As a result of the analysis of the focus group interviews with the students and in-depth interviews with the two trainers, four main themes and subthemes related to these themes, which are presented in detail in the findings section, emerged (Table 1).
Table 1: List of the themes and subthemes that emerged as a result of content and thematic analysis
Main themes
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Subthemes
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Items related to the subthemes
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1. Thoughts on the simulation-based preparation program
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Adequacy of the training content and implementation process
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Comprehensive and well-structured program
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Competency in unstable patient management
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The need to practice stable patient management as well
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Preparation for the clinical setting
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Safe patient intake
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Decreased anxiety level
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Efficient use of algorithms
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Ability to manage an unstable patient
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Benefits and differences from the real clinical environment
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2. Experiences in the clinical setting
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Emotions during real patient encounters
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Emotions, emotional load and the process of getting used to the clinical environment
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Relationships with and emotion management for patients and their relatives
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Definition of roles and responsibilities
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Relationships with other healthcare professionals and conflict management
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Needing more autonomy
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The number of unstable patient encounters and diversity of patients
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Low number and variety of unstable patients
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Differences between clinical settings
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Differences between groups and learners
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The most difficult situations encountered in the real clinical environment
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Uncertainty in roles and responsibilities
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Communication and social/interactional problems with other healthcare professionals
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Intensity of working hours
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Immediate involvement by supervisors in case of failure
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3. Perceptions of the learning climate
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Communication and collaboration with the educators
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Supportive, safe and positive learning environment
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The need to have more autonomy
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Communication and collaboration with the staff in the emergency department
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Not being accepted as a doctor
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Intergroup and interpersonal differences
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The importance of one-to-one personal relationships
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Not receiving the necessary respect
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Communication and collaboration with patients and relatives
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The importance of introducing oneself to patients
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Obtaining permission for examination
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Experiencing conflict management
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4. Improvement in the clinical environment
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Improvement in emergency patient management during the emergency internship
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Improvement in procedural skills
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Awareness of the concept and functioning of emergency services
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Development of ability to work in a team
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Postgraduate level of competence in emergency patient management
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Recognition of unstable patients
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Stabilizing unstable patients
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Transporting unstable patients correctly
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Importance of experience
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Importance of using algorithms
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Thoughts on the simulation-based preparation program
Students generally stated that the SBE Clinical Preparation Program was inclusive, its content was sufficient and the program was well structured. Before starting the internship in the clinic, they stated that what they learned at the CASE increased their self-confidence and facilitated the process of getting used to the clinic. The students suggested that management of stable patients be added to the program and that, if possible, arterial blood gas and liquid electrolyte therapy should be included in the program.
G2K3: “I think it has been very useful forunstable patients. Mostly stable patients come here, but when the unstable patients came, we knew what to focus on thanks to the training we received at the CASE."
G3K2: "All patients were mentioned in the CASE. Cardiac, respiratory, CVO, acute abdominal pain.”
Within the scope of the clinical environment preparation subtheme, the students stated that the training at the CASE prepared them well for the clinical management of unstable emergency patients and cardiopulmonary resuscitation, but they learned the skills needed for the management of stable patients by encountering them in the clinical environment. They stated that because of the SBE program, they were especially well prepared to identify and evaluate emergency patients and perform the necessary intervention, but they needed more practice in requesting permission to examine patients and planning the treatment.
G1K5: “The most important thing to me was anaphylactic shock in the clinic. I remembered that we did the same at the CASE; I knew what to do.
G2K4: “I noticed that I have adopted the algorithms. I realized that I was approachingthe patient faster and more accurately using algorithms. So, the CASE has been very useful.”
Experiences in the clinical setting
The trainers stated that in the first week after beginning their internship, the students had difficulty transferring what they knew to the clinic setting. Although they had successfully applied it in the simulator, they had difficulty visualizing and applying the algorithms they had learned to real patients with the patients’ relatives looking on. They stated that the simulation program prepared the students well for the clinic and gave them a foundation, which was very important. However, the trainers added that, the students had to overcome an emotional barrier when approaching real patients, a process that took 1-2 weeks.
E1: After a week ina real clinical setting, they get used to the environment. After that, they began to recall everything they did at the CASE and apply it to the patients.
E2: Actually, they transferred the training at the CASE very well to the clinic here. The training there allowed them to create an algorithm in their minds.
Regarding clinical experiences, most of the students stated that they had an adjustment period of 1-2 weeks after they entered the clinic and that they felt more secure in the clinic after the training they received at the CASE. However, in the clinic, they also stated that they had to get used to the working environment in various respects related to relations with patients' relatives and other healthcare professionals and the recognition of their roles and responsibilities. They emphasized that when they are given more responsibility at the bedside, they felt much better.
G1K1: “I wasn't always sure of my feeling here. For example, when I first arrived, I did not fully grasp that everything was already done and what I had to do as an intern.”
G3K2: “Management of difficult patients was really difficult for me. For example, there was a code blue, and the patient's relative was crying. I also tried to talk to the patient's relative and inform him.”
The trainers observed that the interns had difficulty managing the emotional process in unstable patients and telling this to the relatives of the patients.
