**3. Our proposed model**

The execution of the model – our proposed tool shown in **Figure 4** describes the use of a design and development research framework to produce instructional materials incorporating mental and deliberate practice. It describes the use of the expert review panel and in-depth interviews to identify the key tasks of complex surgical procedures from the expert's perspective. Incorporating a think-aloud/verbal walkthrough of the index motor skill by experts, followed by content and task analysis [38], allows for creating a detailed mental script to be incorporated into the instructional materials.

#### **Figure 4.**

*Execution of model to create a training programme for a surgical skill.*

The beginning of the model entails designing an instructional video, which includes the live demonstration of surgical procedures by an expert surgeon. The production of an instructional video of the master surgeon performing the procedure based on the task and subtask involved in the procedure will require the framework of multimedia instructional production [35]. In addition, the video will need the narration of the mental script produced from the methodology described in **Figure 4**. This will enable the trainee to perform mental practice and augmented with deliberate practice using low-cost practice models designed and developed by the master surgeons.

The ADDIE model is used to perform a content, task, and subtask analysis of the procedure with expert surgeons, which will aid in creating the storyboard, and designing the instructional video. For example, in tendon repair, a cognitive walkthrough is conducted with an expert surgeon, and the instructions and reflections, inclusive of kinaesthetic cues, are recorded and analysed verbatim to create a mental script validated by the master surgeon. This will be used as the narration for an expert instructional video showing the master performing the tendon repair. The instructional material – the video will then be validated by master surgeons. A lowcost practice model is needed for deliberate practice such as chicken or sheep tendon for tendon repair training. Combining the video and mental practice using the mental script allows the trainees to learn from expert surgeons anytime, anywhere, and improve with deliberate practice using the chicken/sheep practice model. Once they are ready, they are then assessed in the operating room for real-world performance to verify retention and transfer of skills in tendon repair surgery.

This new model that incorporates motor imagery and mental practice, augmented with deliberate practice, will provide an alternative training path for expert performance in surgical procedures. The tools to design and develop the instructional materials (expert instructional videos and mental scripts) with task and content analysis is founded on sound instructional design principles. It will, however, require further validation.

Current surgical training resources have been using various instructional mediums from text and multimedia materials, focusing on the step-by-step procedure

#### **Figure 5.**

*Phases and sub-processes of Self-Regulated Learning (SRL).*

for performing motor tasks. These need now to be expanded to incorporate mental scripts for each standard procedure in surgery.

The theoretical framework for continuous learning is self-regulated learning (SRL) (**Figure 5**). SRL perceives learning as "an activity that students do for themselves in a proactive way". It is a process by which the learner plans, monitors, and evaluates his learning to achieve learning objectives based on his developed strategies [39].

This model and tool that we proposed was executed in a study that used the design and development research framework dedicated to creating new knowledge and validating existing practice in instructional design. In this case study we aimed to demonstrate how to design, develop, and evaluate an online instructional module on micro suturing guided by Mayer's multimedia learning theory and incorporated a mental script for the mental practice of micro suturing.
