Submitted: 26 September 2020
Accepted: 1 March 2021
Published online: 5 October, TAPS 2021, 6(4), 7-16
https://doi.org/10.29060/TAPS.2021-6-4/OA2415

Rasika Manori Jayasinghe¹, Indika Priyanthi Thilakumara¹, Bandara Dhanushka Leuke², Gishan Edirisinghe³, Manil Christopher Nishan Fonseka³, Manjula Attygalla⁴ & Ruwan Duminda Jayasinghe²

¹Department of Prosthetic Dentistry, Faculty of Dental Sciences, University of Peradeniya, Sri Lanka; ²Department of Oral Medicine and Periodontology, Faculty of Dental Sciences, University of Peradeniya, Sri Lanka; ³Department of Restorative Dentistry, Faculty of Dental Sciences, University of Peradeniya, Sri Lanka; ⁴Department of Oral Surgery, Faculty of Dental Sciences, University of Peradeniya, Sri Lanka

Abstract

Introduction: E-learning resulted in a revolution in dental education with continuous educational experiences. General objective of this study was to assess the perspective of undergraduate dental students on effectiveness of e-learning in the Bachelor of Dental Surgery (BDS) programme. Specific objectives were to identify students’ opinion on the factors that promote e-learning, awareness on the effectiveness of using different platforms and social media, barriers imposed and suggestions for the improvement of e-learning in the BDS programme.

Methods: This was a cross sectional descriptive study among undergraduate dental students of the Faculty of Dental Sciences, University of Peradeniya, Sri Lanka using a self-administered pre-tested questionnaire administered via a web-based survey form. Frequencies and percentages were obtained for categorical data and Chi-square test was used to determine the association between variables.

Results: The majority received the e-learning experience well. Fifty-four percent of the participants felt it was better compared to traditional face-to-face learning and the difference between the semesters (p=0.000) and genders was statistically significant (p=0.000). Difference in overall satisfaction on e-learning material across the different semesters was statistically significant. Students felt that e-learning should be used as a supplementary tool mainly by means of procedural videos during delivery of the skill component. Fifty percent participants felt that conducting assessments online is fair for all the students.

Conclusion: A positive learning experience was achieved through the e-learning modalities in comparison to traditional face-to-face learning though in terms of skills training, e-learning modalities should only be considered as a supplementary tool.

Keywords:           E-Learning, Perspective, Dental Undergraduates, Dental Education

Practice Highlights

• Majority felt e-learning was better compared to traditional face-to-face learning.
• Majority were satisfied with interactions with teachers and teacher responses to clarifications.
• Students felt that e-learning used as a supplementary tool during delivery of the skill component.

I. INTRODUCTION

E-learning has resulted in a revolutionising dental education to an extent that more interactive and intuitive e-learning options have evolved which provide students with an enjoyable and meaningful continuum to their educational experience. During the current COVID-19 pandemic electronic learning tools have been invaluable in the delivery of knowledge in many higher education institutions (Li & Lalani, 2020). One of the great advantages of e-learning is the possibility of transferring knowledge and skills to a large number of recipients irrespective of the time of delivery of knowledge (Asiry, 2017). In addition, students can repeatedly peruse the material and follow it in their own pace at a relatively low cost. This is considered an excellent method of overcoming certain difficulties faced with the traditional system of teaching such as the lack of space especially within the lecture halls and a shortage of human resources (Asiry, 2017). However, socio-economic factors play an important role in deciding the type of teaching. Students in the developed countries prefer e-learning modalities while students in the developing countries prefer it as a supplementary method (Schlenz et al., 2020). A study by Asiry (2017) identified e-learning as a helpful supplementary learning method among Saudi Arabian dental students rather than a replacement for traditional teaching methods. According to authors’ experience, though there was much resistance in adopting to e-learning at its infancy, it has now been universally accepted as a learning modality not only by teachers but also by the students. Many are of the view that assimilation of knowledge could be best achieved purely through e-learning modalities where as it should be supplementary in nature in skills acquisition. The popularity of books and hard copies of journals have seen a steady decline due to the availability of e-learning resources and even publishers have realised this trend and supply both hard and electronic versions of their publications which in future may progressively be replaced by electronic educational materials.

The success of e-learning is dependent on a multitude of factors. Computer literacy, availability of appropriate technology, accessibility and having a good high bandwidth internet connection are some of the key factors (Asiry, 2017; Linjawi & Alfadda, 2018). According to a study by Gunawardane and Wijekoon (2017), it was revealed that dental students in the Faculty of Dental Sciences, University of Peradeniya, Sri Lanka had adequate computer literacy and facilities. Although Linjawi and Alfadda (2018) identified that the perceived impact of e-learning and readiness for e-learning though popular and satisfactory among Saudi Arabian dental students, declined as they proceeded to higher semesters. Imparting the skills component has been identified as a major challenge in using e-learning and students were in need of more support in the skills domain (Linjawi & Alfadda, 2018).  Students have been shown to have better skills and motivation for use of online tools for personal or non-educational purposes than for learning purposes. Thus, this should be carefully considered when developing a successful strategy to motivate them for e-learning (Linjawi & Alfadda, 2018). Apart from the above mentioned factors, student characteristics, cognitive factors (performance expectations) and the social environment (learning climate) are considered as some predictors of the perceived satisfaction among students (Venkatesh et al., 2019). Most of the students prefer a combined approach comprising traditional and e-learning methods than relying on e-learning methods alone. Some of the preferred methods of delivery of e-learning resources for pre-clinical dental undergraduates were online flash lectures and procedural videos (Asiry, 2017). Video demonstrations enabled students to reflect on their predominant learning approaches, which emphasise self-directed learning and avoid surface learning techniques (Chonkar et al., 2019). Some dental schools in the developed countries have introduced tools such as Technology Enhanced Learning (TEL) in both pre-clinical and clinical courses with the development of innovative learning platforms and they further assess and monitor student performance in relation to the new approach (Wong et al., 2020). Further, Faculty of Dentistry, National University of Singapore has implemented a multi-stage framework for the academic staff to grasp technology in various aspects such as reflecting teaching practice, designing new technology options and identifying learner impact with changes on teaching methods. 

However, not everyone is in agreement with the benefits of e-learning. University administrators and experts in information technology working in universities have varying opinion (ranging from majority of teaching on traditional classroom mode to predominant e-learning mode) regarding the need of administrational change created by e-learning, generation of resources, impact on enrolment, responsibility for course design and content and the impact on the mission of the university. However, there is a general agreement on challenges such as the requirement of resources and cost of maintenance, need for motivating the teachers to keep abreast with the latest technology and the necessity for cooperation to improve e-learning (Hillenburg et al., 2006). 

The COVID-19 pandemic has made it necessary to impart changers in the modalities of education all over the world. Since schools and universities have been closed to prevent the spread of infection, conducting e-learning sessions has become the prime mode of teaching. The situation in Sri Lanka was without exception. Most programmes including the Bachelor of Dental Surgery had to comply with this requirement in order to provide the students a continuous educational experience during the pandemic situation. E-learning has been used in a very primitive level in the Faculty of Dental Sciences, University of Peradeniya for a long time but had not been utilised to its full potential. As dentistry is mostly a skill based professional degree programme, delivering course content online was a challenge. In addition, resistance to change was evident among the staff due to the fact that they were comfortable with the traditional time tested methods. However, with the new norms, e-learning platforms such as Zoom, Google Meet and WhatsApp discussions were used at the Faculty of Dental Sciences for the learning along with narrated PowerPoint presentations, video demonstrations and online quizzes uploaded onto the existing e-learning platform Dent Moodle. Due to this novel experience, it was considered important to analyse the students’ opinion on e-learning, the difficulties faced by them and expectations to improve e-learning in the field of dentistry. Further, it would be beneficial to identify barriers of e-learning when designing and revising the dental undergraduate curriculum in the future.

II. OBJECTIVES

General objective of the study was to assess the undergraduate dental students’ perception on the effectiveness of e-learning utilised in the Bachelor of Dental Surgery (BDS) programme. The specific objectives were to identify students’ opinion on the factors that promote e-learning, awareness on the effectiveness of using different platforms and social media, barriers imposed and suggestions for the improvement of e-learning in the BDS study programme.

III. MATERIALS AND METHODS

A cross sectional descriptive study was carried out on a  sample comprising of undergraduate dental students of the Faculty of Dental Sciences, University of Peradeniya who had enrolled and followed all online lectures and assignments based on the content taught via e-learning in the first, third, fifth and seventh semesters. A self-administered and pre-tested (25 students representing all batches for the pilot and their responses were excluded from the study sample) questionnaire was administered via a web-based survey form. A covering letter, information sheet and consent form were also annexed to this form. Those respondents who gave the informed consent were able to fill the questionnaire. The survey link was disseminated among the dental students via the email by the faculty administration unit. The questionnaire used in this study comprised of 23 close-ended questions which consisted of demographic data and specific questions on awareness, attitude and practice of e-learning. Examples of e-learning platform stated in the questionnaire were live Zoom presentations, Google Meet, Power Point presentations with voice narrations and supplementary material such as web links, video demonstrations and YouTube and other video links.

Confidentiality and anonymity of the data provided were assured by keeping the questionnaire anonymous. No identification details were included in the questionnaire. Data management and statistical analysis was performed using the statistical software SPSS version 21.0. Frequencies and percentages were obtained for categorical data and Chi-square test was used to determine the association between variables. Ethical clearance was obtained from the Ethics Review Committee of the Faculty of Dental Sciences, University of Peradeniya (ERC/ FDS/UOP/I/2020/21).

IV. RESULTS

The response rate was 82% (250 participants out of 305 of all undergraduates). The sample comprised 19% from the first semester, nearly 25% from the third semester, 26% from the fifth semester and nearly 30% from the seventh semesters of the Bachelor of Dental Surgery (BDS) programme. Seventy-two percent (72%) were females. Approximately 41% claimed that they have either very good or excellent literacy on information technology (IT). Fifty-four percent of the respondents claimed that their English language literacy is very good or excellent. A majority of the population accessed e-learning content using their mobile devices. Half of the sample had experienced some kind of interruptions during e-learning.

A. Satisfaction on E-learning

Seventy-one percent (71%) responded that they were either satisfied or highly satisfied about e-learning materials they received. More than one third of the respondents (39%) felt encouraged to collaborate and interact with their teachers during e-learning time compared to the in-class teaching sessions. A similar percentage of respondents felt that they were more encouraged to work on course materials compared to the traditional learning sessions received at the university. Around 74% of the students felt that the teachers were friendly during e-learning sessions. Moreover, 62% of them were either satisfied or highly satisfied with the provision to ask questions during e-learning sessions. Sixty percent (60%) of respondents was satisfied or highly satisfied with the answers received for the clarifications they requested. Seventy percent (70%) of the students claimed that the interactions between the lecturers and students during question and answer sessions, case scenarios and case discussions were essential for the success of e-learning experience. Fifty-five percent (55%) of them were satisfied with the interactions they experienced during e-learning sessions in their study period. Interestingly, more than one third of the respondents were of the opinion that online lectures were more effective than traditional live lectures. Moreover, 54% of the sample felt that the overall e-learning experiences was better than the traditional learning opportunities they received in the university and the possibility of following the coursework at their own pace (14.8%) was chosen as the main reason for this response.

Females had better overall e-learning experiences than the learning opportunities they received at the university compared to male students and this difference was statistically significant (p=0.000) (Table 1).

Surprisingly, only 1% of the respondents had identified social media as a positive influence on e-learning.

Table 1 describes participants’ response to the questionnaire according to their gender.

Table 1. Comparison of participants’ response according to their gender (in percentages)

B. Preference on Methods of E-learning

Sixty-four percent (64%) of the participants were familiar with Zoom as an e-learning platform. Majority of the students preferred PowerPoint presentations with narrations (68%) to receive lectures. In addition, 69% felt that e-learning materials had helped them to improve their knowledge on the course content specified in the Intended Learning Outcomes (ILOs). Around 34% had identified video demonstrations as an important tool in imparting skills training to achieve the course ILOs. Over 70% rated it as highly useful when students’ opinion is taken in consideration in improving knowledge on the course content.

Sixty-four percent (64%) felt that that e-learning material should be used as supplementary materials for in-class learning within the skills domain. The e-learning materials considered appropriate were video demonstrations, procedural steps described in text documents, YouTube links and case discussions. Majority of the courses in the first semester (Anatomy, Dental Anatomy and Physiology related), third semester (Tooth morphology and occlusion, Human Diseases, Dental Biomaterials), fifth semester (Operative Dentistry, Population Oral Health, Clinical and Diagnostic Oral Sciences [CDOS1] and Child and Adolescent Oral Health [CAOH1]) and seventh semester (Adult Oral Health, CDOS2 and CAOH2) were rated as suitable for e-learning activities.

C. Opinion on Assessment via E-Learning Platforms

The Multiple Choice Questions (MCQ) and Short Answer Questions (SAQ) were the more common forms of assessments provided to the participants. However, some students (9%) had experience with essays too. These assessments were formative in nature whereby the questions were posted after each learning session in order to assess the effectiveness of the learning process. These questions were marked by the teachers or self-marked by the students. Sixty-nine percent (69%) felt that conducting assessments online is fair.

D. Opinion on Barriers Identified in E-Learning

Though the majority of first semester students had identified inadequate opportunities to work with other batch mates as a stumbling block, the majority of the seventh semester had identified technical difficulties in accessing the e-learning resources as the major barrier in e-learning. However, there was no significant difference in the responses between the genders and the semester of study of the student.

E. Suggestions to Improve E-Learning

When the students were requested to suggest ways to use the e-learning to improve the required skills, approximately half (52%) of the respondents preferred video demonstrations on clinical and lab procedures. Furthermore, multiple choice questions, use of charts to explain presentations, discussion forums, quizzes, assignments, web links and supplementary reading material were other ways of improving the learning experience as suggested by the participants. However, 3% of the students had clearly mentioned that e-learning could not be used to improve the required skills in dentistry.

There were multiple suggestions by the majority to improve the overall effectiveness of their e-learning experience. Some of the suggestions were uploading of lectures coupled with assignments, video demonstrations especially for practical scenarios, lectures followed by discussions and lectures on Zoom followed by case discussions. However, the statistical significance could not be assessed between genders or semesters as the number of responses for each option was small.

F. Analysis of Results According to the Respondents’ Current Semester

When the results were assessed according to the current semester, a majority of the first, third and seventh semesters students preferred video demonstrations for e-learning sessions. However, a majority of the fifth semester students preferred a combination of video demonstrations and a text document describing procedural steps or video demonstrations combined with YouTube links and discussion forums. Respondents from first semester had the highest overall satisfaction on e-learning materials they received and the difference between the semesters was statistically significant. (p=0.002). Over two-thirds of the seventh semester students (being the students who were exposed to conventional classroom learning experience for more than three years) confirmed that their overall e-learning experiences were better than the traditional classroom learning opportunities they received at the university and the difference was statistically significant (p=0.000) (Table 2). Further, students’ rating of e-learning materials received from teachers (p=0.002) (Figure 1) and encouragement to work on course material compared to the learning sessions received at the university (p=0.015) (Figure 2) were statistically significant when the semester of study were considered.

Table 2 describes participants’ response to the questionnaire according to their semester of study.

Table 2. Variations of participants’ response according to their semester of study (in percentages)

Figure 1 shows students’ rating of e-learning materials received from teachers according to their semester of study.

Figure 1. Students’ rating of e-learning materials received from teachers according to their semester of study

Figure 2 shows students’ feeling of encouragement to work on course material compared to conventional learning sessions received at the university.

Figure 2. Students’ feeling of encouragement to work on course material compared to conventional learning sessions received at the university according to their semester of study

When the results were analysed according to theory based courses (Anatomy, Oral Biology, Human Diseases, Tooth morphology and Occlusion, Dental Biomaterials) against practical, lab based and clinical training courses (Adult Oral Health, Population Oral Health, Clinical and Diagnostic Oral Sciences, Child and Adolescent Oral Health), the participants’ overall e-learning experience in theory based courses was significantly higher than practical and clinical courses (p= 0.03).

All data are available at https://figshare.com/s/c6c7b8f1d5cfd0076808.

V. DISCUSSION

E-learning is a broad term which encompasses the use of software applications to support learning, whether online or offline (Piccoli et al., 2001). The efficacy of an e-learning experience is dependent on many factors such as availability of devices, access to internet, knowledge on IT and uninterrupted internet connectivity (Asiry, 2017; Linjawi & Alfadda, 2018).

In the present study, half of the sample experienced some interruption during the e-learning sessions. It has been demonstrated in previous studies that students generally have a positive outlook to e-learning in spite of technical problems and related stresses (Brumini et al., 2014). Other studies have also highlighted positive experiences in isolated dental specialties (Bains et al., 2011; Gonzalez & Gadbury-Amyot, 2016; Qi et al., 2013; Reissmann et al., 2015). Our results revealed that students had a better learning experience with e-learning in comparison to traditional methods which was compatible with the findings of similar studies (Turkyilmaz et al., 2019). A study in Germany involving undergraduate dental students stated that participation in online learning was higher compared to “face-to-face” courses which was similar to the findings of the present study (Schlenz et al., 2020). Reasons for popularity of e-learning material over face-to-face learning are that it not only provides flexibility in the learning process (p=0.003) but also saves time (p = 0.012) (Anwar et al., 2021).

When the students’ perception on e-learning resources were analysed, males showed better IT literacy in comparison to female students. Even though the female students were not as confident as male students, a majority of them expressed that the overall e-learning experience was better than the conventional learning. These findings endorse the observations of Linjawi and Alfadda (2018) where the students claimed that they had better skills and motivation for e-learning than conventional learning activities. The identification of social media platforms for e-learning opportunities by a very few students in our study corroborate the fact that formal modalities of delivering e-learning resources should be implemented rather than relying on generic platforms.

Participants’ overall e-learning experience in theory based courses were significantly higher than practical and clinical courses due to the need of hands on experience, simulator training and working with patients for the practical and clinical courses than listening, reading and writing practice. This fact should be carefully considered when developing and planning the modes of content delivery as the knowledge and skills domains should be separately considered. More theory could be delivered through e-learning modalities and this time saved could be utilised for the face to face delivery of practical and clinical procedural teaching in predominantly skills based courses such as the Bachelor of Dental Surgery. However, the findings contradict the previous belief of the faculty that e-learning should only be used as a supplementary tool. There is a possibility to incorporate classroom and e-learning as a blended learning experience when imparting theory components in the future to save time, improve efficient use of limited infrastructure and to focus more on much needed skill development in dentistry. Incorporation of e-learning facilities to the maximum possible level should also be considered in future planning of the state universities in the delivery of undergraduate education in countries such as in Sri Lanka to enhance the quality of learning using the minimal physical and human resources available. Reports from experience in other countries highlight that e-learning processes are also cost effective, due to the availability of low cost or free online tools and platforms which can be used by teachers with a sound background of pedagogical knowledge (Goh, 2018).

