Submitted: 19 February 2025
Accepted: 14 May 2025
Published online: 7 October, TAPS 2025, 10(4), 73-76
https://doi.org/10.29060/TAPS.2025-10-4/SC3672

Astrid Pratidina Susilo¹, Lucia Pudyastuti Retnaningtyas¹, Lisa Aditama² & Karunia Wijayanti³

¹Faculty of Medicine, Universitas Surabaya, Indonesia; ²Faculty of Pharmacy, Universitas Surabaya, Indonesia; ³Faculty of Medicine, Universitas Negeri Surabaya, Indonesia

Abstract

Introduction: Healthcare professionals need to advocate for mothers and understand breastfeeding challenges, especially in a community-based culture. We developed a breastfeeding management course for healthcare professionals and students in health-related majors on an online platform at our university. This study aimed to explore what participants learned from an experiential learning assignment to interview mothers regarding their breastfeeding challenges, and write a reflection on it.

Methods: In this qualitative study, we analysed the written reflections of 56 participants after they interviewed mothers regarding their breastfeeding challenges. Thematic analysis and triangulation among the researchers were conducted to obtain themes.

Results: Four themes were identified: (1) differences in knowledge and beliefs about breastfeeding among mothers and their families, (2) breastfeeding challenges that can be a threat to breastfeeding, (3) healthcare professionals’ central role in providing education and advocating for breastfeeding, and (4) involvement of the family and community in breastfeeding education.

Conclusion: This interview and reflective writing assignment strengthened the participants’ awareness of how to advocate for breastfeeding mothers, including considering the influence of the community context.

Keywords:           Breastfeeding, Communal Culture, Experiential Learning, Reflective Writing

I. INTRODUCTION

Breastfeeding is a natural method of providing the best nutritional intake for babies’ growth and development, and strengthening the emotional bond between the mother and the baby. The low rate of breastfeeding is a global problem because only less than half of babies under six months of age are exclusively breastfed (Balogun et al., 2015).

Several factors influence breastfeeding, including stigma and support from people closest to the mother. These factors are prominent in communal cultures where the influence of family and community is strong (Susilo et al., 2019). Healthcare professionals can encourage the success of breastfeeding programs by providing education to mothers and their families. Therefore, they need to learn about breastfeeding management and strategies to increase public knowledge. Apropos this, mother-centred advocacy tailored to mothers’ needs can be offered by healthcare professional (Mulcahy et al., 2022).

We developed a breastfeeding management training program for healthcare professionals and students through an online course platform. One of the assignments in this course was to interview breastfeeding mothers and write reflections on their experiences. According to Kolb’s Experiential Learning Theory, this learning activity can help learners conceptualise the essential principles they must master (Yardley et al., 2012). Such a learning activity is innovative and scarcely reported in the existing literature. Additionally, this assignment is novel in the field of breastfeeding-related education. A systematic review of breastfeeding training reported that only one breastfeeding training program used reflective writing (Mulcahy et al., 2022). This study aimed to explore what participants learned from an experiential learning assignment of interviewing mothers on their breastfeeding challenges and writing reflections afterwards.

II. METHODS

This qualitative study used an interpretive descriptive approach to identify themes and patterns among subjective perspectives based on the reflections of breastfeeding management training participants. The training was conducted online through our university’s open online course platform Ubaya Global Academy (UGA). This online course consisted of six sessions and targeted healthcare professionals and students from different domains (medicine, pharmacy, and midwifery). The six sessions were basic science of breastfeeding, common challenges in breastfeeding for healthy mothers (part 1), common challenges in breastfeeding for healthy mothers (part 2), supporting breastfeeding in mothers with specific health issues (non-communicable disease), supporting breastfeeding in mothers with specific health issues (communicable disease), and essential principles in breastfeeding (wrap up and reflection). Students should have completed their first year of education to have basic exposure to health sciences. We invited all participants who had attended the training to participate in this study. At the beginning of the second session, each participant interviewed a mother who had breastfeeding experience, following which, they wrote a reflective writing of 200-500 words.

