Web-based problem-based learning (PBL) and scenario simulation teaching in airway management for undergraduate students

doi:10.21203/rs.3.rs-3136161/v1

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Web-based problem-based learning (PBL) and scenario simulation teaching in airway management for undergraduate students

https://doi.org/10.21203/rs.3.rs-3136161/v1

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Background

This study aimed to evaluate the effectiveness of web-based combination of problem-based learning (PBL) and scenario simulation teaching in airway management course for undergraduate anesthesia students.

Methods

Sixty-five undergraduate students participated in the web-based airway management course. Both pre- and post-class quizzes were administered to assess students' knowledge. The effectiveness of the teaching modality was observed by comparing the pre- and post-class quiz scores, along with the technical skills scores and non-technical skills scores in two simulation scenarios. Additionally, an anonymous questionnaire was distributed to evaluate the students' perceptions and experiences.

Results

The results revealed a significant improvement in students' scores on the second quiz after completing the PBL combined with simulation course compared to the first quiz (p < 0.001). Moreover, during the second simulation, students demonstrated enhanced technical skills across all four simulation scenarios (p = 0.030, p = 0.037, p = 0.028, p = 0.028, respectively), as well as non-technical skills (including task management, teamwork, communication, sustained vigilance, crisis identification, decision-making, and self-confidence). The questionnaire responses indicated that students found the course enjoyable and helpful in improving their problem-solving skills. Furthermore, 97.3% of the students believed that the course enhanced their self-learning and teamwork skills, while 97.22% of students felt that it facilitated the mastery of anesthesia skills.

Conclusions

The combination of PBL and simulation-based teaching proves to be a highly effective approach in online anesthesia education. It stimulates students' interest in learning and fosters the development of critical thinking and non-technical skills.

anesthesia

web-based

simulation

PBL

airway management

With the extensive development of mobile Internet, online medical teaching has become an important approach due to its unrestricted nature in terms of time and space [1]. It enables various teaching activities to be conducted through the web. In recent years, several online education models have emerged by combining traditional medical education with the web [2–4]. However, there is less research on conducting web-based anesthesia teaching and xploring the effectiveness and efficiency of online teaching.

Problem-based learning (PBL) is a typical student-centered, interactive teaching method that places learning directly in complex clinical situations [5]. Students collaborate in groups to solve problems, which contributes to their autonomous and independent learning abilities, and build capability in terms of communication and teamwork [6]. However, in teaching practice, PBL requires students to be in the dominant position in the class, and the lack of proper guidance from teachers can lead to unfocused course content [7]. Additionally, PBL teaching predominantly focuses on theoretical discussions, with insufficient attention given to practical application [8].

Simulation training involves creating realistic medical scenarios wherein students play different roles. It places greater emphasis on clinical practice training compared to PBL [8]. As a valuable form of professional teaching, simulation training not only organizes and integrates theoretical knowledge, but also effectively combines foundational knowledge with clinical practice. Simulation training assists students in improving their teamwork, critical thinking, and clinical decision-making abilities [9]. To achieve the optimal outcome of simulation training, debriefing is usually implemented in the teaching process. Teachers guide students to reevaluate the simulation process and review their performance in clinical process, which enables students to cultivate systematic and reflective learning, and address aspects of improvement [10–12].

The main issue of online teaching is student engagement, which is difficult to achieve in an online synchronous learning environment [13]. We employed the teaching modality combining PBL with simulation training, which not only reinforces students' professional knowledge but also systematically structures knowledge from various subjects. Moreover, it focuses on real-time interactions between teachers, students, and peers [14]. This is most imperative to medical education as medical teaching focuses on collaboration, situational learning, and promotion of student’s presentation and decision-making skills [15]. In this teaching modality, students are more engaged in the online course, while teachers are able to take better control of the course and improve teaching quality.

Airway management is a crucial aspect of an anesthesiologist's clinical work. Identifying and managing difficult airways pose significant challenges for anesthesiologists, as failure in airway management can lead to serious adverse consequences [16]. Consequently, we choose the teaching content related to difficult airway management. Our aim is to first organize the professional knowledge content through PBL teaching on difficult airways, stimulating students' enthusiasm for online learning, and then proceed with online simulation teaching on difficult airways, incorporating effective direct debriefing. This study will examine the effectiveness of the combination of PBL and scenario simulation teaching in airway management course within online education modality.