First semester had the highest overall satisfaction on e-learning. This group consisted of students who hardly had any noteworthy face-to-face learning experience in the Faculty of Dental Sciences due to the abrupt closure during pandemic situation. Therefore, it seems that they could not effectively compare the two learning methods. Though less than first semester, more than 50% of the seventh semester students had a positive attitude towards e-learning experience. Our finding is in agreement with the findings of a previous study where it was shown that the perceived impact of e-learning and readiness for e-learning became less acceptable as students became mature (Linjawi & Alfadda, 2018).

Positive feedback regarding e-learning experience showed statistically significant differences between students of different semesters in relation to overall satisfaction on the e-learning materials received; encouragement to work on course materials; feeling that the teachers were friendly during the e-learning sessions; satisfaction on the student-teacher interaction during e-learning sessions. These findings should be considered when modes of learning for different components are planned by the Faculty of Dental Sciences during future revisions to the curriculum. Similarly, a recent report on undergraduate dental education during the COVID-19 pandemic has described that e-learning has been appreciated not only by students and teachers, but also in relation to the teacher-student interaction (Bennardo et al., 2020).

A majority of the students felt that the best way to receive the theory component was through PowerPoint presentation with voice narrations. This was statistically significant when compared among different semesters. This is in contrast with the preferred e-learning method among the Saudi Arabian dental students whereby online flash lectures were the most preferred method (Asiry, 2017).

Similar to our findings, a study on health care students belonging to 11 countries among the developed and developing nations also identified that 60% agreed that clinical and practical skills are best learned in clinics and laboratories (Abbasi et al., 2020). Another study involving over 3000 medical students of all years from over 13 schools in Libya has revealed only 21% agreed that e-learning could be used for clinical aspects, as compared with 55% who disagreed with this statement and 24% who were neutral (Alsoufi et al., 2020). The students ‘most preferred mode to learn skills as prescribed in the ILOs was through the use of procedural videos. A previous study carried out in the same institute to investigate the efficacy of procedural video versus live demonstrations revealed that that there was no appreciable difference in the development of skills in dental laboratory technology procedures (Thilakumara et al., 2018). This outcome could be applied to our findings that e-learning sessions, if followed by discussion forums with the teachers, as suggested by the participants would dramatically improve the e-learning experience.

E-learning with its virtual learning environment also requires different skills and a positive attitude from instructors. The positive attitude of the instructors towards technology, the interactive teaching style, and control over the technology were found to have an important influence on students’ reactions to the learning environment (Piccoli et al., 2001). This highlights the importance of professional development in two main aspects; technical and e-pedagogical areas (Conole & Oliver, 2002). The significance of institutional support should be highlighted. Therefore, the need of training for the teachers in the use of efficient methods for e-learning is emphasised. Furthermore, the faculty needs to have a long-term plan to encourage learning facilities through the use of different platforms, use of web links and production of supplementary video for demonstrations in order to encourage students towards a lifelong learning experience. Investment in more user-friendly and versatile software and resources to improve e-learning activities should be prioritised in order to make this endeavour more effective, interactive and receptive to the end users.

A. Limitations of the Study

Our study was performed in a single country and in a single institution as the country has only one dental school. Therefore, the results may not be generalised to other countries and to the region. The results must be validated through further multi-centre studies in order to obtain an overall opinion. Multi-national studies would provide a better understanding on how e-learning could replace the bulk of conventional dental undergraduate clinical learning and provide cost effective solutions for the developing countries with limited physical and human resources to avoid disruption of clinical training during difficult times such as the present COVID-19 pandemic. Another limitation is the cross-sectional nature of the study design, which limited our ability to identify causal associations.

VI. CONCLUSION

A positive learning experience was achieved through the e-learning modalities by the undergraduate dental students in comparison to traditional face-to-face learning. In terms of skills training, e-learning should only be considered as a supplementary tool. These findings will be useful when designing the study courses as a major part of theory component via e-learning mode and skill component with combined e-learning and conventional modes in the future.

We recommend adapting interactive e-learning platforms by using highly sophisticated technologies along with virtual clinical experience with combined clinical scenarios and assessments based on discussions of patient cases. Cost-effective solutions are needed to reduce disruption of undergraduate dental education especially in developing countries in the region like Sri Lanka and there should be new collective effort by the countries in the South Asian region in planning and sharing less expensive e-learning solutions in order to overcome financial issues. Such measures may vary from learning theory and virtual clinical and lab-based experience, followed by limited hands-on experience on live patients in a safe environment during difficult times of this nature.

Notes on Contributors

Principal and corresponding author (Rasika Jayasinghe) conceptualised the research and edited the initial draft and wrote the results after analysis. She also did the final approval of the version to be published and agreed to be accountable for all aspects of the work.

Manjula Attygalla edited the initial draft of the manuscript and supported in modification of the questionnaire. He also did the final approval of the version to be published and agreed to be accountable for all aspects of the work.

Manil Fonseka supported planning of the study, edited the research proposal and manuscript. He also did final editing and approval of the version to be published and agreed to be accountable for all aspects of the work.

Dhanushka Leuke Bandara supported planning of the study, designed the Google form, carried out the survey and entered the data in addition to editing of the manuscript. She also did final approval of the version to be published and agreed to be accountable for all aspects of the work.

Gishan Edirisinghe carried out the literature survey and did the final approval of the version to be published and agreed to be accountable for all aspects of the work.

Ruwan Jayasinghe supported planning of the study, prepared the initial draft of the research proposal and edited the final draft of the manuscript. He did the final approval of the version to be published and agreed to be accountable for all aspects of the work.

Indika Thilakumara supported planning of the study, edited the first draft and wrote the discussion. She did the final approval of the version to be published and agreed to be accountable for all aspects of the work.

Ethical Approval

Ethical clearance has been granted by Ethics Review Committee, Faculty of Dental Sciences, University of Peradeniya. (ERC/FDS/UOP/I/2020/21).

Data Availability

All data are available at https://figshare.com/s/c6c7b8f1d5cfd0076808 and can be accessed on request and approval from the corresponding author.

Funding

No funding sources are associated with this study.

Declaration of Interest

Authors declare that they do not have possible conflicts of interest, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest.

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Thilakumara, I. P., Jayasinghe, R. M., Rasnayaka, S. K., Jayasinghe, V. P., & Abeysundara, S. (2018). Effectiveness of procedural video verses live demonstrations in teaching laboratory techniques to dental students. Journal of Dental Education; 82(8), 898-904. https://doi.org/ 10.21815/JDE.018.086

Turkyilmaz, I., Hariri, N. H., & Jahangiri, L. (2019). Student’s perception of the impact of e-learning on dental education. Journal of Contemporary Dental Practice, 20(5), 616-621.

Venkatesh, S., Rao, Y. K., Nagaraja, H., Woolley, T., Alele, F. O., Bunmi, S., & Malau-Aduli, B. S. (2019). Factors influencing medical students’ experiences and satisfaction with blended integrated e-learning. Medical Principles and Practice, 29, 296-402. https://doi.org/10.1159/000505210

Wong, M. L., Lee, T. W. O., Allen, P. F., & Foong, K. W. C. (2020). Dental education in Singapore: A journey of 90 years and beyond. The Asia Pacific Scholar, 5(1), 3- 7. https://doi.org/10.29060/TAPS.2020-5-1/GP1086

*RM Jayasinghe
Department of Prosthetic Dentistry,
Faculty of Dental Sciences,
University of Peradeniya
Tel: +94777806314
Email: manorija@pdn.ac.lk/ manoripathiraja@yahoo.com

Submitted: 18 December 2020
Accepted: 12 April 2021
Published online: 5 October, TAPS 2021, 6(4), 1-6
https://doi.org/10.29060/TAPS.2021-6-4/GP2451

Dora J. Stadler^1,2, Halah Ibrahim^3,4, Joseph Cofrancesco Jr⁴ & Sophia Archuleta^5,6

¹Department of Medicine, Weill Cornell Medical College, Doha, Qatar; ²Walter Reed National Military Medical Center in Bethesda, United States of America; ³Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates; ⁴Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America; ⁵Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore; ⁶Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore

Abstract

Introduction: Gender equity in academic medicine is a global concern. Women physicians lag behind men in salary, research productivity, and reaching top academic rank and leadership positions.

Methods: In this Global Perspective, we provide suggestions for overcoming gender bias, drawn from a multidisciplinary literature and personal experiences working as clinician educators in the international academic arena. These suggestions are not exhaustive but inform a tool kit for institutions and individuals to support the advancement of women in academic medicine.

Results: Barriers include limited access to same gender role models and mentors, fewer networking opportunities, fewer nominations for awards and speakership opportunities, as well as implicit gender bias. Institutional interventions can address disparities along the career continuum focusing on scholarship, promotion and leadership opportunities. Women faculty can also seek out professional development programmes and mentorship to support their own advancement. Informal and formal networking opportunities, using a variety of platforms, including social media, can help build relationships to enhance career development and success, and provide social, emotional and professional support to women at all stages of their career. The National University Health System’s Women in Science and Healthcare project is an example of a successful group formed to empower women and foster personal and professional development.

Conclusion: Successful incentives and policies need to consider local institutional and cultural contexts, as well as approaches to mitigate implicit bias. Achieving gender parity in academic medicine will promote a personally and professionally fulfilled global healthcare workforce to improve patient care and clinical outcomes worldwide.

Practice Highlights

• The gender gap in academic medicine persists worldwide, especially at higher academic rank & leadership positions.
• Institutions should develop strategies to address gender equity in faculty recruitment, retention & advancement.
• Female faculty can help to advance themselves and each other through seeking self-development, mentorship and networking opportunities, utilising local as well as global resources available through a variety of channels, including social media.
• Women faculty groups can facilitate networking opportunities and create a critical mass of individuals, who can provide effective personal and professional support.

I. THE STATE OF GENDER EQUITY IN INTERNATIONAL ACADEMIC MEDICINE

Gender inequity in academic medicine has been a global concern for several decades. Although the enrolment of women in medical schools has reached or exceeded parity in many parts of the world, disparities remain in academic rank, career advancement, and leadership positions internationally (Stadler et al., 2017). Women faculty lag behind their male colleagues in several domains, including salaries, research productivity, and resource allocation. Various terminologies have been used to describe this phenomenon, including the leaky pipeline, sticky floor, broken rungs, and glass ceiling. Regardless of the phrasing, the outcome remains the same – the gender gap persists, particularly at the highest academic ranks and in medical leadership positions. As recent studies have linked physician female gender to improved patient clinical outcomes, hospitals and academic institutions now have additional incentives to train and retain a diverse workforce.

Though much of the literature on gender disparity in academic medicine is Western-based, global studies also document ongoing inequity. For example, a comparative study in Scandinavian countries found significantly fewer women in higher income specialties and in leadership positions, despite policies and cultural attitudes that support and promote work-life balance. Even in countries, such as Russia, where the majority of the physician workforce is comprised of women, the authors found significantly fewer women in prestigious specialties, tertiary care and academic medicine. In a multinational study of newly accredited postgraduate training programs in Singapore, Qatar and the United Arab Emirates, women comprised 25% of the clinician educator workforce and only 18% of hospital CEO/ CMOs, and were significantly less likely to hold an academic appointment (Stadler et al., 2017).

There are multiple barriers to female physician advancement, including limited access to same gender role models and mentors, fewer networking opportunities, lower salaries, less funding and resources (administrative staff, laboratory space), and fewer nominations for awards and conference speakership opportunities (Ibrahim et al., 2019a). These disadvantages start early in a female physician’s career and continue throughout her education, training and employment and, ultimately, impact her career trajectory. The cause is multifactorial, but there is a large body of literature that suggests that implicit gender biases play a significant negative role in the recruitment, retention and promotion of female physicians. Gender stereotype threat, which goes beyond how women are perceived and evaluated, and affects how they actually perform, could further augment disparity. There is currently a dearth of literature on successful initiatives to improve gender equity in the international arena and further research is needed to identify effective interventions in local contexts. Given the complexity of the underlying causes of gender inequity, initiatives to advance women in academic medicine should be comprehensive and multi-pronged, and include both institutional and individual interventions.

 II. INSTITUTIONAL INITIATIVES

International academic institutions can vary considerably in faculty gender composition, resources available, and institutional culture. International medical education is evolving, and now is the time for healthcare institutions to assess the diversity of their faculty and review policies and protocols for any evidence of systemic bias, as well as formally assess organisational climate. The leaky pipeline model offers a framework to address these issues along the continuum of a female physician’s career. First, explicit policies to recruit, hire and retain more female academic faculty are necessary. Institutions need to analyse their current status and set goals for improvement (Ibrahim et al., 2019b), and need to ensure equity in advancement, with a focus on success in scholarship, promotion and leadership. Contributors to the leaky pipeline and a summary of possible approaches to resolve issues are described in Figures 1 and 2, respectively.

Figure 1. Barriers to recruitment, retention, and advancement

Figure 2. Institutional strategies to support female faculty recruitment, retention and promotion

Implicit or unconscious bias affects all aspect of this process; therefore, continued training to recognise and mitigate its effects is vital to success. Effective institutional policies for recruitment of a diverse faculty have included bias training for members of search and promotion committees, ensuring committee diversity (representative of gender, minorities and clinical tracks), as well as accountability through tracking of female faculty applicants and hires. Successful initiatives for retention of faculty have focused on development of policies that facilitate work-life balance and integration, such as part-time work, job sharing, and on-site childcare. The facilitation of an institutional culture that makes these options accessible without fear of stigma or penalty is crucial for these programs to succeed. Transparency in policies and salaries, systematic review and adjustment of pay structure, as well as offering negotiation workshops for female faculty, have all been shown to be successful in equalising the salary gap. Formal institutional support in terms of funding, space, time allotment, and interdepartmental activities to foster collaboration can boost research productivity and decrease isolation reported by female academic faculty. Structured professional development for faculty at all career levels, with a family friendly schedule, can be a positive factor in women physicians’ career satisfaction and retention.

Institutional review and focus on parity in advancement can help to identify and fix the ‘broken rungs’ on the ladder to promotion and leadership positions for women. Adjusted promotion and tenure guidelines to account for childcare and part-time work are also integral to advancement. While many of these recommendations are based on literature from Western academic institutions, the overall framework and guiding principles can be adapted globally. Further, gender-based research in international academic institutions is needed to better address inequity and barriers in local contexts.

III. INDIVIDUAL INITIATIVES

Institutional change is a long-term process and transforming institutional culture can take time. Despite the systemic gender bias, women physicians can take proactive steps to advancement.  Women physicians face a set of internal challenges such as their own implicit bias, susceptibility to gender stereotype threat that can affect performance, and higher rates of imposter syndrome. Individual faculty members can seek out and request to participate in faculty development programs that support addressing these topics, as well those that support career advancement. Women can seek mentors and sponsors at their own or other institutions through local, regional and national networks. In addition to structured faculty development and formal mentorship processes, networking, a less formal relationship, can be utilised to support female faculty. Networking, a process used to build, maintain and use relationships to enhance career development and success, can provide social, emotional and professional support to women at all stages of their career. It can also combat professional and personal isolation often experienced by female faculty. In today’s globally dispersed and pandemic affected medical communities, the power of social media cannot be undervalued. Social media platforms can be used to form communities to share knowledge, address isolation, facilitate networking, and provide mentoring (Ibrahim et al., 2020). These platforms also serve as effective venues to broadcast and celebrate accomplishments. Networking can occur through individual channels and through grassroots efforts to build a community of women with shared goals and interests. A useful guide to building an international women’s group to facilitate and support female physician networking is illustrated in Figure 3 and exemplified through the following project.

Figure 3. Framework for building a women’s group

IV. AN EXAMPLE OF SUCCESS IN THE LOCAL ARENA: THE WISH PROJECT

Solutions to achieve meaningful change require multidimensional and comprehensive strategies. However, there is limited information in the medical literature about developing or running an academic women’s group, especially in the international arena where policies and support systems for gender parity may be lacking. Often, a “bottom-up” approach, by women for women, is needed. Therefore, in 2017, to help the advancement of women at our institution, we formed the National University Health System Women in Science and Healthcare (NUHS WISH), dedicated to empowering and supporting women in healthcare and science fields in the NUHS ecosystem (Yoong et al., 2019). We viewed this group as more than a social opportunity, but rather as a vehicle for women’s empowerment. Borrowing from a multidisciplinary literature on group formation and change management, we structured our initiative according to John Kotter’s 8-step process of transformational change, as seen in Figure 3. First, we assembled a small team of passionate and dedicated women who served as transformation leaders. With the simple mission of supporting the personal and professional advancement of women in healthcare, the team communicated their vision through word of mouth and social media. Next, the transformation leaders worked with institution leadership to highlight and address barriers to female advancement in healthcare. We shared short-term wins, and planned for the future. Viewing the women’s group as an opportunity for culture change, rather than a single initiative, encourages sustainability and innovation. We deliberately alternated informal social gatherings and formal structured events. Workshops were planned for women at all career stages, with specific focus on the development of skills essential for success in healthcare, including leadership and mentorship. Given the varied professions and career stages of the members, we provided early career professionals the opportunity to network with experienced women, who offered career-related and other advice. Senior members benefitted from interacting with individuals in key leadership positions. WISH is now in partnership with senior leadership, and has grown to be a strong group of empowered female health professionals. We believe this network of developmental relationships is critical for the retention and success of women in academic medicine.

In conclusion, ensuring gender equity should be an important goal for academic medicine institutions worldwide. Our recommendations are based on personal experiences, as well as a review of best practices. The suggestions are not exhaustive and we are cognisant that no single model fits all institutions; culture and context must always be considered. Nonetheless, we believe that multilevel, institution-wide approaches to support the advancement of female faculty will benefit the institution as a whole, and help to foster inclusivity and equality in the international medical workforce. Women can also create structures to help support their advancement. By supporting all healthcare professionals to reach their full potential, we can strive for a personally and professionally fulfilled global healthcare workforce to improve patient care and clinical outcomes worldwide.

Notes on Contributors

Dora J. Stadler conceived the manuscript design, reviewed the literature and drafted the manuscript. Halah Ibrahim reviewed the literature and drafted the manuscript, Joseph Cofrancesco Jr. advised the manuscript design and gave critical feedback to the manuscript. Sophia Archuleta conceived the manuscript design, reviewed the literature and gave critical feedback to the manuscript. All authors have read and approved the final manuscript.