Submitted: 11 January 2025
Accepted: 11 August 2025
Published online: 7 October, TAPS 2025, 10(4), 77-80
https://doi.org/10.29060/TAPS.2025-10-4/SC3818

Yassar Alamri

Department of Medicine, University of Otago, Christchurch, New Zealand

Abstract

Introduction: Response rates to surveys of medical students and junior doctors have not previously been explicitly examined. Reasons for the observed response rates have not been scrutinised.  The aims of the present study were to establish an expected response rate to electronic survey among medical students and junior doctors, and to explore reasons behind non-response.

Methods: A follow-up online survey was sent to 93 medical students and junior doctors. The primary method for participants to complete the survey was via the Internet using a well-known and established survey tool. Descriptive and inferential statistics were used to assess response rates and reasons for non-response.

Results: Out of 93 invited medical students and junior doctors, 47 returned the follow-up survey (response rate = 50.5%). The main reasons for non-response were: there were too many surveys (74.4%), lack of time (25.5%), and the original survey being too long (10.6%).

Conclusion: We found a mediocre response rate (50.5%) to electronic surveys by medical students and junior doctors included in this study. Several factors that may impede response to surveys (survey-related, and participant-related) have been identified, and these may be specifically targeted to improve survey response rates.

Keywords:           Medical Student, Survey, Response Rate, Research, Methodology

I. INTRODUCTION

Surveys offer an important method of collecting quantitative data from physicians and medical students on various aspects of medical and clinical research. The ease and convenience of online and web-based surveys (compared with telephone or face-to-face interviews) should theoretically enhance response rates. However, the ideal method of surveying the medical workforce (which would yield a high rate of and representative responses) is yet to be identified.

Physicians have traditionally been reported to have poor response rates to surveys in general. Studies that have specifically assessed response rates to surveys among physicians revealed overall rates of 35–50% (Cunningham et al., 2015). Response rates to surveys and reasons for non-response by medical students and junior doctors have seldom been specifically examined. Previous response rates to the National Physician Survey in Canada reported response rates of approximately 28–35% by medical students and junior doctors (Grava-Gubins & Scott, 2008), although these data are almost two decades old now.

Several reasons for non-response emerge from reviewing the pertinent literature; these can be divided into: survey-factors, and respondent-factors. Survey-factors include the length of the questionnaire (Grava-Gubins & Scott, 2008), perceived interest in and sensitivity of the surveyed topic (Cunningham et al., 2015), and the mode of survey delivery (i.e., electronic, telephone or face-to-face) (Grava-Gubins & Scott, 2008; Weaver et al., 2019). Several incentives have been instigated in order to improve response rates by addressing some of these survey-factors, including utilising electronic surveys that can be completed in more than one setting (at the participants’ convenience)(Weaver et al., 2019), monetary gifts or “educational credit” for participation (Grava-Gubins & Scott, 2008; Viera & Edwards, 2012), and employing internal “buy in” from a respected member of the intended sample (e.g., senior clinician or head of department) (Akl et al., 2011). Respondent-factors for non-response include lack of time, demographic differences, and the specialty of the respondent.

The aims of the present study were to establish an expected response rate to electronic survey among medical students and junior doctors, and to explore reasons behind non-response. No previous study has focused on medical students and junior doctors (i.e., junior medical workforce); therefore, addressing these issues would help fill several gaps in our knowledge.

II. METHODS

A. Study Setting

A previous study (Alamri et al, in press) invited all medical students at the University of Otago, and junior doctors at the Christchurch Hospital (both in Christchurch, New Zealand), to complete an electronic ‘index questionnaire’ on their research activities. The overall response rate of the original survey was 36% despite employing an online survey, several reminders and monetary gift vouchers.

B. Study Participants and Instrument

For the present study, eligible participants were medical student and junior doctor who had started the ‘index questionnaire’, but never completed it. The identified ‘non-responders’ were then invited to a secondary follow-up survey which was sent after the allotted time-period for the index questionnaire had lapsed (August–September 2018).

The follow-up survey was intentionally designed to be very brief, and based upon previous similar surveys (Cunningham et al., 2015). It only included four questions: participant age and sex, current career, and “what were the reasons for not completing [the index questionnaire]?”.

