Perceptions of Undergraduate Students towards Utilization of Clinical Simulation in Teaching and Learning in Rural Universities in Uganda: A Mixed method study

Background: Simulation is a new pedagogical method in Africa that underscores the need to operationalize it and generate context-specific scholarship regarding clinical simulation in Africa. Despite the superior learning outcomes of using simulation in medical education, its use in developing countries is often limited, compounded by limited scholarship on simulation especially relevant to an African context. The research aimed to explore perceptions surrounding the use of simulation among undergraduate students. Methods: A mixed method convergent parallel design was used in which both the quantitative and qualitative approaches were employed currently to explore the perception of the undergraduate students towards the use of clinical simulation in teaching and learning. The quantitative approach assessed the perception of the students on a five-point Likert from strongly disagree to strongly agree scale while the qualitative approach employed a focused group discussion to explore the perception of the students in regards to clinical simulation. Quantitative data was analyzed using Stata Version 17. Qualitative results were analyzed through thematic analysis by Brauna and Clark. Results: 298 participants were recruited into the study. The mean age of the participants was 27 years with a standard deviation of 5.81 years. The majority 152(51.01%) of the participants were males. Most 111(37.25%) of the participants were pursuing Bachelor of Medicine and Bachelor of Surgery. The grand mean of the perception scores of the students towards the use of simulation in clinical teaching was 3.875269 ±0.5281626. The participants strongly agreed that it is incredibly helpful to have someone who works in the field debrief with them after completing a scenario and their overall perception towards this was high (Mean =4.65241±0.6617337). Conclusion This exploratory study revealed that medical, nursing, and midwifery students from the rural Universities of Busitema and Lira demonstrated a positive perception of the use of clinical simulation in teaching and learning. The results conclude that simulations help students better understand concepts in clinical settings, provide them with valuable learning experiences, and help them stimulate critical thinking abilities. Further, the participants perceive simulation to be realistic, and knowledge gained could be transferred to the clinical areas.


Background
The rising number of health students coupled with advancing technology has necessitated to adoption of new methods in teaching [1].
The traditional apprentice model of medical and nursing training has enormous inherent weaknesses [2].The apprentice model of, "see one, do one, and teach one" causes' performance anxiety as students get to practice on a real patient for the rst time without prior experience [1][2][3].The traditional model limits students' ability to experience and or acquire clinical skills for rare clinical conditions, while a high volume of students relative to the number of patients comprises the quality of the bedside traditional model of clinical teaching [2,3].
Clinical simulation offers numerous superior bene ts compared to the traditional model of teaching [5].Clinical simulation mimics a reallife clinical setting [6] and offers an opportunity for students to learn, re-learn, and make mistakes while uncompromising patient safety and reducing students' performance anxiety [3][4][5]7].Besides the acquisition of clinical psychomotor skills and compatibility with ethical principles [4,5], simulation enables students to acquire cognitive soft skills such as inter-professional collaboration, teamwork, and communication skills among many other skills which ordinarily were not possible in the traditional model of teaching [5,8].
Although Simulation has been in use since the 16th century and is widely used in developed countries, and its utilization in resourceconstrained settings such as Uganda is still low [7,9].The associated high cost of equipment for simulation, the lack of infrastructure, and human resources have been noted to limit the utilization of simulation in low-income countries [8,10].Although Clinical simulation offers students more time to practice and hone their clinical skills in a safe learning environment, the, negative perceptions towards the use of clinical simulation may hinder its utilization in medical training.
A limited number of studies in Uganda have generated context-based evidence vital to scaling up the utilization of clinical simulation among health professionals.The purpose of this study was ll the knowledge gap by exploring the perception of undergraduate students towards utilization of clinical simulation at Busitema University and Lira University in Uganda.

Study design
A mixed method convergent parallel design was used in which both the quantitative and qualitative approaches were employed currently to explore the perception of the undergraduate students towards the use of clinical simulation in teaching and learning.

Study site
This study was conducted at Busitema University and Lira Faculty of Health Science.Both universities have a skills laboratory, while Busitema University has an additional simulation center that provides students with opportunities to acquire clinical skills.Busitema University had undergraduate nursing, anesthesia, and medicine programs, while Lira University had a Bachelor of Midwifery Sciences.All the program follows a competency-based curriculum and provides graduate nurses, anesthetists, and medical students with opportunities to learn clinical and professional skills through simulation-based learning.The undergraduate programs at Busitema University currently admit about 25-30 nursing students, 20-25 anesthesia students, and 60-70 medical students annually.Lira University admits about 60 midwifery students in a year.

