A WISH questionnaire to measure the faculty perceptions of the medical simulation environment as their workplace


 Background

The medical simulation environment is a specific type of work environment. It would seem essential for educators to have a tool with which they could identify its features to maximize the effectiveness of medical simulation – teachers’ workplace - and optimize their work efforts. The purpose of this research study was to construct a proprietary tool, which would help to characterize the medical simulation environment as a type of work environment and also to identify particular factors that are important in organizing the educational environment in simulation.
Methods

At first, six faculty members took part in semi-structured interviews, whose findings were used to develop a standardized questionnaire consisting of 30 items. The authors then validated the questionnaire in a survey among the other 32 academic teachers involved in teaching with the use of medical simulation.
Results

The Work In Simulation Healthcare questionnaire addresses the aspects of teaching in a simulation environment referring to technical-administrative conditions, teacher development, and the overall score. The Cronbach's alpha reliability index for the overall result of the questionnaire is α = 8.22 based on standardized items; the reliability index for the scale of ‘the technical and administrative conditions’ and ‘the professional development of teachers’ is α = 0,57 and α = 0,76, respectively. The questionnaire allowed the authors to know the ratings of academic teachers for the two scales.
Conclusions

The Work In Simulation Healthcare questionnaire allows educators to identify the traits of the simulation-teaching environment. It provides the potential to optimize the conditions of medical simulation, improve the quality of teaching and the overall educational process, as well as design effective faculty development programs. The authors of this study consider the WISH questionnaire the first method of this type.


Abstract Background
The medical simulation environment is a speci c type of work environment. It would seem essential for educators to have a tool with which they could identify its features to maximize the effectiveness of medical simulation -teachers' workplace -and optimize their work efforts. The purpose of this research study was to construct a proprietary tool, which would help to characterize the medical simulation environment as a type of work environment and also to identify particular factors that are important in organizing the educational environment in simulation.

Methods
At rst, six faculty members took part in semi-structured interviews, whose ndings were used to develop a standardized questionnaire consisting of 30 items. The authors then validated the questionnaire in a survey among the other 32 academic teachers involved in teaching with the use of medical simulation.

Results
The Work In Simulation Healthcare questionnaire addresses the aspects of teaching in a simulation environment referring to technical-administrative conditions, teacher development, and the overall score.
The Cronbach's alpha reliability index for the overall result of the questionnaire is α = 8.22 based on standardized items; the reliability index for the scale of 'the technical and administrative conditions' and 'the professional development of teachers' is α = 0,57 and α = 0,76, respectively. The questionnaire allowed the authors to know the ratings of academic teachers for the two scales.

Conclusions
The Work In Simulation Healthcare questionnaire allows educators to identify the traits of the simulationteaching environment. It provides the potential to optimize the conditions of medical simulation, improve the quality of teaching and the overall educational process, as well as design effective faculty development programs. The authors of this study consider the WISH questionnaire the rst method of this type.

