We conducted 7 key informant interviews and these comprised representatives from the different clinical departments in the faculty of medicine namely Obstetrics and Gynecology, Pediatrics, Surgery, Internal medicine and the Institute of Maternal & Child Health. We also interviewed two representatives from the University administration.
We conducted three FGD with the undergraduate Medicine and Nursing students. One FGD comprised medicine students in year 4 and 5. The second one comprised year 3 nursing students and the third was a combination of both nursing and medicine students and the full composition is shown in Table 1.
Table 1
Composition of FGD participants
| FGD # | Number of participants | Composition |
| Gender | Program | Year of study |
| Male | Female | Medicine | Nursing | III | IV | V |
| FGD one | 9 | 5 | 4 | 8 | 0 | 5 | 0 | 4 |
| FGD two | 8 | 3 | 5 | 4 | 4 | 0 | 4 | 4 |
| FGD three | 9 | 2 | 7 | 0 | 9 | 0 | 9 | 0 |
Emerging themes
Overall, findings were categorized into four broad themes: 1. Current challenges of medical education 2. Prior experience and understanding of medical simulation 3. Opportunities arising from introduction of medical simulation; and 4. Drawbacks to establishment of medical simulation and these are summarized in Table 2.
1. Current challenges of medical education
The study participants presented several challenges in current medical education and these ranged from the limited opportunity for students to interact with patients on ward and holistic patient management to limited exposure to rare cases in nature which on many occasions are left to the senior staff such SHOs (Senior Housing Officers). This often culminates into inadequate experiential learning.
…‘touch’ [hands on] experience is limited, for medical trainees especially on the surgical ward. When we go to the field, we are expected to perform cesarean section and yet at year five, this is not done, we only assess patients. The PGs (Post Graduates) do the rest yet they are too many (Medical Student FGD 2).
The respondents noted there was a large student of numbers thus a large student to patient ratio which limits students’ full access to the patients. There was not enough opportunities to conduct clinical examination. The participants noted that many learners trying to practice negatively affects the privacy of the patients. Students’ assessment was also mentioned to be inclined towards theory rather than practice. Students expressed concern of finding a balance between theory and clinical practice.
The resources are not there. By the fact that we are in a class of 78 and still cannot receive what we are supposed to be getting. The first years are 95 students so you can imagine such a number [when they get] in third year.. I don’t know how they will do it. (Medical Student FGD 1)
Of course, one of the issues is that numbers have grown in the faculty. Being able to demonstrate these life experiences to students is hard because they are so many. In simulation everybody can be able to practice. So, it eases the teaching ( Male Faculty of Medicine Administrator )
The students also revealed that the clinicians were not always available for the students. They mentioned that many of them had to juggle between their clinical and teaching roles. The students usually rely on the Senior House Officers (SHOs) or postgraduate medical doctors for training yet these are equally occupied with their student roles. They also noted there was limited time allocated for student training on ward, specifically seven and a half weeks per rotation, which the students thought was insufficient. The students noted the requirement to have their log books signed overrode their interest to meticulously acquire the required clinical skills.
…there is not enough time on the wards, we are given log books which are good but some of them are really big in that you seem not to focus on what you are going to learn but to fill it and get over with it. So instead of taking time doing a procedure and learning it, appreciating it; you are rushing it because you have to observe something else on another section to get a signature (Medical Student FGD 2).
Students articulated that such challenges often culminated into negative learning outcomes like limited confidence to handle patients, restricted exposure to rare cases, truncated team building and low student motivation. The students mentioned they were compelled to engage in poorly supervised clinical practice during term holidays, a practice they referred to as ‘quacking’ in order to acquire these required clinical skills.
2. Prior experience and understanding of simulation-based learning
Most students and key informants displayed reasonable knowledge of medical simulation as a method of teaching. Most of their descriptions fitted the broad definition; a new innovation in medical education involving the use of scenarios, models or mannequins to mimic real life situations rather than dealing with patients directly; which is the traditional mode of teaching. Although they did not have direct experience with SBL, they had picked up from external sources such as watching movies and television programs where these methods had been applied. Only one participant expressed lack of knowledge of specifically on what medical simulation is but alluded to the fact that it was an innovative teaching method for medical students.
I would say medical simulation is trying to get people or lecturers embrace innovative ways of addressing the challenges that are related to maternal new born and child health (Male University Administrator).
Several key informants mentioned they had some prior experience with medical simulation. While some reported having participated in training at external institutions, they had on rare occasions practiced it while teaching students. Medical simulation is presently used in training in some skills in the nursing school, pediatric training under the Emergency Triage and Treatment (ETAT) program as well as the essential surgical skills course for the fifth-year students.