C. Statistical Analysis

Descriptive statistics (means ± standard deviations, and percentages) were used to analyse most of the data. Comparisons between medical students and junior doctors (two sub-populations with different responsibilities and time commitments) were conducted using Chi-square analyses for categorical values (e.g., sex, and entry to medical school), and Mann-Whitney U test for nonparametric continuous variables (e.g., age). Statistical significance was determined if type I error rate was < 5% (p-value < 0.05). All analyses were performed using the Statistical Package for Social Sciences software (SPSS Statistics®, version 22.0.0.0).

III. RESULTS

A. Study Participants

A total of 93 eligible participants were identified as potential participants. Following electronic invitation, 47 returned the follow-up survey (response rate: 47/93 = 50.5%). Two thirds (31/47; 66%) of the respondents were female. The median age was 23 years (range, 19–42). Most of the respondents (40/47, 85.1%) were medical students (see Table 1).

Submitted: 13 February 2024
Accepted: 28 April 2025
Published online: 1 July, TAPS 2025, 10(3), 75-79
https://doi.org/10.29060/TAPS.2025-10-3/SC3235

Tayzar Hein¹ & Susan Somerville²

¹Department of Medical Education, Defence Services Medical Academy, Myanmar; ²University of Dundee, Scotland

Abstract

Introduction: Case-Based Learning (CBL) is increasingly used in modern medical schools to improve students’ critical thinking and problem-solving skills. While CBL is established in Western Resource-Structured (WRS) educational settings, its use in Asian-Pacific regions like Myanmar is under explored. This research studied the integration of CBL at the Defence Services Medical Academy (DSMA) in Myanmar, focusing on the perspectives of both students and faculty involved in curriculum reforms.

Methods: This study used constructivist grounded theory to gather data from 24 DSMA participants through four focus group discussions. Twelve students and twelve faculty members, were invited a subgroup of six, and after providing informed consent discussed their experiences of CBL, aiming to assess its effectiveness and relevance in their specific educational and cultural context.

Result: Analysis shows that students valued CBL for enhancing group discussions, reflecting upon real-world situations, and building critical thinking abilities. Faculty members also appreciated CBL for its capacity to create realistic applications and its support for student-centered learning and interpersonal skills development. Both groups acknowledged CBL as an effective method for simulating the complexities of medical practice.

Conclusion: This study found that CBL is well-regarded at DSMA for preparing students competence and confidence for clinical encounters. However, faculty indicated that the extensive time required in preparation of this teaching modality was a significant challenge for the wider adoption of CBL. These insights highlight the adaptability and potential challenges of implementing CBL in non-Western educational settings and suggest possible areas for development for its broader application in the Asia-Pacific region.

Keywords:           Medical Education, Case-based Learning, Perceptions, Grounded Theory, Focus Group Discussion

I. INTRODUCTION

In 2017, Defence Services Medical Academy (DSMA) in Yangon, Myanmar, introduced an outcome-based integrated curriculum incorporating Case-Based Learning (CBL) as a key pedagogical approach. This shift from teacher-centered to student-centered learning was aimed at encouraging students to take greater responsibility for their education. However, CBL’s widespread adoption across all subjects at DSMA remains uncertain, highlighting the need for further research. CBL has been established in Western Resource-Structured (WRS) medical education, where it fosters critical thinking, active learning, and problem-solving skills (Thistlethwaite et al., 2012). However, its adoption in the Asian-Pacific context, including Myanmar, has been limited. Cultural and institutional challenges such as insufficient faculty training, resource constraints, and resistance to pedagogical change present unique barriers (McLean, 2016; Yoo & Park, 2015). These challenges underline the importance of research to adapt CBL to resource-constrained settings.

At DSMA, CBL is relatively new, and while the institution can be considered an early adopter within the local context, faculty have faced challenges transitioning from traditional teaching methods due to inadequate training and support (Thistlethwaite et al., 2012). This study aimed to explore how students and faculty perceive the implementation of CBL and to assess the opportunities and challenges of CBL in a resource-constrained, Asian-Pacific context. By addressing gaps in the CBL literature, this research contributes valuable insights for adapting pedagogical practices to diverse cultural and educational settings.

This study aimed to explore:

1. How students and faculty at DSMA perceive the implementation of CBL.
2. The opportunities and challenges associated with implementing CBL in a resource-constrained, Asian-Pacific context.

 

By addressing gaps in the CBL literature, particularly in non-WRS settings, this research contributes to a better understanding of how pedagogical practices can be adapted to diverse cultural and educational contexts, offering insights for both early and late adopters within similar settings.