Background
Educators have been interested in studying the educational environment more thoroughly since the 1960s. With the rst inventories, they started to evaluate the quality of the learning environment as its in uence on the students' professional development has become more widely acknowledged. There are a few very useful tools, which have been used to investigate speci c or general aspects of the educational environment; like the Dundee Ready Education Environment Measure [1], the John Hopkins Learning Environment Scale [2], or the Medical School Learning Environment Scale [3]. However, these tools do not gauge the speci c aspects of the simulation environment, let alone include teachers as their subject.
A few authors conducted research related to medical simulation [4][5][6][7][8][9]. Some of them used the Satisfaction with Simulation Experience Scale to learn students' perspectives on the simulation learning experience or their satisfaction with a particular type of simulation equipment and methodology [10].
Nevertheless, hardly any study has been found describing the simulation environment as a speci c kind of educational environment as seen by the academics as their work environment.
Contemporary medical simulation has become so signi cant and widely recognized teaching methodology that not only does it affect the medical education environment but also a successful implementation of the program curriculum. Its organization and effectiveness are highly dependent on the teachers, which, on the other hand, is further re ected in the students' perception of the education process and their performance. Acknowledging the importance of the simulation environment for the implementation of a wide range of clinical objectives, the authors attempted to characterize this particular type of education environment as the teachers' workplace.
Teachers play an important role in shaping the conditions of the education environment, including the environment of medical environment. Their role is to make the most use of it so as to maximize the effectiveness of simulation methods and provide the students with the highest quality education. Their duty is to make this particular education environment resemble the conditions found in real clinical departments, but also to follow the requirements of good simulation teaching, that is: providing feedback, assuring coherence of the curriculum, meeting the standards of medical schools, diversifying the level of di culty, using different teaching strategies, or controlling the environment. Due to their commitment, they individualize the learning process for students and let them study clearly de ned clinical objectives giving them the opportunity to make, capture, and correct mistakes without negative consequences [11].
Although it creates more challenges for the teacher in terms of handling the equipment or using speci c methodologies, it gives more opportunities for providing education when compared to classical forms of teaching, such as lectures or seminars. More frequent and deeper clinical interactions of students in a simulation setting allow them to integrate the cognitive and motoric content with knowledge and skills as well as enhance their professional development, which is paramount to the teachers' mission [12].
When planning the implementation of clinical objectives in the simulation environment it is necessary to take care about proper training of the teaching staff to work with the use of simulation methods. Their continuous education and improvement of quali cations are important for meeting the criteria of highquality education for students in medical faculties [13]. Even though the simulation teachers' role gradually seems to be acknowledged, the authors of the study found no method with which it would be possible to identify the features of that speci c educational environment as viewed by the teachers themselves.
In this paper, the authors wanted to present the construction and initial application of a new method used to gauge the teachers' perspectives on the simulation environment as their work environment. The information that can be obtained with this unique method may be useful to understand the simulation environment as an educational environment, to form the basis for the improvement and adjustment of educational conditions to implement the curriculum, and design faculty development programs.

Construction of the Work In Simulation Healthcare (WISH) questionnaire
Despite quite a few methods and questionnaires describing the educational environment or the attitude towards medical simulation, no method speci cally designed for academic teachers' use has been found.
Thus, it was considered necessary to construct an appropriate psychometric tool.
Teachers co-create the educational environment [14,15]. They are among the pillars of this environment. However, their work conditions are also organized by those, who manage education, including educators, administration staff, school authorities, and respective state departments of education. Thus, the great potential of simulation methods should be thoughtfully maintained to be used effectively. The authors of the study were determined to identify the aspects of that setting that need to be recognized and taken care of while organizing teachers' work in simulation. It was considered more valuable if the information would come directly from the people engaged with this particular environment. Hence the authors of the study invited the academics involved in simulation-based teaching and implementation of the curriculum with dedicated equipment and teaching methodologies.
A literature search helped to nd available tools used to evaluate the education environment; included were: Dundee Ready Education Environment Measure [1], the John Hopkins Learning Environment Scale [2], and the Medical School Learning Environment Scale [3]. The authors of the study analyzed them to identify the aspects they found important for their research project; they were: curriculum implementation, interactions with the academic community, sense of the education climate, and facilities.
The construction of the tool (ethical approval no. KE-0254/241/201 of the Medical University of Lublin, Poland) started with semi-structured interviews of six academic teachers who conducted classes in a simulation environment. The interview questions were created based on the information coming from the student research, observation of academic teachers' work, and literature on the subject. It consisted of a metric and 53 open questions addressing the aspects related to work in a simulation environment. The interviewees answered the questions using the CAWI (Computer Assisted Web Interview) method. Their analysis allowed the authors to create two main scales that were included in the design of the questionnaire-based tool: "the technical and administrative conditions" and "the professional development of teachers". The nal version of the method, called the Work In Simulation Healthcare (WISH) questionnaire, included a metric and 30 items to which respondents were given a 5-point Likert scale: 'I completely agree (5)' and 'I completely disagree (1)' as the answer options. The questionnaire standards, along with its scales were divided into quartiles. Figure 1 presents the procedure of the WISH construction. [ Figure 1 -near here] Medical simulation is claimed to be an expensive teaching environment. However, if properly managed, these costs are cost-effective [16][17][18][19]. It is therefore considered important to include the nancial aspect of available teaching resources in planning a simulation-based curriculum. For this reason it was also included in the WISH questionnaire. Studies by other authors also justify the distinction of such areas in the assessment of the educational environment by teachers [20]. The medical simulation environment as a speci c type of educational environment also seems to t into this trend. Moreover, research results indicate that there are speci c factors and principles that teachers should be aware of when working with medical simulation [21]. This therefore justi es taking into account the scale of professional development of teachers, which should be an inherent factor of working in a simulation environment [22][23][24].
The reference for the above mentioned construction of the WISH questionnaire and validity of the distinction of the two scales related to the technical-administrative conditions and the professional development of teachers may be con rmed with the statement of Issenberg et al. (2006) [5], that the effective use of simulation assumes the presence of three components: training resources, trained educators, and curricular institutionalization. These aspects were also included in the WISH questionnaire. The literature refers to studies on the investigation of educational environment, however, it is the perspective of students rather than academic teachers [2,26]. All the more important seems to be the construction of a new tool, allowing to de ne the teacher's perspective in terms of working in a simulation environment as a speci c educational environment.