Acknowledgement

The authors wish to thank Siok Ching Chia, BS, National University Hospital for her assistance in preparing the manuscript for submission.

Funding Statement

There were no funding sources for this study.

Declaration of Interest

The authors declare no conflicts of interest.

References

Ibrahim, H., Abdel-Razig, S., Stadler, D. J., Cofrancesco, J., Jr., & Archuleta, S. (2019a). Assessment of gender equity among invited speakers and award recipients at US annual medical education conferences. JAMA Network Open, 2(11), e1916222. https://doi.org/10.1001/jamanetworkopen.2019.16222

Ibrahim, H., Stadler, D. J., Archuleta, S., Anglade, P., & Cofrancesco, J., Jr. (2019b). Twelve tips for developing and running a successful women’s group in international academic medicine. Medical Teacher, 41(11), 1239-1244. https://doi.org/10.1080/0142159X.2018.1521954

Ibrahim, H., Anglade, P., & Abdel-Razig, S. (2020). The use of social media by female physicians in an international setting: A mixed methods study of a group WhatsApp chat. Women’s Health Reports, 1(1), 60-64. https://doi.org/10.1089/whr.2019.0015

Stadler, D. J., Archuleta, S., Ibrahim, H., Shah, N. G., Al-Mohammed, A. A., & Cofrancesco J., Jr. (2017). Gender and international clinician educators. Postgraduate Medical Journal, 93(1106), 719-724. http://doi.org/10.1136/postgradmedj-2016-134599

Yoong, J., Alonso, S., Chan, C. W., Clement, M.-V., Lim, L. H. K., & Archuleta, S. (2019). Investing in gender equity in health and biomedical research: A Singapore perspective. The Lancet, 393(10171), e21-e22. https://doi.org/10.1016/S0140-6736(18)32096-8

*Sophia Archuleta
1E Kent Ridge Road
NUHS Tower Block, Level 10
Singapore 119228
Tel: +65 6772 6188
Email: sophia@nus.edu.sg

 

Submitted: 31 August 2020
Accepted: 17 February 2021
Published online: 13 July, TAPS 2021, 6(3), 91-94
https://doi.org/10.29060/TAPS.2021-6-3/SC2353

Melissa Su Yi Yong, Xing Tong Yong, Olga Hillary Li Chew & Kuan Chen Zenne T’ng

Speech Therapy Department, Tan Tock Seng Hospital, Singapore

Abstract

Introduction: During the COVID-19 epidemic in Singapore, there was an urgent demand to train more nurses within a short timeframe to perform the Water Swallow Test (WST). The previous training model involved training with actual patients and was time-consuming. Hence, the model was revamped and standardised patients (SPs) were engaged for nurses’ training. This study further investigated nurses’ feedback about the new training model and compared the efficiency and learner-reported outcomes of the previous and new models.

Methods: Nurses who completed WST training from January 2018 to July 2020 were enrolled. Training records were accessed to determine the number of nurses trained under the previous and new models. Nurses were invited to complete post-training evaluation forms and their responses were analysed. Descriptive statistics and the Mann-Whitney U test were used for data analysis. 

Results: Under the previous model, 52 nurses were trained over 2 years, whereas under the new model, 112 nurses were trained over two months. From the evaluation form responses, the majority of nurses trained under the new model agreed that they achieved the learning objectives and were confident in performing the WST. There was also no significant difference (p>0.05) found between learner-reported outcomes for both training models. 

Conclusion: Our findings demonstrated that the new model that engaged SPs was more efficient in training more nurses. Nurses were also satisfied with the new training model, which achieved similar learner-reported outcomes as the previous model.

Keywords:            Water Swallow Test, Standardised Patients, Train-the-Trainer, Dysphagia Screening

With the new training model implemented, the following research questions were posed:

1) Is the new training model more efficient in training providers to perform the WST compared to the previous model? 

2) Are providers trained under the new model confident that they have achieved the learning objectives of the training and in performing the WST? 

3) Is the new training model able to achieve similar learner-reported outcomes for providers as compared to the previous model?

It was hypothesised that:

1) The new training model is more efficient in training providers than the previous model.

2) Majority of providers trained under the new model will feel confident that they achieved the training learning objectives and in performing the WST. 

3) The new training model will achieve similar learner-reported outcomes for providers when compared to the previous model. 

II. METHODS

Nurses who completed WST training as providers from January 2018 – July 2020 were enrolled. Nurses were trained using the previous training model from January 2018 – April 2020. The new training model was implemented from May 2020. 

In order to evaluate the efficiency in training providers under both models, nursing training records were accessed retrospectively to obtain the numbers and dates of providers who completed their training from January 2018 – July 2020. Total training hours under the previous model were computed based on the number of providers who completed training (three hours per provider). Under the new model, total training hours were calculated based on the number of training sessions (three hours per session) conducted from May – July 2020.

In order to evaluate the providers’ confidence in achieving the training’s learning objectives and in performing the WST, providers trained under both models were invited to complete an anonymous course evaluation form generated by the authors and select their responses on a 5-point Likert scale (i.e., strongly agree, agree, neutral, disagree, strongly disagree). The evaluation form was updated along with the new training model, however, these three statements remain unchanged in both versions and were used to analyse learner-reported outcomes:

1. I have a clear understanding of the contraindications of performing the WST.

2. I am confident of accurately identifying all the signs of dysphagia during the WST.

3. I am confident of performing the WST independently.

For data analysis, ‘strongly agree’ and ‘agree’ responses were collapsed into a single category and assigned a score of 1, ‘neutral’ response was assigned a score of 2, and ‘disagree’ and ‘strongly disagree’ responses were collapsed into a single category and assigned a score of 3. Statistical analysis was performed using SPSS statistics version 27.0. Descriptive statistics and the Mann-Whitney U test were used to analyse the evaluation form responses.

Implied consent was obtained from providers who voluntarily completed the form. This study was exempted from a formal NHG Domain Specific Review Board review.

III. RESULTS

A. Number of Providers Trained and Duration Required

Under the previous training model, 52 providers were trained over 24 months (January 2018 – December 2019). The total number of training hours was 156 hours (i.e., 52 providers x three hours). Under the new model, 112 providers were trained in 15 training sessions over two months (end May – mid-July 2020). The total training hours were 45 hours (i.e., 15 sessions x three hours). 

Hence, one provider was trained every three-hourly training session and an average of 2.17 providers were trained per month under the previous model. Contrastingly, an average of 7.57 providers were trained every three-hourly training session and an average of 56 providers were trained per month under the new model.

B. Evaluation Form Responses

13 evaluation form responses (N_previous = 13) were received under the previous model, and 111 responses (N_new = 111) were received under the new model. The mean scores obtained for the three selected statements were: 

1. I have a clear understanding of the contraindications of performing the WST (Previous model: M = 1.08, SD = 0.277; New model: M = 1.22, SD = 0.624).

2. I am confident of accurately identifying all the signs of dysphagia during the WST (Previous model: M = 1.08, SD = 0.277; New model: M = 1.23, SD = 0.567). 

3. I am confident of performing the WST independently (Previous model: M = 1.15, SD = 0.555; New model: M = 1.22, SD = 0.563).

C. Comparison of Learner-Reported Outcomes

Scores from the new evaluation form (mean ranks = 62.76, 63.03, 62.90) were higher than scores from the previous form (mean ranks = 60.31, 57.96, 59.08) for all three statements. A Mann-Whitney U test indicated that the differences in scores between the previous and new model for all three statements were not statistically different, U_Statement1 (N_new = 111, N_previous = 13) = 693.00, z = -0.438, p = 0.661; U_Statement2 (N_new = 111, N_previous =13) = 662.50, z = -0.786, p = 0.432; U_Statement3 (N_new = 111, N_previous = 13) = 677.00, z = -0.608, p = 0.543. 

The above data set and analysis is available online (Yong et al., 2020).

IV. DISCUSSION

A. Efficiency of New Training Model

The new training model was more efficient than the previous model. Comparing the average number of providers trained per month, the new model was 25 times more efficient. Engagement of SPs allowed more staff to be trained in a single session by seven-fold, versus training with actual patients. Several factors made the new model more efficient: i) greater control over scheduling, ii) saving time from identifying suitable patients for training, and iii) reduced motion waste from accessing actual patients. Hence, more nurses could be trained to meet the needs of outbreak wards.

B. Feedback on Training

The mean rating scores for the three statements in the new evaluation form indicated that providers were satisfied with their training, as they mostly agreed or strongly agreed to achieving the training learning objectives and were confident in performing the WST.

C. Comparison of Learner-reported Outcomes under Both Models

No significant differences were found between responses in the previous and new evaluation forms. Thus, regardless of whether providers trained with actual patients or SPs, most perceived they fulfilled their learning objectives and felt confident to perform the WST independently. These findings indicated that providers did not perceive their training quality to be compromised with the use of SPs and shorter training duration.

D. Limitations

A limitation was that only 25% of providers completed the optional evaluation form under the previous model. The staff who responded likely had a positive training experience and this could lead to potential selection bias. We also acknowledge that the three statements from the evaluation form require further validity and reliability testing to analyse providers’ confidence levels and can be explored in future studies.

V. CONCLUSION

Our study demonstrated that having standardised patients as part of the training method translated to a significant increase in the efficiency of WST training. Potential scale-up of this WST training method can ensure that there is a steady pool of providers and trainers in the workforce to cope during peacetime and crises. Adopting the WST as part of routine dysphagia screening ultimately ensures safer feeding management and early access to Speech Therapy intervention. Further directions include investigating the effectiveness and validity of the new WST training model in various healthcare settings, such as acute and community hospitals and nursing homes, to improve training standards for dysphagia screening in the region, especially in light of the ongoing COVID-19 pandemic.

Notes on Contributors

Yong Su Yi Melissa and Yong Xing Tong evaluated the training model, conducted the training and wrote the manuscript. Olga Hillary Chew Li conducted the training and performed data collection. Zenne T’ng Kuan Chen initiated the design of the training model and gave critical feedback to the writing of the manuscript. All authors read and approved the final manuscript.

Ethical Approval

This study has been reviewed by NHG Domain Specific Review Board (DSRB) for determination of ethics requirement and does not require formal review (NHG DSRB Ref: 2020/00953).

Acknowledgements

We would like to acknowledge:

Senior Nurse Educator Kylie Tang and Nurse Educator Zhao Yue for their feedback in the design of the training model, accessing training records for data collection and collaboration in facilitating WST training for the Nursing Services department.

Senior Speech Therapist Ei Leen Fong for vetting the final manuscript

Principal Speech Therapist Kwong Seh Ling for her guidance in the data analysis and feedback on the manuscript.

Funding

There is no funding involved for this study.

Data Availability

All available data can be accessed publicly via https://doi.org/10.6084/m9.figshare.13110617.

Declaration of Interest

The authors declare there are no conflicts of interest.

References

Betihavas, V., Bridgman, H., Kornhaber, R., & Cross, M. (2016). The evidence for ‘flipping out’: A systematic review of the flipped classroom in nursing education. Nurse Education Today, 38, 15-21. https://doi.org/10.1016/j.nedt.2015.12.010  

Kowitlawakul, Y., Chow, Y. L., Salam, Z. H., & Ignacio, J. (2015). Exploring the use of standardized patients for simulation-based learning in preparing advanced practice nurses. Nurse Education Today, 35(7), 894–899. https://doi.org/10.1016/j.nedt.2015.03.004

Pearce, J., Mann, M. K., Jones, C., van Buschbach, S., Olff, M., & Bisson, J. I. (2012). The most effective way of delivering a train-the-trainers program: A systematic review. The Journal of Continuing Education in the Health Professions, 32(3), 215–226. https://doi.org/10.1002/chp.21148

Suiter, D. M., & Leder, S. B. (2008). Clinical utility of the 3-ounce water swallow test. Dysphagia, 23(3), 244–250. https://doi.org/10.1007/s00455-007-9127-y

Yong, M., Yong, X. T., Chew, O., & Tng, Z. K. C. (2020). Training nurses to perform water swallow test with use of standardised patients (raw data & analysis) [Data set]. Figshare. https://doi.org/10.6084/m9.figshare.13435310.v2

*Yong Su Yi Melissa
Tan Tock Seng Hospital,
11 Jalan Tan Tock Seng,
Singapore 308433
Tel: +65 8522 8013
Email: melissa_sy_yong@ttsh.com.sg

Submitted: 31 August 2020
Accepted: 9 December 2020
Published online: 13 July, TAPS 2021, 6(3), 87-90
https://doi.org/10.29060/TAPS.2021-6-3/SC2394

Juanita S. M. Kong^1*, Boon See Teo^2*, Yueh Jia Lee¹, Anu Bharath Pabba¹, Edmund J.D. Lee¹ & Judy C. G. Sng¹

¹Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ²Department of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

^*Equal contribution; first co-authors are in alphabetical order

Abstract

Introduction: With the COVID-19 pandemic, Singapore underwent a national lockdown in which most organisations, including schools were closed. Halting face-to-face tutorials resulting in decreased clinical contact for medical students. Prior to the pandemic, we had developed the Virtual Integrated Patient (VIP). Equipped with conversational technology, it provides students online practice in various clinical skills such as history-taking, physical examination and investigations. The aim of this paper is to describe the supplementary use of VIP in the second-year class, in which a pilot study was conducted.

Methods: The VIP platform was introduced to the cohort and used to supplement the teaching of history-taking in the “Communication with Patients” (CWP) module for second-year students. Traditionally, CWP tutorials involve face-to-face history-taking from standardised patients (SPs). Students, who consented to participating in the trial, had an additional 3 weeks’ access to VIP to practice their history-taking skills. They completed a survey on their user experience and satisfaction at the end of the 3 weeks.

Results: Out of the 106 participants, 87% strongly agreed or agreed that using VIP helped in remembering the content while 69% of them felt that VIP increased their confidence and competence in history-taking.

Conclusion: VIP was well-received by students and showed promise as a tool to supplement history-taking tutorials, prior to students’ encounter with SPs and real patients. Hence, this trend showed its potential as an alternative when clinical rotations were delayed or cancelled. Further research can be done to evaluate its effectiveness in this context.

Keywords:            Medical Education Tool, Virtual Patients, Communication, Skill Acquisition, Chatbot, Conversational

I. INTRODUCTION

Clinical skills that are commonly practised face-to-face were a challenge for students to practise during the onset of the Novel Coronavirus (COVID-19) in Singapore. Singapore underwent a 2-month lockdown during which time most non-essential organisations, including medical schools were closed nationwide. In our institution, lectures and tutorials were moved online and face-to-face clinical teaching on campus and in hospitals were cancelled. This move necessitated the use of virtual tools, such as remote meeting through Zoom and the use of virtual patient simulators that do not require the students to be physically on campus.

Virtual patient simulators have been used in a wide range of medical education settings, ranging from the teaching of clinical reasoning, procedural skills, communication skills, and integrated performance to critical thinking (Kononowicz et al., 2019). In recent years, there has been increasing use of virtual patients in the healthcare sector and technology improvements will continue to grow. The Virtual Integrated Patient (VIP) is a virtual patient simulator that was created by our team prior to the pandemic. It leverages on artificial intelligence (AI) technology advancements in the area of naturalistic conversational technology. Prior to VIP, existing technology platforms were focused on the linear, semi-linear and menu-driven (with drop-down option boxes) simulators and there were very few developed in free-text conversations (Kononowicz et al., 2015). The VIP has a natural language processor that is flexible to adapt and adjust to conduct a realistic conversation that can enhance specific skill acquisition (Cendan & Lok, 2012; Kononowicz et al., 2019).

The next unique feature of the VIP is the random patient generator (Figure 1a and b). Every time a student logs in, a new patient is generated. They can revisit the past patients if they have not completed the case and restart where they have left off. The random patient generator provides a realistic situation for users that no two doctors will see the same patient at the same time increasing in variability of patients and potentially, diagnoses. Users can also probe into their virtual patients’ history in their unique ways. Integration of natural language processing using conversational technology has allowed users to chat with the virtual patient as though they are chatting with a real person (Figure 1c). The virtual patient is trained with data sets and is AI-learning enabled. Wi-fi connectivity allows VIP to be accessed anywhere and at any time. It is a safe environment where students are able to make mistakes without any penalty and learn from it. VIP has interfaces for history-taking through a chatbot, physical examination, and laboratory investigations as seen in Figure 1c to d.

The aim of this short communication is to describe how VIP has been employed in a history-taking module for second-year medical students. VIP may play a role in providing a platform for users to consistently practise their skills during a global pandemic where face-to-face tutorials are limited.

Figure 1. a to d. Screenshots of the Virtual Integrated Patient (VIP) interface; b. An example of a random patient generator with no same patient; c. In the history-taking screen, the user can chat with a randomly generated virtual patient, who generates answers using the pre-loaded content and the natural language processor; d. Left: The physical examination screen. d. Right: The laboratory investigations screen which provides realistic case information given explicit buttons throughout interface for easy navigation. Bottom Panel: e to f: Skill Retention Confidence survey results.

II. METHODS

This study’s information sheet, study plan, instruction slides, and survey forms were submitted to the National University of Singapore’s (NUS) institutional review board (IRB) for assessment. It was approved with the study approval code of S-19-263.  

VIP was introduced to Phase II “Communications with Patients” (CWP) module in Academic Year (AY) 2019/2020. In this module, students usually clerk a total of three to six standardised patients (SPs) for three sessions over a course of 3 weeks. VIP was introduced to supplement the CWP curriculum. On top of clerking three to six SPs in 3 weeks, participants were given access to VIP during the same 3 weeks. VIP was loaded with cases that complemented and reinforced the contents taught during tutorials, with the aim to deepen students’ understanding of the tutorial content and train them to use the history-taking framework taught during the module.

The VIP team introduced the VIP computer programme and how to use it during the first lecture of the CWP module. Recruitment was done and informed consent was taken from the willing participants for the study. All Phase II students enrolled in the course (n=296) were divided into two groups: the first group received access at the first tutorial (intervention group) and the other group with no access (control group). Eventually, all students from both groups (intervention and control) had received access to the VIP by the end of first week and they could practise over the remaining 2 weeks of the study. Participants were asked to complete a survey at the end of 3 weeks. This is to provide an insight on their confidence levels in executing the history taking exercise and key takeaways with VIP usage at the end of the study.  