II. METHODS

This qualitative study used a constructivist grounded theory approach, focusing on the experiences and meanings constructed by participants engaged with CBL in the DSMA integrated curriculum.

A. Sampling and Focus Group Composition

Purposive sampling (Patton, 2014) was used to select participants with direct involvement in CBL activities, either as facilitators or active learners. The study included 24 participants, evenly split between 12 students and 12 faculty members. Four focus groups, each containing six participants, were conducted. To reduce power dynamics, the focus groups were divided by role, with separate groups for students and faculty.

B. Participant Demographics

Table 1 below shows the demographic breakdown of participants is for understanding the responses and receptivity to CBL.

Table 1. Participant demographic

C. Theoretical Framework

The constructivist grounded theory approach guided both data collection and analysis. This approach emphasises the co-construction of knowledge, meaning participants not only shared their experiences but actively engaged in interpreting them. The analysis followed a constant comparative method (Patton, 2014), allowing key themes to emerge from the data.

D. Data Analysis

Data were analysed using MAXQDA software, and the constant comparative method was applied to identify recurring themes and refine categories as new insights developed.

E. Ethical Considerations

Ethical approval was granted by the DSMA Ethical Review Board. Informed consent was obtained from all participants, ensuring they were aware of the study’s aims and their rights. Confidentiality and anonymity were maintained throughout the study, and all focus group discussions were audio-recorded with consent.

III. RESULTS

The core category identified in the study was that CBL is a student-centered approach that develops critical thinking, simulates discussion about real-world scenarios, and enhances interpersonal skills, making it a key facet of modern medical education. These findings emphasise the role of CBL in bridging theoretical knowledge with practical application and supporting the development of essential skills for clinical encounters. Both students and faculty members offered different but aligned perspectives, providing valuable insights into the opportunities and challenges associated with CBL.

A. Students’ Perceptions of CBL

1) Theme 1: CBL as group discussion: Students welcomed the collaborative nature of CBL, emphasising the shared learning experience it offers. One student stated, “It’s like a team effort where we learn from each other while solving problems.” This highlights the significance of peer interaction in CBL, which is consistent with research indicating that collaborative learning enhances problem-solving skills.

2) Theme 2: Real-World Relevance: Students appreciated the practical aspects of CBL, particularly its similarity to real-life clinical scenarios. A participant remarked, “It feels like we are preparing for actual hospital situations.” This theme aligns with studies showing how CBL effectively bridges the gap between theoretical knowledge and clinical practice, preparing students for real-world medical challenges.

3) Theme 3: Fostering Critical Thinking: Students frequently mentioned the role of CBL in promoting deeper analytical skills. One student shared, “CBL makes us analyse why things happen instead of just memorising.” This observation reflects the literature that highlights critical thinking as a fundamental outcome of CBL, encouraging students to engage more deeply with the material.

B. Faculty Perceptions of CBL

1) Theme 1: Preparation for Clinical Practice: Faculty members emphasised the effectiveness of CBL in preparing students for real-world medical contexts. One faculty member noted, “CBL allows students to apply their knowledge in realistic medical contexts.” This highlights the need for carefully designed scenarios that accurately mimic clinical challenges, supporting students in applying theoretical knowledge.

2) Theme 2: The Role of Facilitator: Faculty highlighted the critical role of facilitators in guiding effective CBL sessions. A faculty member stated, “Guiding discussions and asking the right questions is key to effective CBL sessions.” This underscores the importance of facilitator training, as their competence significantly impacts the success of CBL in achieving its objectives.

3) Theme 3: Development of Personal Skills: Faculty also emphasised the role of CBL in cultivating essential personal skills for medical practice, such as communication and empathy. One faculty member remarked, “CBL is instrumental in teaching students how to communicate effectively and empathise with patients, which are essential skills in medicine.” This theme reflects a structured focus on skill development, complementing students’ emphasis on the experiential aspects of learning.

IV. DISCUSSION

This study identified both the opportunities and challenges of adopting CBL in a resource-constrained, Asian-Pacific context. Students recognised CBL’s role in fostering teamwork and critical thinking, consistent with previous research (Ferguson & Lee, 2012; Thistlethwaite et al., 2012). Faculty highlighted its effectiveness in preparing students for clinical practice and developing essential interpersonal skills. However, both groups noted challenges, such as the time-intensive nature of CBL and the varying levels of facilitator preparedness.