Study population
The study was conducted among students of nursing, midwifery, and medicine.This will include students in clinical years in Busitema University starting from the third year to the nal year of study and students in third to fourth year in Lira University.

Sample size determination
The combined universities have approximately 300 students in the clinical years.Therefore, the whole population of students was included in the study because of the small population.As such, we invited all members of the study population to participate in the study.
The sample size for qualitative was obtained by saturation.

Sampling technique
For quantitative, consecutive sampling was used to select participants for the study while purposive sampling was employed for qualitative.

Data collection tools and data collection procedure
A self-administered questionnaire was used to assess the status of the utilization of the simulation.The questionnaire will assess the readiness to conduct simulations including the equipment that is available for simulation activities, the availability of scenarios developed, the number of simulation scenarios conducted in a semester, the number of simulation sessions conducted in the skills laboratory, and the courses for which simulation was conducted.The ve-point Likert scale was used to assess the perception of the undergraduate, medical, nursing, and midwifery students toward the use of clinical simulation in clinical teaching.

Rigors/ trustworthiness of the study
The trustworthiness of the study was ensured by the following terms: credibility, transferability, conformability, and dependability [3].

Credibility
This was ensured through establishing a conducive rapport with participants and conducting a pilot interview before collecting data so as to include questions that might have probably been missed out and also, omitted irrelevant questions.Open-ended questions were used and the participants were given ample time for interaction to allow them express their views fully.The focus group discussions were able to capture all the information from the students without any omission.

Conformability
The researcher made vigorous attempts to be objective, which therefore ensured provision of accurate and relevant data.This was done by evaluating interview questions to ensure that they are open ended and not leading questions.Codes used for each participant was used to allow proper matching of each participant's description.

Dependability
Careful listening to the recorded responses to explain phrases that are used by the participants was done.All the activities were recorded from the rst step of the study.The research team agreed on the patterns of phrases and categories so that the data remains solid.

Transferability
This was achieved by eliciting rich descriptions of study methods and population, adequate sampling and through achieving data saturation point.

Data management and Analysis
The quantitative approach assessed the perception of the students on a ve-point Likert from strongly disagree to strongly agree scale while the qualitative approach employed a focused group discussion to explore the perception of the students in regard to clinical simulation.Quantitative data was analyzed using Stata Version 17 in which descriptive statistic was used to assess the perception of the students.
This for qualitative data, the study employed Braun and Clarke's six-phase approach to thematic analysis [4] to analyze the data.The phases are "(i) familiarizing the researcher with the data, (ii) generating the initial codes, (iii) searching for themes, (iv) reviewing themes, (v) de ning and naming themes, and (vi) producing a report".
Data were presented narratively.The reporting of data is as per the consolidated criteria for reporting qualitative research (COREQ) guidelines [5].

Demographics of the participants
A total of 298 participants were recruited into the study.The mean age of the participants was 26.7 years with standard deviation of 5.81years (Table 1).The majority of the participants 152(51.01%)were males.Most of the participants 111(37.25%)were pursuing Bachelors of Medicine and Bachelors of Surgery.

Utilization of clinical simulation
The use of clinical simulation was determined using direct questions on how many times students used simulation in an academic semester or indirectly by asking the number of times students spent in the skills or simulation lab.Overall, close to 50% of students had never been to a skills/simulation lab or were there once or a few times which underlines low utilization of clinical simulation (Table 2).The predominant course for simulation was the Obstetrics and gynecology course.Preference of students to learn using clinical simulation.
Preference to use simulation was asked in different ways of which all of them gave a similar response.Although the utilization of clinical simulation was low, 96% of the students preferred to learn clinical skills using clinical simulation (Fig. 1).