Students who declined to participate in the study would still have received access to the VIP, but only after the study period of 3 weeks. This ensured fairness for all second-year medical students to have 6 months to practice on the VIP system before their OSCE (Objective Structured Clinical Examination) at the end of the semester.

Following the 3 weeks of tutorials, students were encouraged to continue practising using the VIP prior to the OSCE which was scheduled to be at the end of the academic year. The original study protocol included collection of participants’ history-taking scores at the OSCE, but this was not possible as the OSCE was cancelled due to the COVID-19 situation in Singapore.

III. RESULTS

We obtained quantitative survey responses (n=106 respondents out of 298; 35% response rate). They indicated positively to VIP with 87% of students feeling that using VIP helped in remembering the content. And 69% of the students strongly agreeing or agreed that VIP increased their confidence in taking history (Figure 1f and g).

Students also provided qualitative responses of the key takeaways with the supplementary usage of VIP with their curriculum. First, they indicated that they were able to execute the history-taking procedures more efficiently with additional practice on the VIP. Second, students indicated that they could better remember the methodological content taught in class after repeated usage, thus reinforcing the procedural history-taking skills. Last but not least, survey respondents also reported enhanced understanding of the multiple facets of presenting cases. Where they learnt more about each diagnosis from the summary page after each case completion. 

IV. DISCUSSION

VIP was well-received by students in CWP. Users’ survey responses reiterated that more practice aided their skill acquisition, helping them to score in their examinations. By keeping the simulation realistic, they could transfer the skills back into their clinical attachments in future. Also, adding VIP supplementary to the planned curriculum, students were provided additional practice that past years students have requested for in course feedback.

Traditionally, CWP students could only clerk three to six SPs during the whole course of module over a span of 3 weeks. Thereafter, they would not have any chance to practice their history-taking skills through the clerking of SPs until their OSCE which would happen half a year later. Over the years, students provided feedback that they did not receive adequate practice prior to the OSCE and practising on their friends was not feasible due to the hectic nature of their curricular commitments. However, this barrier could not be overcome due to the constraints of the packed timetable of the Phase II students. Therefore, current phase II students who reported that VIP enhances their efficiency and has provided them with adequate practice suggest that VIP is a promising supplement for the course.

One key objective of the VIP is to focus on the processes of getting to a diagnosis rather than just the right diagnosis itself. Medical students’ focus usually stems from the diagnoses to symptom as they are taught in that framework. The enhanced understanding of case definition through the case summaries were welcomed due to the realistic nature of their experiences and how it can be related in the actual clinics. This therefore enhances the students’ enthusiasm toward the usage of the platform. Furthermore, the intention of this was to ease the performance anxiety faced by the students by preparing them in a low-stakes environment, helping them to boost their confidence, in facing SPs or real patients. The study results resonated with this purpose as the students reported greater confidence and efficiency in taking family history after using VIP.

Moreover, the availability of VIP appealed to the students. Due to their curricular commitments, students are more often than not, on the go. While travelling or waiting for a class, where there is available Wi-Fi connectivity, they can log on and practise clerking patients on the simulator. Some students who were not able to attend tutorials were slightly disadvantaged as they would lose one or two SP clerking from the 3 weeks.

V. CONCLUSION

With greater confidence and better utilisation of CWP framework among the students who utilised VIP, VIP is promising as a tool to supplement face-to-face history-taking tutorials. It may have potential use in a pandemic situation where medical students have reduced access to in-person clinical teaching. However, further research is needed to establish its effectiveness as an alternative to in-person clinical teaching.  

Notes on Contributors

Author 1, Juanita Kong, was involved in the data collection, analysis, writing, reading, and the final submission of this manuscript. Author 2, Teo Boon See was involved in the planning and execution of this study, writing, reading, and the submission of this manuscript. Both Authors 1 and 2 have equal contribution to the manuscript. Author 3, Lee Yueh Jia, was involved in the data collection, analysis and the reading of this manuscript. Author 4, Anu Bharath Pabba, was involved in the data collection and programming of the tool. Author 5, Edmund Lee was involved in the conceptualisation of the study, data collection, analysis, reading and the final approval of this manuscript. Judy Sng, was involved in the conceptualisation of the study, data collection, analysis, reading and the final approval of this manuscript.

Acknowledgements

We would like to thank the students who participated and provided us with additional feedback when we requested for it. Additionally, we would like to thank all the people who has helped us along the way. Last but not the least, we are grateful for the people who believed in this project.

Funding

The development of the VIP was initially funded by the MOE Tertiary Research Funding (2018 to 2020). It is currently supported by the Yong Loo Lin School of Medicine, under the Innovation Project. 

Declaration of Interest

There are no conflicts of interests in this study.

References

Cendan, J., & Lok, B. (2012). The use of virtual patients in medical school curricula. Advances in Physiology Education, 36(1), 48–53. https://doi.org/10.1152/advan.00054.2011

Kononowicz, A. A., Zary, N., Edelbring, S., Corral, J., & Hege, I. (2015). Virtual patients – What are we talking about? A framework to classify the meanings of the term in healthcare education. BMC Medical Education, 15(1), 1–7. https://doi.org/10.1186/s12909-015-0296-3

Kononowicz, A. A., Woodham, L. A., Edelbring, S., Stathakarou, N., Davies, D., Saxena, N., Tudor Car, L., Carlstedt-Duke, J., Car, J., & Zary, N. (2019). Virtual patient simulations in health professions education: Systematic review and meta-analysis by the digital health education collaboration. Journal of Medical Internet Research, 21(7), e14676. https://doi.org/10.2196/14676

*Judy C. G. Sng
Department of Pharmacology,
Yong Loo Lin School of Medicine,
National University of Singapore
MD3, 16 Medical Drive #04-01
Singapore 117600
Tel: +65-65163676
Email: phcsngj@nus.edu.sg

Submitted: 30 August 2020
Accepted: 12 November 2020
Published online: 13 July, TAPS 2021, 6(3), 83-86
https://doi.org/10.29060/TAPS.2021-6-3/SC2390

Rahman Habeebul

Department of Psychiatry, Tan Tock Seng Hospital, Singapore

Abstract

Introduction: Archetypes in psychology are complete models of behaviours, thoughts and feelings, representative of universal experiences. From Plato’s description of Forms to Jung’s analytical introduction to archetypes in psychology, to common use of Moore’s masculine archetypes in popular culture, we use such “complete representations” to enable change.

Methods: In examining psychologically driven responses to the recent and ongoing pandemic crisis, the use of a graphic representation of interacting archetypes is proposed—the ‘archetypogram’.

Results: Drawing on concepts from psychodynamic therapy practise, including Transactional Analysis and Jungian theory, four main archetypes are proposed for their interdependence—the prisoner, the soldier, the sage and the jester/trickster, and a model describing their interactions is presented with the intention of enabling helpful behaviours in response to crisis. The model further proposes positive and negative positions within each archetype, labelled as ‘creating’ and ‘consuming’ behaviours respectively. The ‘archetypogram’ thus is a visual representation of three main components – the four archetypes, creating vs consuming behaviours, and movement between the various positions. Use of the ‘archetypogram’ is aimed at enabling individuals in crisis to move from consuming to creating behaviours.

Conclusion: The ‘archetypogram’ is a model of change which may be applied to persons distressed in crisis, and is able to move behaviours towards positive and creating self-states.

Keywords:            Archetypes, Psychology, Crisis, Distress

I. INTRODUCTION

This was a crisis borne on the wings of travellers, leaving in its wake the term ‘a new norm’. In reflecting on observed and experienced emotional responses to the crisis, a structure emerged that identified three main themes—1) feelings of helplessness 2) seemingly never-ending activity and 3) a wish to be able to rise above billowing waves of information and misinformation.  Hence the archetypes of a prisoner, a soldier and a sage seemed appropriate.

It was expected that psychological reactions of anxiety, worry, grief and helplessness would run their course in this new crisis, but behavioural responses were unpredictable, from hoarding of toilet roll to disregard of rules and breaking of lockdown laws, to apathy. Why was there a difference between a leader of a nation (Luce, 2020) and a 9-year-old girl (Harris, 2020); one denying the problem at its outset, and the other, deciding to sew personal protective equipment (PPE) gowns to help her local doctors? What enables one person to do what needs to be done in crisis, and yet paralyses another into inaction? Many concepts have been put forth, with names such as grit, resilience, and growth mindset, but are there quick descriptors we can apply, that can help us move out of unhelpful states into more effective, useful ways of being?

II. OBSERVATIONAL PERSPECTIVE

We gravitate towards archetypes—“whole” descriptions of images that we identify with externally, and which we identify within ourselves internally. Jung’s description of archetypes has enabled a scaffold on which we can build our understanding of basic human reactions and behaviours in a Gestalt manner. In archetypes we unite both unconscious and conscious domains of being, and place intention second to observation.

The first evident experiences observed in the thick of the outbreak were feelings of being stuck, or being held hostage by the situation with feelings of helplessness that imprison the person. The prisoner was both angry and sad, and endured a mind filled with comparisons e.g. “Were there other prisoners being better treated? Was the suffering equal? Would someone else gain whilst we were denied of something possibly essential to our well-being, such as PPE?” Locus of control was felt externally (Rotter, 1954).

Amongst those who would put action to thought, a different set of behaviours was noted. There was a sense of constant effort, of having to negotiate endless tasks for a small ‘win’. Life was a blur of activity with anticipation of further problems, and resentment (signalling a slip back into prisoner state), but most times the effort of doing kept away negative emotions. This seemed to be the role of a tireless soldier, who would get wounded through unpreparedness.

There was yet a third group, who seemed untouched by the outbreak. They would go about their usual activities, or turn to alternatives effortlessly. This group I called the sage, and hypothesised that few of us would achieve the transcendental nature they exuded, in keeping with Maslow’s topmost hierarchy of being values (Maslow, 1998). 

However, referencing Transactional Analysis (Berne, 1961) where the ego-states of Parent, Adult and Child were further divided into negative and positive functional states depending on how stable they were, a further split within the three archetypes could be seen, with negative positions and positive positions. Hence, for the prisoner archetype, whilst inactivity was observed as a behaviour, the prisoner in a positive position was able to plan, or conserve parts of themselves for further action, to either rise as a soldier or guide as a sage.

The positive position of soldier archetype was decisive, enabling energy to effect change without burning themselves out, and able to make difficult decisions. Behaviour was internally motivated and pragmatically guided by agency. 

For the sage archetype, the positive position enabled them to nurture those around, lending stability to the system while being transcendental- as encompassed in the description by Maslow who placed this at the apex of the hierarchy of needs. Such a person is ‘care-ing’, not just caring of those around him or her, but also actively engaged in ‘care’ which is a constant state of being present.

III. INTERVENTIONAL PERSPECTIVE

Pathological emotions, thoughts and behaviours were proposed to arise from a primary prisoner state. Subsequently, as responses to helplessness and anger, three main behaviours were noted. 1) Continued inactivity (staying in the helpless prisoner state). 2) Busyness in ‘doing’, but where excessive activity was used to deflect uncomfortable feelings of helplessness (escape into soldiering) or 3) Non-responsiveness, where the uncomfortable feelings are avoided altogether (escape into sageing). These corresponded to efforts to defeat the source of conflict, but being ineffective, resulted in inaction (self-defeat), ineffective activity (other-defeat) or avoidance (reality-defeat).

Figure 1.  The Crisis Archetypogram

If we were to look to the negative positions, we see the behaviours as ‘consuming’, where either time, effort or emotional energy are consumed with poor outcomes, or no change in adapting to crisis.

If we were to look to the positive positions, we see the behaviours as ‘creating’ – ideas are born, work is done to engage parts of the system, there is nurturing of others and effort is concise, allowing adaptation and solving of problems.

In looking at ‘creating’ from the positive position, a further archetype emerges—that of the jester. This was the archetype who was flexible and not imprisoned, not always embattled nor always aloof and calm. This archetype would defuse tense situations with humour as a mature defence mechanism. The utility of the jester lies in the ability to bind people (and oneself) to a common cause; in the absence of hugs, laughter does a fair job of oxytocin production, and of fostering attachment. Pulled into negativity however, the jester’s negative position manifests as a trickster who would undermine with cunning the work done by the planning prisoner, the decisive soldier and the nurturing sage. The trickster at work was observed in the form of self-sabotage, or by disrupting efforts of the group with jokes belittling the efforts of others.

 A. Completing the Circle – The ‘Archetypogram’

The ‘Archetypogram’ in Figure 1 seeks to visually represent the interconnectedness of the various archetypes, in positive (creating) and negative (consuming) positions. How may we use such a crisis archetypogram to help ourselves and those around us?

The first step would be to identify where we are in the archetypogram—remembering that the position we are holding is temporary and a state (a current and temporary manner of being or interacting in domains of thoughts, feelings and behaviour), not a trait (longer term more durable repeated patterns of interactions).

The second regular step is to move to creating rather than consuming, and meeting the needs of the future instead of being mired in the past. In times of crisis, resources are limited. By moving to a creating state (which is often creative), we make better use of resources available, or contribute more if we agree to change. In a consuming state, time is a price to pay for opportunity lost when not moving forward, even if no other resources are used (anxiety paralysis).

B. Limitations in Change

Having applied the archetypogram in change management, limitations in effectiveness have been observed in situations where either there was a clinical disorder giving rise to anxiety and depression, or if there was resistance to the idea of change being possible within the archetypogram (similar to being in the pre-contemplative state of change). It is hoped that with development of the archetypogram, limited therapy sessions may be used to address clinical disorders. 

IV. CONCLUSION

Whilst it is ideal that we move in the general direction of actualization we need to be mindful of limitations in resources; flexibility in approach is paramount, as is being kind to ourselves no matter the approach we adopt.

In a crisis, the ‘work to do’ therefore is to:

1. Identify the state we are in – Prisoner/ Soldier/ Sage/ Jester-Trickster.

2. Identify the outcome of our behaviours – creating or consuming.

3. Identify how we can move ourselves from a consuming to a creating position, first by moving within our archetype (e.g. from angry/ helpless prisoner, to a conserving/ planning prisoner), then up archetypes (eg on to a decisive soldier, and eventually to a nurturing and care-ing sage). The movement can be internal via self-awareness (a practiced skill incorporating conservation of energy by mindfulness/ relaxation exercises and problem solving) or external via a coach, counsellor or therapist.

4. Be aware of the tendency to move upwards within the consuming rank states where avoidance and burnout from the sage and soldier states respectively can reinforce a primary angry / helpless prisoner’s distressed negative position.

5. Be mindful that the distressed position is often at the base of what one feels and thinks as ‘problems’. Emotional responses of grief, anxiety and anger arise from helplessness or loss, and these responses can be true of individuals as well as groups, but still amenable to working through with the aid of the archetypogram.

In conclusion, while the use of archetypes in verbal tradition is established, the visual archetypogram proposes an exciting model to move behaviours in crisis towards positive and creating self-states, in fields ranging from coaching, to counselling, to psychotherapy.

Note on Contributor

Dr Habeebul Rahman is solely responsible for all observations and ideas contained within this manuscript.

Ethical Approval

Ethics review (including informed consent) was not sought for this manuscript owing to the hypothetico-deductive nature of the paper.

Acknowledgement

The writer wishes to acknowledge TTSH Department of Psychiatry, Organisational Development and Operations for their contribution to the development of this work.

Funding

No funding was sought or obtained for this paper.

Declaration of Interest

No conflicts of interest.

References

Berne, E. (1961). Transactional analysis in psychotherapy: A systematic individual and social psychiatry. Grove Press.

Harris, E. (2020, May 11). For Malaysian schoolgirl, homework is sewing PPE gowns to help beat coronavirus. Reuters https://www.reuters.com/article/us-health-coronavirus-malaysia-protectiv-idUSKBN22N037

Luce, E. (2020, May 17). Inside Trump’s coronavirus meltdown. The Straits Times. https://www.straitstimes.com/world/united-states/inside-trumps-coronavirus-meltdown

Maslow, A. H. (1998). Toward a psychology of being. Wiley.

Rotter, J. B. (1954). Social learning and clinical psychology. Prentice-Hall.

*Rahman Habeebul
Tan Tock Seng Hospital,
11 Jalan Tan Tock Seng,
Singapore 308433
Email: habeebul_rahman@ttsh.com.sg

Submitted: 16 July 2020
Accepted: 16 September 2020
Published online: 13 July, TAPS 2021, 6(3), 95-98
https://doi.org/10.29060/TAPS.2021-6-3/SC2342

Shin Ying Thng, Bao Yu Geraldine Leong, Guat Keng Yvonne Goh, Ching Ching Elaine Tan, Jimmy Kock Keng Goh & Kaibin Kelvin Kuan

Emergency Department, Changi General Hospital, Singapore

Abstract

Introduction: Singapore was one of the earliest countries affected by the COVID-19 outbreak, requiring our emergency department to respond urgently to this surge. A designated Fever Area (FA) with a resuscitation room was rapidly set up to manage patients at risk of COVID-19. Our paper describes measures put into this new area to optimise safety outcomes of these patients.

Methods: Plan-Do-Study-Act (PDSA) cycles incorporating in-situ simulation in the FA resuscitation room were conducted. Using varied resuscitation scenarios and facilitated debriefing, we identified safety gaps and took immediate steps to rectify them in a collaborative manner involving various respective stakeholders.

Results: Following reflective debriefing and studying of work processes, latent safety threats were identified resulting in successful improvements and modifications to protocols, equipment, staffing and processes in the FA resuscitation area.

Conclusion: PDSA cycles involving in-situ simulation helped to identify safety threats and refine work processes in a newly set up FA facility. As a result, our healthcare team was more prepared to manage the complexities of COVID-19 patients in a high-risk environment.

Keywords:            Simulation, COVID-19, Medical Education

I. INTRODUCTION

Singapore was one of the first countries to be affected by the COVID-19 pandemic and has the highest number of Covid-19 cases in South East Asia to date. When the COVID-19 outbreak first reached Singapore, healthcare facilities had to prepare for a surge of patients with suspected or confirmed COVID-19. Our Emergency Department (ED) serves a 1006 bed hospital and sees an average of 400 patients daily pre-COVID-19. We were required to quickly reconfigure our space, equipment and staff. There was a need to segregate high risk or suspect COVID cases to be seen in a separate area in order to minimise cross-infection risks to our vulnerable patients. There was also a need to limit exposure of high-risk patients to a designated team of doctors and healthcare professionals in order to ensure continuity of services.