For example, the surgical skills, it uses medical simulation. Instead of cutting real patients, students are taught to address certain procedures using animals, goats…., goats’ intestines and all that. It has been going on for some time (Female Medical officer).
The students and key informants who had recently been introduced to SBL also described their experiences at the newly established simulation center at MUST. Medical students from the nursing and medicine departments were introduced to practice simulation sessions. However the time allocated for the exercise was felt to be short as the training lasted for only two days for students. Nevertheless, most students acknowledged that medical simulation provides a safe and comfortable learning environment for them. They mentioned the benefit of lack of fear of the potential negative patient outcomes which can occur when one is dealing with real patients directly. Simulation allowed them time to master a skill before directly handling a patient.
I cannot panic that much. The first morning we came in, they read to us a scenario and trust me the adrenaline was very high but as time went on, they told us what should be done. We got used however much they were not the same scenarios as the first but as we did more; we got used and got to know what should be done say universally for emergencies since that’s what we dwelt on the most. There are some things supposed to be done to have the patient survive. There were basics that we got to know (Student FGD One).
The key informants also mentioned SBL has potential to provide an environment where there is limited concern about patient safety and the learners are confident. This was particularly important among the students initiating their clinical years. Simulation also allows for reflection on the scenarios, correct mistakes and hold discussions which may not be possible in a real life scenario in the wards where patients may need direct interventions. Working on patients’ hands on does not give time for reflection once confronted by the patient as mentioned in this excerpt;
… I had given an example of a patient having acute asthmatic attack. You should have a way of having a model that simulates that asthmatic attack so as to see the signs and symptoms of asthma then the students study and practice what they are expected to do. After wards you sit down and reflect on what they have done well, what would have been done better and then may be repeat it to see if they have improved on performance (Male Medical Officer).
Further still, medical simulation allows sufficient time for students to get constant feedback especially during the scenario execution. Participants further reiterated that medical simulation was important for learning about or demonstrating rare conditions as well as conditions that are risky and emergency in nature. There are also certain conditions that cannot be practiced on patients; for example neonatal resuscitation. They mentioned that such practices were delicate and could only be taught through simulation. One student in the FGD described how their recent exposure to simulation enabled them recall and apply skills they had gained from the simulation session straight to a real patient on the ward in a case of post-partum hemorrhage.
The important thing I learnt [from simulation] was identifying the danger signs. If I encounter such a case, I know where the alarms are going to arise from. I think it was the case [in the simulation scenario] of postpartum hemorrhage… I forgot that this person [mannequin] can bleed from a tear. There was something I did not do and the patient ended up in the operating theatre. The alarm signals are still ringing in my ears... As we were managing the case [of postpartum hemorrhage] on ward as an emergency, I remembered the alarm signals that came up in the management while in the simulation session. The mother had a cervical tear that was going way back into the uterus. The knowledge and teamwork I had learnt from simulation helped me and I enjoyed [managing the patient]. I am prepared if such a case comes up again (Student FGD3).
Teamwork was also reported to be a significant benefit of the simulation exercise and this encouraged active participation of all trainees in the simulation exercise. Students also reported that medical simulation promoted mutual respect between the instructors and the learners. Students were comfortable around their instructors, there was free exchange of information and they had the opportunity to spend more time together with their instructors unlike the real life clinic setting.
When doing simulation in terms of teaching it was more effective than on ward. He had more time with us. He first corrected then told us what to do. It was better there. On wards at times we want to see how our senior does it, he is a team leader and is practicing what he preaches (Student FGD one).
During simulation the lecturers were down to earth and were talking as if talking to a colleague and on ward or class you are a student and they shout and do whatever they want. Sometimes you feel intimidated and you cannot talk to them, they are like ‘gods.’ But in simulation they were so friendly, they would talk to you and you would be able to learn (Student FGD Two).
3. Opportunities arising from introduction of medical simulation
Overall, respondents were upbeat about the variety of opportunities and benefits that were likely to arise from the introduction of simulation based learning. There was anticipation among most of the study participants that being the first of its kind in the East African region, the simulation center would improve the visibility of the university. There was excitement this would attract more students to MUST. Respondents also expected the new teaching method would create more skilled doctors and nurses that will be widely recognized world over. There was also anticipation that the simulation center will bring in more partnerships which will support in building more capacity in medical simulation at the medical school
If MUST medical school takes it up definitely the visibility of the medical school will go up and also by virtue of the skills acquired by the graduates since most medical schools in developed countries use it as a form of training. Our graduates would be widely accepted like their peers who are in other institutions where this is a practice. It’s like marketing the institution (Male, Administrator).
