MIXED

Introduction

The use of simulators
in medical education had favorable effect on learning clinical skills and assessing
competencies. Unlike standardized patients, simulators were easily accessible,
replicated in several clinical settings and provided realistic experiences to learners.1
The practice with high-standards simulators had suggested promising role in the
development of clinical reasoning and problem solving skills.2

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Previous studies
showed that effective use of medium fidelity simulator helped students in the
management of medical emergencies3 and learning outcomes were increased
in terms of application of knowledge, mastering skills in a safe environment,
communication skills, handling medical emergencies and willingness to participate
in emergency situations.4 A study with novice faculty members and students found that experience with
simulation helped them in understanding the material and teaching clinical
skills.5 Moreover, it is useful method to reduce anxiety, acquisition of knowledge and
memory.6 As the new teaching modality, recent
studies demonstrated that through simulation teaching students’ cognitive and
psychomotor skills could be assured.7-9 In addition, study reported
that teaching with simulators enhanced learning outcomes regarding diagnosis
and patients management in health care system.10

Use of simulation for acquisition of knowledge and clinical skills is
frequently been used in many institutions elsewhere, however many medical
colleges are still unaware of potential benefits of SBL.  The primary aim of this study was to assess the medical
student experience of simulation in learning clinical skills. Second aim was to
explore further the challenges and implications of
simulation in hospital setting in order to support medical educators to improve clinical teaching using
simulation in the context of experiential learning and to ensure its implementation
in the medical curriculum.

Methods

 

This was a
mixed method design in which the quantitative investigation was collected with a
structured questionnaire on five point Likert scale and a qualitative
evaluation using an interpretivist framework collected through semi structured
focus group interview with internees. The
study was conducted in the College
of Medicine at King Saud bin Abdulaziz University for Health Sciences in Riyadh (COM-KSAU-HS/R) from November 2016-January 2017.  We used mixed method to get a better
understanding of the problems than using either method alone.11It was
observed that the combination of quantitative and qualitative methods provides
an accurate nature of the subject matter and reflects on the diversity of the needed
knowledge.12With triangulation the results may be used to produce a comprehensive
representation of the problem being studied.13

The underpinning theoretical
framework of this study was based on Kolb’s experiential learning.14
Simulation use in teaching stimulates student’s experience of critical thinking,
decision making, clinical skills and professional behaviour. Experiential
learning is capable of stimulating students to reflect on the potential benefit
of their learning experiences.15 This type of experiential learning
also provide opportunities to acquire decision making, motivation to engage in
problem situations.16

This
study sought ethical approval from King Abdullah International Medical
Research Center (KAIMRC) of the University to protect the rights of the
participants. For inclusion, non-probability convenience sampling technique was
utilized. All pre-clinical and clinical years students exposed to simulation based learning were invited to
participate in the present study. Sample size was calculated by using
the Raosoft software. Keeping confidence level of 95 percent and
margin of error at 10%, and 50% response distribution the calculated sample
size was 270 students. For qualitative
approach, the investigators recruited volunteer internees
from hospital [n=6].

A self-administered
structured questionnaire consisting of 20 items on a Likert scale was used to
get the responses of the students. Items were scored as 5 – for strongly agree, 4 – for agree, 3 – for don’t
know, 2 – for disagree and 1 – for strongly disagree. The main variables
included in the questionnaire were quality of tutor’s feedback, deliberate practice, simulation fidelity, skills
acquisition, problem solving and availability of facilities. To support its
validity, four faculty members including one statistician were asked to review
the initial 25 items questionnaire for relevance and clarity. Five overlapping
items were eliminated based on their feedback. Twenty items remained unchanged.
The
reliability of the scale was checked and the Cronbach’s alpha calculated was
0.76. For second part of the study, a semi
structured focus group interview was conducted by the first author using
open ended questions. Since the use of simulation is new method of experiential
learning, the results from interviews are important to the development of medical
curriculum and to improve learning strategies.

Information
regarding study objective was given to participants. They were assured about the privacy and confidentiality of the information. Subsequently, a written consent from the
students was obtained. A questionnaire with demographic information was distributed after simulated sessions. The whole procedure took not more than 10 to 20 minutes. The information
on all domains of the questionnaire was checked for any missing information in
student’s presence. Student was requested to provide missing information if
found. No incentive for
participation was offered.   

For quantitative
study, the data was encoded into SPSS version 20. Mean and standard deviation was
calculated for continuous variables like age while percentage/proportion was reported
for categorical variables like year currently studying. T-test and ANOVA was used
to assess the differences across domains and demographics. Qualitatively, focus group interview was
recorded and transcribed verbatim in addition to interviewer’s notes. Interview was coded for emergent
themes and subthemes. The themes were analyzed by using the Glaser (1965)17
constant comparison method. This was done by two researchers to include areas
of agreement and to avoid disputed themes.

 

Results

Total of 145
students consented to participate with response rate of 73%. Among them 9% were
from first year, 10% from second year, 41% from third year and 39% from fourth year.
The proportion of male and female students was 68% and 32% respectively (Table 2).

All students who participated in the study, the percentages
of satisfaction in aspects of SBL in most items were higher. Whereas the
percentages on adequate skill lab facilities, available time for
practice, debriefing and students’ reflection during the debriefing sessions were
all lower