1.Ethical approval and informed consent

No patients were involved or harmed in this study. The entire training process was conducted online through the Tencent Meeting. The simulation teaching process involved were conducted by applying vital signs simulation software (LLEAP Distribution-Laerdal Medical). The study was covered under the ethics review of First Affiliated Hospital of Dalian Medical University and received approval from the Teaching Management of Dalian Medical University (the Teaching Guideline version 2015). The curriculum was implemented in accordance with the teaching standards of Dalian Medical University. ALL procedures and methods were carried out in accordance with relevant guidelines and regulations. Formal consent was obtained from all participants in the study.

2. Preparation phase

Sixty-five students participated in the study, comprising two classes of undergraduate anesthesia students from the class of 2019 (32 students in Class A and 33 students in Class B). All students had completed the theoretical course in anesthesia and the relevant training course in tracheal intubation prior to before this course. However, it should be noted that all students had not received training in PBL or simulation courses. We provided the students with study materials, including the latest airway management guidelines [16, 17], in both Chinese and English. Each student was required to study these materials along with the textbook before class.

3. Professional knowledge quiz

The detailed process of the web-based anesthesia teaching study is presented in Fig. 1. Participants were not informed about the training content before its commencement. All students underwent an initial 20-minute quiz, which assessed their knowledge of airway management. The quiz included questions on the following topics: 1. How to perform airway assessment in patients with head and neck trauma; 2. Tracheal intubation preparation and extubation precautions in patients with pharyngeal tumors; 3. Causes of hypoxia after anesthesia induction in patients with normal preoperative airway assessment; 4. Measures to be taken after multiple failed intubations during general anesthesia induction. The instructor did not provide answers during the quiz, and the results were kept hidden. The same topics were retested at the end of the study to assess changes in students' proficiency in professional knowledge.

4. PBL teaching process

After completing the quiz, the students were randomly divided into eight groups, with each group consisting of four students. Since there were 33 students in Class B, the eighth group had five students. We prepared eight questions of similar difficulty, one question for each group, and scored their answers. After a group finished answering their assigned question, other groups could contribute supplementary answers, and they could earn points for correct responses. In order to encourage student participation, the process was conducted as a competition with rewards. Following the question and answer session, we provided detailed explanations for each question. The specific topics covered were: 1. Risk factors for difficult mask ventilation; 2. Risk factors for difficult tracheal intubation; 3. Approaches to awake tracheal intubation; 4. Processes involved in anticipated difficult tracheal intubation; 5. Grading of laryngoscopic exposure; 6. Treatments for bronchospasm; 7. Methods for establishing an invasive airway; 8. What should be noted when extubating a patient with difficult tracheal intubation?

5. Roles and scenario setting of simulation training

After completing the PBL teaching, we conducted scenario simulation training. Before the training started, we assigned six roles: two first-line anesthesiologists, two second-line anesthesiologists, a director of anesthesia, and a nurse. To facilitate the simulation process, two instructors took on the roles of patient and surgeon, respectively. We prepared four simulation scenarios, comprising two anticipated difficult airway cases and two unanticipated difficult airway cases (Table 1). Each scenario had a duration of 20 minutes, followed by a teacher-led debriefing of the simulation from technical and non-technical perspectives. Subsequently, the same student conducted the second simulation. The Instructor assessed and scored the students' performance during two simulations. After completing the training for each case, the instructor provided a summary of the entire process. The discussion included an analysis of any adverse effects on the patient during the simulation and whether decisive actions and effective precautions were taken.

6. Scenario simulation training process

Before the start of the simulation, the teacher provided students with an explanation of the entire process, the simulation method, and the role of each character. We fully simulated the actual clinical workflow, including a preoperative visit to the patient, and first-line anesthesiologists seeking help from the second-line anesthesiologists and the director when encountering difficulties. Virtual props, such as a laryngoscope, laryngeal mask, light stick, fiberoptic bronchoscopy, and other tools, as well as drugs utilized in simulations, were provided to students. The teacher simulated the patient's vital signs and corresponding scenarios using online vital signs simulation software (LLEAP Distribution-Laerdal Medical), while the students treated the patient based on the vital signs and scenarios described during the training. Students were able to communicate with the patient and the surgeon at any time to obtain information about the patient's medical history and the surgery.