The simulation center was viewed as having great potential to generate income for the university through fees levied on external users of the center specifically in-service clinicians and medical students from other institutions within the region as well as attracting more grants into the university.
4. Drawbacks to establishment of medical simulation
There was concern about the possibility of staff turnover at the simulation center especially because these are high skilled staff and are difficult to replace. This was the same challenge presented for both the university staff and the project staff. There is limited expertise in the area and the few trained staff could leave for better positions in the region.
We usually have a challenge with staffing both in number and at times the turnover. Some who are good may leave to go to other institutions or other environments so you lose people who are skilled and experienced and difficult to replace (Male, University Administrator).
There was concern about the sustainability of simulation center since it was starting with external funding, there is a need to ensure a steady flow of funding to sustain it. It was not clear whether the institution can commit to step in, in the event of lack of external funding. There was also concern about the maintenance of the equipment at the center as some of it has high end technology.
SIM for life is coming in as a project and projects end and unless there is continual funding, its sustainability becomes a challenge so I think right from the start integrating it in the Faculty and University system for me it’s the best way of sustainability so that the external funding that comes in is just supplementing what is already in the university system and budget (Male, Administrator).
It has been started with support from these collaborators. The only future would be that even if you have promises from these collaborators to support us now for the next 3–4 years, you cannot know whether support will be there after that period. Like any other project you have to be worried about the financial aspect for it to move to another level (Male; Medical officer).
Some respondents mentioned that some faculty may not be amenable to embracing a new form of teaching that they themselves did not undertake when they were students. They queried whether the level of acceptability of medical simulation would be high among all faculty, particularly those who were getting exposed to medical simulation for the first time. Further analysis of the stakeholders generated a new stakeholder group rather termed the ‘opposition’. These include groups of people or individuals anticipated to be important in contributing to the success of medical simulation but may not have buy-in into the use of medical simulation as a method of teaching. These were mainly teaching staff who are very loyal to the traditional methods of teaching and specifically those who do not believe that medical students can be taught using inanimate objects.
…there are some members of staff who feel you don’t teach a doctor on a lifeless object and some who traditionally are opposed to the idea especially those that did not have this component in their medical training. They feel it’s not necessary and it gives the student a different impression of how patients should be handled. They feel some students may think you can handle a human being as a lifeless object (Male, teaching staff).
On the other hand, there was potential concern within some of the clinicians that medical simulation would engender a lack of seriousness among the students as they found it difficult to relay simulated scenarios with real life situations and thus not obliged to ensure patient safety.
There might be a possibility that because I know I am working with a model, there is lack of seriousness […] they may think I can get away with anything […] During the scenarios and the debriefing the terms we use like being reminded that your patient’s blood pressure is reducing or the temperature is going up or the heart beat is up. It’s easy to work in such a scenario but you need to do something because if this was a real patient, how would I handle it? You can become relaxed and not take it too seriously; it can be tough. […] they tell you “oh a woman is bleeding… If I see real blood its better because it will make me run faster but now I am seeing a cloth that has been painted red, I may not take it serious (Female Medical Officer).
Some faculty members were concerned that the time table for teaching is already congested and that there would not be sufficient time allocation for medical simulation within the existing time table.
Some administrators were concerned that there might not be sufficient space for hosting the simulation laboratory. There was concern that there would not be enough space to accommodate the growing number of students in the Faculty of Medicine.
As you know the university has a drive to increase the admission numbers. Already on the wards we feel the students we have are a bit many so if they increase, I don’t know what it could mean. I cannot be sure the space at the simulation center will accommodate these numbers (Male, Teaching Staff).
The space we currently have is not enough to put us on that level. Even nationally I don’t think. It’s just small so we really need a better facility than what we have (Male Administrator).
Potential remedies
Respondents suggested that attempts should be made to integrate medical simulation into the existing curriculum. They mentioned that this could be achieved if the Simulation center works with the individual departments to develop working guidelines. It was emphasized that the university could fund the simulation center to ease running of the activities including staffing and maintenance.
Table 2
| Theme | Components |
| Current challenges of medical education | Limited opportunities to interact with patients Large number of students Potential breach of patient privacy Heavy clinical workload for teachers |
| Prior experience and understanding | Significant knowledge of simulation Limited prior experience Early positive experiences among students |
| Opportunities arising from introduction of medical simulation | Visibility of the institution Income generating More skilled doctors |
| Drawback to establishment of SBL | Staff turnover Limited staff Sustainability of learning method Burdensome to the teachers |