Characteristics of the study group
Out of 273 students who took part in the survey, 165 (60%) were women and 108 (40%) were men with a median age of 25 years (range 23 to 33 years).
[Table 1 near here]
Table 1
Participants n = 273 |
GENDER n, (%) Men Women | 108(40) 165(60) |
AGE Median Minimum Maximum Lower and upper quartile 25%-75% | 25.00 23.00 33.00 24.00–26.00 |
The interpretation of statistical differences is presented below. Data in Table 2 confirms that most of the results are statistically significant, except for communication in team (p = 0.182).
Table 2
Analysis of students’ opinion about the effectiveness of manikin–based and SP-based simulation scenarios for learning particular clinical objectives
Procedures | Percent | t | df | P |
Manikin | SP |
Checking arterial blood pressure | 25 | 77 | 9.54 | 272 | p < 0,001 |
Patient monitoring | 68 | 40 | 4.62 | 272 | p < 0,001 |
Physical examination | 23 | 74 | 10.00 | 272 | p < 0,001 |
Taking patient history | 12 | 86 | 18.59 | 272 | p < 0,001 |
Auscultation of the rate and lungs | 27 | 68 | 7.66 | 272 | p < 0,001 |
Communication with patient and his/her family | 7 | 84 | 22.59 | 272 | p < 0,001 |
Learning reaction in response to particular symptoms | 27 | 59 | 6.08 | 272 | p < 0,001 |
Communication in team | 45 | 53 | 1.34 | 272 | 0.182 |
[Table 2 near here]
Analysis of students’ experience with manikin-based and SP-based simulation training (questions 1–4)
All respondents experienced manikin-based and SP-based simulation training. Answers to questions 2 and 4 included lists of courses, in accordance to the curriculum, realized manikin-based and SP-based high-fidelity simulation scenarios. An ‘other’ answer option was added in the case students experienced such training during any extracurricular activities. Students could mark more than one answer and their responses were organised using multiple dichotomies (1 – yes; 0 – no).
[Figure 1 near here]
As far as SP-based simulation was concerned, students most frequently pointed to Infectious diseases (69%; 189 answers), Basic Clinical Skills (45%; 124 answers) and Elderly Medicine (42%; 116 answers), as to the courses that provided them with the biggest experience with this modality. Ninety-four students marked ‘other’ answer option, and some provided names of the courses: Integrated Clinical Skills (3%, 3 answers), Integrated Simulation-based Clinical Training (7%, 8 answers) and Family Medicine (3%; 3 answers).
The students received the biggest SP-based simulation experience during Infectious Diseases (69%).
[Figure 2 near here]
With respect to manikin-based simulation, students most frequently pointed to Basic Clinical Skills (94%; 257 answers), Thoracic Surgery (88%, 241 answers) and Elderly Medicine (85%; 231 answers), as the courses that provided them with the biggest experience with this modality. A high proportion of students’ answers (74%) was also noted for courses like Infectious Diseases, Gynaecology, Anaesthesiology and Integrated Clinical Skills. 19 students marked ‘other’ answer option − 2 students (11%) pointed to Integrated Simulation-based Clinical Training and 1 student (5%) pointed to Family Medicine. 16 students (84%) did not provide any further details. The students received the biggest manikin-based simulation experience during Basic Clinical Skills (94%).
According to the accumulated data, students learnt clinical objectives by means of high-fidelity simulation more often with manikins than with simulated patients. Their experience with high-fidelity SP-based medical simulation appeared to be most advanced in Infectious Diseases course. It is worth noting, however, that the second most frequently marked course was Basic Clinical Skills, during which, SPs were not employed to support the educational process. Nevertheless, students might have taken learning medical procedures with colleagues or with a teacher, for instance, pulse taking, as a form of this modality. Basic Clinical Skills was also the course during which students received the biggest manikin-based simulation practice.
Analysis of students’ opinion about the effectiveness of manikin–based and SP-based simulation scenarios in clinical education (questions 5 to 26, 28 to 52, 54 to 56)
For the purpose of the analysis, the questions were grouped in two categories: learning clinical objectives and features/limitations of a method vs. realism. They addressed the same aspects of the learning process when using either a manikin or an SP to observe, if, with the increase of values in the scale presenting students’ opinion about the effectiveness of high-fidelity SP-based simulations, the values reflecting their opinion about the effectiveness of manikin-based simulations decrease. A mean percentage was calculated separately for each of possible answers (definitely not, probably not, probably yes, definitely yes), each of the questions in a particular group (learning clinical objectives and features/limitations of a method vs. realism), and separately for the questions referring to using manikins and SPs. The data were presented in Figs. 3 and 4.