7. Evaluation

The teacher evaluated the entire simulation process based on technical and non-technical criteria. Technical points were assigned based on the following scoring criteria: 2 points for each exercise, 2 points for completing all exercises, 1 point for completing more than 50% of the exercises, and 0.5 points for completing less than 50% of the exercises. Non-technical points were assessed based on the criteria outlined by the Stanford Anesthesia Cognitive Aid Group [17], which included various aspects such as task management (e.g., task assignment, equipment preparation), teamwork, communication, sustained vigilance, crisis identification, decision-making, and self-confidence. Each completed item was awarded 1 point, partially completed items received 0.5 points, and items not completed received 0 points. The detailed scoring scale for Scenario simulation teaching is provided in Table 1.

8. Questionnaire

We administered a course feedback questionnaire to gather input from the students. The questionnaire included the following questions: 1. Are you satisfied with the teaching method that combines PBL and scenario simulation teaching? 2. How does this course compare to previous traditional coursed? 3. Difficult airway simulation teaching feels incredibly real? 4. Does this course effectively improve problem-solving skills? 5. Does this course effectively improve self-learning ability? 6. Does this course effectively improve teamwork skills? 7. Does this course effectively increase interest in professional knowledge learning? 8. Difficult airway learning provides great benefits in improving anesthesia skills? 9. I am able to grasp the content of this course?

9. Statistical analysis

The results data were presented as mean ± standard deviation. All results were statistically analyzed using SPSS 25.0 software. The scores of the pre- and post-class quizzes were compared using a paired t-test. The groups and scenarios were randomly assigned during the simulation. We evaluated both technical and non-technical aspects in each of the four scenarios. The pre- and post-class data were subjected to statistical analysis using a paired t-test. A significance level of α = 0.05, with p < 0.05, was considered statistically significant.

1. Student basic information

Table 2 presents a detailed overview of the participants' information. All students had successfully completed theoretical learning and practical exams. However, they had not gone through PBL training, simulation training, or clinical practice.

2. Web-based anesthesia simulation teaching demonstrated high effectiveness

Table 3 presents the evaluation of technical and non-technical points for four scenarios: two anticipated difficult airway scenarios and two unanticipated difficult airway scenarios. While there was no statistically significant difference in technical and non-technical points among the scenarios, it is evident that the second simulation achieved a higher score compared to the first simulation. The total score (technical points + non-technical points) for the four scenarios significantly improved in the second time compared to the first time, and this difference was statistically significant(p<0.05).

Table 2

Demographics
Variable	Number	Percentage (%)
Gander
Female	43	66.2
Male	22	33.8
Age
25	1	1.5
24	2	3.1
23	11	16.9
22	37	56.9
21	14	21.5
Normal Training Phase
Theory qualified	65	100
Technical qualified	65	100
Problem-based learning
Yes	0	0
No	65	100
Scenario of simulation experiences
Yes	0	0
No	65	100
Clinical experiences
Yes	0	0
No	65	100

Table 3

Comparing performance in the first and second simulations
Classification	Term	First time	Second time	P value
Scenario A	Technical points	2.25 ± 0.354	5.00 ± 0.000	0.058
	Non-technical points	2.25 ± 0.354	4.75 ± 1.061	0.126
	Total score	4.50 ± 0.707	9.75 ± 1.061	0.030
Scenario B	Technical points	2.75 ± 1.061	4.50 ± 0.707	0.090
	Non-technical points	3.00 ± 0.000	5.50 ± 0.707	0.126
	Total score	5.75 ± 1.061	10.00 ± 1.414	0.037
Scenario C	Technical points	3.00 ± 0.000	5.75 ± 0.354	0.058
	Non-technical points	1.75 ± 0.354	4.75 ± 0.354	0.105
	Total score	4.75 ± 0.354	10.50 ± 0.000	0.028
Scenario D	Technical points	2.75 ± 1.061	5.25 ± 0.354	0.126
	Non-technical points	2.25 ± 0.354	5.50 ± 0.707	0.144
	Total score	5.00 ± 0.707	10.75 ± 1.061	0.028

3. Web-based anesthesia simulation teaching promotes mastery of professional knowledge

We excluded the data of two students as their quiz results were not received. Therefore, Table 4 displays the quiz scores of 63 students. Following the completion of the training, the second quiz scores exhibited a distinct increase compared to the first quiz scores, and the difference was statistically significant (p<0.05).