An area comprising the original admission transit area (with three isolation negative pressure rooms) and unused outpatient clinics next to the main ED underwent reconfiguration to become the new designated Fever Area (FA). This was to allow easy access to shared ED resources. The new FA had a combined capacity of 58 patients. Two FA resuscitation rooms were set up to cater for rapidly deteriorating patients that will require endotracheal intubation and resuscitation, both for COVID related complications as well as non-infectious related medical emergencies, such as an acute myocardial infarction or an acute surgical abdomen. Adequate resuscitation and stabilisation facilities in the FA were needed to minimise unnecessary movements of these infectious critically ill patients to the resuscitation area in the main ED, thus, decreasing the risk of cross-infection in other personnel.

The first few patient resuscitations conducted in the FA were challenging. There were many issues raised by the healthcare team concerning resuscitating and performing high-risk procedures in an unfamiliar environment. The FA team recognised an urgent need to improve system workflow competence in the FA resuscitation area. The healthcare team had to be shown that the improved FA resuscitation rooms were as well equipped as the main ED resuscitation area to handle critically ill patients and that such patients can be stabilized effectively there.

II. METHODS

In-situ simulation was the chosen modality as many of the difficulties encountered were systemic issues related to acute care in the unfamiliar FA resuscitation rooms and appropriate usage of Personal Protective Equipment (PPE) in such a scenario. In-situ simulation occurs where the case scenario is simulated in the actual clinical care area with real inter-professional teams instead of in an artificial setting in the simulation centre. By carrying out in-situ simulation, the team hoped to be able to recognise and remedy potential active failures and latent threats (Couto et al., 2018) present in the FA resuscitation rooms before any real-life adverse outcomes (Raemer et al., 2018) can occur.

Four emergency physicians and two nurse clinicians experienced in simulation design and debriefing conducted four in-situ simulation sessions with a high-fidelity mannequin in the FA (Dieckmann et al., 2020). Safety of all faculty, staff and patients were a priority and careful measures were taken to ensure participants and patients were not put at risk by simulating in-situ (Knight et al., 2018). Simulation sessions were conducted at the time of lowest patient load and all participants were outfitted in full PPE. They were also educated prior on potential safety hazards of in-situ simulation. Participant numbers for each simulation session were kept small at five to six with two facilitators.

The simulation scenarios, comprising of COVID-19 patients deteriorating from acute myocardial infarction, respiratory failure and cardiac arrest, were designed to challenge the complexities of adapting clinical management, manpower and equipment requirement and existing workflows to an infectious setting.

A multidisciplinary team comprising of eight nurses, six doctors and two radiographers involved in patient care at the FA participated in four simulation sessions held over two months. Verbal informed consent was taken from participants prior to simulation and confidentiality of participants was ensured. Centralised Institution Review Board (CIRB) review was submitted and waiver of consent was obtained. After each simulation scenario, formalised debriefing was carried out immediately, focusing on work process issues, communication failures and latent threats identified within the FA. Questions were crafted to guide participants to attain dialogical reflection and to move past a description of errors. They were encouraged to consider the implications of observations and come up with solutions for change using Fleck’s framework of reflection levels (Kihlgren et al., 2015).

The list of ideas generated was gathered and studied for common themes. A separate session was held where clinical, operational and administrative representatives brainstormed to find feasible and practical solutions to each problem identified. Immediate steps were taken to implement improvements and modifications to clinical protocols, equipment, staffing and workflows. Plan-Do-Study-Act (PDSA) quality improvement cycles were used to evaluate the improvements instituted after each simulation. This was carried out by a multidisciplinary team, comprising of medical, nursing and allied health staff.

III. RESULTS

The latent safety threats that surfaced were broadly categorised into five descriptive categories: Equipment, Organization, Staffing, Communication and Protocol (Refer to Table 1).

Table 1: Results

In-situ simulation uncovered the problems of insufficient Powered-Air Purifying Respirators (PAPR) and viral filters, as well as, missing defibrillator pads and bag valve masks from resuscitation trolleys. A checklist of essential equipment and medications was created with mandatory checks and re-stocking carried out by the FA nurses every morning. Medications vital for resuscitation were also found to be inadequate. A pharmacist was recruited to draw up and stock an essential list of drugs in the FA. Medications, which required refrigeration, were packed in a portable box so they could be easily brought to the FA resuscitation room from the fridge when required. Drug and resuscitation charts were put up as reminders and easy reference to improve patient safety.

Workspace organization issues that surfaced from in-situ simulation included the need to maintain patient privacy with mobile screens during resuscitation. Confusion over the head-foot orientation of the trolley bed resulted in suction and oxygen ports being too far for efficient use when it was placed in the wrong configuration. To correct this, the FA resuscitation room floor was labelled with tape indicating the proper orientation. The small FA resuscitation room area made manoeuvring equipment, trolleys and personnel difficult. Efforts were taken to re-site equipment to specific demarcated areas outside the FA resuscitation room, with the added benefit of reducing equipment contamination. A crisis phone was set up so that existing staff in FA could quickly call for additional staff deployment in event of a surge, thus improving communication and increasing situational awareness of the entire department to emergent needs at the FA.

Protocols were also adapted to the needs of the FA. During a resuscitation scenario, too many healthcare workers crowded into the room, raising a safety concern. It was protocolised that staff numbers should be minimized in the FA resuscitation room, especially during Aerosol Generating Procedures (AGP). PPE use was a barrier to communications, with “handovers” and “read back” being disrupted or unclear. The importance of adhering to these communication tools was reinforced. There was no fixed route identified for the transport of infectious patients to critical inpatient areas, thus, these were delineated so as to minimize confusion and decrease the infectious footprint, and risk of cross-infection to others. Staff protection during AGP was found to be inconsistent; hence PPE education was reinforced and educational resources provided to staff.

IV. CONCLUSION

Many issues were surfaced and lessons learnt via in-situ simulation, which allowed immediate risk mitigation to be carried out. Simple, immediate changes were made in FA with the available resources, resulting in improved patient and staff safety—which is especially important during surges due to the COVID-19 pandemic. We have successfully used in situ simulation with PDSA cycles to test and develop new facilities and protocols whilst managing the demands of a pandemic.  Similar outcomes had also been demonstrated in other in-situ simulation studies. Using this modality to test pre-existing protocols and equipment in the FA resuscitation rooms offered an opportunity for the identification of potential threats and service gaps that would otherwise not have been detected as efficiently via conventional reporting systems (Knight et al., 2018). This method of PDSA testing is useful in the rapidly evolving COVID-19 situation, and may be replicated in other hospitals and regions safely when required. It ensures the safety of healthcare workers and actively improves patient safety despite the limitations of the pandemic.

A follow-up study to look at the usage of the FA resuscitation area, number of critically ill patients in the FA being transferred into the main ED resuscitation room, and patient morbidity and mortality data would be necessary to further determine the success of our intervention at a higher Kirkpatrick level of behavioural change to improve patient outcomes in the FA.

Notes on Contributors

Dr Elaine Tan carried out the literature search and instituted the changes. Dr Geraldine Leong ran the simulation, wrote the manuscript and instituted the changes. Dr Jimmy Goh set up the fever area, advised regarding the manuscript and instituted the changes. Dr Kelvin Kuan ran the simulation, wrote the manuscript and instituted the changes. Dr Thng Shin Ying designed the simulation, ran the simulation, and wrote the manuscript. Dr Yvonne Goh designed the simulation, ran the simulation and wrote the manuscript.

Ethical Approval

This study was exempted from CIRB review- 2020/2640.

Acknowledgements

The authors would like to acknowledge the staff of Changi Simulation Institute for their technical help and assistance with this project. We would also like to thank Dr Syahid Hassan for providing his expertise in the methodology of this project.

Funding

No funding was required.

Declaration of Interest

The authors state no conflict of interest.

References

Couto, T. B., Barreto, J. K. S., Marcon, F. C., Mafra, A. C. C. N., & Accorsi, T. A. D. (2018). Detecting latent safety threats in an interprofessional training that combines in situ simulation with task training in an emergency department. Advances in Simulation, 3(1), 23. https://doi.org/10.1186/s41077-018-0083-4

Dieckmann, P., Torgeirsen, K., Qvindesland, S. A., Thomas, L., Bushell, V., & Langli Ersdal, H. (2020). The use of simulation to prepare and improve responses to infectious disease outbreaks like COVID-19: Practical tips and resources from Norway, Denmark, and the UK. Advances in Simulation, 5, 3. https://doi.org/10.1186/s41077-020-00121-5

Kihlgren, P., Spanager, L., & Dieckmann, P. (2015). Investigating novice doctors’ reflections in debriefings after simulation scenarios. Medical Teacher, 37(5), 437-443. https://doi.org/10.3109/0142159X.2014.956054

Knight, P., MacGloin, H., Lane, M., Lofton, L., Desai, A., Haxby, E., Macrae, D., Korb, C., Mortimer, P., & Burmester, M. (2018). Mitigating latent threats identified through an embedded in situ simulation program and their comparison to patient safety incidents: A retrospective review. Frontiers in Pediatrics, 5, 281. https://doi.org/10.3389/fped.2017.00281

Raemer, D., Hannenberg, A., & Mullen, A. (2018). Simulation safety first: An imperative. Simulation in Healthcare, 13, 373-375. https://doi.org/10.1097/SIH.0000000000000341

*Thng Shin Ying
Changi General Hospital
2 Simei Street 3
Singapore, 529889
Email: thng.shin.ying@singhealth.com.sg

Submitted: 14 July 2020
Accepted: 16 September 2020
Published online: 13 July, TAPS 2021, 6(3), 99-103
https://doi.org/10.29060/TAPS.2021-6-3/PV2343

Colleen Cheek^1,2, Richard Hays³ & Janie Smith²

¹Education and Research, Tasmania Health Service North West, Australia; ²Faculty of Health Sciences and Medicine, Bond University, Australia; ³Centre for Rural & Remote Health, James Cook University, Australia

I. INTRODUCTION

Research ability is considered important in preparing medical graduates for their future work roles, providing openness to critical inquiry and astute information management (Frenk et al., 2010). The role of knowledge integrator, facilitator, and advisor, incorporating finely-tuned judgement, reasoning and decision-making, are important in achieving the leadership expected of the profession (Frenk et al., 2010). Engaging medical students in research training has historically proven challenging, and there is variable understanding of the level expected in primary medical training.

Most medical schools in Australia have now adopted a Master’s Level ‘Medical Doctorate’ (MD) for primary medical training. Both the Australian Qualifications Framework (2013) requirements (pertaining to the level of qualification) and the Australian Medical Council (AMC) standards (pertaining to the profession) expect graduates of an MD to have understanding of research principles, process and methods, and to be able to apply these to professional practice (Australian Medical Council Limited, 2012). Many schools have interpreted this as a requirement for more intensive research training. While research knowledge and skills are integrated throughout curricula, there is substantial variation in the way these are taught, and little evidence of effective learning exists.  

Varying approaches to align courses internationally may have muddied the situation further. For example, in the UK, primary medical training is considered to meet the requirements of a UK Level 7 Master’s Degree, although most programmes have retained historical titles of Bachelor of Medicine, Bachelor of Surgery, abbreviated as BM BS or MBChB. In Canada, graduates of primary medical training are awarded the degree of Doctor of Medicine (MD) but are considered to have achieved academic outcomes at Bachelor level. In the US, graduates of primary medical training are awarded the degree of Doctor of Medicine (MD) and widely assumed to achieve Master’s level learning outcomes. European medical schools, through conformance with the Bologna Declaration, are tending toward a 2nd cycle, or Master’s degree. In the Asia-Pacific region, Singapore retains a Bachelor of Medicine, Bachelor of Surgery (MBBS), as do Malaysia (a Level 6 Bachelor degree), Japan and New Zealand. In Australia, there are some Bachelor (Level 7) programmes but most medical schools have adopted a Master’s Degree (Extended) (Level 9E) for primary medical training, conferring a ‘Medical Doctorate’ (MD). In these examples there is little correlation between learning outcome levels and programme duration, which ranges from four to six years. 

 A. Defining Learning Outcomes and the Level of Understanding Required

The most recent standards of the World Federation for Medical Education promote ‘constructively aligned’ medical education. That is, teaching activities and assessment aligned with student-centred learning outcomes where the type of knowledge, whether declarative (book knowledge) or functional (professional know-how required in the workplace), and the level of understanding required are clear. 

The level of understanding can be mapped from taxonomies of action verbs. The Structure of Observed Learning Outcomes (SOLO) is one taxonomy (Biggs & Collis, 2014). It consists of five levels of understanding that reflect increasing learning complexity. The first is pre-structural (no understanding); through uni-structural and multi-structural (representing two stages of qualitative comprehension) to relational and extended abstract. The verbs ‘order’ and ‘compute’ might describe learning action at uni- and multi-structural stages, whereas ‘construct’ and ‘extrapolate’ describe learning action at relational and extended abstract stages. Once learning outcomes are explicit, decisions about teaching activities that will allow the student to achieve the learning outcomes can be made. For example, functional knowledge verbs e.g. ‘assess’ or ‘reflect’, reflects activity performed in the workplace (ideally), or an authentic simulated environment.   

Here we provide a perspective of the research knowledge and skills required of graduates of an Australian MD to promote shared understanding of the level of learning and the key elements for orientating teaching to medical practice.

II. METHODS

To define the Individual Learning Outcomes (ILO)  relating to research competency in Australia, the Level 9E Australian Qualifications Framework (AQF) criteria and descriptors (Australian Qualifications Framework, 2013) and the AMC standards and graduate outcomes (Australian Medical Council Limited, 2012) that pertained to research knowledge and skills were collated (Appendix 1). Using the SOLO taxonomy (Biggs & Collis, 2014), the types of knowledge and the required level of understanding was determined (Appendix 2).

III. RESULTS

Three issues emerged. The first was that the highest levels of understanding required (extended abstract), pertain to functional knowledge such as critically analysing information, reflecting on and applying theory. Graduates are expected to have ‘expert’ knowledge and abilities in this area based on ‘research, experience or occupation’. This may imply that achieving the higher-level learning outcomes requires a substantial research experience, such as a completed project that engages students in all aspects of planning, conducting, and reporting research. This reflects what happens during the AQF Level 10 (doctoral level) research training and may be difficult to achieve during a Level 9E programme.    

The second was that a high level of functional knowledge (relational) is required to plan and execute project work, reflecting the more traditional, Master’s (Research) programme. This should be achievable during Master’s (extended) programmes if the learning takes place over time and provides ‘reasonable’ experience in aspects of research. For this to fit in with the clinical immersion learning experience, such projects should engage students with healthcare delivery.   

The third was that a fairly high, but lower level of declarative knowledge (multi-structural and relational) is required pertaining to scientific methods, ethical and privacy principles, and these should be heavily grounded in application to the profession. This is consistent with the inclusion of research training modules in coursework, but without a requirement to complete a research project.

IV. DISCUSSION

Medical curricula should constantly evolve to meet the perceived needs of the changing population and health systems. Cooke et al. (2010) tell us that the virtues of being curious, of being open to further learning, taking time to consider different perspectives and weigh up the options are metacognitive skills that should be developed early in medical training to cultivate lifelong learning and drive for continuing improvement in health systems. The emphasis in current medical education commentary is to provide options and electives for flexible, student-led approaches to learning.

The AMC graduate outcomes (Australian Medical Council Limited, 2012) affirm that a critical component of developing competency as a doctor is the opportunity to hone generic skills such as communication and teamwork and apply developing knowledge through authentic experience in the clinical setting. Functional knowledge is demonstrated through project work conducted (ideally) in real work settings. This experience provides opportunities to learn to adapt to unforeseen medical problems and to learn interactive and reflective skills important in achieving both specialist professional performance and life-long learning. Fostering knowledge and skills in seeking information, considering alternatives, collaborating, making decisions, planning and executing the plan may better prepare medical professionals for leadership roles that are required of responsive health systems where emerging technology and global forces are likely to drive adaptation and reform. Facets of critical inquiry, such as recognising a knowledge gap, seeking information, seeing multiple perspectives, taking time to consider alternatives and then make a judgement, are also qualities of an adaptive leader. Achieving all of this through a completed research project during primary medical education is challenging. Performing one component well may be enough if it is known how the component fits as part of the whole.

Specific requirements for knowledge and skills in research and their application are still inherent in both AQF and AMC standards. Expertise in defining a searchable question and finding and assessing the evidence are realistic and useful goals for primary medical training and are professionally relevant to the work of doctors in the 21st century. Conducting literature reviews about topics that matter to the local community can be achieved in primary training. There are models of collaboration within healthcare settings where medical students are supported in a community of practice with more senior doctors overseeing local quality improvement projects. Quality improvement projects in Primary Care offer further opportunity.

There may be other ways of achieving Master’s level learning outcomes that do not require research experience, as some students are not ready for this. Examples include project work in professional and capstone settings, where students performed skills associated with developing leadership and management competency in a range of different contexts.

V. CONCLUSION

Achieving higher-order thinking by the end of primary medical education is emerging as crucial to graduating doctors who are better prepared for managing the future challenges of healthcare. Integration of research thinking with work-based experience may be the critical attribute to foster this and may also be achieved through professional and capstone projects. There is a case for providing stronger guidance on just what is intended and achievable within the constraints of contemporary medical education. It is unlikely that the move to Master’s level programmes in Australia will on its own result in more research capable graduates; more important may be how students are introduced to research knowledge and practical experiences. However, adopting Master’s level outcomes as the endpoint may improve consistency in achievement of higher-level thinking and the inferred ability to find solutions to challenges as healthcare evolves. 

Notes on Contributors

Colleen Cheek developed the methodological framework for the study, performed data collection and data analysis as part her PhD research project, and wrote the manuscript, collated edits and approved the final manuscript.

Richard Hays reviewed the study design and interpretation and developed the manuscript, read and approved the final manuscript.

Janie Smith reviewed the design of the study and gave critical feedback to the writing of the manuscript, read and approved the final manuscript.

Funding

No funding source was required.

Declaration of Interest

We have no conflict of interest to declare.

References

Australian Medical Council Limited. (2012). Standards for assessment and accreditation of primary medical programs by the Australian Medical Council. https://www.amc.org.au/wp-content/uploads/2019/10/Standards-for-Assessment-and-Accreditation-of-Primary-Medical-Programs-by-the-Australian-Medical-Council-2012.pdf

Australian Qualifications Framework. (2013). Australian Qualifications Framework (2^nd ed.). https://www.aqf.edu.au/sites/aqf/files/aqf-2nd-edition-january-2013.pdf.

Biggs, J. B., & Collis, K. F. (2014). Evaluating the quality of learning: The SOLO taxonomy (Structure of the observed learning outcome). Academic Press.    

Cooke, M., Irby, D. M., & O’Brien, B. C. (2010). Educating physicians: A call for reform of medical school and residency (Vol. 16). John Wiley & Sons.

