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We adapted Peyton’s 4 stage teaching approach for acquisition of procedural skills, so that it was applicable for the virtual session . Students were shown a skill (e.g. tying a reef knot) in its entirety via a pre-recorded video demonstration, they were split into virtual breakout rooms where the instructor deconstructed the skill; giving students the chance to ask questions and identify the next steps, the students were then supervised whilst performing the skill themselves and given real-time feedback. The process was repeated for each subsequent skill. To supervise each student in the breakout room, instructors would ‘pin’ student screens to enlarge the view of the individual undertaking the skill, give immediate feedback and ensure they could carry out the skill, before observing the next student in the breakout room. The instructors were also rotated for each breakout session whereas the student groups remained the same; to enable the group to build rapport. All students were either ‘very satisfied’ or ‘satisfied’ with the use of breakout rooms to practice the skills in a supervised environment. Instructors commented on the need for clear articulation of instructions to ensure student progression in the online teaching space, due to inability to provide tactile or other modes of feedback.
A dedicated instructor per breakout room was integral to the success of our teaching and progression of students at a similar pace. Wallace, Sturrock and Gishen  also used breakout rooms for procedural skills practice for medical students in their fourth year of medical school. Rather than assigning an instructor for each breakout group, tutors dropped in to troubleshoot when necessary. Emergent themes from student feedback indicated that students liked the use of breakout rooms as they were able to socialise and learn with their peers however, there were comments regarding their overuse and the slow pace of the sessions. Co and Chu  and Co, Chung and Chu  conducted a web-based basic surgical skills session with final year medical students in Hong Kong. In this session, 30 students were taught by 1 instructor and breakout rooms were not used. The authors of this paper felt this may have prevented adequate supervision and meant that training time for each individual skill took longer. If a student was having difficulty in performing a skill, the entire class would have to wait until that individual was proficient before being able to move on to the next activity.
During surgical skills breakout sessions, our instructors were communicating via a separate private messaging channel. This enabled the groups to coordinate timings and ensure the session ran smoothly. If a student was having difficulty with skills practice, the instructor was able to highlight this to the teaching team via this channel; so that when groups were rotated they could spend a little extra time with that individual. The use of breakout rooms can be time efficient especially when teaching students of differing skills and abilities however, good communication between instructors needs to be maintained throughout to optimise and coordinate their use.
Prior to the session, 40% of students ‘agreed’ or ‘strongly agreed’ that their view of the surgical skills demonstrations would be negatively impacted by holding the session online, 30% were neutral. Following the session, only 10% ‘agreed’ (0% strongly agreed) that their view was negatively impacted and 15% were neutral.