A. Student Perspectives

Students appreciated the collaborative nature of CBL, noting that it enhanced communication and problem-solving skills. They also valued its practical relevance, which bridged the gap between theory and clinical practice. However, challenges related to the time commitment and inconsistent preparation for case studies were identified.

B. Faculty Perspectives

Faculty acknowledged the value of CBL in preparing students for real-world challenges but emphasised the importance of facilitator training. Inconsistent facilitation was cited as a barrier to effective implementation, suggesting the need for structured training programs focusing on communication and group management skills.

C. Adapting CBL for the Asian-Pacific Context

Cultural dynamics at DSMA, including hierarchical relationships, were seen as barriers to open dialogue and peer-led activities. Strategies such as peer-led activities and anonymous feedback could help mitigate these issues, creating a more inclusive and collaborative environment. Although hierarchical relationships are common across educational settings, these challenges may be viewed as institutional factors rather than unique cultural issues. Thus, the solutions proposed peer-led activities and feedback are relevant for various contexts beyond Asian-Pacific.

D. Core Category and Future Directions

The findings underscore the need for ongoing research to explore facilitation models and cultural adaptations that can optimise CBL in diverse settings. Future studies should examine how CBL can be further refined to address institutional factors like hierarchical relationships, and how these adaptations can be applied in resource-limited settings.

V. CONCLUSION

This study highlights both the strengths and challenges of implementing CBL at DSMA. Students valued CBL for its relevance to clinical scenarios and its emphasis on clinical reasoning, while faculty recognised its potential in fostering interpersonal skills. However, challenges such as inconsistent facilitation, insufficient faculty training, and the lack of localised case studies were identified. Moving forward, DSMA should focus on enhancing faculty development, particularly in facilitation skills, and integrate case studies that reflect local clinical realities. Additionally, leveraging technology to support CBL in resource-limited settings could improve access and engagement.

For the broader health education community, this study underscores the importance of adapting CBL to local contexts, considering cultural dynamics and institutional constraints. Successful implementation of CBL in resource-constrained settings requires flexibility in adapting global pedagogical methods to meet the needs of local learners and educators. Expanding CBL at DSMA, with a focus on faculty training, case study development, and the use of technology, will better prepare students for the challenges of medical practice. This study contributes to the growing body of literature on CBL and provides actionable recommendations for institutions in similar settings.

Notes on Contributors

Dr. Tayzar Hein contributed significantly to the manuscript’s conception, design, and writing, leveraging his expertise to shape its content.

Dr. Susan Somerville provided essential support during the research process, particularly in data collection and analysis, contributing to the manuscript’s presentation.

Ethical Approval

Ethics approval was granted by the Ethical Review Committee of the DSMA, Ethical Review Board (2/ ERB/ 2022).

Data Availability

The data that support the findings of this study are openly available in https://doi.org/10.6084/m9.figshare.26550262.v1.

Acknowledgement

The author would like to express sincere gratitude to their supervisor, Dr Susan Somerville, for her thoughtful guidance throughout the research project. Dr Susan Somerville provided invaluable suggestions, constant encouragement, and generously dedicated her time during video chats, despite being on the other side of the world. The support of the Ethical Review Committee at DSMA is also deeply appreciated. Their rigorous adherence to ethical standards ensured that the study met the highest research ethics guidelines, which is essential to both advancing medical knowledge and protecting human subjects.

Special thanks are extended to the Phase II medical students and faculty members who participated in interviews and provided honest, insightful discussions that significantly contributed to the research. Phase II students, typically in the years of medical education, engage in more clinical-based learning and were crucial in offering perspectives on applying Case-Based Learning (CBL) to real-world medical scenarios. Faculty members from both basic science and clinical practice domains also played an integral role in facilitating these discussions. The assistance of the Medical Education Department faculty in facilitating these interviews was also instrumental, and their support is gratefully acknowledged.

Finally, the author wishes to express heartfelt thanks to his wife and son for their unwavering support and encouragement throughout the academic journey. Without their constant love and understanding, this research project would not have been possible.