Frenk, J., Chen, L., Bhutta, Z. A., Cohen, J., Crisp, N., Evans, T., Fineberg, H., Garcia, P., Ke, Y., Kelley, P., Kistnasamy, B., Meleis, A., Naylor, D., Pablos-Mendez, A., Reddy, S., Scrimshaw, S., Sepulveda, J., Serwadda, D., & Zurayk, H. (2010). Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. The Lancet, 376(9756), 1923-1958. https://doi.org/10.1016/S0140-6736(10)61854-5

*Colleen Cheek
ADON Education and Research,
Tasmania Health Service North West
PO Box 258, Burnie 7320
Email: Colleen.Cheek@ths.tas.gov.au

Submitted: 17 August 2020
Accepted: 30 September 2020
Published online: 13 July, TAPS 2021, 6(3), 111-113
https://doi.org/10.29060/TAPS.2021-6-3/PV2375

Nicholas Beng Hui Ng¹, Terri Chiong¹, Perry Yew Weng Lau¹ & Marion M Aw^1,2

¹Khoo Teck Puat – National University Children’s Medical Institute, National University Health System, National University Hospital, Singapore; ²Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

I. INTRODUCTION

The Coronavirus Disease (COVID-19) pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus has led to significant disruptions globally with alarming mortality rates and increasing economic burden. For the medical community, aside from massive changes in workflow, healthcare worker fatigue and direct risk of infection, COVID-19 has also resulted in significant disruptions to medical training. During a pandemic, it is not surprising that manpower, financial resources and time are allocated fully to contain the disease. We believe however, that structured teaching activities amidst this crisis play an important, if not pivotal role, in keeping the medical community united and informed of the rapidly changing evidence surrounding this disease. Our department instituted measures to ensure that disruptions to post-graduate training were minimised amidst the clinical workflow changes. In this article, we share our experience of how teaching activities were sustained through implementing various strategies. We also discuss the benefits derived from ongoing teaching during this pandemic.

II. EXECUTION AND EXPERIENCE

When Singapore first announced the escalation of the Disease Outbreak Response System Condition (DORSCON) alert level from yellow to orange in response to increasing community spread of COVID-19, all healthcare institutions immediately put in place protocols and workflow to cope with the demands of COVID-19 (A Singapore Government Agency Website, 2020). Our department, a paediatric department in a university hospital, followed suit with plans for team segregation and clinical workflow protocols for children with respiratory illnesses. At the same time, all face-to-face teaching activities and meetings were suspended, in an attempt to minimise gatherings of clinicians.

The Residency Programme Director quickly formed a dedicated Education Task Force (ETF) to look into adapting the post-graduate teaching activities to take into account clinical service needs, as well as team segregation. Prior to the pandemic, our post-graduate teaching (in additional to clinical learning on the job) were largely based on face-to-face large group sessions, as well as small group clinical bedside teaching.  As the department adjusted to the new COVID-19 clinical workflow, the ETF effectively morphed the delivery of post-graduate education to cater to the education needs of residents and faculty.

Our teaching sessions have been transformed from in-person to on-line delivery via the Zoom video-conferencing platform. This has allowed residents (interns, medical officers, senior residents) from different clinical locations, who are not allowed to meet physically, to attend. An added benefit is that residents off-site may also choose to attend these teaching activities. In addition, faculty members who would previously not attend resident teaching have also been able to attend these sessions and collectively contribute to the teaching and learning process. We have been able to conduct almost all our continued medical education (CME) programmes via video-conferencing; journal clubs, mortality rounds, radiology rounds, topic reviews, history taking sessions, case-based discussions and importantly, COVID-19 clinical workflow updates.

The ETF outlined ground rules for the on-line teaching sessions at the outset: participants have to sign in with appropriate identification, unmute microphones only when speaking and respect the confidentiality of teaching materials without taking pictures or recordings unless explicit permission is obtained. In order to ensure the security of these video-conferencing sessions, each session is managed by a host, with controlled admission of participants.

A. Modified Clinical Teaching

During this pandemic, we have been able to continue clinical history-taking teaching sessions for residents with real patients via video-conferencing. In this format, one resident in the “hot-seat” takes the history from the patient remotely, while other participants observe the encounter via a live video stream from different locations. This “live” history-taking session is followed by a discussion between the resident and faculty on the patient’s clinical history as well as management. Other residents are also able to participate in the discussion. We have been extremely encouraged by the responses from patients and their families who have readily consented to these video-streaming teaching sessions. Our experience has reinforced the notion that patients are willing to participate in medical education as a means to give back to the medical community (Stacy & Spencer, 1999; Thomas et al., 1999). In a time of crisis like this, where the medical community has to quickly learn and rapidly adapt to new discoveries of COVID-19, the role of patient involvement in teaching and research cannot be better overstated.

B. Specific Mock Code Training

Aside from core teaching sessions for residents, the department quickly recognized the importance for on-the-go pandemic-preparedness training for the residents. Faculty from the critical care division has developed COVID-19 relevant mock code scenarios for residents using high fidelity simulation equipment. These sessions are conducted during designated time slots and adhere to the team segregation plans. The scenarios involve the use of powered air-purifying respirator (PAPR) equipment and personal protective equipment (PPE). Residents are given the opportunity to perform the initial clinical assessment, cardio-pulmonary resuscitation and intubation, as well as communicate with the rest of the clinical team whilst dealing with mock patient emergencies in negative-pressure isolation facilities. Many of the junior doctors as well as nurses quickly realized the added challenge of performing seemingly standard resuscitation in isolation facilities whilst in full PPE. Routine tasks such as communication between team members, preparation of drugs, use of resuscitation drug charts and even mobile phones while wearing PAPR and PPE can be extremely difficult. These simulation sessions highlighted to us that good planning, coordination and communication between healthcare workers are all the more crucial while resuscitating in a COVID-19 setting.

C. Increase Trainee Participation

An initial unanticipated benefit of this style of teaching and learning was increased trainee participation in these sessions. We noticed that a proportion of residents who would otherwise have remained silent in an open group teaching encounter were now more willing to ask and answer questions, either through their voice audio or using the chat function of the Zoom platform. What is most interesting is that when we compared our teaching attendance rates for residents at these video-conferencing CME compared to the usual face-to-face teaching, there was an increase from an average of 32% (pre-COVID-19) to 68% (during COVID-19) in daily attendance rates. This increase attendance was seen for both COVID-19 and non-COVID-19 related teaching sessions, suggesting that it was not only the COVID-19 updates that drew participation for these sessions. Contributing factors could include the ease of access afforded by learning from various (remote) locations, particularly for residents posted off-site who are unable to travel back. In addition, the Zoom video-conferencing tool is readily available on a variety of platforms, including laptops, tablets and mobile phones.

D. Limitations and Challenges

The main issue raised had been that of internet connectivity in certain areas around the hospital, but this has been rectified with specific locations allocated as “teaching hubs”.

Another shortcoming of the on-line teaching programme is that bedside teaching for clinical skills has not been possible, in the interest of staff and patient safety. The ETF has since explored other innovative approaches; using video clips of clinical signs, as well as preparing pre-taped clinical examination signs with patient and caregiver consent.

III. THE RECIPE TO SUCCESS

The feedback received from residents for this on-line delivered teaching has been extremely positive, with 42 of 46 residents rating it positively on a feedback survey. Many of our residents look forward to attending these sessions, not only as a means to learn, but also as an opportunity to connect with fellow colleagues.

We believe that our success in maintaining a relevant teaching programme during the COVID-19 pandemic is attributed also to the following factors:

• Strong teaching culture with a mission of ensuring that residents are appropriately trained.
• Faculty realising the importance of pandemic-preparedness training for residents.
• The ability to innovate and the flexibility to adjust the delivery of medical education to meet the needs of the current pandemic situation.
• The availability of reliable resources and use of latest educational technology such as the Zoom Video-Conferencing to allow delivery of web-based teaching.

IV. CONCLUSION

As our health workers continue to brave the frontline battling against COVID-19, we are frequently reminded of the importance that flexibility and adaptability is crucial during this pandemic. While we continue to deliver the best possible patient-centred care and ensure the safety of our healthcare workers amidst this COVID-19 pandemic, structured teaching in our department continues to be an important part of our daily routine. We experienced first-hand the benefits of web-based learning and would retain some of these sessions post-pandemic. The deliberate strategies taken by our department to ensure that teaching activities continue has allowed learning to persist in a structured and relevant way. Importantly, on-the-go training for pandemic-preparedness for residents is a highly valuable skill to teach during this time. We are very proud to be able to continue to learn and keep abreast the latest developments on COVID-19 as a department. As former United States First Lady, Abigail Adams so eloquently said, “Learning is not attained by chance, it must be sought for with ardour and attended to with diligence”.

Notes on Contributors

Ng Nicholas Beng Hui contributed in design, analysis and interpretation of data, drafting the article, and final approval of the version to be published. Chiong Terri contributed in analysis and interpretation of data, revising it critically for important intellectual content, and final approval of the version to be published. Lau Perry Yew Weng contributed in conception and design, and interpretation of data, revising it critically for important intellectual content, and final approval of the version to be published. Aw Marion M contributed in conception and design, and interpretation of data, revising it critically for important intellectual content, and final approval of the version to be published.

Acknowledgement

We thank Dr Dimple Rajgor for helping with in editing, formatting and in submission of the manuscript for publication.

Funding

No funding is required for this paper.

Declaration of Interest

The authors have no conflicts of interest, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest.

References

A Singapore Government Agency Website. (2020). Additional measures introduced with DORSCON Orange Singapore. Retrieved March 10, 2020, from https://www.gov.sg/article/additional-measures-introduced-with-dorscon-orange

Stacy, R., & Spencer, J. (1999). Patients as teachers: A qualitative study of patients’ views on their role in a community‐based undergraduate project. Medical Education, 33(9), 688-694.

Thomas, E. J., Hafler, J. P., & Woo, B. (1999). The patient’s experience of being interviewed by first-year medical students. Medical Teacher, 21(3), 311-314. https://doi.org/10.1080/01421599979608

*Ng Nicholas Beng Hui
Khoo Teck Puat-National University
Children’s Medical Institute,
National University Health System,
1E Kent Ridge Road,
NUHS Tower Block Level 12,
Singapore 119228
Email: nicholas_bh_ng@nuhs.edu.sg

Submitted: 19 July  2020
Accepted: 7 October 2020
Published online: 13 July, TAPS 2021, 6(3), 67-74
https://doi.org/10.29060/TAPS.2021-6-3/OA2347

Tess Lin Teo, Jia Hao Lim, Choon Peng Jeremy Wee & Evelyn Wong

Department of Emergency Medicine, Singapore General Hospital, Singapore

Abstract

Introduction: Singapore experienced the COVID-19 outbreak from January 2020 and Emergency Departments (ED) were at the forefront of healthcare activity during this time. Medical students who were attached to the EDs had their clinical training affected.

Methods: We surveyed teaching faculty in a tertiary teaching hospital in Singapore to assess if they would consider delivering clinical teaching to medical students during the outbreak and conducted a thematic analysis of their responses.

Results: 53.6% felt that medical students should not undergo clinical teaching in the ED and 60.7% did not wish to teach medical students during the outbreak. Three themes arose during the analysis of the data – Cognitive Overload of Clinical Teachers, Prioritisation of Clinical Staff Welfare versus Medical Students, and Risk of Viral Exposure versus Clinical Education.

Conclusion: During a pandemic, a balance needs to be sought between clinical service and education, and faculty attitudes towards teaching in high-risk environments can shift their priorities in favour of providing the former over the latter.

Keywords:           Disease Outbreak, Pandemic, Faculty, Medical Students, Attitudes, Clinical Teaching, Emergency Medicine

Practice Highlights

• In a pandemic, a balance needs to be sought between clinical education and risking learner exposure to the virus.
• A crisis situation can affect educators’ priorities and attitudes towards the provision of clinical education, in favour of providing crucial clinical services.

Since the first reported cases of COVID-19 infections in Wuhan, in December 2019, the month of January 2020 saw Singapore’s Ministry of Health (MOH) issue guidelines and implement a series of calibrated defensive measures to reduce the risk of imported cases and community transmission (Lin et al., 2020; WHO, 2020). Singapore has a Disease Outbreak Response System Condition (DORSCON) framework, which guides the nation’s response to various emerging infectious diseases outbreaks. The four-level colour-coded system of Green, Yellow, Orange and Red, describes the increasing severity of the outbreak in the community  (Quah et al., 2020).

The Department of Emergency Medicine (DEM) of Singapore General Hospital saw 130 000 visits in 2019 (SGH, 2019). It hosted 158 medical students (MS) through the year. Aside from some elective students, the majority were in their second year of clinical postings. Formal clerkships consisted of four weeks of clinical exposure in which they were expected to clerk and present cases to teaching faculty and perform minor procedures such as intravenous cannulation and insertion of bladder catheters etc., with about nine hours of classroom tutorials.

In early January 2020, DORSCON yellow was declared, indicating either a severe outbreak outside Singapore or that the disease was contained locally with no significant community spread (Quah et al., 2020). All DEM staff were required to wear personal protective equipment (PPE). Hospital elective surgeries were postponed. Other outbreak measures included setting up new isolation areas for patients. DEM staff had their leave embargoed to ensure that there was adequate manpower to staff these areas in anticipation of a gradually worsening outbreak (Chua et al., 2020).

On 7 February 2020, the outbreak alert rose to DORSCON Orange (DO) as there were cases of community transmissions (Quah et al., 2020). Based on previous experience managing the Severe Acute Respiratory Syndrome (SARS) outbreak 17 years prior, the DEM transitioned to an Outbreak Response Roster, where physicians and nurses of the DEM were split into teams that worked 12 hour shifts, with no overlapping shifts, hence limiting staff contact to only those within their teams (Chua et al., 2020). With DO in effect, the department needed to come to a rapid decision about whether or not to accept MS in the ED. A group of 12 MS that the DEM was supposed to host this April already had their clerkship cancelled due to concerns of breaching infection control and safe distancing measures. There have been no studies to date on faculty attitudes towards clinical teaching of MS during a pandemic, although papers have been published about students’ attitudes towards clinical training during disease outbreaks. The Clerkship Director conducted a short and focused survey amongst the faculty between the 27th-29th of March, amidst rising public concerns that the country might soon be locked down, to explore their attitudes on having MS clerkships during the COVID-19 pandemic. The results of this survey allowed the Director to quickly understand the sentiments of the faculty and thus decided that an entirely remote, online teaching program would be created instead. 9 days after the survey, on the 7th of April, the Singapore government officially announced the implementation of a lockdown, known locally as a ‘circuit breaker’ (Quah et al., 2020).

II. METHODS

Clinical teachers of the DEM were issued an anonymous survey over a period of three days via an online survey tool, SurveyMonkey (www.surveymonkey.com). Participants were informed prior to completing the survey that it was anonymous, and by proceeding with the survey they consented to the results being used for research purposes. The data collected included their professional appointments in the department and two yes/no questions: “Do you think medical students should be performing their EM clerkship during DO?” and “Are you keen on teaching MS clinically during DO?”. Participants answering “No” to the latter were asked to elaborate. All participants were asked to write about any concerns they had about having MS in the emergency department (ED) during DO. No other personal identifying information was sought. The survey was deliberately kept short and easy to answer to promote staff participation within the short timeframe the DEM had to make the decision about accepting students. Informed consent was waived as per the Institutional Review Board (IRB).

A simple descriptive quantitative analysis of responses to the 1^st two yes-no questions identified the overarching sentiment of the department towards hosting MS during DO and was followed by a thematic analysis of the free-text answers to the last two open-ended questions (Braun & Clarke, 2006).

As many participants used the last question (‘any other comments?’) to emphasise or elaborate on the preceding question (‘why aren’t you keen to teach?’), the majority of the qualitative data gathered pertains to the issues of having MS in the department during DO. There was a paucity of data detailing why participants were in favour of teaching MS, as the survey did not specifically ask this. Hence, the authors chose to focus on analysing the responses of participants who were not keen to teach during this time. This analysis yielded three different themes. However, a small number of respondents supportive of MS felt strongly about teaching and volunteered their reasons in response to the last question. While this data is insufficient to support a robust thematic analysis, a small section is included at the end in order to present as complete a discussion as possible.

III. RESULTS

A. Participant Background

Participants consisted of Emergency Medicine (EM) specialists, permanent registrars or middle grade staff and EM senior residents. These groups were chosen because they each hold significant roles, such as being named supervisors or clinical instructors of MS, and have considerably more contact time with MS in the DEM as opposed to nursing staff or junior doctors.

B. Quantitative Results

A total of 28 out of 45 (62.3%) responses were recorded. Except for two individuals, all other respondents in favour of hosting MS in the ED during DO (46.4%) were also keen to teach them. About two-thirds of the participants (60.7%) were not keen to teach MS during DO. However, of this latter group, 23.5% of respondents offered (without prompting) a compromise – where they proposed teaching only during the relatively less busy night shifts, in their response to ‘Any other comments?’  Table 1 shows the breakdown of responses.

C. Qualitative Results – Reasons Against

Each of the three themes presented here begins with a short paragraph that describes the situational context in which this survey took place, followed by a series of selected statements, and ends with a general summary and discussion of the responses within the respective theme. In order to maintain the authenticity of the data, each response is reproduced verbatim, sometimes in Singlish, the local colloquial variety of Standard Singaporean English (Bokhorst-Heng, 2005). Any edits to the text for clarification purposes have been clearly identified.

1) First theme: Cognitive overload of clinical teachers– There is only so much one can handle: Emergency physicians are no strangers to high stress environments, and are aware that as frontline workers they will be at the forefront in dealing with any emerging infectious disease. The move into DO represented the shifting of the local virus epidemiology from predominantly imported cases that could be easily identified and isolated, into the community-at-large. With this shift came changes to existing workflows and the re-arrangement of department space to form isolation areas for treating potential infectious cases. The implementation of a strict team-based roster described earlier meant that almost half the entire department would not physically meet the other half, and a surge in manpower requirements saw many junior doctors from other departments being rotated into the ED to help tackle the increased clinical load. Being new to the DEM, these new doctors required more supervision and assistance in adapting to the unfamiliar work environment. Responses that supported this theme include:

“High clinical load, long hours. Already cognitively overloaded. Not conducive for teaching. New [junior doctors] need to be taught also.”

Participant #6, Specialist

“Focus on daily evolving challenge first.” and in response to the last question “Please no.”

