This study was reviewed and approved by the local ethical committee (KE-0254/309/2015), which granted its acceptance of our study.
2.1. Participants
The sample population consisted of 806 first-, second- and fourth-year medical students enrolled in the Basic Clinical Skills course at the Medical University of Lublin (MUL), Poland.
The participation was voluntary. The research was implemented between June 2015 and June 2017. The respondents' group constituted of four subgroups:
I - a group from the first stage of research, II year medical students year 2014/2015,
II - a group from the second stage of research, II and IV years medical students, 2014/2015 and 2012/2013
III - a group from the third stage of research, I year, medical students, 2016/2017,
IV - group from the third stage of research, II year medical students, 2015/2016.
The study scheme is presented in Figure 1.
2.2 Research instruments
The research method was a diagnostic survey, and the tools - an original questionnaire and analysis of the practical final examination results of basic clinical skills.
Subjective feedback was collected using an original questionnaire with a five-point Likert scale (1-5) with the following answering format:
- strongly disagree
- rather disagree
- no opinion
- rather agree
- strongly agree
Besides, the survey collected sociodemographic data.
The questionnaire in 2015 investigated participants' overall opinions on the course, as well as the usefulness of its content. It contained three sociodemographic questions: age, year of study, and place of residence.
The tool used in the second stage of the research with the original instructional videos included the questions mentioned above, as well as one concerning the use of instructional videos in teaching procedural skills, four sociodemographic questions were also added: age, year of study and place of residence, nationality.
Similarly, the third educational intervention in 2017, when the Peyton approach was introduced to the methodology of BSC laboratories, included questions on the opinion on the original instructional videos, the general course assessment, and its content. Three sociodemographic questions also were incorporated: age, year of study, and place of residence.
The research also analyzed documentation from practical exams OSCE carried out at the end of the course Basic Clinical Skills in 2015, 2016, and 2017. Data from the examination documentation were selected and used for this work.
The data included the content of checklists used during the OSCE:
the total score of students from each of the five OSCE examination stations,
individual results of students from each of the five OSCE examination stations.
2.3 Statistical analyses
Data obtained from the examination documentation and questionnaires were collected in the Microsoft Excel database of the MS Office 2010 for Windows 10. The obtained results were subject to statistical analysis based on Statistica 13.1 (StatSoft Polska).
Descriptive and inferential statistical analyses were employed, depending on the variables tested. Significance tests were completed to examine the relationships between variables.
To study the differences between the two groups, the Student t-test was used for dependent samples as well as non-parametric tests for variable related tests (Wilcoxon test) and independent (Mann Whitney test). The χ² test was used to assess the significant relationships between the analyzed qualitative variables. When the number of rows was not greater or equal to five in each cell of the table, the Yates correction for 2x2 tables was applied. Spearman's rank correlation was used to check the relationship between selected variables.
Logistic regression analysis investigated the impact of one variable on the other.
P-values less than 0.05 were considered as statistically significant.
The values of the analyzed qualitative data from the open responses were examined by the authors using a thematic analysis method to identify emerging themes. The study employed two coding strategies: a priori and a posteriori categorization of data. A priori coding focused on developing appropriate categories. A posteriori coding refers to developing categories based on the received data (23).
2.4 Course Goal, Learning Objectives, Learning Method, and Activities
Due to guidelines aimed at reducing the number of medical errors in invasive procedures, medical curricula are seeking ways to assist their students with mastering them through medical simulation (24).
The overall purpose of the course (in all three editions) was to help students acquire a deeper understanding and ability to perform most commonly performed basic procedural skills.
The Basic Clinical Skills (BCS) course lasted 15 teaching hours over the course of 5-weeks, and it was introduced as an innovative course for medical students of MUL, for the undergraduate medical program (a six-year curriculum. The lab sessions focused on practical procedural skills. Taught skills included bureau of vital signs (BVS) including heart valve auscultation, heart rate check (HR), peripheral vein cannulation (PVC), urinary bladder catheterization (UBC), digital rectal examination (DRE), later on, replaced by intramuscular injections (IM), and non-invasive blood examination, implemented on the task simulators ensuring the repetitiveness of the procedure, using online resources. BCS was implemented in the summer semester, just before students began nursing holiday clerkship. Assigned learning objectives were extracted from the Polish national regulation on teaching standards in the fields of medicine, dentistry, nursing, and obstetrics (25). Classes were conducted in groups of five by an interprofessional and interdisciplinary team of academic teachers with a minimum of 2-semester experience. Each year, the course coordinator organized a 3-hour training course to prepare for conducting laboratories to ensure teaching standardization. In the next stage, the instructors were trained by the technical team to use the appropriate task trainers.
BSC 2015
The first educational interventions in the form of teaching using medical simulation techniques were introduced for second-year medical students, the 2013-2019 study program (Figure 2).
BCS 2016
Subsequent educational intervention introduced into the structure of the BCS course based on medical simulation techniques was the use of original instructional videos presenting the taught procedures, which replaced the 30-minute theoretical part of the class. The purpose of this educational intervention was to increase the time allocated to practice without modifying their duration or financial costs. They were introduced for second-year (2014-2020) and fourth-year (2012-2018) medical students in the academic year 2016/2017 (Figure 3).
BSC 2017
The next educational intervention modified the teaching methodology of the BCS course by introducing the Peyton’s approach, i.e., four-step methods: demonstration, deconstruction, comprehension, practice (26) in an academic semetre 2017/2018 (Figure 4).
2.5. Objective Structured Clinical Examination
The Objective Structured Clinical Examination was implemented at the end of the course, to provide an objective assessment of the skills acquired as it was found to be a reliable tool in assessing technical skills (27).
A division into five OSCE stations was introduced: auscultation of the heart and pulse rate, non-invasive blood pressure measurement, peripheral vein cannulation, urinary bladder catheterization and per rectum examination in the first stage of the examination, and intramuscular injection in the second and third stage instead of DRE with an adequate checklist for each station. The stations are described in the OSCE blueprint (Appendix 1).
To build a reliable assessment tool covering a range of basic clinical skills that were considered crucial for nursing clerkship, the OSCE scope was assembled using the Delphi method. Constructing the binary checklists was implemented through a repetitive consultation process with a team of experienced lecturers from the Medical University of Lublin until an agreement was reached on the components of checklists that should be included in the individual OSCE stations. The list of potential components of skills checked during the OSCE exam has been checked and ranked in order of priority.
This multi-stage process was carried out by a panel of experienced academic teachers of medical faculties who reviewed and suggested corrections on the marking scheme and construction of individual OSCE exam stations.
This process was intended to ensure that the tasks were appropriate to the student syllabus and whether they rated/checked what we wanted to assess with proper accuracy (its reliability). The panel of experts also assessed the consistency of the checklists used (28,29).
Each consecutive year, teachers leading the assessment, as well as educationalists, analysed used binary checklists and submitted requested changes or modifications to the OSCE coordinator.