The characteristic of the research process
The rst part of the survey was an online structured interview and the second part was a survey based on the interviews. The author who conducted the survey was PhD Izabela Mamcarz, an academic teacher, female. She had had the experience of collecting data for several studies as well as for two doctoral dissertations. She had also nished a seminary in methodology of social sciences.
Before the study commencement the relationship has been established between the participants. They learnt the goals of the survey and the fact that the survey was designed for cognitive, theoretical and practical goals. Another information the participants received were as follows: participation was voluntary; the survey consisted of a certi cate and a questionnaire; the obtained research results would be analyzed and discussed from an empirical point of view, and would serve to answer the research questions posed in the study; the study was oriented on the assessment of teachers' work under simulation conditions; the completion of the questionnaire was an expression of consent to participate in the survey; the results of this survey would be processed anonymously and used only for scienti c purposes. There was no facilitator in the research because the rst part of the survey was a structured online form and the second one consisted of short sentences assessed by the participants with a Likert scale.
To underpin the study, the content analysis was stated. Participants were selected purposively; they were approached by online form and face-to-face. In the study there were 32 participants. No one refused to participate in the study nor dropped out.
The data was collected at home and no other person was present besides the participant and the researcher. The sample was academic teachers working in medical simulation environment. Questions were provided for the online form and then speci c items were developed for the questionnaire step. No repeat interviews were carried out and no recording was used to collect the data. Because there weren't any facilitators, there were no eld notes. The data saturation wasn't discussed.
One data coder coded the data. The themes for the rst part of analysis were derived from the collected data. The participants didn't provide feedback on the ndings. There was consistency between the data presented and the ndings. The major themes were presented in the ndings in the analysis of the two scales and the minor themes were described in the analysis of particular sentences of the questionnaire. The result of the rst part of the survey was a survey on its own. It was planned as an initial stage in construction of a questionnaire for the second part of the survey and it should not be considered as a separate qualitative research.

Characteristics of the study group
The authors of the study used a targeted selection method to choose the participants for the project as a wish to get reliable information of the simulated environment. In their opinion this had to be academics with a professional experience in teaching with simulation methods. Thirty-two teachers of the Medical University of Lublin agreed to take part in the survey with the use of the new tool. The number was considered su cient for this study project as it constituted about 10% of all academics involved in teaching with simulation methods at that university.
The average age of the respondents was 39 years. The lowest value reported by the respondents was 25, while the highest value was 56. Table 1 shows the average and standard deviation for the age of the participants based on the metric information. [Table 1. Age of respondents -near here]. Of the 25 academic teachers who provided the answers, 22 declared that they were clinically active. Figure 2 presents data on the teachers surveyed in terms of years of service. [ Figure 2 -near here]. That information was further divided into two groups: short -up to seven-year long experience, and long, the experience of more than seven years in that eld. This criterion was based on the fact that an average time of promotion at that university, from the position of an assistant to the position of an assistant professor, is seven years. Short-term job experience was reported by 34.4% of people, while long-service, by 65.6% of people.

