Effects of partial substitution of pre-clinical skills training by attachments to primary health care centers: An experimental study

Abstract

Background: Recent studies indicate that students may encounter problems when they have to apply clinical skills learned in a skills laboratory to patients. To facilitate this transition, it has been advised to include patient contacts early in the pre-clinical curriculum.

Objective: To compare clinical skills performance and level of preparedness for entering the clerkships between students who were prepared exclusively in a skills laboratory and peers for whom part of their skills training program was substituted by training in a primary health care (PHC) center.

Methods: Pre-clinical students either trained clinical skills exclusively in a skills laboratory while their peers attended a mixed program of laboratory trainings and practice in PHC centers. Students’ perception of preparedness for the clerkships was explored through the Preparation for Hospital Practice Questionnaire. Students’ clinical skills were assessed by an Objective Structured Clinical Examination (OSCE) and by supervisors in PHC centers.

Results: Students following the mixed program felt better prepared for their clerkships than skills lab-trained peers. Students’ perceptions were supported by assessments by their supervisors. However, mean OSCE scores of both groups did not differ significantly.

Conclusion: PHC centers can be involved to better prepare pre-clinical students for their clerkships.

Introduction

In many medical schools all over the world, clinical skills training is offered to pre-clinical students in facilities called skills laboratories. Skills laboratories usually avail of manikins, medical equipment and simulated patients to train students’ clinical skills (Van Dalen et al. 2001; Smith 2006). A systematic review by Lynagh et al. (2007) has confirmed that clinical skills performance of medical students improves by skills training in skills laboratories.

On the other hand, several studies have indicated that students may encounter problems with the transition of skills learned in the skills laboratory to the hospital setting (Lynagh et al. 2007). Obviously, the clinical environment is very different from the skills laboratory setting. Skills laboratory staff is fully devoted to education, whereas hospital staff will prioritize patient care over teaching. Moreover, training with manikins and simulated patients cannot fully mimic hospital practice, and experiences gained in the laboratory setting may be neglected by the students in clinical contacts with patients (Nielsen et al. 2003; Smith 2006). The resulting “clinical culture shock” may negatively impact on students’ motivation for learning (Prince et al. 2005).

Therefore, medical students should be given opportunities to meet patients in the pre-clinical curriculum (Prince et al. 2005; Dornan et al. 2006). Such “early clinical experiences” may promote the learning behavior of pre-clinical students by exposing them to clinical role models, improving their clinical skills, and eventually reducing the stress of meeting patients (Dornan et al. 2006). Early clinical experiences have been shown to give students more confidence to interact with patients in their first clerkships (Hampshire 1998; Smith 2006).

Primary health care (PHC) settings are often involved in education of medical students and students may prefer practicing in PHC centers over training in teaching hospitals (Hampshire 1998; Haffling et al. 2001). PHC centers provide first line health services to communities and may offer adequate learning facilities for medical students. PHC centers can adequately show students health problems which are common in the community (O'Sullivan et al. 2000; Worley et al, 2006).

The objective of this study was to compare students’ level of preparedness to enter the clerkships and clinical skills performance between students who received clinical skills training exclusively in a skills laboratory and peers for whom part of their skills training program was substituted by training in PHC centers.

Table

Practice points

Pre-clinical students who participated in a mixed program of skills training in a skills laboratory and PHC settings felt better prepared for their clerkships than peers exclusively trained in a skills laboratory. Supervisors in PHCs confirmed students’ progress during their practice in PHC. In this study, OSCE scores of both groups did not show a significant difference.