  Participant #2, Senior Resident 

“During DORSCON ORANGE we are in stress, if clinical teaching sessions start then other [doctors’] stress and workload level will increase.”

Participant #25, Staff registrar

“May be more a hassle if we have to look after the new [junior doctors] rotating and students [as well].”

Participant #4, Specialist

“We are also in a 12-hour outbreak roster which is physically, emotionally and mentally draining. Teaching students in this environment is far from ideal” and in response to the last question “Am fairly strongly against this idea”.

Participant #8, Specialist

“Day shifts no bandwidth to teach […] also can’t pay attention to [medical students] during day shifts, too tiring and too busy […] but I feel I can’t do [medical students] justice because I can’t debrief after a shift either, too tired.”

Participant #17, Specialist

Many of these responses conveyed a sense of exhaustion, reflecting the toll that constant workflow changes, longer work hours and relative social isolation was taking on the faculty. Teaching and supervising MS appeared to be viewed as a “hassle” or “extra work”, an additional drain to a clinical faculty’s energy during a busy and stressful shift.

This brought the department to a discussion on the provision of clinical services versus clinical education – whether teaching the next generation of future doctors was as important as treating the patient in front of us. One school of thought held that as clinician educators, physicians should – as the name implies – be clinicians first before educators. However, the interplay between these two roles is likely dependent on the faculty’s attitudes towards learners, as will be described later. Being cognitively overloaded naturally results in a shuffling of One’s priorities, which is seen next.

2) Second theme: Prioritisation of staff welfare – whose welfare is more important, staff or students? : It is well known that mental health can be adversely affected in crisis situations, and as the COVID-19 situation unfolded, boosting morale and maintaining the welfare of all staff became an important consideration (Matsuishi et al., 2012; McAlonan et al., 2007). At the forefront of this effort was the need to provide the staff with a supply of good quality personal protective equipment (PPE) so the staff would feel safe and confident in existing infection control measures. Although Singapore had yet to experience a shortage of PPE, there was still a concerted effort made by all hospitals to conserve these resources. Staff wellness was a theme seen in several responses:

“[I] can’t do the [junior doctors] justice because having a [medical student] attached to them is another stressor in an already stressful shift.”

Participant #17, Specialist

“Having to keep our doctors and nurses safe takes up a lot of energy. Students are young and naïve and will require even more time and resources to ensure they are safe.”

Participant #22, Specialist

“Furthermore, they will need to use PPE and again this should be conserved during the period of the outbreak.”

Participant #27, Specialist

“Medical students are important for future but I feel staff currently working in the department should be look after well.”

 Participant #25, Staff registrar

“Waste PPE.”

Participant #20, Specialist

The importance of conserving PPE during a pandemic is undisputed and the concern that MS would use them up is valid. It was interesting to note in these responses hints of an “us-versus-them” mentality, where MS were seen as competition for the limited resources of PPE, time, and energy. Students were not viewed as part of the DEM team and perceived more as “stressors”, who required attention because they were “young and naïve”, and their use of PPE was viewed as a “waste”. This identification of an “in-group” of staff and an “out-group” of students led to a prioritisation or favouring of the former over the latter. This behaviour can be explained by the Social Identity Theory (SIT), which states that part of an individual’s self-image or self-concept is derived from the social groups to which they perceive themselves to belong to (Hogg & Reid, 2006; Tajfel & Turner, 1979). Thus, in order to maintain a positive self-image, there is a tendency for people to favour the in-group and discriminate against the out-group. This phenomenon was famously demonstrated by Tajfel et al in their Minimal Group Paradigm studies, which essentially showed that the mere perception of belonging to one of two distinct groups was enough to trigger social discrimination between the groups (Tajfel et al., 1971). Behaviour like this is indicative that a significant number of the department hold the belief that there is a distinct divide between students and staff, rather than seeing MS as belonging to the wider group of the medical fraternity. Creating such a divide between staff and student is problematic because it hinders effective teaching, especially because MS will eventually transition from the “out-group” of students to the “in-group” of staff upon graduation, and clinician educators are responsible for providing a safe environment for them to learn in. However, beyond this discussion of intergroup competition, there were concerns amongst the faculty with regards to the appropriateness of siting clinical learning in the high-risk, front-line location of the ED in a pandemic, as discussed in the next theme.

3) Third Theme: Risk of viral exposure vs clinical education – What is the price to pay and who pays it?: During the initial period of DO, medical schools pulled MS out of the clinical environment and moved to online learning, with the aim of protecting them from unnecessary exposure to the virus and for safe distancing. However, when they proposed that students be allowed back into the hospitals after undergoing PPE training, this risk of exposure had not changed, as the number of positive cases was rising daily still. Responses that reflected this theme included:

“Don’t think it’s appropriate to have students around in a high-risk environment.”

Participant #4, Specialist

“Having medical students around not only will expose them to infection it will also compromise the rest of the staff in the event of a breach in infection [protocols]. Also, them just hanging around & not allowed to have hands-on [participation] in the procedures, clerking, [patient] contact etc will not be of any benefit [to them] at this time.”

Participant #7, Senior Resident

“Student safety issue. No minder to ensure students’ adherence to strict PPE as Doctors and Nurses will be busy with clinical service.”

Participant #11, Specialist

“I think medical students are not providing clinical care to patients and having them in the ED increases risk to patients (without the attendant benefits) and increases risk to themselves (without the moral obligation to do so as doctors) and their family.”

Participant #27, Specialist

“Can students be [held] responsible for their own health? Or the school or the department? As doctors, we know it as our duty and occupational hazard. But as students – their duty is to learn (best done in a safe environment), not put their health at risk.”

 Participant #6, Specialist

Responses that addressed the risk of virus exposure in the ED could be divided into two groups –those that were predominantly concerned about the students themselves catching the virus, and those that were more concerned about the consequences of such an event. The risk of catching the virus was seen as too high a cost – one that was borne not only by the individual student but by the patients and the staff as well. The benefits of clinical bedside instruction were called into question, as students’ movements would be restricted to low or medium-risk areas only. More than one participant raised the potential issue of students breaching infection control protocol or needing supervision in donning their PPE, despite reassurances given that schools would send MS for PPE training. This reflected a lack of trust in MS – themselves adult learners – who could be reasonably expected to understand the importance of infection control protocols. It begs the question of how big a role the educator plays in the personal safety of a MS and that of the patients and staff they interact with.

D. Qualitative Results – Reasons For

The survey design did not specifically ask responders about their reasons for supporting teaching MS during this pandemic. However, some participants felt strongly enough about this to advocate for clinical postings. Their reasons are shared below.

1) Theme: For the sake of tomorrow – In defence of teaching amidst a crisis:

“I feel we can still provide a meaningful learning experience for these students. We just need to lay out clear instructions and precautions for them to follow. It is a good opportunity to show to students how emergency medicine is adaptive, versatile, and for them to appreciate how quickly workflows can change, or how triage works in a disaster setting.”

Participant # 15, Specialist

“The way it is done has to be different […] the traditional method of teaching, where the students look to the seniors and may expect some form of spoon feeding […] Only when this mind-set is removed, will the tutors […] look at them as part of the team and incorporate them […], and will students see […] themselves as Drs to be [sic], practice safe habits from the very start and protect themselves as the patient’s doctor. This sense of ownership, accountability, professionalism can be started from that stage as a medical student. This is the perfect opportunity to state that this is what is expected and groom them likewise.”

Participant #19, Specialist 

“I feel that the teaching should as much as possible be a simulation of working life and that working in high-risk areas such as these gives a semblance of pressure which cultivates good habits such as mindfulness of hand hygiene, donning of PPE etc.”

Participant #26, Senior Resident

The responses share a commonality of seeing the pandemic as an opportunity for modelling positive attitudes that would benefit the student in the future. This point of view advocates for the acknowledgement of the realities of being a doctor and assumes that students are already part of the “in-group” of the medical team rather than the “out-group” as seen in the earlier discussion.

IV. DISCUSSION

A. Limitations

This study has its limitations, chiefly being the lack of qualitative data representing the opinions of those who were keen to teach MS as the initial survey was conducted with the purpose of gauging whether or not the department would be open to receiving MS during DO. This lack of data meant that this study is at best a one-sided representation of the department’s opinion.

Additionally, all four of the authors have a keen interest in the education of MS and two of the authors are actively involved in faculty development. They were all both participants in the study as well as its evaluators. Prior to evaluation of results, the authors themselves suspected that majority of the faculty would be too overwhelmed with the changes the pandemic wrought to want to teach students, which may have contributed to confirmation bias in the analysis of the data. However, throughout the analysis, every attempt was made to ensure that the themes uncovered remained true to the data, and much of the original data was reproduced here faithfully to maintain transparency, such that the reader may draw their own conclusions.  

Another limitation of the study was that the survey was unable to measure shifts in the attitudes of faculty as the pandemic evolved, which would have allowed us to understand the amplitude of the effect of the pandemic itself more clearly.

B. New Insights

It was worth noting that nearly two-thirds of the department did not want to teach MS during DO, despite each participant having taught MS routinely prior to this pandemic. Initial analysis of the reasons given for this refusal revealed three distinct themes of Cognitive Overload of Teachers, the need to Prioritise Staff Welfare and the Risk of Viral Exposure to Students – themes that are transferrable to many departments involved in pandemic response, regardless of locality.

Expounding further on this topic, it can be seen in some of the responses detailed under the themes of Cognitive Overload and Prioritising Staff Welfare, that there was a perceived increase in the need to supervise the new junior doctors rotating into the department on short notice (as opposed to the junior doctors who were already in the middle of their rotation and thus more familiar with the department’s protocols). This supervision is an important component of the continuing clinical education of junior doctors, which in itself is part of a larger debate surrounding the competing aims of clinical service versus clinical education that has been ongoing for many years (Woods, 1980). It is often the case in EM that when overwhelmed with patients, clinical education is sacrificed for clinical service without much short-term complications. Indeed, even amongst EM residents, more research is needed to define the optimal balance between service and education (Quinn & Brunett, 2009). However, a pandemic presents a rather unique situation in that most junior doctors will not have worked in a pandemic before. Thus, the need to educate junior doctors on both pandemic response and the importance of personal safety – with its direct impact on patient safety – now cannot be sacrificed without directly affecting the provision of clinical service.

It is beyond the scope of this paper to comment on whether educating MS on pandemics through clinical immersion programs during a pandemic better prepares them for future outbreaks, or in the broader sense, whether the clinical education of today’s MS by immersive learning can bolster the clinical service of tomorrow’s junior doctors. In fact, it seems almost premature to consider this question given the paternalistic attitude many of our faculty appeared to have towards students, perceiving them as learners to be looked after – to the extent that they could not even be trusted with their own safety and that of the patients and staff they interact with. Interestingly, this view seems to be shared by MS themselves – an electronic survey conducted at one of Singapore’s medical schools showed that a third of currently enrolled MS were concerned that they might introduce possible risks to the patient should they return to the clinical setting (Compton et al., 2020). These findings are indicative of a more deeply rooted mindset in which the social hierarchy draws a clear line between Teacher and Student. This becomes clearer when one considers that in Confucian Heritage Cultures such as Singapore (Biggs, 1998), the teacher holds great authority and students brought up in such cultures tend to defer to such authority as a matter of course (Ho, 2020). Given the multiple factors that contribute to this debate, it is unlikely that we will be able to arrive at a clear answer without further research, but what is certain is that medical students are not essential workers and, in a pandemic, medical schools need to balance their educational needs and ethical obligations to keep students safe (Menon et al., 2020).

Within our paper, it is heartening that many participants who were not keen to teach still tried to offer a compromise of teaching during the relatively less busy night shifts instead, and that 46% of our department were willing to accept MS during this period. COVID-19 allowed us to uncover some of the underlying attitudes towards MS and to consider them in the context of Singapore’s cultural heritage. These attitudes are important for us to address if we are to improve the delivery of medical education in the ED and we would like to invite the reader to consider whether the same uncovering has occurred in their respective departments.

V. CONCLUSION

The balance between clinical service and clinical education is a precarious one that appears to shift quickly in favour of the former in the high-risk environment of an evolving pandemic, which presents significant challenges even for experienced educators to overcome. As seen in our paper, cognitive overload of educators and the need to prioritise the welfare of junior staff inexperienced in pandemic response takes clear precedence over the education of MS. The paternalistic view that majority of our faculty hold leads to doubts about the ability of MS to keep themselves and their patients safe from virus exposure, doubts that are surprisingly shared by MS as well, and is indicative of the social hierarchy deeply ingrained in Confucian Heritage Cultures such as Singapore and surrounding countries in the region, where students tend to defer to authority as a matter of course. In order to improve as medical educators, we must place further effort into uncovering the underlying attitudes of both faculty and MS and address them in ways specific to our cultural heritage.

Notes on Contributors

Author Teo TL analysed the transcripts, conducted the primary thematic analysis and wrote the manuscript. Author Lim JH co-wrote the manuscript. Author Wee JCP conducted the literature review and developed the manuscript. Author Wong E designed and conducted the study, performed the data collection and developed the manuscript. All the authors have read and approved the final manuscript.

Ethical Approval

IRB approval for this study was obtained (SingHealth CRIB reference number 2020/2134).

Acknowledgement

The authors would like to acknowledge all participants of the survey.

Funding

No funding sources are associated with this study. 

Declaration of Interest

All authors work in SGH DEM and answered the survey as participants.

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*Evelyn Wong
Department of Emergency Medicine,
Singapore General Hospital
Outram Road
Singapore 169608
Email: evelyn.wong@singhealth.com.sg

Submitted: 30 August 2020
Accepted: 9 December 2020
Published online: 13 July, TAPS 2021, 6(3), 56-66
https://doi.org/10.29060/TAPS.2021-6-3/OA2440

Gayathri Devi Nadarajan¹, Kirsty J Freeman², Paul Weng Wan¹, Jia Hao Lim¹, Abegail Resus Fernandez² & Evelyn Wong¹

¹Department of Emergency Medicine, Singapore General Hospital, Singapore; ²Office of Education, Duke-NUS Medical School, Singapore

Abstract

Introduction: COVID-19 challenged a graduate medical student Emergency Medicine Clinical Clerkship to transform a 160-hour face-to-face clinical syllabus to a remotely delivered e-learning programme comprising of live streamed lectures, case-based discussions, and telesimulation experiences. This paper outlines the evaluation of the telesimulation component of a programme that was designed as a solution to COVID-19 restriction.

Methods: A mixed methods approach was used to evaluate the telesimulation educational activities. Via a post-course online survey student were asked to rate the pre-simulation preparation, level of engagement, confidence in recognising and responding to the four clinical presentations and to evaluate telesimulation as a tool to prepare for working in the clinical environment. Students responded to open-ended questions describing their experience in greater depth.

Results: Forty-two (72.4%) out of 58 students responded. 97.62% agreed that participating in the simulation was interesting and useful and 90.48% felt that this will provide a good grounding prior to clinical work. Four key themes were identified: Fidelity, Realism, Engagement and Knowledge, Skills and Attitudes Outcomes. Limitations of telesimulation included the inability to examine patients, perform procedures and experience non-verbal cues of team members and patients; but this emphasised importance of non-verbal cues and close looped communication. Additionally, designing the telesimulation according to defined objectives and scheduling it after the theory teaching contributed to successful execution.

Conclusion: Telesimulation is an effective alternative when in-person teaching is not possible and if used correctly, can sharpen non-tactile aspects of clinical care such as history taking, executing treatment algorithms and team communication.  

Keywords:           Telesimulation, COVID-19, Emergency Medicine, Programme Evaluation

Practice Highlights

• Telesimulation doesn’t replace but can be an effective alternative when in-person teaching is not possible.
• When implemented correctly, it can sharpen non-tactile aspects of clinical care.
• It is possible to achieve a level of fidelity and realism in a telesimulation environment.
• Simulation faculty needs to be skilled in debriefing techniques that enable the learner to reflect.
• Limitations of telesimulation can be reframed as learning opportunities.

I. INTRODUCTION

COVID-19 brought about unexpected challenges to medical education, especially to student clinical clerkships where medical students would spend time within a clinical discipline, interacting with clinicians and learning from patients. Healthcare institutions restricted student movement within clinical environments and barred students from entering the high-risk frontline areas to reduce exposure risk.

Prior to COVID-19, students undertaking an Emergency Medicine (EM) Clinical Clerkship, would have the opportunity to manage and deliver care to high acuity patients, with bedside teaching, small group tutorials, problem-based learning and simulation modalities. With COVID-19, students were not permitted into the Emergency Department (ED) and face-to-face teaching activities were halted. Hence this clerkship had to be conducted remotely. The EM clerkship was transformed from a 160-hour clinical programme to a remotely administered programme comprising 40 hours of e-learning, 40 hours of interactive live online session and 15 hours of telesimulation. As part of this programme, we decided to utilise telesimulation to help students achieve some of the objectives of a clinical clerkship.

Telesimulation is defined as the “Process by which telecommunication and simulation resources are utilised to provide education, training and/or assessment to learners at an off-site location” (McCoy et al., 2017). By allowing simulation to be conducted through devices such as the computer and phone, it mitigates the problem of physical proximity. Though telesimulation has existed for about a decade, its utilisation appears limited to the rural settings and studies mainly describe its usage for learning skills (Mikrogianakis et al., 2011; Naik et al., 2020; Okrainec et al., 2010) rather than for emergency management of patients. With the need to adapt teaching to remote experiences, telesimulation is gaining popularity (Sa-Couto & Nicolau, 2020).

A. Programme Overview

This remote learning programme was developed in a tertiary ED in Singapore which receives both undergraduate and postgraduate medical students for their EM clerkship. There were 58 postgraduate medical students undertaking their 4-week EM clerkship in June 2020. The EM core clinical training curriculum was taught by EM faculty via online modules and interactive classroom sessions delivered via the video conferencing platform, Zoom. The learners spent the mornings in interactive online sessions with faculty, and afternoons in self-study as part of a flipped classroom learning, using provided learning materials. The telesimulation session was scheduled in the last week, over five days. The students were split into ten groups each comprising of five to six students, where two groups participated in one telesimulation session each day.

Our objectives for this telesimulation programme was to ensure that the students could take a focused clinical history from the simulated patients, communicate with them, construct a list of differentials and manage them  accordingly in the emergency setting. The secondary objectives were to train them to prioritise the investigations and management of critically ill patients and to communicate and work effectively within a team. Using Kern’s six step approach, the team of simulation and clinical educators’ planned and implemented the telesimulation activity to achieve these outcomes (Harden et al., 1999; Smith & Dollase, 1999) during their EM clerkship.

