A manikin or human simulator—development of a tool for measuring students’ perception

Introduction

Simulation has become a popular tool in undergraduate medical education in many countries (Ministry of Health, 2012; Coffey et al., 2016; Alsaad et al., 2017). The use of medical simulation methods brings several advantages to the process of teaching and learning medicine, e.g., increasing the realism of performed procedures, ensuring a safe environment, minimizing the risks involved in learning how to perform procedures, and enabling students to reproduce specific tasks planned in the scenario, etc. (Gaba, 2004; Cleland, Abe & Rethans, 2009). Commonly used methods like standardized patients or low and high-fidelity manikins can help in achieving these benefits (Majmudar, Colucci & Landman, 2015a; Majmudar, Colucci & Landman, 2015b; Bragard et al., 2019).

Implementation of medical simulation in undergraduate medical education may involve high-fidelity manikins used in simulation scenarios designed for individual courses (Newcomer, Hatry & Wholey, 2015). Manikins can help teach students clinical procedures and assess their level of performance. Nowadays, this modality is quite common and useful in achieving numerous educational objectives (Norman, 2010).

The study of using manikins in medical education has provided evidence and expertise about the effectiveness of this teaching tool for health care professionals (Akhu-Zaheya, Gharaibeh & Alostaz, 2013; Swamy et al., 2014). Manikins highlight the importance of experiential learning in introducing and managing various clinical cases without the risk of patient vulnerability and distress (Ziv, Small & Wolpe, 2000). Students usually find manikins useful when they practice performing complicated diagnostic procedures or following complex medical algorithms, and the process decreases their stress and increases satisfaction with their clinical achievements (Cooper, 2004; Ahmed et al., 2013; Bragard et al., 2019).

Another teaching technique that has been implemented in medical schools is cooperation with standardized patients. Many authors report employing standardized patients to teach and assess medical students’ clinical skills (Bergin & Fors, 2003; Beyea, 2004; Nestel & Bearman, 2014). Sessions with SPs provide broader clinical experience as they allow a well-organized teaching and learning process of selected range of clinical scenarios (Bokken et al., 2009; Cleland, Abe & Rethans, 2009), development of communication skills, and assessment of professionalism (Swanwick, 2013). Students also find the scenarios with SPs more realistic (Sanko et al., 2012). When they incorporate various technical and non-technical skills, students become more and more confident in their abilities to provide the best quality care (Bokken et al., 2009; Cleland, Abe & Rethans, 2009; Swanwick, 2013).

Our goal was to develop a tool for measuring students’ perception of using two modalities—standardized patients and manikins—in the learning process. The article presents a pilot study to test the psychometric values of the tool. In the process of developing the tool, a semi-structured interview was conducted to gather the knowledge of the phenomenon discussed. Together with the authors’ expertise and experience, it was the source of the questionnaire construction. The article presents the process of tool construction as well as the results of factor analysis, reliability and internal consistency.

The construction of a tool to measure students’ perspectives on the modalities can be an important contribution to broaden the knowledge in that area that is fundamental to curriculum design and planning. Being aware of students’ perspectives, educators can work on building students’ knowledge and awareness of learning with manikins and standardized patients, among other things, during training, or during the pre-briefing. Further research in this field could help answer the question, whether increasing students’ knowledge regarding the use of manikins and standardized patients translates into the effectiveness of using these modalities in teaching, influences reaching the learning outcomes, or changes students’ opinions about these modalities. It is also noteworthy that no similar tool has been found in the literature that would allow comparison of these two modalities based on the students’ perspective. The questionnaires like, for example, the Satisfaction with Simulation Experience Scale (SSES) (Levett-Jones et al., 2011) used to measure satisfaction with simulation experience, or the Dundee Ready Education Environment Measure (DREEM) (Roff et al., 1997), the Johns Hopkins Learning Environment Scale (JHLES) (Shochet, Colbert-Getz & Wright, 2015; Sengupta, Sharma & Das, 2017) measuring educational environments, do not include the aspects related to students’ opinions about particular instructional methods.

Some authors attempted to compare student opinions and experiences regarding the use of the manikin and SP (Meerdink & Khan, 2021; Liaw et al., 2014). Reviews on both modalities also appear in the literature (Cook, Erwin & Triola, 2010; Cheng et al., 2015). However, it is difficult to find works that present tools allowing the comparison of specific effects that can be achieved by working with both techniques. Therefore, we considered to present a tool that would allow to learn students’ opinions about the use of the manikin and SP in learning medicine, but in relation to specific skills that can be developed during learning with the use of medical simulation.