[Figure 3 near here]
Figure 3 provides a distribution of students’ opinion about the effectiveness of manikin-based and SP-based high fidelity simulation scenarios for learning clinical objectives. The analysis revealed that answers ‘definitely not’ (27%) and ‘probably not’ (29%) were most prevalent for questions referring to the effectiveness of learning clinical objectives with the use of a manikin. On the other hand, the effectiveness of learning clinical objectives with the use of an SP was confirmed by almost 70% of the students (28% of ‘probably yes’ and 40% of ‘definitely yes’ answers). By this analysis, it can be stated, that students’ opinions about the effectiveness of learning clinical objectives during manikin- and SP-based high fidelity simulation scenarios are quite contradictory.
[Figure 4 near here]
Figure 4 provides a distribution of students’ opinion about the influence of features and limitations of the manikin-based and SP-based high fidelity simulation scenarios on the sense of realism of the learning process.
According to the results, student’s opinions about the influence of features and limitations of manikin-based simulations on the sense of realism of the learning process were divided, as ‘definitely not’ constituted 20% of their answers and ‘definitely yes’ was marked by 37% of the students. On the other hand, almost three quarters of respondents (35% of ‘probably yes’ answers; 37% of ‘definitely yes’ answers) confirmed that the features and limitations of SP-based simulation scenarios affect the sense of realism of the learning process.
Although the students’ opinion appeared to be contradictory when comparing the influence of manikin-based and SP-based simulation scenarios on the sense of realism of the learning process, their answers were less diversified than in the previous category about learning clinical objectives.
Having established the students’ general views, a more detailed comparative analysis of students’ answers to questions, addressing the same aspects of clinical education with respect to each modality, was conducted (Table 3).
Table 3
Comparison of students’ answers to questions in the category ‘learning clinical objectives’
Area of testing | Classes with a manikin | Classes with an SP | Z value** | P value** |
Facilitating of the work on eliminating mistakes when performing medical procedures Median; lower and upper quartile 25%-75% Min – Max n = 200* | 3.00; 2.00–4.00 1.00–4.00 | 2.00; 2.00–3.00 1.00–4.00 | 4.449 | p < 0,001 |
Facilitating of the development of effective teamwork Median; lower and upper quartile 25%-75% Min – Max n = 194* | 3.00; 2.00–4.00 1.00–4.00 | 2.00; 2.00–3.00 1.00–4.00 | 2.657 | 0,008 |
Facilitating of the development of patient-doctors communication skills Median; lower and upper quartile 25%-75% Min – Max n = 229* | 1.00; 1.00–2.00 1.00–4.00 | 4.00; 3.00–4.00 1.00–4.00 | 12.505 | p < 0,001 |
Possibility to learn different diagnostic and therapeutic procedures Median; lower and upper quartile 25%-75% Min – Max n = 216* | 3.00; 3.00–4.00 1.00–4.00 | 2.00; 2.00–2.00 1.00–4.00 | 8,781 | p < 0,001 |
Possibility to learn rare and pathological cases Median; lower and upper quartile 25%-75% Min – Max n = 198* | 3.00; 3.00–4.00 1.00–4.00 | 2.00; 2.00–3.00 1.00–4.00 | 6.374 | p < 0,001 |
Facilitating of the development of technical skills Median; lower and upper quartile 25%-75% Min – Max n = 229* | 4.00; 3.00–4.00 1.00–4.00 | 2.00; 1.00–2.00 1.00–4.00 | 11.437 | p < 0,001 |
Facilitating of the development of patient history taking skills Median; lower and upper quartile 25%-75% Min – Max n = 227* | 2.00; 1.00–2.00 1.00–4.00 | 4.00; 1.00–4.00 1.00–4.00 | 12,583 | p < 0,001 |
Support of the professional behaviour when performing medical procedures Median; lower and upper quartile 25%-75% Min – Max n = 223* | 2.00; 1.00–2.00 1.00–4.00 | 4.00; 3.00–4.00 1.00–4.00 | 12.338 | p < 0,001 |
Facilitating of the understanding of patient’s feelings during physical examination Median; lower and upper quartile 25%-75% Min – Max n = 234* | 1.00; 1.00–2.00 1.00–4.00 | 4.00; 3.00–4.00 1.00–4.00 | 12.721 | p < 0,001 |
Facilitating of the understanding of patient’s rights Median; lower and upper quartile 25%-75% Min – Max n = 235* | 2.00; 1.00–2.00 1.00–4.00 | 4.00; 3.00–4.00 1.00–4.00 | 12.267 | p < 0,001 |
Facilitating of the development of a doctor-patient rapport Median; lower and upper quartile 25%-75% Min – Max n = 248* | 1.00; 1.00–2.00 1.00–4.00 | 4.00; 3.00–4.00 1.00–4.00 | 13.236 | p < 0,001 |
Facilitating of the development of non-technical skills Median; lower and upper quartile 25%-75% Min – Max n = 218* | 2.00; 1.00–2.00 1.00–4.00 | 4.00; 3.00–4.00 1.00–4.00 | 10.096 | p < 0,001 |
* count of compared pairs |
* * Z and p value for Wilcoxon matched-pairs test |
[Table 3 near here]
The data suggests that, students’ opinions about the effectiveness of manikin–based and SP-based simulation scenarios in clinical education are statistically different. The preference is for learning non-technical skills with an SP rather than with a manikin. Non-technical skills in the category ‘learning clinical objectives’ included: understanding the feelings of a patient during physical examination, doctor-patient communication and rapport or taking patient history. However, students considered manikin-based simulation training more useful for learning technical skills, for instance, error management when performing medical procedures, developing teamwork skills, increased possibility of learning rare and pathological cases and for learning different diagnostic and therapeutic procedures.
