy of a quaternary ammonium compound in reducing coagulase-positive staphylococcal colony counts in veterinary dermatology exam rooms following two cleaning instruction protocols.

Nosocomial meticillin-resistant (MR) staphylococcal infections are of global concern. Veterinary dermatology exam room surfaces may be a reservoir given the commonness of staphylococcal pyoderma. First, efficacy of exam room surface decontamination using a quaternary ammonium compound was assessed after use of two different cleaning instruction protocols. Second, coagulase-positive staphylococcal (CoPS) colony counts were assessed after use of rooms by dogs with pyoderma, and then after cleaning and disinfection. In Part I, 10 room surfaces were tagged with a discreet fluorescent dye, Glo Germ, to assess the efficacy of surface cleaning between two Virex II 256-based cleaning protocols. In Part II, CoPS colonies were quantified via 3M Staph Express System. Ten standardised room surfaces were sampled after use by a dog with staphylococcal pyoderma, and immediately after a detailed cleaning and disinfection protocol. A total of 24 of 100 and 81 of 100 surfaces were completely cleaned by the general and detailed protocols, respectively. The mean number of surfaces adequately cleaned was higher with the detailed protocol (P = 0.003). The detailed protocol reduced CoPS colony counts of eight surfaces (P < 0.01), and not chairs (P = 0.055). No CoPS were isolated from the exam table under a table mat. Detailed exam room cleaning and disinfection protocols are recommended to minimise contamination of veterinary exam room surfaces with staphylococci. The appropriate disinfection of chairs necessitates further study.

Effects of an expert-modeled attentional focus cue structure on skilled jump rope performance and learning.

Instructions that direct attention externally have been shown to enhance motor performance. However, research on skilled performers and on learning effects has produced some distinct findings. Further, many studies have presented an overly simplistic view of attention and learning, such that all-internal focus protocols are contrasted with all-external focus protocols. Contrary to this approach, skilled performers have reported adopting combined focus strategies, revealing the need to test more realistic instructional protocols. The current study provided an experimental test of focus instructions that were modeled after the strategies of elite jump rope athletes. Four groups of skilled jump rope athletes practiced novel skills under various focus instructions. The internal focus (IF) and external focus (EF) groups were given traditional internal and external focus instructions, respectively. The expert modeled (EM) group was given a set of instructions that were based on experts' reported focus strategies. The expert modeled-autonomous (EM-A) group was allowed to choose how they used each of the expert-modeled instructions. All groups completed a baseline assessment, four practice sessions, and a learning assessment. Results of a chi-square test of independence revealed no relationship between group assignment and performance during baseline or practice. There was a significant relationship between group assignment and performance during the learning assessment (p<.05). Specifically, the IF group performed below expected values while the EM group performed better than expected. Findings support previous research showing learning detriments associated with internal focus instructions and also provide new insight into the advantages of using instructional approaches that are modeled after experts' strategies. Implications and suggestions for future research are discussed.

Intra-individual variation of upper airway measurements based on computed tomography.

The aims of this study were (1) to quantify the intra-individual variation in the upper airway measurements on supine computed tomography (CT) scans at two different time points; and (2) to identify the most stable parameters of the upper airway measurements over time. Ten subjects with paired CT datasets (3–6 months interval) were studied, using computer software to segment and measure the upper airway. The minimum cross-sectional area of the total airway and all its segments (velopharynx, oropharynx, tongue base, and epiglottis) generally had the largest variation, while the length of the total airway had the lowest variation. Sphericity was the only parameter that was stable over time (relative difference <15%), both in the total airway and each subregion. There was considerable intra-individual variation in CT measurements of the upper airway, with the same patient instruction protocol for image acquisitions. The length of the total airway, and the sphericity of the total upper airway and each segment were stable over time. Hence, such intra-individual variation should be taken into account when interpreting and comparing upper airway evaluation parameters on CT in order to quantify treatment results or disease progress.

Cultivating a Culture of Bilingualism: Evaluating a Home Language Arts Curriculum for SIFE

This study is a mixed-methods exploratory study of a Spanish Home Language Arts (HLA) pilot curriculum designed for Students with Interrupted Education (SIFE) as it was implemented across six different schools in New York State during the 2019–2020 school year before the onset of COVID-19. The focus of the study was to observe whether the HLA curriculum improved teacher practice in the increased use of the gradual release of responsibility and the curriculum-prescribed protocols. Another goal was to examine whether the use of the curriculum helped to improve student writing and bilingual literacy. A final goal of the study was to survey teachers on their perceptions of the curriculum, especially in how the lesson design fostered student engagement and collaboration with others. The results of the internal evaluation showed that the teachers improved in their practice, especially in the areas of gradual release and increased student time on task. The students were able to develop specific text analysis and writing skills using instructional protocols used in the home language and in English that were transferable across classroom contexts. In addition, the lessons encouraged students to leverage literacy skills and background knowledge in Spanish as a way to support learning new skills in both Spanish and English. Finally, the study showed that the use of the curriculum increased student engagement and collaboration in the classroom.

Building Clinical Skills Teaching Materials: A Study of Cognitive Task Analysis Versus Free Recall Instruction to Teach Canine Indirect Ophthalmoscopy.

Ophthalmoscopy is a core component of a complete ophthalmic examination. Due to its complex technical aspects and patients becoming uncooperative if the procedure is prolonged, it can be a difficult skill for a novice to learn and develop proficiency in. Skills instruction is typically provided by subject matter experts (SMEs) through free recall without an agreed-upon instructional framework. This can lead to unintentional omission of essential steps and knowledge required to perform skills correctly. Cognitive task analysis (CTA) allows for construction of standardized instructional protocols that encompass the knowledge and skills experts apply when performing tasks. The objectives of this study were to (a) develop a CTA-based teaching protocol for canine indirect ophthalmoscopy and (b) compare the steps verbalized or demonstrated by SMEs during free recall instruction versus those ultimately identified by CTA. Four SMEs participated in free recall instructional sessions and interviews used for the development of a CTA-based teaching protocol for novice learners. The CTA-based protocol identified 66 steps and sub-steps considered essential for successfully performing canine indirect ophthalmoscopy. During instructional sessions, SMEs on average failed to verbalize 57.1% of clinical knowledge steps, did not verbalize or demonstrate 68.3% and 9.5% of action steps, and did not verbalize or demonstrate 73.2% and 40.4% of decision steps, respectively. This study demonstrates that SMEs teaching indirect ophthalmoscopy by free recall may unintentionally omit important steps, suggesting that compared with free recall, CTA may generate more comprehensive and thus potentially more effective instructional materials for teaching technical skills in veterinary medicine.