Methods

Design of the study

This study was conducted with a class of 193 fourth year pre-clinical students of the Faculty of Medicine at Gadjah Mada University (FM-GMU) in Jogjakarta, Indonesia. All pre-clinical students of the school participate from the beginning of their studies once or twice a week in a clinical skills training program, which is integrated in the curriculum. Trainings are held in a skills laboratory allocated on the Faculty's campus. Students practice in small groups of eight to ten students, supervised by a skills instructor who can be a general practitioner (GP) or a medical specialist. Students practice in the skills laboratory on manikins, with peers, and with simulated patients. Skills laboratory trainings are designed in accordance with Indonesia's national standard of medical competency which is oriented on cases which are common in the community, like acute respiratory tract infection, diarrhea, and muscular pain. Moreover, students can arrange for 2-h supervisor-independent practice sessions in the skills laboratory, facilitated by skills laboratory assistants. Skills laboratory assistants are senior medical students trained by skills laboratory supervisors to facilitate their peers’ training in accord with the standards prescribed by the skills laboratory. Based on their individual needs, in such sessions, students can practice skills selected by them as often as they wish. On average, an individual student arranges for 5.4 supervisor-independent practice sessions per year.

Randomly, a sample of 59 students was drawn from the class. This group (designated primary care trained, PT) followed the same instructional program as their 134 peers (not primary care trained, NPT), but for PT students practical trainings with in skills laboratory assistants were substituted with trainings in PHC centers, with a student assistant from the skills laboratory and under supervision of GPs. Eleven PHC centers hosted groups of five or six students each for 11 days over a 5-week period. PT students assisted in providing health services, patient management, and health promotion in communities. Moreover, they interviewed health workers and wrote reports and reflections.

Students in NPT and PT groups had comparable opportunities to practice their clinical skills. NPT students practiced in the skills laboratory under safe and structured conditions supervised by GPs or medical specialists, but did not meet with real patients. PT students practiced in PHCs and met with real patients supervised by GPs; however, in this setting, skills training depends on the availability and variety of patients.

Assessing students’ preparedness to enter the clerkships

Students in both PT and NPT groups filled in the “Preparation for Hospital Practice Questionnaire” (PHPQ) which consists of 41 questions on 8 domains: interpersonal skills, confidence, collaboration, management, science, prevention, holistic care, and self-directed learning (Hill et al. 1998). These authors defined the eight domains as follows. Interpersonal skills refer to effective and competent communication with patients; confidence to skills to cope with uncertainty; collaboration to the importance of a team approach to care; management to efficient patient management and performance of practical skills, sciences to understanding the scientific backgrounds of disease etiology and therapy; prevention to preparedness to incorporate health promotion and disease prevention in patient care; holistic care to an appreciation of the impact of multiple (e.g., socio-economic) variables on patients’ health and disease; and self-directed learning to reflection on self-performance with identification of educational needs including expansion of knowledge and skills.

The questionnaire was translated from English into Indonesian language; to secure correctness of the translation, another interpreter performed a reverse translation from Indonesian to English and his translation was compared to the original text.

In classroom sessions attended by the first author, PT students filled in the PHPQ just before the start of their PHC attachments; PT and NPT students filled in the PHPQ shortly after conclusion of the PHC attachments. Reponses on the PHPQ were given on a Likert scale ranging from 1 (very inadequately prepared) to 6 (very adequately prepared).

Assessing students’ clinical skills performance

After conclusion of the skills training program for both PT and NPT students, all attended a nine-station “Objective Structured Clinical Examination” (OSCE) (Harden et al. 1975). At each station, a skills instructor assessed a different clinical skill using a standardized checklist. OSCE assessors were “blinded” with respect to information to which experimental group a student belonged (Jefferies et al. 2007).

Assessing students’ progress during practice in PHC

Clinical supervisors in PHC were asked to assess PT students five times during their attachment to PHC centers, using a checklist derived from PHPQ by FM-GMU skills laboratory staff (Alreck and Settle 1995). PT students were not informed about these additional assessments to avoid “assessment-induced behavior.” The checklist contained eight items matching the eight PHPQ domains and used a six-point rating scale ranging from very poor performance (1) to very good performance (6).

Statistical analysis

Differences in mean scores of PT and NPT students on the PHPQ questionnaire after execution of the skills training program, and on the OSCE were statistically analyzed using Mann–Whitney's test. The consecutive scores given by supervisors during PT students’ attachments to PHC centers were analyzed using Wilcoxon's signed rank test. To avoid false conclusions on significance from a multitude of interdependent data, a Bonferroni correction was applied to determine appropriate p-values to accept statistical significance (Bryman and Cramer 2001).