Funding

This research is entirely self-funded, as there is currently no external financial support available for the project, necessitating the coverage of all expenses independently.

Declaration of Interest

The author conducted original research and wrote this dissertation, which was not previously submitted for a degree. The author has the copyright to the dissertation according to UK Copyright Acts and University of Dundee’s rules. Any use of material from this thesis should be acknowledged.

References

Ferguson, A., & Lee, E. (2012). Desperately seeking… relevant assessment? A case study on the potential for using online simulated group based learning to create sustainable assessment practices. Legal Education Review, 22(1), Article 6. https:/​/​doi.org/​10.53300/​001c.6258

McLean, S. F. (2016). Case-based learning and its application in medical and health-care fields: A review of worldwide literature. Journal of Medical Education and Curricular Development, 3, S20377. 

Patton, M. Q. (2014). Qualitative research & evaluation methods: Integrating theory and practice (4^th ed.). SAGE Publications.

Thistlethwaite, J. E., Davies, D., Ekeocha, S., Kidd, J. M., MacDougall, C., Matthews, P., Purkis, J., & Clay, D. J. (2012). The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Medical Teacher, 34(6), e421-e444. https://doi.org/10.3109/0142159X.2012.680939

Yoo, M. S., & Park, H. R. (2015). Effects of case‐based learning on communication skills, problem‐solving ability, and learning motivation in nursing students. Nursing & Health Sciences, 17(2), 166-172. https://doi.org/10.1111/nhs.12151

*Tayzar Hein
Defence Services Medical Academy,
Pyay Road, Mingalardon Township,
Yangon, Myanmar
+9595188093
Email: dr.tayzarhein@gmail.com

Submitted: 30 October 2024
Accepted: 8 April 2025
Published online: 1 July, TAPS 2025, 10(3), 89-92
https://doi.org/10.29060/TAPS.2025-10-3/SC3562

Shanya Shanmugam¹, Rajeswari Kathirvel^1,2, Kayda Soh² & Xinyi Li^1,2

¹Lee Kong Chian School of Medicine, Singapore; ²Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, Singapore

Abstract

Introduction: The Objective Structured Clinical Examination (OSCE) is a popular method for assessing medical students’ clinical proficiency. Mock OSCEs are often incorporated into medical curricula to help students familiarise themselves with the examination format. While the impact of mock OSCEs on academic performance has been studied, their perceived utility remains less explored. This study aimed to assess the effectiveness of a mock OSCE in preparing medical students for their final examinations.

Methods: A prospective study was conducted at a tertiary hospital in Singapore, involving medical students undergoing their Obstetrics and Gynaecology posting. The mock OSCE consisted of five stations and included immediate feedback from examiners. Students completed three questionnaires: pre-mock OSCE, post-mock OSCE and post final examinations, rating the utility of the session and their confidence levels.

Results:  Of the cohort of 147 students, 121 responded to the pre-mock OSCE survey, 132 responded to the post-mock OSCE survey, and 105 to the survey after their final examinations. The percentage of students who found the mock OSCE useful/very useful increased significantly from 97.5% before to 98.5% after the session, and significantly decreased to 96.2% after the examinations. Confidence levels rose significantly from a mean score of 2.34/5 pre-mock to 3.89/5 post-mock, to 4.67/5 post-exam. Qualitative feedback was positive, highlighting the benefit of familiarisation with examination mark schemes.

Conclusion: The mock OSCE was well-received by students and perceived as a valuable tool in preparation for examinations. Despite the limited sample size, these findings support the implementation of mock OSCEs to enhance students’ learning and exam preparedness.

Keywords:           OSCE, Undergraduate, Medical Education, Medicine, Students’ Perception

I. INTRODUCTION

The Objective Structured Clinical Examination (OSCE) is a well-established, widely utilised method for assessing the clinical proficiency of medical students. This format comprises multiple stations where students perform clinical tasks, including history taking, physical examination, and discussing clinical management. Despite being a crucial assessment tool, OSCEs can be a daunting experience for medical students. Educational institutions often incorporate mock OSCEs into curricula to alleviate this stress, allowing students to familiarise themselves with the format and receive feedback. These sessions aim to mimic the actual OSCE, allowing students to familiarise themselves with the format and requirements, and offer an opportunity to receive feedback. 