Results
The presented results describe the researched group of academics and come from data obtained with the authors' proprietary WISH questionnaire. Table 2   Cronbach's alpha reliability index for the overall result of the WISH questionnaire is α = 8. The descriptive analysis in the scale of "the technical-administrative condition" revealed two items to which 100% of respondents selected "agree" or "completely agree." All of them "agreed" or "completely agreed" that the number of exercise groups is an essential factor in uencing the effectiveness of the content (item 8) and additional equipment, or the interior design of the room increases the realism of the scenario (item 20). The knowledge about the capabilities of simulation equipment as being essential for the effective conduct of classes in simulated conditions (item 4) was an important factor for 93,76% of the respondents. More than 50% of the respondents were not sure if the cost of simulated classes is higher than in a clinic (item 25). More than 81% of them mostly agreed with the fact that the cost of work with simulated methods is an important aspect of learning planning (item 28). About 75% of the surveyed academics supported the fact that the technical problems often make it di cult to conduct classes in simulated conditions (item 3).
Taking into consideration the second scale, "the professional development of the teachers" -there were six items to which 100% of the surveyed participants agreed or completely agreed, they were: -conducting classes in a simulated environment requires a proper organization of time (item 5); -an adequately prepared scenario helps to implement the content of courses in simulated conditions effectively (item 6); About 84% of the teachers agreed or completely agreed with the fact that debrie ng is an essential stage of conducting classes in simulated conditions (item 21), and carrying out classes in a simulated environment can be a challenge for the teacher (item 24). There are a few statements where more than 70% of respondents marked 4 or 5 on a Likert scale. According to the results, 75,01% of respondents selected they agree or completely agree with the fact that they feel well prepared to teach in a simulated environment (item 1); 78,13% -that, conducting classes in a simulated environment requires a more open attitude towards the student (item 7); 71,88% that, the simulation environment can be stressful for the student (item 23) and 71,55% that, working with simulated methods requires a higher level of quali cations from the teacher, i.e., communication skills (item 15). Almost 70% of the respondents agreed or completely agreed with the fact that the teachers would like to improve their quali cations necessary to conduct classes in simulated conditions (item 13); the effectiveness of simulated methods is higher than in traditional classes (item 14); and that the teacher's communication skills in the simulated environment should be higher than in the conventional environment (item 17). More than 40% of the surveyed participants completely disagreed or disagreed with the fact that the di culty in effective implementation of classes is more often on the student than the teacher (lack of preparation, involvement) (item 11). The results were quite equally distributed in the items 29 (Teachers were aware of the costs associated with the use of simulated methods in teaching) and 30 (Teachers consider the costs of teaching using simulated methods in the planning of lesson plans).