E1: “I think their technical skills were sufficient. For example, I think they had good knowledge of resuscitation. Here, there were factors other than technical skills when applying it to real patients. While ventilatingthe patient, there were those who were tearful and crying, and such emotional moments were experienced.”
The students stated that they could not see a sufficient variety of patients in the clinical environment and that they did not encounter many unstable patients coded as red; instead, most of the cases were stable and coded as green. Although the interns did not frequently encounter unstable patients, they added that they could easily handle such situations by remembering the algorithms for emergency patient management that they learned in SBE training.
G2K4: “If you ask which patients you have seen the most here, fever and abdominal pain. The variety could have been more, but I think there is nothing to do about it; it's a bit a matter of luck."
G3K2: "It is always said that you have to meet at least 10 life-threatening patients; I could not meet alone."
Interviews with the trainers indicated that the students saw a sufficient variety of patients in the emergency internship.
E2:“They all see. I cannot say that they lack a case. Okay, not many patients come, but the patients who come have multiple problems.”
The students stated that defining their roles, especially in the clinical environment, is important not only for themselves but also for other healthcare professionals, patients and educators. They stated that they had difficulty in the clinical environment when the roles were not defined. They especially noted the communication problems they experienced with other healthcare professionals in front of patients and their relatives. They stated that their difficulty communicating and cooperating with some trainers and nurses in different learning environments was one of the most serious problems they had at the bedside in the clinic.
G2K2: "We had difficulties because our role as interns at X hospital was not fully defined."
G3K5: “I think an orientation program should have been prepared for us here when starting the internship. What we will do while standing at the counter, what we will do in the back, what is expected of us, etc."
During the interviews with the trainers on these themes, the most common difficulties mentioned by the students were communication and conflict management with other healthcare professionals and patients’ relatives.
E1: "I think it was more important to cross the threshold in the social area ofrelations with patients and their relatives and nurses rather than in their technical skills."
Perceptions of the learning climate
The opinions of the students regarding their education were that a supportive and positive learning environment was prepared them. They desired slightly more autonomy from their trainers in prescribing and ordering at the end of the internship.
G2K3: “I think we should be able to order here in the last weeks. I think I have this skill. Then they can check my work. But they should give us this responsibility before we finish and leave.”
G3K5: “We have to take more responsibility. It is over now; we will do everything ourselves from now on."
The views of the trainers on these themes were as follows.
E2: “Yes, our only goal is to teach them something, I think they see it. I think this is probably effective. They are aware that we worry about them. I think they are aware that we are working so that they do not suffer after graduating from here."
When the learning climate was evaluated in terms of communication and cooperation with other healthcare professionals, the differences observed between groups and individuals were striking. Students who had difficulty in their relationships stated that they did not receive the necessary respect at the bedside and they were not accepted as doctors and that this situation put them in a difficult position at the bedside; in particular, some warnings and speaking styles were disrespectful.
G2K4: “You know you aren’t wanted; you feel like you are excess. Even if they don't say anything, you feel like you are too much because of their behavior."
G2K1. “When a problem arose, I usually tried to solve it by communicating. Let our definition be clear so they understand."
The views of the trainers on this theme are as follows.
E1: “In the first adjustment period, we tell our friends(emergency department staff) that they will get used to you and here. That is why the first week expectations are low; they have a period of mutual adjustment. By the second week, everyone knows each other, and there is no problem. We give importance to communication with other healthcare professionals.”
They stated that there were no major problems with the patients and their relatives. They explained that the reason for this was that if the interns introduced themselves to the patients, explained the situation and asked permission from the patient to examine them, they typically did not encounter any problems. They stated that some patients' relatives are aggressive in crisis situations, but the students can cope with these situations by providing the necessary information to the relatives. They added that other healthcare professionals are very successful in the management of conflicts regarding patients and their relatives. They also stated that patients' attitudes towards the interns during the bedside process affected their approach to the patient.
The opinion of one of the trainers about this was as follows.
E:2 “I have not received any complaints from the patients nor witnessed any disrespectful behavior.”
Improvement in the clinical environment
The last major theme was the evaluation of further development during the clinical internship. Although the students thought that the CASE experience prepared them well for the clinical environment and that they did not see the number and variety of patients they expected during the clerkship, they stated that they improved significantly in clinical emergency patient management during the eight weeks. They added that they felt competent in identifying, stabilizing and directing emergency patients to the right place in primary care after graduation. They said that they saw patients and believed they would gain even more experience in the years to come. They also expressed that they were very confident in approaching unstable patients and performing the necessary intervention. The reason for this is that both the SBE program and the positive learning climate that the trainers especially established for them in the clinical environment were effective.
G2K4: “If I were to score improvement, it would be 1-2 before the CASE, 5 after the CASE, and 8-9 after the internship."
G4K1: “Initially, I felt like a student while working with the patient; towards the end of the internship, I started to feel like a doctor. This has been very good for me. But I wish we could see more patients."
The views of the trainers were as follows.
E2: “When they are alone with the patient, they learn how to talk to the patient and how to examine them. After a few weeks, the problem with this issue ends; at this time, the question of what I will prescribe and what tests I will request begins.”