The correlation between mock OSCE practice and performance in the actual OSCE has yielded mixed results in literature. Studies on medical students (Townsend et al., 2001), and residents from internal medicine (Pugh et al., 2016), paediatrics (Hilliard et al., 1998), and emergency medicine (Lee et al., 2021) have established positive correlations between mock OSCE scores and final examination scores. Conversely, a study on second-year medical students concluded that while the mock OSCE led to improved performance in individual stations, it did not cause a significant change in the pass rate of the final examinations (Chisnall et al., 2015).

While the impact of mock OSCEs on students’ academic performance has been examined, the perception of their utility among participants has not been extensively analysed. As OSCE is viewed as a stressful component of medical assessments, the introduction of mock OSCE sessions is thought to mitigate this stress by fostering confidence and familiarity among students (Chisnall et al., 2015).

We performed a study to determine the perceived effectiveness of a mock OSCE in preparing its participants for their final examinations. More specifically, the study aimed to assess whether participation in the mock OSCEs improved students’ understanding of the domain-based exam scoring system employed by markers, enhanced their time management skills, delivered valuable content, helped them develop effective approaches to OSCE stations, and boosted their confidence levels.

II. METHODS

This prospective study evaluated students’ perceptions of the mock OSCE’s utility. This was conducted at KK Women’s and Children’s Hospital (KKH), which is a tertiary hospital in Singapore. KKH caters to students from the three different medical schools in Singapore including Lee Kong Chian School of Medicine (LKC), Yong Loo Lin School of Medicine and Duke-NUS Medical school.

A mock OSCE programme was organised by the Obstetrics and Gynaecology (O&G) department for the fourth-year medical students from LKC during their O&G posting from 2022-2023. The mock OSCE was conducted three times as the students attended in three streams. This is the first of such a programme in the O&G curriculum and was introduced as this cohort had reduced clinical exposure due to COVID-19 restrictions during their clinical years.

The mock OSCE included five 10-minute stations covering history taking, physical examination, and clinical management in O&G. Students were evaluated according to the domain-based scoring system used by LKC for their final examinations. The assessment was designed to be formative in nature and the students received immediate feedback at the conclusion of each station. 

The students were asked to complete anonymous questionnaires before and after participating in the mock OSCE, and after completing their final year examinations. A 4-point Likert scale was used to gauge the usefulness of the mock OSCE session, with 1 being “not useful at all” and 4 being “very useful” and a 5-point Likert scale was used to gauge confidence for final examinations, where 1 represented “not confident” and 5 represented “very confident”. The responses collected before and after the mock OSCE session were compared. The study also examined the impact of the mock OSCE on insight into exam scoring system, time management, and content relevance through Likert scale questions. Qualitative feedback was obtained through open-text responses. The data obtained through the Likert scales were combined into nominal categories. Statistical significance was determined by performing Chi-square tests, with p<0.05 being considered significant.  Informed consent was implied through the voluntary participation of individuals in the questionnaires.

The study was approved and given exempt status by the Nanyang Technological University Institutional Review Board for research (IRB 2023-677).

III. RESULTS

There were 147 fourth-year medical students for the academic year 2022–2023. 121 students responded to the questionnaire prior to the mock OSCE (82.3%), 122 (83.0%) after the mock OSCE, and 105 (71.4%) after their final examinations.

Before the mock OSCE, 97 (80.8%) students believed that it would be very useful for their exam preparation, while 20 (16.7%) believed it would be useful, and 3 (2.5%) were unsure. After the mock OSCE, 120 (91.6%) students thought it was very useful for their exam preparation, with 9 (6.9%) believing it was useful, 1 (0.8%) being unsure, and 1 (0.8%) believing it was not useful. After the final examinations, 77 (74.8%) students found it to be very useful for their exam preparation, 22 (21.4%) found it was useful, 3 (2.9%) were unsure, and 1 (1.0%) found it was not useful (Figure 1). Overall, the percentage of students who found the mock OSCE useful/very useful increased from 97.5% before to 98.5% after the session and decreased to 96.2% after the examinations. The difference in perceived utility of the mock OSCE, as determined by the combining “very useful” and “useful” into one category and “unsure” and “not useful” into another, from before the OSCE, after the OSCE, and after the examinations, was statistically significant at p<0.05, with a p-value of 0.0147.