Results

Fifty-seven PT students completed their skills training program (96%). Two students resigned from the attachment program: one student because of family matters and another one became ill. All NPT students completed their skills training program. All students participated in the OSCE. All GPs in PHC centers supervised PT students throughout the program and five times scored their performance. One student was not scored by his supervisor because he rarely showed up in the PHC center; results are based on supervisors’ scores for the remaining 56 PT students.

PT students gave higher scores on PHPQ than their NPT peers. Scores of the two groups were significantly different in the domains: confidence (difference between mean score of PT and mean of NPT: p = 0.000), management (p = 0.003), collaboration (p = 0.001), self-directed learning (p = 0.000), and holistic care (p = 0.003). In the domains prevention (p = 0.23), science (p = 0.27) and interpersonal skills (p = 0.133) differences were not significant. OSCE scores of PT and NPT students were not significantly different on all nine stations included.

Comparison of scores of the PT group on PHPQ before and after their training program showed a significantly improved sense of preparedness in the students in three domains: confidence, collaboration, and self-directed learning. The largest effect was in the domain of confidence (difference between mean scores: 0.64), followed by collaboration (0.42) and self-directed learning (0.31) (Table 1).

Table 1.  Comparison of scores by 57 PT and 134 NPT students on PHPQ scores and OSCE at the end of their clinical skills training programs.

Item scores	PT students		NPT students
	Mean	SD	Mean	SD	p* (Mann–Whitney test)
OSCE stations
Integrated patient management I	77.24	11.75	76.89	12.68	0.94
Integrated patient management II	72.63	7.91	73.36	10.40	0.22
Integrated patient management III	76.44	9.96	76.35	11.13	0.97
Obstetrics and Gynecology	92.93	6.78	90.94	8.59	0.16
Cardio-pulmonary resuscitation	85.87	13.09	86.73	12.07	0.73
Endotracheal intubation	87.54	11.47	88.18	11.54	0.40
Emergency skills	85.24	14.88	86.23	13.00	0.74
Minor surgery	77.10	13.46	75.17	14.65	0.47
Clinical reasoning skills	67.75	16.46	66.80	16.51	0.76
PHPQ sub-scale
Confidence	4.33	0.64	3.72	0.75	0.000*
Management	4.25	0.82	3.83	0.70	0.003*
Collaboration	4.29	0.59	3.88	0.80	0.001*
Prevention	4.57	1.24	4.17	0.68	0.023
Self-directed learning	4.33	0.57	3.93	0.71	0.000*
Holistic care	4.33	0.62	3.97	0.73	0.003*
Science	4.09	0.68	3.83	0.70	0.027
Interpersonal skills	3.75	0.80	3.54	0.82	0.133

Note: *Statistically significant. After Bonferroni correction, statistical significance was accepted at p < 0.0055 for the OSCE scores, and p < 0.006 for PHPQ scores.

PHC supervisors observed gradual improvement in PT students’ performance in all eight domains scored (Figure 1). Differences between first and last scores were significantly different on all domains (p < 0.00). According to the scoring by the supervisors, at the end of their attachments to PHC centers, PT students had made most progress in the domain interpersonal skills, consecutively followed by collaboration, science, and self-directed learning.

Figure 1. PT students’ progress as scored by PHC supervisors. Note: I–V: Students were weekly assessed on eight domains by their PHC supervisors using a 6-point Likert scale ranging from 1 (very poor performance) to 6 (very good performance).

Discussion

This study demonstrates the increased effectiveness of a clinical skills training program to prepare pre-clinical students for clerkship practice if practical training in the skills laboratory is partly substituted by training in PHC centers. Both PT students themselves and their supervisors in PHC centers felt that students’ level of preparedness for the clerkships increased significantly in several domains by PHC attachments. On the other hand, PHC attachments had no influence on students’ performance on a nine-station OSCE.