Since we did not assume the dimensions that the statements of our method might consist of, we decided to use Exploratory factor analysis (EFA). It is used in academic research and allows summing the items into specific dimensions. EFA is also used in scale development process to condense a large number of items into methodologically sound instrument (Hooper, 2012). Exploratory Factor Analysis was conducted separately for the SP and the manikin sections of the questions.

Materials & Methods

This study project aimed to develop a tool for measuring students’ opinion about using manikins and SPs in learning medicine. Its construction had been preceded by semi-structured interviews with sample students, whose answers constituted the basis for the questionnaire items. It allowed the authors to verify whether their questions arising from the literature review and experience were relevant to the purpose of the study. They referred to the courses integrating clinical skills based on a medical simulation that employed both manikins and standardized patients as teaching modalities. The curricula were designed by an internist with a ten-year clinical experience; a psychologist, who was a specialist in SP-based simulation (completed a course at the University of Cambridge); a surgeon with a twelve-years of clinical experience and an MSc in Clinical Education; and a fellow in infectious diseases with twenty-five years of clinical experience. The teaching faculty had had a four-year-long experience in conducting high-fidelity simulation sessions with manikins and standardized patients.

Ethical approval for the survey was granted by the Medical University of Lublin Bioethics Committee, the Ethical approval no. KE-0254/59/2018, and the survey was performed following the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Results

Out of 273 students who took part in the survey, 165 (60%) were women, and 108 (40%) were men with a median age of 25 years (range 23 to 33 years) (Table 1).

Discussion

In this article we have reported development, initial validation and dimensionality of a questionnaire for measuring students’ perception about manikins and SPs used for learning in medical simulation. The tool presented in this article captures many aspects related to working with a manikin and an SP, which can be grouped into two areas: related to the development of skills relevant to building doctor-patient rapport and understanding, and to the acquisition of practical skills necessary in the work of the physician. In the Flössel et al. (2021) study, the practical aspect of the course implemented using the manikin and SP was taken into account during the survey and was rated highly by the respondents. Other skills, such as communication skills developed during medical simulation classes, were also studied by researchers (El Naggar & Almaeen, 2020).

The conducted research allowed the construction of a tool that makes it possible to obtain students’ opinion regarding the use of manikins and standardized patients in medical simulation courses. This opinion refers to the specific skills that are assumed to be developed when working with these modalities. Considering the manikin and SP scales separately makes it possible to use them independently to match the research needs. At the same time, the tool can be the basis for comparing students’ opinions on the two modalities. Our main finding is that the questionnaire was worth developing and may subsequently be very helpful in planning curricula and organizing the teaching process making it possible to achieve the assumed educational objectives.

The information obtained from the respondents in the first stage of the study made it possible to construct statements that constitute a scale assessing students’ perceptions about working with the two modalities—a manikin and an SP. The need to construct a scale was recognized by the intention to get to know the students’ perspective on the use of the manikin and SP in the learning process. This aspect seems to be important when organizing courses using medical simulation, as an additional variable, next to the capabilities and level of technological advancement of the unit, the objectives of the course and the curriculum, the strategy adopted by the teacher to achieve the objectives. All these elements seem to be very important to organize the teaching process in a reasonable and effective way—especially assuming high possibilities of using simulation and the nature of organized classes, that is practical classes. Knowledge of students’ perceptions of the modalities is therefore an important input in the process of making decisions on how to effectively implement the curriculum. At the same time, it allows for the selection of the appropriate modality in the context of the possibility of achieving the objectives and incurred costs. Moreover, it seems important to answer the question whether the examined modalities can be treated interchangeably or complementarily, which in educational practice may be of significant importance. The starting point for these conclusions may be to know precisely what are the students’ experiences and perceptions of working with a manikin and an SP. Other studies also show that student’s experience with medical simulation appears to be an important variable (Winter-Taylor & Richardson, 2020; Badowski, Rossler & Reiland, 2021).

The work presented herein can be a good starting point for evaluating issues concerning the described phenomena. The developed tool could be used by other medical centers, universities, and educators.

The developed scale can have practical application in the organization of the teaching process. It takes into account two frequently used modalities in medical simulation, i.e., using a manikin and working with a standardized patient, and allows for their comparison. Also, other studies juxtapose these two modalities and provide an opportunity to compare them in the context of their use in medical education (Bello et al., 2020; Meerdink & Khan, 2021; Sterz et al., 2022).

Additionally, it covers two areas—doctor-patient relation and practical aspects—often developed in simulated conditions. Characteristics of students’ experiences in terms of these two areas can provide important input into the decision-making process regarding the planning and evaluation of courses implemented using medical simulation.

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