As medical students, the learners are at a novice stage according to The Dreyfus Model of Skill Acquisition (Benner, 2004; Dreyfuss & Dreyfus, 1980). Hence, the deliberate attempt not to assess skills such as intubation or defibrillation through telesimulation as it may create unnecessary anxiety and feelings of incompetence (Papanagnou, 2017). Furthermore, it was deemed challenging to conduct procedural skill teaching through this modality. Instead, the focus was on clinical reasoning and patient management. The clinical students fall under the category of “show how” within the Miller’s pyramid, with regards to history taking, clinical reasoning and management. As adult learners, a problem centred (Knowles, 1990), experiential learning approach (Kolb, 1984) would be more valuable. Hence telesimulation was an appropriate modality. 

Each telesimulation session was conducted by two simulation and one physician faculty. There was a total of four scenarios for each session, where one group, consisting of five to six students, will participate in the scenario, while the other group observes, before switching. This allowed each group of students to participate in two clinical scenarios. The topics chosen for telesimulation were Anaphylaxis, Cardiac Arrest, Meningitis, and Syncope where the theory was covered in the core topics in the preceding weeks. Each of these scenarios began with the students taking a history from the simulated patient, before the patient progressively deteriorated and required resuscitation. Figure 1 shows a summary of the scenarios. The scenarios were selected as they did not require much procedure-based interventions (e.g. chest tube insertion in a poly trauma victim) which would be difficult to assess via Zoom.

Figure 1. Brief case description of simulation scenarios and visual presentation of the flow of the telesimulation experience

The sessions commenced with a briefing where the students were orientated to the online environment, including the use of video and microphones. As depicted in Figure 1, using the share screen feature, the simulation technician switched between different views. The briefing included a photo of the patient as a visual cue, along with the text of the presenting case. One of the simulation faculty played the circulating nurse, providing prompts to aid students’ engagement and asking participants to clarify their statements or orders as the scenario progressed. Using existing mannequin software and ensuring sharing of screen sounds, real-time patient monitoring was provided to the learners when requested. Upon request, additional visual cues of investigation results would be displayed, reverting back to either a picture of the patient or the patient monitoring. With their video off, the clinical faculty voiced the patient. At the conclusion of the scenario, all participants and faculty turned their video and microphones back on to participate in the large group debrief before proceeding on to the next scenario. 

The objective of this paper is to describe the students’ experience of telesimulation as part of an online clerkship programme and how such techniques can be used to meet learning outcomes (Harden et al., 1999) in various settings. At the time of writing, there is no literature describing evaluation of the use of a telesimulation programme within the ED for medical student education, with this paper aiming to address this gap.

 II. METHODS

A mixed methods approach was used to evaluate the introduction of telesimulation to the EM online clerkship, and to gain students’ perspective on learning through telesimulation. Programme evaluation research aligns with a mixed methods approach as the collection of both quantitative and qualitative data provide a deeper understanding of the student experience (Cohen et al., 2011).

A. Participants, Data Collection and Analysis

58 final year medical students who participated in the EM Online Clerkship programme were invited to participate in a post-telesimulation activity evaluation survey. Using a 5-point Likert scale, students were asked to indicate their agreement on 11 items addressing pre-simulation preparation, their level of engagement, confidence in recognising and responding to the four clinical presentations and telesimulation as a tool to prepare for working in the clinical environment. Seven open-ended questions were asked to enable the students to describe their experience in greater depth. 24hrs after completing the telesimulation session, students received an email with a link to the survey. Qualtrics online survey software was used to build, distribute and collect the survey responses. Voluntary consent was assumed by participation in the anonymised online evaluation. A statement outlining the purpose of the survey was included at the start of the survey and require an agreement before the survey could be commenced. Completion of the survey therefore implied consent.  The survey took between three and five minutes to complete, all responses were anonymous, with no identifiable data collected.

Descriptive statistics was used to analyse the responses to the Likert scale questions, with thematic analysis of the open-ended survey questions. Author one (GN) and author two (KF) reviewed the transcripts separately, making note of key phrases, outline possible categories or themes. Both authors then jointly rearranged and renamed the codes, developing higher order themes. NVivo 12™ was used to store, code and manage the qualitative data.

III. RESULTS

Of the 58 students who were invited to participate in the survey, 42 complete responses were received, a response rate of 72.4%. As seen in table 2, the results demonstrated that 97.62% of respondents agreed/strongly agreed that participating in the telesimulation session was interesting and useful to their learning. In relation to the use of visual and auditory cues, 93% of respondents felt that these helped them engage in the simulation. In relation to their level of preparedness to participate in the telesimulation experience, nearly 17% of respondents reported that the pre-session handout did not adequately preparing them for what to expect in the session.

Table 1. Results of the student responses to the Likert scale items

When asked to rate if they felt more confident recognising and responding to the four clinical presentations (anaphylaxis, cardiac arrest, meningitis, and syncope), between 90% and 93% agreed/strongly agreed that participating in the telesimulation sessions resulted in them feeling more confident in recognising and responding to the specific clinical presentations (Figure 2).

Figure 2. Student rating to the question “I feel more confident in recognising and responding to a patient with …”

Four key themes were identified following the data analysis of the open-ended survey questions, describing around the telesimulation experience of the respondents: 1) Fidelity; 2) Realism; 3) Engagement; and 4) Outcomes. As demonstrated in Figure 3, the themes do not exist in isolation, but intersect as they describe the telesimulation experience that the students had. The students feedback reflected the benefits and limitations which fall under these main themes.

Figure 3. Themes reflecting the students experience with telesimulation

A. Fidelity – Physical, Psychological and Conceptual

The theme Fidelity reflects how closely the telesimulation mimics or reproduces, reality.  Subthemes of conceptual, physical and psychological fidelity were also reflected. The students’ feedback reflected limitations in physical fidelity while conceptual and psychological fidelity was present mostly.

They reported that the auditory and visual stimulus from the dynamic display of investigations and real-time vital signs monitoring, provided a high level of physical fidelity.        

“Auditory and visual information on patients’ vitals and results were really helpful in generating the differential list.”

Student 37 

“The noise and sights is a good proxy for real life cases in a virtual environment.”

Student 4 

“Seeing the vitals of the patient in real-time allows us to experience the importance of time in managing critically ill patients”

Student 20 

However, aspects of physical fidelity, particularly related to the patient assessment, were reported as challenging via telesimulation. With the patient represented as a static picture, voiced by the clinical faculty, students shared how the lack of non-verbal and visual cues from the patient impacted their ability to perform a physical assessment of their patient.

“….we don’t get to observe the body language of the patient as much as we would like”  

Student 12 

“More difficult than in real life. Seeing and hearing a real patient gives much information”

 Student 15 

“I think what is lacking is being able to visually evaluate the patient”

Student 21

In terms of the level of psychological fidelity, the auditory cues from the ‘patient’ and the real-time vital signs monitoring simulated the ED resuscitation room, which appears to have instilled a similar sense the stress and the need to think under pressure, as reflected by the students’ feedback.

“Have to work around the distractions of beeping monitors, seizing patient, teammates asking questions/suggestions.”

Student 33

“It’s dynamic and gives us the opportunity to think under pressure.” 

Student 13 

“Stressful but probably close to reality?” 

Student 35

The students’ statements reflected the subtheme of conceptual fidelity, where they felt the context and sequence was similar to what they would encounter in the ED, where they are required to deliver timely and lifesaving treatment. This was possibly because the faculty made deliberate attempts to ensure that events during the simulation would unfold as it usually would in the ED room, based on the learners’ actions. 

“It simulates a clinical environment with real time updates of vitals and test results in addition to the history and communications.”

Student 5 

What the students did report struggling with however, was the limitations of the platform in terms of multiple actions occurring simultaneously. Unlike in real life, multiple tasks could not be performed at the same time over the online platform, and this impeded the conceptual fidelity.

“In reality, multiple interventions would be carried out in tandem.”

Student 35 

“More challenging to perform tasks concurrently over Zoom.”

Student 36 

“…many things cannot occur concurrently.”

Student 2

B. Realism

The theme Realism captures the degree to which the experience represented details or situations in a way that is accurate or true to life. Students reported that aspects of the telesimulation experience represented what they thought an actual ED encounter would be like.

“I think the process is similar to the actual clinical environment, it is difficult, especially when the patient is deteriorating in front of you, and your team are waiting for you to make the decisions.”

Student 41

“The pictures/videos and the beeping of the monitor, they make it more real”.

                                                                           Student 42 

“It was realistic as getting the differentials was time sensitive”.

Student 13

The students also acknowledged the limitations in achieving realism presented by telesimulation as the various team members could not perform tasks simultaneously and take in cues from the patient to assess the outcome of their actions. 

“Harder to communicate with my teammates compared to real life because only one person could speak at a time while in real life, multiple conversations could be occurring”

                                                                           Student 3 

“More difficult than taking a history in real life – more technical issues (can’t hear properly), Can’t see the patient”

Student 8 

C. Engagement

The theme Engagement relates to the level of interest, attention and involvement in the learning experience. The level of fidelity and realism impacts the level of engagement of the learners. Most students were able to immerse themselves and fully engage in the scenarios, possibly because aspects of fidelity and realism were deliberately given close attention during the preparation phase.

“I actually forgot that the patient was being voiced by the clinical tutor”

Student 41

“My heart was racing doing the simulation – what will I be like when I am there for real?”

                                                                           Student 41

However, on the downside, without being together in the same place, some felt that the scenario was too “messy” and “chaotic” and found it difficult to follow.

“It was a little hectic with the many other ongoing tasks in the background”

                                                                           Student 6 

“Easier to detach oneself from the patient (less affected by patient’s appearance, tone of voice, blood, gore, suffering etc.)” 

Student 28

 

At the same time, some students faced technical difficulties, such as small or flickering screen, poor internet connection or poor audio, which were barriers to their engagement.

“…there were some issues hearing the faculty clearly which may affect the quality of learning.”

                                                                           Student 6 

By addressing the concepts of realism and fidelity, the students reported increased levels of engagement, although it appears that technical barriers unique to telesimulation provide challenges for some students achieving a greater level of engagement.

D. Outcomes- Knowledge, Skills and Attitudes

The theme Outcomes encompasses what students feel they learnt from the experience that could be useful in future clinical encounters. Under outcomes, there were sub-themes of knowledge, skills and attitudes. From a knowledge perspective, students reported that the telesimulation reinforced their clinical reasoning to arrive at a differential list.

“It was very useful and helped with our clinical reasoning. It was also useful in learning how to generate differential diagnoses as a team and going down the path of a working differential diagnosis while keeping others in mind.”

Student 32 

Whilst the lack of hands-on practice was acknowledged, the telesimulation environment required them to practice the skills of prioritisation, leadership, teamwork and effective, close loop communication to manage the patient and this accounted for their skills gained.

“I will be able to apply the concept of teamwork, thinking on my feet, thinking broad, and constant reassessment of the unstable patient in my clinical training over the next few months”

                                                                           Student 6 

“Stay calm, go back to first principles, have the approach at your fingertips, make an effort to remember drug doses and administration route”

Student 2

IV. DISCUSSION

In relation to Kirkpatrick’s model for evaluating educational outcomes, the results of this study (table 1) demonstrate achievement of both level one (reactions) and level two (learning) outcomes (Kirkpatrick & Kirkpatrick, 2009). Whilst these findings may not determine the effectiveness of telesimulation, it does however provide insight into the learners’ experience that have highlighted the strengths and limitations of telesimulation, which the authors of this paper believe provides a foundation upon which others can build. 

It is well documented in the simulation literature that fidelity and realism are important concepts that need to be considered when planning simulation-based education (Oliver, 2002). And this was an initial concern by the educators. The lack of a physical ‘patient’ on which to carry out procedures and physical examination could limit the effectiveness of the telesimulation experience. To address this limitation, faculty briefed the learners about the limitations and the strategies, such as the use of a ‘nurse confederate’ to provide clinical information, as well as having visual cues such as pictures and videos to trigger their actions. Interestingly, the feedback suggests that the lack of a physical ‘patient’ to examine, resulted in more emphasis being placed on the audio and visual cues during the session. This allowed the learners to proactively compensate for the lack of tactile cues with audio and visual ones, reinforcing the importance of clinical alerts and alarms. The inability to perform a physical examination provided an opportunity for the debriefer to emphasise the importance of the skill in clinical care.

There was a deliberate attempt to create scenarios that were commonly seen in the ED in as much details as possible to achieve realism in the virtual space. This limited the scenarios that could be used as we had to use ensure procedures were not required for the patient management to progress (for example, trauma was deemed inappropriate). The faculty feel that the typical, non-complex ED scenarios compounded with the sequence of events as it would occur in real life possibly contributed to the student’s perception of realism during the telesimulation.

Instructional scaffolding was key to student engagement.  The faculty configured the telesimulation session to be held after three weeks of interactive and didactic sessions on Zoom. This allows the learners to acquire essential knowledge which they can then apply during the telesimulation session. With the background baseline knowledge, the telesimulation setup and audio and visual prompts of a real ED environment, the faculty felt that they were able to immerse the students within the scenario rather than conducting it as an online Problem-Based-Learning session. This may have contributed to their engagement.

Communication skills were a common thread reported by the students, both positively and negatively in many of their statements. They described the shortcomings of communication over Zoom and felt that the session highlighted how non-verbal cues and the physical presence influences the way one communicates. At the same time, the absence of visual and tactile stimuli forced them to practice good communication to get their points across when managing the patients.

Interestingly, though many students scored high on the Likert scale about feeling confident in managing emergencies, with the open-ended questions, they reflected feelings of nervousness, fear and a lack of confidence to working in the ED, showing that perhaps this cannot replace patient contact.

Cognisant of the limitations of telesimulation, most of the learners enjoyed the session. This may have been due to the novelty of it and ED room mimics such as the beeping of the monitors and the realistic scenarios. Faculty also realise that the limitations of telesimulation and used them as discussion points to highlight elements that one may take for granted during their patient encounters, such as the non-verbal cues and the tactile stimuli.

Key to this successful telesimulation session was establishing realistic and focused objectives (Harden et al., 1999). Failing to recognise that telesimulation differs from conventional simulation and therefore emphasising on tactile skills such as procedures and physical examination will minimise the effectiveness of the session. Knowing the inherent limitations helped faculty to prepare holistically for the session. Learning objectives focused on non-tactile aspects, such as history taking and executing treatment algorithms. In addition, as tactile cues are limited in the telesimulation setting, all other cues such as visual and audio were optimised.

Debriefing during the telesimulation sessions has an even more vital role in student learning compared to conventional simulation sessions (Fanning & Gaba, 2007). The debriefer not only has to highlight salient clinical points regarding the case, but also probe learners to think about limitations of the telesimulation modality. Therein, understanding the importance of highlighting tactile and visual feedback. For example, one learner recognised that he was “unable to visually observe and direct the teammate”; another came to the conclusion that “being able to see the patient and physical expression of fellow doctors/nurses is crucial”. This allows the educator to discuss the importance of situational awareness and non-verbal cues in enhancing team dynamics. However, if the debriefer fails to address this limitation, the learners may leave the session feeling dissatisfied or inadequate with their performance at the session. The uniqueness of telesimulation adds another facet to debriefing where the debriefer needs to be able to address the limitations of telesimulation and relate it back to clinical relevance. Therefore, there might be a need to provide additional training for educators in debriefing telesimulation sessions.

Simulation-based training is an effective modality to teach procedural skills, put into practice treatment algorithms and hone soft-skill relevant to team dynamics. (Lateef, 2010; Sirimanna & Aggarwal, 2014). As demonstrated through this innovative programme, it has an important role to play in medical education during such a pandemic where it might be used to mitigate the negative educational impact of no patient contact, team-based training and protocol development and testing  (Chaplin et al., 2020; Dieckmann et al., 2020). All this is done within a psychologically and physically safe environment.

Based on the feedback collected, a conceptual framework below (Figure 4) was drawn, showing the relationship between the concepts of fidelity and realism in the telesimulation experience to the level of engagement and therefore outcomes perceived by the learners. This is supported by the objectives, experiential learning and a safe learning environment.

Figure 4. Conceptual framework

V. CONCLUSION

The role of face-to-face interactions with patients and immersing oneself in the acute care environment in bridging the theory to practice gap experienced by all healthcare students is essential to their clinical training.  The restrictions encountered due to COVID-19 have required clinical educators to be agile and innovative in their approach the clinical clerkships. The EM clerkship telesimulation programme set out to provide an avenue for medical students to hone their clinical skills (history taking) and clinical reasoning (deriving differential diagnosis) in a safe environment. The evaluation of this programme has highlighted key areas of telesimulation which educators need to consider when planning to use it. The feedback from the students is promising and it highlights certain teaching points which may not be reflected upon during in-person simulation. Educators who wish to implement a telesimulation programme should pay particular attention to the learning objectives and debriefing methods. Whilst this paper has outlined how telesimulation can be implemented during a pandemic, it is envisaged that educators from other healthcare disciplines could use these findings to support the adoption of telesimulation in a variety of educational contexts. Telesimulation is a good alternative in settings such as this pandemic or during distance training programmes and may be a convenient way to hone history taking, clinical reasoning and communication skills without the use of an expensive simulation laboratory. The modality needs to meet the learning objectives and the debriefing should be adopted for telesimulation. However, the authors/faculty feel it cannot replace the full benefits of in-person simulation or learning from direct patient contact.

Notes on Contributors

Gayathri Devi Nadarajan and Kirsty J Freeman conceptualised the article, undertook the thematic analysis, contributed to article sections, and reviewed and revised manuscript based on suggestions from the other authors.

Lim Jia Hao, Wan Paul Weng and WONG Evelyn contributed to the conceptualisation of the paper, contributed to the article sections, reviewed and revised drafts.

Abegail Resus Fernandez undertook the quantitative analysis, and reviewed drafts.

All authors were involved in the development and delivery of the EM Clerkship Telesimulation Programme. All the authors have read and approved the final manuscript.

Ethical Approval

The SingHealth Centralised Institutional Review Board (CIRB) granted an exemption, CIRB Ref. No.: 2020/2719, as this study was assessed as a quality improvement project.

Data Availability

All relevant data are within the manuscript.

Acknowledgement

We would like to thanks the students who participated in this unit and their willingness to adapt to the online platform with grace and enthusiasm. 

Funding

This work has not received any external funding. 

Declaration of Interest

All authors declare that there are no conflicts of interest.

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*Gayathri Devi Nadarajan
Department of Emergency Medicine
Singapore General Hospital
1 Outram Road, Singapore 169608
Tel: +65 96804724
Email: gayathri.devi.nadarajan@singhealth.com.sg