This study confirms the results from several studies performed earlier in the setting of industrialized countries. Exposure of pre-clinical students to patients increased their confidence to meet patients, as also concluded by Dornan et al. (2006) in a BEME review. Attending and managing the patients in collaboration with other health workers increased students’ sense of preparation for entering the clerkship, as also demonstrated by Hampshire (1998) and mitigated problems with the transfer of clinical skills from the skills laboratory to the hospital setting (Seabrook 2004; Morton et al. 2006).

Five consecutive assessments by clinical PHC supervisors indicated gradual improvement of performance of PT students on all eight PHPQ domains: interpersonal skills, self-directed learning, confidence, collaboration, management, prevention, holistic care, and science. However, PT students themselves had the same sense of preparedness as NPT students in the domains of interpersonal skills, science, and prevention. In the domain of interpersonal communication, this may in part be explained by the fact that these skills are less stressful for students than performing physical clinical skills (Sarikaya et al. 2006; Stewart et al. 2007). Furthermore, pre-clinical students may be trained adequately in communication in the skills laboratory with peers and simulated patients (Van Dalen et al. 2001). Lack of an improved sense of preparation with the PT students in the domains of science and prevention may be related to the characteristics of PHC centers in developing countries. Some of these centers have limited facilities and human resources, so these centers may fall short in executing preventive activities. Furthermore, these centers usually have neither library nor learning resources, which may hamper students’ expansion of medical knowledge (Shields and Hartati 2006). However, facing clinical problems in reality apparently motivated students to reflect on their own performance, as shown by the higher score of PT students in the domain of self-directed learning. It may be assumed that those students expanded their knowledge and skills using “contextual” learning resources like GPs and other health workers in the PHC centers.

In the PHC centers, it was not possible to execute all clinical procedures to be addressed in the skills training program due to limitations in budget, human resources, and availability of suitable patient cases (Shields and Hartati 2006). Nevertheless, PT students’ performance on an OSCE was similar to that of NPT students. The other way around, one might have expected PT students to perform better than NPT students at least on some OSCE stations. Failure to find difference may be explained by the fact that some OSCE stations addressed clinical procedures like resuscitation and intubation which were most likely not exercised with patients in PHC centers.

A limitation of this study is that students’ perception of preparedness for the clerkships and their clinical skills performance were only explored quantitatively using PHPQ, supervisors’ scorings, and an OSCE. In a follow-up study, we will qualitatively investigate possible differences in performance between PT and NPT students early in their clerkships.

Offering PHC attachments to all pre-clinical students will be quite a challenge. Because of their limited clinical experience pre-clinical students need intense supervision (Haffling et al. 2001; Smith 2006). Students, patients and their supervisors should experience a safe setting during the teaching and learning process. The cost of this program should also be taken in consideration, because all stakeholders involved should receive appropriate reward and benefits from the attachment program (Dornan et al. 2006). Prolonged availability of budget must warrant that the attachment program is not soon discontinued. In that regard, preparation, planning, and organization of this program must be performed effectively and efficiently, especially in the context of a developing country where budgetary limitations may affect education stronger than in industrialized countries (Stark and Fortune 2003).

Conclusion

Inclusion of PHC attachments in the clinical skills training program for pre-clinical students improved their perception of preparedness for their clerkships. Improvements pertained particularly to domains which cannot be covered sufficiently in the skills laboratory, including improving confidence in attending patients, families, and communities; collaborating with other health workers; and self-directed learning in uncertain situations. The attachment program did not negatively, but neither positively impact on students’ performance in an OSCE.

Acknowledgments

We acknowledge Mrs Dany Lukita Sari for assistance with data collection from medical students and PHC supervisors as well as our dedicated student assistants Bina Muntafia Dewintari, Rachmad Ansyori, Muhammad Rizky Yanuar Fauzi, Aloysius Angga Wibowo, Octavianus Kevin and Sesarius Bimo Wicaksono. We express our gratitude to the skills laboratory and the community-based education unit (K3M) in FM-GMU for cooperating in this study. We are indebted to the Dutch NPT Project for financial support.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.