To summarise, students preferred learning non-technical skills with an SP and technical skills with a manikin.
[Table 4 near here]
Table 4
Comparison of students’ answers to questions in the category ‘Features/limitations of a method vs. realism’
Area of testing | Classes with manikin | Classes with SP | Z value** | P value** |
Limitation of the sense of realism of a particular clinical case Median; lower and upper quartile 25%-75% Min – Max n = 202* | 3.00; 3.00–4.00 1.00–4.00 | 2.00; 1.00–200 1.00–4.00 | 9.196 | p < 0,001 |
Artificiality of the method Median; lower and upper quartile 25%-75% Min – Max n = 207* | 3.00; 3.00–4.00 1.00–4.00 | 2.00; 1.00–2.00 1.00–4.00 | 11.098 | p < 0,001 |
The influence of the scope of the patient’s responsiveness on the fluency of interaction and decision making process Median; lower and upper quartile 25%-75% Min – Max n = 118* | 3.00; 3.00–4.00 1.00–4.00 | 3.00; 3.00–4.00 1.00–4.00 | 0.137 | 0,891 |
Limitation of the scope of procedures available to be performed Median; lower and upper quartile 25%-75% Min – Max n = 228* | 2.00; 1.00–2.00 1.00–4.00 | 3.00; 3.00–4.00 1.00–4.00 | 10,908 | p < 0,001 |
Limitation of the possibilities to perform certain diagnostic and therapeutic procedures related to rare and pathological cases Median; lower and upper quartile 25%-75% Min – Max n = 148* | 3.00; 2.00–3.50 1.00–4.00 | 3.00; 2.00–4.00 1.00–4.00 | 1.841 | 0,066 |
Difficulty in caring for patient’s privacy and intimacy when performing a medical examination Median; lower and upper quartile 25%-75% Min – Max n = 157* | 2.00; 1.00–3.00 1.00–4.00 | 3.00; 3.00–4.00 1.00–4.00 | 4.925 | p < 0,001 |
The influence of the ability to sense patient’ real body and their reactions to touch on the reliability of the case Median; lower and upper quartile 25%-75% Min – Max n = 129* | 3.00; 2.00–4.00 1.00–4.00 | 4.00; 3.00–4.00 1.00–4.00 | 2.780 | 0,005 |
The influence of the ability to observe patient’s subjective reactions during medical examination on the reliability of the case Median; lower and upper quartile 25%-75% Min – Max n = 120* | 3.00; 3.00–4.00 1.00–4.00 | 4.00; 3.00–4.00 1.00–4.00 | 2.861 | 0,004 |
The realism of the simulation scenario Median; lower and upper quartile 25%-75% Min – Max n = 229* | 2.00; 1.00–2.00 1.00–4.00 | 4.00; 3.00–4.00 1.00–4.00 | 11,936 | p < 0,001 |
The influence of the technical limitations of a simulation scenario on the sense of its realism Median; lower and upper quartile 25%-75% Min – Max n = 171* | 3.00; 2.00–4.00 1.00–4.00 | 3.00; 2.00–4.00 1.00–4.00 | 0,681 | 0,496 |
The influence of the diversity of patient’s looks and behaviour on the sense of realism of a simulation scenario Median; lower and upper quartile 25%-75% Min – Max n = 129* | 3.00; 2.00–4.00 1.00–4.00 | 3.00; 2.00–4.00 1.00–4.00 | 0,344 | 0,731 |
* count of compared pairs |
* * Z and p value for Wilcoxon matched-pairs test |
Table 4 indicates that from the students’ point of view, simulation-based classes are more realistic when conducted with the use of an SP than with a manikin due, possibly, to the subjective reactions of a simulated patient. No statistically significant differences occurred between students’ answers to questions 14 and 40, 22 and 48, 29 and 55, 30 and 56, which can be interpreted, that students’ sense of realism of the learning process was not affected by the level of responsiveness, with the possibility to present rare and pathological symptoms or physical limitations of a manikin or an SP. Students provided statistically significant different opinions referring to the limitations of learning medical procedures with a manikin and an SP as well as the fact of working with a real person for understanding patients’ rights and feelings (answers to questions: 11 and 37, 12 and 38, 21 and 47, 23 and 49, 25 and 51, 26 and 52, 28 and 54).