Discussion
The results presented in this article draw attention to the fact that for the surveyed academics the aspects related to their work environment, the technical-administrative conditions as well as professional development are important when managing the teaching process in a simulated environment. All teachers agreed that the external aspects, such as the number of simulation session groups, additional equipment and interior design of the room are important in organizing this process. Paying attention to the equipment, teachers were also aware of the fact that their knowledge about that speci c equipment is essential. As referred to another aspect included in "the technical-administrative conditions" scale -the costs of simulating classes -the surveyed academics were not sure about the difference between expenses involved in teaching classes in simulation conditions or in a clinic. They were not aware of the high costs of the former, which may be an important factor in planning the education process.
Proper organization of time and planning functional scenarios for simulation sessions were important for all surveyed participants. They also found the involvement of the simulated patients intrinsic in the implementation of simulation sessions and agreed that the effectiveness of the sessions depends on the teacher's and the student's preparation. They considered simulation as an essential complement to clinical teaching and a reliable method of teaching.
The surveyed participants agreed with the statement that work in simulation requires teachers' preparation for classes, a thoughtful organization of the teaching plan, implementation of special methodologies and well-established technical-administrative conditions of the simulation setting. Since it is a complex process it requires appropriate decisions based on experience, available literature, and reliable research results.
The shortage of health professionals, including doctors in Poland, triggered a series of system-based changes in the undergraduate education system. The changes included implementing a new Higher Education Act and introducing new standards of education, i.e., medical simulation. The Polish government invested in a network of Simulation Centres based in Polish medical schools and required the application of the simulation methods for providing education to students of medical curricula. Included were: a transfer of minimum of 5% of clinical education into simulation conditions, employment of simulated patients to assist students' professional skills acquisition in the patient-doctor communication and the implementation of the Objective Structured Clinical Examination (OSCE) aimed at the assessment of health care students' professional skills and competencies. The above mentioned system-based requirements raised the need to expand the pool of quali ed faculty capable of carrying out simulation-enhanced educational process. To be able to establish an effective simulation environment, develop high standards for students learning with the use of medical simulation and hold the responsibility for teachers' quali cations in that eld, the authors of this study aimed to create a standardized tool, which could help to characterize the medical simulation environment as teachers' workplace. In addition, the designed questionnaire enabled the assessment of the individual aspects that make up the simulation environment as an education environment.
Harden and Crosby (2000) [27] list twelve teacher roles that can be classi ed into six areas: (1) Teacher as a provider of relevant information in the teaching process in lectures or a clinical context, The authors point out that some teachers' roles are more focused on a person with medical knowledge, and some emphasize the role of an educator.
The effectiveness of the methods and methodology depends on the teacher's knowledge and involvement [12]. It is the teacher who has the opportunity to decide on the type of a teaching method, curriculum design, implementation of educational objectives, and the legitimacy of applied tools. The conditions of the simulation environment that must be provided for the teaching to bring the expected outcomes can only occur with the participation of academic teachers, the majority of whom are regular clinicians. Their expertise in the eld of patient care is precious; however, their availability is often limited due to clinical obligations. With medical simulation requiring a unique teaching methodology, concentration, and attentive evaluation of students' skills and competencies, the educational load of medical simulation teachers is much higher. What is more, the knowledge of the academic teacher's role, the scope of his or her duties or expectations related to the implementation of the education process is critical in the process of matching the teachers' tasks to the existing curriculum, the faculty evaluation, as well as designing programs for faculty development.
The authors of the study embraced the information mentioned above to look for the answer to their research question -what is the teachers' perspective on their work in the medical simulation environment. The initial stage was based on the interviews, which revealed certain tendencies in the opinion of academics regarding working in simulated conditions. Then, further works aimed to design a more standardized tool -the Work in Simulation Healthcare questionnaire.
The construction of the WISH questionnaire proved to be effective for describing the perspectives of academic teachers on their work in simulated conditions. The questionnaire seems to ll up the niche in this particular research area, and to present the applicability of the new tool its construct was juxtaposed with the DREEM [1], JHLES [2], MSLES [3] and SSES [10] inventories. As demonstrated in Table 3, the new questionnaire addresses the same aspects of a general education environment as the above-mentioned well-established tools; however, the area of the study is narrowed, in that case, to simulation conditions.
[ Table 3. Comparison of the DREEM, JHLES, MSLES, SSES, WISH -near here]. Another unique feature of this tool is that the authors changed the source of information from the students to academic teachers. It also allows expanded evaluation of the educational environment by investigating both students' and teachers' preparedness to classes, as this mutually affects the perspectives of the learning and teaching processes.

S-students; T-teachers
The authors of the presented study project have found no other tools in the available literature that would speci cally identify the factors helping to describe golden standards for setting up effective simulation environment and allow the academics to provide their viewpoint on these issues. The WISH questionnaire was designed to identify these factors and to understand the perspectives of academic teachers on working in a simulation environment. The presented research results highlight the areas which most of the surveyed participants found relevant when working in a simulation environment. The authors of that research project consider the results of their survey useful and potentially applicable worldwide when deciding on the process of organizing and teaching simulation-based curriculum.

Limitations
A high-reliability index of the entire method in the initial version of the tool makes the measurement reliable. To improve the reliability of individual scales, coe cients items with low discriminatory power (less than 0.3) should be removed and re-analyzed. To determine all the psychometric values of the method, a large population of academic teachers should also be examined.

Conclusions
Medical simulation is a unique educational environment for students. It has great potential, which, to be fully utilized, requires skillful management by the teachers [27]. To be able to establish an effective simulation environment, develop high standards for students' education with the use of medical simulation and hold the responsibility for teachers' quali cations in that eld, the authors of this research project wanted to characterize the medical simulation environment as teachers' workplace, thus created a standardized tool called the Work In Simulation Healthcare questionnaire. The authors consider the WISH questionnaire the rst method of this type. KT has made substantial contributions to the conception and designing the work; IM has carried out both stages of the study, the interviews and questionnaire stage, and analyzed the data; NR has made literature search, language revision, and preparation of the manuscript; PM has contributed to the analysis of the data; AT substantively revised the work Competing Interest Figure 1 Construction of WISH -procedure Number of respondents in terms of years of service