Following our mixed methods approach, we present the integrated quantitative (Tables 1 and 2) and qualitative results for utilization of hybrid simulation in teaching PAG exam, with illustrative quotes from participants (Table 3) and conceptual model illustrating factors influencing learning in hybrid model high-fidelity simulation environment (Figure 2).
Participants’ attitudes: comparison between hybrid model and pelvic task trainer.
During data evaluation the answers to questions pertaining to each of the three domains were combined and such analysis revealed that residents valued the hybrid model higher over task -trainer-SP-voice model in regards to all three attitude components: cognitive (95%), affective (87.5%) and behavioral (83.7%).
Analysis of individual items revealed that almost 63% of participants felt more anxious with the hybrid model as compared to trainer. In addition, 81% of participant felt it was easier for them to practice technical aspects of the exam with pelvic trainer. These observations suggest that hybrid model could more challenging due to stress comparable to the one present in real live conditions.
The Cronbach’s alfa for the questionnaire was 0.96. The correlation analysis of the items showed that coefficients for sister questions were negative for all but one pair of items and were statistically significant in 10 out of 17 pairs (Table 2). That indicated consistency in participants answers. The lack of statistical significance or inverse correlation was characteristic of the items pertaining to the affective domain and inquiring about participant’s anxiety and the difficulty of the task.
Effects on acquisition of skills in PAG exam
Self-perceived skills in PAG exam increased significantly after the workshop, with no change noted in regards to an adult exam (Table 1). Significant differences in particular skills were noted between OBGYN and pediatrics residents. As it could be expected pediatricians scored themselves low in skills pertaining to adult examination and that did not change after the workshop. The differences regarding the PAG exam, which were present prior to intervention were leveled following the training (Table 1).
The Cronbach’s alfa for pre and post self-assessment questionnaires were 0.94 and 0.95, respectively.
The results of the direct observation assessment showed no difference between scenario-1 and scenario-2. Interestingly, no differences were observed between pediatrics and OBGYN residents either.
Analysis of the interviews uncovered six themes pertaining to factors that affect learning in the simulation environment using hybrid model of PAG examination. Illustrative quotes from participants pertaining to each theme were presented in paragraphs below and all quotes in the Table 3.
Theme 1. The degree of physical realism and perceived task difficulty influenced learning
Participants perceived the hybrid model more real when compared with the pelvic trainer-SP-voice. The physical realism was perceived as factor that positively influenced learning and helped in developing complex skills
“I felt practicing with hybrid more real ... more serious...”
“...fidelity of simulation with hybrid model helps to perform the task...”
At the same time the participant experienced that hybrid model made the task more challenging:
“I think working with hybrid model was more challenging because of alive patient”
“In my opinion practicing with hybrid is more challenging because you need to deal with two people”
Interestingly, the pelvic trainer-SP-voice scenario was not described as less challenging, but in terms of its realism participants perceived it as causing difficulty in learning of communication skills
“Communication was difficult to practice with trainer”
“It felt weird to talk to plastic in case of the trainer scenario”
On the other hand, other skills like e.g. palpation of vulvar area were perceived as easier to execute using pelvic trainer-SP-voice model.
“It is easier to perform exam without a human”
Theme 2. The degree of emotional realism influenced learning
It was often expressed that participants could experience SP’s emotions with hybrid model, which was not possible with pelvic trainer-SP-voice and that affected their learning
“...contact with living human can reinforce learning, especially reactions presenting discomfort...”
“It felt I gained more from the sim with hybrid, because of emotions, mimics and reactions of the simulated patient during the exam”
Theme 3. Participants’ emotional states during simulation were important for learning experience
Although the interview questions did not inquire about emotions, participants talked a lot about their feelings during simulations. The emotions experienced were stress and confusion. Stress was higher with hybrid model, and was perceived as positive or necessary element. Confusion was in part connected with the hybrid model and in part with the simulation as the learning modality in general.
“I felt a lot of stress during the sim but I think this stress can be necessary ....”
“Definitely, I felt less stress with trainer”
“I was not sure where does the trainer ends and SP begins – it made me confused”
Emotional involvement with the patient was also discussed. Participants said they felt emotionally involved only in case of hybrid model.
“I must say I felt no emotional involvement with the patient in the scenario with trainer”
“I was really emotionally involved with the case in the scenario where there was a hybrid model”
Theme 4. Comparison of the task difficulty between two types of simulation.
This theme also emerged and was often outlined although participants were not asked about it directly and it was usually discussed in the connection to realism (mostly emotional)
“It was much more difficult for me to perform task in case of hybrid model as it required combining various skills”
Theme 5. Engagement and attention with the patient were increased with hybrid model
Participants recalled deeper engagement and attention with the patient’s problems and experiences, when they performed PAG examination using hybrid model
“I felt more engaged in the scenario when the alive person was present in the chair; alive human is an asset”
„I needed to pay more attention with hybrid model and felt more responsible for the patient”
Theme 6. Scenario with hybrid model was perceived as high-fidelity in contrast to the scenario with the trainer-SP-voice
Although both scenarios were conducted in high-fidelity environment with the only difference being the hybrid model, participants seemed to perceive “the fidelity” of the pelvic trainer-SP-voice scenario as low. They often used a term “trainer”, did not appreciate the SP voice coming from the speaker or even considered it a distractor.
“The voice from the speakers distracted me during the sim with pelvic trainer”
“With trainer it was possible to practice only technical skill - not communication”