Answers to additional pairs of questions that were not included above also provided statistically significant differences. The students’ awareness of working with a real person (a simulated patient) rather than a manikin may decrease their ability to concentrate and be precise when performing medical procedures (Z = 2.651; p = 0.008). Moreover, statistically more students compared learning with an SP to learning with a real patient (me = 4 vs. me = 2; Z = 11.975; p < 0.001) and more students were more cautious when performing a physical examination on an SP rather than on a manikin (x2 = 215.21; P < 0.001).
Analysis of students’ opinion about types of teaching modalities that can provide the most effective way of learning particular clinical objectives (questions 57–63)
The students were asked to mark which teaching modality provides the most effective way of learning particular clinical objectives. They were to mark one answer out of the following: ‘with an SP’, ‘with a manikin’, ‘with both manikin and SP’, and ‘none’.
[Table 5 near here]
Table 5
Students’ opinion about the effectiveness of using particular teaching modality for learning clinical objectives
Which type of medical simulation is more effective in: | SP n; % | Manikin n; % | SP and manikin n; % | None n; % | Total n;% |
Doing non-invasive simulation scenarios | 133; 49% | 18; 6% | 117; 43% | 5; 2% | 273; 100% |
Doing invasive simulation scenarios | 9; 3% | 155; 57% | 103; 38% | 6; 2% | 273; 100% |
Learning technical Skills | 14; 5% | 152; 56% | 102; 37% | 5; 2% | 273; 100% |
Learning medical procedures | 14; 5% | 142; 52% | 113; 42% | 4; 1% | 273; 100% |
Learning complex medical procedures | 7; 3% | 170; 62% | 93; 34% | 3; 1% | 273; 100% |
Developing communication skills | 208; 76% | 9; 3% | 51; 19% | 5; 2% | 273; 100% |
Developing appropriate doctor – patient rapport | 198; 73% | 9; 3% | 58; 21% | 8; 3% | 273; 100% |
Data do not add up to 100%, because students could indicate more than one answer |
Figure no. 2 Courses using manikin-based simulation scenarios |
According to the students, SP-based simulation scenarios were the most effective simulation-based way for learning non-invasive medical procedures. For learning invasive procedures, the majority of students preferred using a manikin. The most effective way of learning technical/manual skills, for example EKG, or endotracheal tube insertion, was provided during classes with a manikin (56%) or a combination of both modalities. In terms of learning basic medical procedures, like, for instance, preparing the patient for a surgery, or taking biopsy, classes with a manikin (52%) or a combination of both modalities (42%) were considered most effective. 62% of students stated, that learning complex tertiary medical procedures was most effective with a manikin but 34% of them would combine using both modalities. Learning communications skills, including development of an appropriate doctor-patient rapport, was best facilitated with employment of an SP (76%; 73%).
In summary, the students preferred manikin-based classes when learning technical skills, including invasive and non-invasive procedures, however, some of them would choose a combination of using both manikins and SPs. In terms of developing communication and interpersonal skills, students were consentaneous about the high effectiveness of SP-based classes for learning this objective.
Performing particular medical procedures with a manikin and an SP (questions 64 and 65)
Students were asked to mark which medical procedures are better learnt with a manikin or an SP. In order to allow reliable analysis, examples of the same medical procedures available to be performed with both a manikin and an SP were provided as a list under each question. Students were allowed to mark more than one answer.
[Figure 5 near here]
Figure 5 presents that students favoured the assistance of an SP when learning most of the above-mentioned medical procedures. Learning about patient monitoring was one exception, as 108 students (68%) stated that it is easier when training with a manikin. The procedures considered to be learnt most effectively when practiced during SP-based simulation scenarios included taking patient history (86%, 235 answers) and communication with patients and their families. The most comparable result of this juxtaposition could be observed with reference to developing communication in a team, which, in students’ opinion, can be practiced with a manikin (45%; 122 answers) and an SP (53%, 145 answers) with almost the same level of effectiveness. This may be due to the fact, that learning communication in a team shifts the object of the learning objective from a patient to team members.
57 questions investigating students’ opinion about manikin-based and SP-based classes, which used the 4-point Likert scale, were taken into consideration to evaluate the internal consistency of the questionnaire. The statistical testing yielded Cronbach’s alpha of 0.811 for that instrument, which confirms high reliability of the applied scale.