4. Course feedback and satisfaction survey results

The survey results (Fig. 2) indicated that all students were willing to embrace the combination of PBL and scenario simulation teaching, finding it superior and more engaging compared to their previous learning approach. The students highly appreciated this teaching modality, and the simulation scenarios in the airway management course were perceived as realistic by 88.89% of the participants. The survey respondents unanimously agreed that the course effectively enhanced their independent exploration and problem-solving skills. Moreover, 97.3% of the students concluded that the course contributed to the improvement of their self-learning and teamwork abilities. 97.22% of the students reported that the course enhanced their difficult airway management skills and subjectively believed that this teaching method positively influenced the learning outcome. Additionally, the majority of students (83.33%) expressed confidence in their mastery of the course content.

Table 4

Comparison of quiz scores before and after the course
Classification	First time	Second time	P value
Question 1	5.05 ± 2.986	7.94 ± 2.382	P < 0.001
Question 2	4.21 ± 2.377	7.92 ± 1.659	P < 0.001
Question 3	4.62 ± 2.246	8.05 ± 1.539	P < 0.001
Question 4	3.44 ± 2.867	8.63 ± 1.937	P < 0.001
Total score	17.32 ± 8.056	32.54 ± 5.376	P < 0.001

Under the Internet ecosystem, various types of application software are available for learning professional knowledge using cell phones, computers, and other devices [18, 19]. Students can access diverse professional knowledge through online resources that are boundless, cost-free, and offer a wide range of options [20, 21]. However, in order to create a systematic online teaching process, classical knowledge needs to be guided, organized, and summarized by teachers. While online teaching has achieved partial success in medical education, its application in anesthesia teaching is still rare and requires further exploration and study.

During the online teaching process, we implement a competition model of PBL to encourage students to actively participate in the online course and help them review the knowledge they have studied before the class. Research has demonstrated that PBL is an effective method for theoretical learning [22]. Questions in PBL were designed to be realistic and closely aligned with clinical scenarios, without fixed answers, allowing students to develop critical thinking and remain highly motivated throughout the training process. Students engaged in problem-solving through self-learning, research, discussion, and collaboration within their groups [7]. When students take responsibility for their own learning, students experienced a significant enhancement in self-efficacy, this represents an important shift from passive learning to active exploration [23].

The limited clinical experience of undergraduate students, their lack of flexibility in applying knowledge, and their weaknesses in crisis identification and disease diagnosis highlight the need to enhance clinical practice by integrating isolated knowledge into a structured knowledge system through simulation training [24]. Increasing numbers of medical training institutions worldwide are incorporating simulation to create experiential courses for medical students. Simulation training offers a safe environment for multiple professional team members to practice technical and non-technical skills [9]. Anesthesiologists, in particular, face the challenge of performing invasive procedures and managing vital signs in a high-risk clinical environment, making simulation teaching well-suited for learning and practicing the technical and teamwork skills required in anesthesia practice [24, 25]. In simulation training, classical knowledge contents are realistically presented, leading to students’ deeper immersion in the real clinical anesthesia management process [26]. Given that airway management is a key point in anesthesiologists' clinical work, we specifically chose cases related to difficult airways to explore anesthesia simulation training. Our results showed that web-based anesthesia simulations significantly improved students' mastery of airway management content, facilitated the conversion of theoretical knowledge into operational skills, and led to improved performance in subsequent simulations. Students' clinical abilities in airway management were significantly enhanced, and they demonstrated excellent execution and leadership skills in crisis situations, aligning with findings from previous studies [27]. At the same time, non-technical skills (including task management, teamwork, communication, sustained vigilance, crisis identification, decision-making, and self-confidence) have been improved. The benefits of the simulation training include increased confidence, reduced anxiety, and increased proficiency [28].

In our study we observed a significant increase in students' quiz scores (from 17.32 to 32.54) when comparing the scores before and after the class, indicating the effectiveness of the teaching modality combing PBL with scenario simulation training. The questionnaire results showed that all students believed the method was beneficial, enhancing their learning efficiency and interest in systematic professional learning. They also noted that the course improved their independent exploration and problem-solving skills, with 97.3% of students considering it helpful for improving self-learning and teamwork skills. 97.22% of the students reported that the course enhanced their difficult airway management skills and subjectively believed that this teaching method positively influenced the learning outcome. Through the scientific combination of online teaching and scenario simulation teaching, undergraduate anesthesia students were able to develop crisis management skills, which were essential for solving practical clinical problems. Overall, out findings suggested that the combination of PBL and scenario simulation training is highly effective and appealing for anesthesia education.

