Introduction

Simulation-based
education (SBE) is a rapidly developing discipline that can provide safe and
effective learning environments for students. 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

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 SBE.  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.

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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 March 2017-April 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. By using the Raosoft software, the
response distribution was estimated to be 50% with confidence level at 95% and
margin of error of 7%, the calculated sample size was 195 medical 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 same. 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 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 open 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 74%. 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 SBE 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 (Table 1). The higher percentages of
responses were from the domain related to process and lowest from tutors’ feedback
domain.The prominence and benefits associated with the simulation
use in clinical setting had encouraged medical colleges to initiate the
simulation use in medical curricula. Present study assessed the SBE impact on
learning. In this study the percentage scores on most of the items were
all in favor of SBE. The results were comparable with the study by Joseph et al
that reported overall positive perception of medical students.18The
result indicated that teaching on simulation had improved students’ learning in
term of knowledge, critical thinking, reasoning and self-confidence. Literature
also confirmed the effective use of
simulation in teaching and learning medicine19 and nursing.20
In addition, students showed general agreement on type, number and quality of
the equipment provided by the college.

It is known fact that debriefing is
crucial aspect of SBE which increased performance and improved reflective
practice.21 However,
tutors’ debriefing and feedback skills were highly criticized and considered inadequate
by many participants. This issue of feedback and its role in the skill
development is an area that needs consideration. This is vital to strengthen
the deep learning process and to support development. As a reliable means to assess competencies, the
contribution of tutor’s constructive feedback in learning should be further
investigated.22Moreover,
result emphasized on the importance of training sessions and curriculum reform
by developing experiential learning approach in teaching. Form the
results it is evident that within the framework of experiential learning increasing
use of simulator in teaching and more exercises may contribute to better
learning outcomes. Additionally, proper implementation of debriefing
may increase the influence of simulation-based education. 

Furthermore, this
study observed a significant increase in the scores based on the level of the
students in college. The students’ experience and practice on simulated
patients at different level of study might be a reason of this significant
difference. Interestingly, a significant increase among genders on the domains
of process, equipment and feedback suggested the overall satisfaction of female
students as compared to male students with this modality.

Even though, few students who gave unfavorable
feedback, the qualitative analysis in this study, acknowledged the benefits of
simulation teaching in practice. The shared benefits summarized as; confidence
building, improved communication and acquisition of reasoning skills. The group of participants raised attention to two features
issues facts; first, simulation center and tutors had a critical role in the
advancement of teaching clinical skills. Secondly, initiative and involvement
of leadership in the necessity of prioritization with regard to
standards and demands of simulation resources in the clinical setting. The findings were consistent with a study
done on nursing students argued on the critical role of stakeholders in
enhancing the clinical learning experience to students.20 Reflecting on our results, a
lack of explicit directions to support faculty and students were found.

Study
limitations

Some
limitations that prevented the generalization were small number of participants
from one institution but it suggest the need to include sample from other
colleges of the region. Secondly, there was no control group for comparison to
see the contribution of other modalities on students learning. The findings
despite certain limitation will guide the stakeholders on how students’ learning
needs should be addressed. This recognition is important in planning, implementation
and evaluation of SBE in medical education.

Conclusion and
recommendations

SBE in this
study generally recognized as useful and effective way of learning skills. The current integration between
clinical teaching methods and simulation is still at its start, and there is
vast potential for further association. It would be important for educational leaders in the institution to
understand that all the stakeholders have a significant role in teaching the
clinical knowledge and skills to medical students. There is a need to
communicate benefits of simulation with faculty members and students and to
review the current strategic goals of the
use of simulation to include this approach in medical curricula. Enactment of
the process is an important step to make it clear and evident to all students. Further
studies to explore the current and future implications of simulation in
clinical learning are required.  

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