Perception of students towards use of simulation in clinical teaching
The grand mean of the perception scores of the students towards use of simulation in clinical teaching was 3.87 ± 0.528.The participants strongly agreed that it is incredibly helpful to have someone who works in the eld debrief with them after completing a scenario and their overall perception towards this was high (Mean = 4.65 ± 0.66).In addition, the participants agreed that it's important to have simulation experiences because the nurses are not too helpful especially during the rst week of clinical placement (Mean = 3.750446 ± 1.081552).
The participants disagreed with the thinking that simulation is very stressful and over whelming (Mean = 2.365772 ± 1.204832).Furthermore, the participants were neutral about not really learning many interpersonal skills from practicing on a doll (Mean = 3.218127 ± 1.32678).The results are summarized in Table 3 (Additional File 1)

Qualitative Results
Qualitative results on the Perception of the students towards the use of clinical simulation in teaching themes emerged regarding the satisfaction of the students with the use of clinical simulation in teaching and learning; these include "mismatch between number and students and available space in the simulation laboratory"; Simulation not integrated into the training curriculum; and Low delity of the simulation (Table 4).
Theme one: Mismatch between student numbers and available space in the simulation laboratory One of the major factors that emerged among the participants is the mismatch between student numbers and available space in the simulation laboratory.The student perceived the number of students to overwhelm the available simulation laboratory: "…I am not satis ed.This is because the number of students assigned to a patient are many and it cause collision and there is lack of communication.The ratio of students to patient should be something like 5:1 instead of…..." [FGD 13b Midwifery].
"…yes I would say partially it's ne because this simulation is only in 2 departments, that is, anesthesia and nursing.For the medicine, we do not do simulation.Even with nursing, the space at the simulation center is actually not enough…."[FGD 3b] Theme two: Simulation not integrated into the training curriculum The second theme that emerged from the participants is "Simulation not integrated into the training curriculum".They verbalized this to be one of the major reasons for their dissatisfaction with simulation.This was expressed in terms of simulation not being aligned with theory classes, simulation not being included in the normal teaching timetable but only during examinations: "…I am not satis ed with simulations because we only have them when it is a progressive assessment or there's someone doing a research study and they want to…..…." [FGD 14b Midwifery].
"…I am not satis ed, Some of the barriers, challenges yeah simulation has not been included in the university curriculum and you nd that it is only done because there is actually an exam but it is not as part of the day to day lectures students are having……" [FGDA1] Theme three: Low delity of the simulation The nal theme that emerged from the participants "Low delity of the simulation".The participants perceived simulation to be real when compared to clinical practice.They stated this to be one of the major reasons for their dissatisfaction: "… I am not satis ed in a way that there is a lot of imagination you will nd that you want to administer maybe oxygen they tell you it is already connected like you want to administer any IV uid you bring a cannular and tie it with a strip so there is a lot of imagination…."

Discussions
This study investigated the perception of the undergraduate, medical, nursing and midwifery students towards the used of clinical simulation in clinical teaching.
Generally, the students had good perception towards the use of medical simulation in clinical teaching.This is demonstrated by their grand mean of their perception scores of the Likert scale to be 3.875269 ± .5281626.This grand mean of their perception score is greater than the criterion/Decision mean which "3" for a ve-point Likert scale.
Expounding further on this, Aalto, Heponiemi [6], found that overall, about 170(73.9%) of the students were very satis ed with use of clinical simulation in teaching and about 191(83%) of the medical students were satis ed with instructors' cooperation.
Madhavanprabhakaran, Al-Khasawneh [9] in Oman found that undergraduate nursing students perceived simulation to facilitate enhancement of their knowledge and skills in regards to clinical nursing.El Naggar and Almaeen [10] in Saudi Arabia reported that about 170(73.9%) of the students were satis ed with the use of clinical simulation in teaching and learning.Codeço, Dias Coutinho [12], in Japan demonstrated that students perceived clinical simulation to "contributes to an active participation of learners in their learning process, promotes" the development of skills such as communication, priority management and decision-making.
Elliott and Brumbaugh [13] reported that the simulation learning experience led to a positive perception in regards to utilization of simulation in assessments and understanding of the testing procedures.Furthermore ndings among nursing students in a large study conducted among students in the United kingdom and Saudi Arabia Universities revealed that students perceived clinical simulation in teaching and learning to enhance their "self-awareness, self-con dence, clinical performance, and e ciency" in practicing the nursing procedures [14], However, the ndings are contrary to other studies elsewhere [15,16].Nel and Stellenberg [15] found that though the students were comfortable with clinical, they felt more con dent and competent after practicing on humans.Woodruff, O'Neill [16] on the contrary found that generally the students were undecided (neutral) in regards to use of clinical simulation to facilitate teaching in the University of California.
The possible explanation for these inconsistences between the ndings of the present study and that of other related studies elsewhere could be due to differences in study settings and study designs For example Nel and Stellenberg [15] assessed not only perception of the students in regards to clinical simulation but their study also compared clinical simulation with the real patient practice which our study did not measure.Similarly, Woodruff, O'Neill [16] conducted their study from California and among the advanced practice nursing students of which some of the students had experience with clinical simulation.This is therefore a possible explanation for the inconsistency between the ndings of the present study and their study ndings as our study was conducted among the undergraduate medical, nursing and midwifery students with no prior exposure to clinical simulation before joining the study Universities.
Findings from this study demonstrated that students strongly agreed with the statement of having someone to having an instructor who works in the eld to be present during the debrie ng phase of clinical simulation.This nding is consistent with that in related studies elsewhere [6,11].Aalto, Heponiemi [6] found that the nursing students acknowledged good cooperation from the simulation instructors from the real led in the simulation session.García-Mayor, Quemada-González [11], found that students strongly agreed that the presence of quali ed healthcare professionals for example quali ed nurses enriched the simulation experience.This noted that the medical students agreed to having clinical simulation during the rst week of clinical placement.
This ndings is similar to that in other related studies [17].García-Mayor, Quemada-González [17] found that the students perceived simulation to prepare them for clinical years.In regards to facilitating the realization of student's areas of weakness that need improvement, the students strongly agreed that clinical simulation facilitates the awareness of one's ability, strengths and weakness which are then improved before interfacing with the actual patients.This ndings form this study of clinical simulation being an avenue for skill improvement is consistent with ndings from other studies elsewhere [10].El Naggar and Almaeen [10] found that majority 147(74.2%) of the students reported simulation to help improve on their practical and communication skill.
Though the students had overall positive perception towards the use of clinical simulation in teaching and learning, there satisfaction is still de cient.This was expressed in terms of "mismatch between number and students and available space in the simulation laboratory"; Simulation not integrated into the training curriculum; and Low delity of the simulation.