In the web-based simulation teaching, active student engagement is crucial. However, teachers find it difficult to closely monitor the classroom and ascertain the actual participation rate of students in online teaching modality. Lack of control over the simulation course directly impacts teaching quality and hampers achieving the desired teaching effect [14]. Direct debriefing effectively addresses this drawback by increasing teaching sessions, motivating students, and improving teachers' control over the online classroom. Based on the learning outcomes reflected in the direct debriefing phase, teachers guide students to re-enter the simulation scenario, identify areas of deficiency, supplement relevant knowledge, and integrate it into a systematic knowledge framework. The traditional teaching style, which often involves one-way transmission and passive learning, is transformed into an interactive teaching pattern with two-way feedback. Debriefing encourages students to express their thoughts and emotions during a situational phase, allowing them to uncover individual and collective experiences and ideas [29]. An effective debriefing guides learners to think through their actions and reactions, allowing learners to incorporate the simulation session into their prior experiences [9]. Moreover, the "claim-explore-verify" questioning strategy is utilized in direct debriefing to help students learn through analogies and form a systematic, patterned, and comprehensive workflow for clinical anesthesia management, enabling them to express their professional views and engage in further discussions. The debriefing and discussion of the simulation process helped to identify deficiencies in performance and also contributed to the construction of the professional knowledge framework [30]. This approach not only systematically integrates theoretical knowledge but also completes the "real-virtual-real" transition of clinical anesthesia management [31]. A set of scientific and systematic inquiry-based learning methods is established for students, reflecting the advanced, humanistic, and enjoyable features of an intelligent online course.

However, this study has several limitations. Firstly, the number of participants was insufficient, and only four scenarios related to difficult airways were applied, which may have introduced bias in the results. Secondly, the absence of blinding in our study led to inevitable bias in the analysis of subjective observations. Thirdly, we acknowledge that there was no control group, as the students required to receive the same teaching approach to ensure fairness in performance assessment. However, we adopted a self-pairing analysis, which enhanced the observation of self-improvement. Moving forward, we will continue to explore this teaching style and plan to follow the progress and growth of these students in the long term. Additionally, we intend to conduct multicenter, randomized controlled trials with larger sample sizes to further investigate the efficacy of this teaching method.

In conclusion, the combination of PBL and scenario simulation training proved to be a highly effective and engaging way of online teaching and learning for undergraduate anesthesia students. Integrating theoretical knowledge with practical application not only enhances students' learning interest but also nurtures their critical thinking skills. Meanwhile, it improves non-technical skills, including task management, teamwork, communication, sustained vigilance, crisis identification, decision-making, and self-confidence.

PBL

problem-based learning

Ethics approval and consent to participate

The study was conducted on line, and no patients were involved or harmed in this study. The entire training process was conducted online through the Tencent Meeting. The simulation teaching process involved were conducted by applying vital signs simulation software (LLEAP Distribution-Laerdal Medical). The study was covered under the ethics review of First Affiliated Hospital of Dalian Medical University and received approval from the Teaching Management of Dalian Medical University (the Teaching Guideline version 2015). Information was taught strictly following the established standards of Dalian Medical University. ALL procedures and methods were carried out in accordance with relevant guidelines and regulations. All anesthesia students provided written informed consent.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was supported by Liaoning Teaching Science Researching Program, China (Grant NO. JG21DB154)

Authors’ contributions

YL and PG designed the study, drafted and wrote the manuscript. YL, TT-W, YY-H and XY-L Jointly participated in teaching. LJ-G collected the data and did statistical analysis. SAH and PJO helped with English-language editing. QP-W and PG revised the manuscript critically and final approval of the manuscript. All authors gave intellectual input to the study and approved the final version of the manuscript.

Acknowledgements

We would like to thank the students who participated in this study. We would also like to thank Yi-tong Zhang for her efforts and performance during this study.

Author details

¹Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, NO.222 Zhongshan Road, 116011 Dalian, China. ²Department of Graduate, Dalian Medical University, 116044 Dalian, China. ³Department of Physiology and Cell Biology, The Ohio State College of Medicine, 43210 Columbus, Ohio, USA. ⁴Department of Anesthesiology, Dalian Medical University, 116044 Dalian, China.

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Table 1 is available in the Supplementary Files section.

No competing interests reported.

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Web-based problem-based learning (PBL) and scenario simulation teaching in airway management for undergraduate students

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