Conclusion
This study's ndings support the integration of the simulation in the curriculum, as evidenced by the positive perception of the medical, nursing and midwifery students at the rural universities of Busitema and Lira.Simulations help students better understand concepts in clinical settings, provide them with valuable learning experiences, and help them to stimulate critical thinking abilities.The participants perceived simulation sessions to be realistic, and that the knowledge gained from simulations could be transferred to the clinical areas.Therefore there is need to escalate the use of simulation as an instrument of teaching and learning with the need for more investment in terms of infrastructure and equipment which will make the simulation more real and closer to the real world that students experience in the wards.Furthermore, there is a need for curriculum revision to include simulation within the existing curriculum.

Figures
Figure 1 [FGD 14b Midwifery]    I nd myself being extra con dent when I am doing a simulation during simulations because I know at times I am not managing the real life….."[FGD A6 midwifery]

Table 2
Utilization of clinical simulation in Lira and Busitema University

Table 3
Perception of the students towards utilization of simulation in clinical teaching [On a simulator, you can't tell if you're actually hurting them.you don't

Table 4
Satisfaction of the students with use of clinical simulation in teaching and learning I am not satis ed because for the simulations I have had there has been a problem of poor time management.This makes the students who present themselves at the different stations be rushed because they give you little time so that the next group can come and occupy that space so there is that weakness of poor time management[FGD 15b Midwifery] am not satis ed in a way that there is a lot of imagination you will nd that you want to administer maybe oxygen they tell you it is already connected like you want to administer any IV uid you bring a cannular and tie it with a strip so there is a lot of imagination…."[FGD14bMidwifery]-Alot of Imagination "…..I am not satis ed,,,,yea to shed light on that I can give you like a scenario where you are in an examination and you nd out a breach and you know the maneuvers you can do them and you nd a fellow student putting on that dummy staff and pushing the baby so in the process of you doing the maneuvers you nd that when doing the maneuvers the baby has already come out and the person giving you marks will be like you have done nothing and they fail you from there so…"[FGD 13b]We further explored the perception of the students towards the possibility of translating simulation skills to real practice.Generally, the students perceived the skill acquired in clinical simulation to be translatable to real clinical practice patients care: "…….Simulation are actually teaching sessions, so if I get to know something from a simulation and I am faced with it in real life, what hinders me from actually applying it?.......[FGD A1]"……………I think the skills translate because some things that we have learned from simulation have been able been able to also do them in te clinical setting and they have really helped me……………."[FGD A2].