Figure 1. Comparison of perceived utility of mock OSCE

When asked to rate their confidence regarding their final examinations, the overall score improved from 2.34/5 before the mock OSCE to 3.89/5 after, to 4.67/5 after the examinations. This rise in confidence levels was statistically significant, with a p-value of <0.00001. 

We asked the students to rate the domain that they found the mock OSCE helped them with the most, including improved insight into domain-based exam scoring system, improved time management, useful content, prepare an approach for OSCE stations, and improved confidence. Almost a third (n = 32, 30.5%) of the students found that the mock OSCE helped them to prepare an approach for OSCE stations the most. This was followed by improved confidence (28, 26.7%), improved insight into exam scoring system (21, 20.0%), useful content (15, 14.3%), and lastly, time management (9, 8.6%). Furthermore, a majority of students (n=70, 66.7%) felt that the O&G mock OSCE was helpful not only for the O&G component, but for the entire OSCE examination.

Qualitative feedback obtained from the students was largely positive. The common theme that surfaced was how the mock OSCE allowed students to familiarise themselves with what to expect from the final examination. Examples include:

“Helped to give us a broader understanding of how 1) clinician thinks and how 2) an examiner grades.”

“It was a great opportunity for medical students to learn about history taking and physical examination in a controlled environment.”

IV. DISCUSSION

Overall, the mock OSCE was well-received by students as a useful tool in preparation for final examinations. The differences in the perceived utility of the mock OSCE from before the OSCE, after the OSCE, and after their final examinations was statistically significant. This supports the value of the mock OSCE programme, given the students’ lack of exposure to clinical scenarios and examination structure as previously outlined. Interestingly, the proportion of students who found the mock OSCE programme useful/very useful decreased from 98.5% after the OSCE to 96.2% after final examinations. This drop can be explained by the qualitative feedback obtained, which cites the examination’s increased complexity and variations in content.

Most students felt that the mock OSCE helped them prepare their approach to OSCE stations, consistent with previous studies showing that mock OSCEs help students familiarise themselves with the format. (Lee et al., 2021, Chisnall et al., 2015) These sentiments are echoed in the qualitative feedback obtained. Furthermore, the difference in confidence levels before and after the mock OSCE was statistically significant.

This study is limited by its small sample size, ranging from 105 to 132 students. As participation was voluntary and the questions were not compulsory, some students did not complete the survey, leading to discrepancies in response rates. Furthermore, due to the anonymous nature of the surveys, we are unable to monitor for survey drop-offs. Using Likert scales to assess the utility of the mock OSCE may not fully capture participants’ opinions. Students may have interpreted the scales differently, as utility is subjective to the individuals’ standards for themselves. This could have resulted in less reliable data due to the diversity in how participants understood the scales.

V. CONCLUSION

The results of this study indicate that a mock OSCE is perceived to be an important part of examination preparation for medical students. Despite being a single-specialty mock OSCE, most students felt it was useful for preparing for their entire final exam.

These findings suggest that there is great potential in using mock OSCEs as a revision tool for medical students and support the implementation of such programmes to guide students in their learning and examination preparation.

Notes on Contributors

Shanya Shanmugam is a medical student at Lee Kong Chian School of Medicine, who is interested in medical education. She reviewed the literature, analysed data and wrote the manuscript.

Dr Rajeswari Kathirvel is a senior consultant at KK Women’s and Children’s Hospital and the principal lead for Obstetrics and Gynaecology at Lee Kong Chian School of Medicine. She, alongside with Dr Li Xinyi, designed the study, developed the questionnaire, and developed the manuscript.

Kayda Soh is an executive in KK Women’s and Children’s Hospital OBGYN Academic Clinical Programme. She was involved in administering the questionnaires and collating the data.

Dr Li Xinyi is a consultant at KK Women’s and Children’s Hospital and the posting lead for Obstetrics and Gynaecology at Lee Kong Chian School of Medicine. She, alongside with Dr Rajeswari Kathirvel, designed the study, developed the questionnaire, and developed the manuscript.

Ethical Approval

The study was approved and given exempt status by the Nanyang Technological University Institutional Review Board for research (IRB 2023-677).

Data Availability

The data that support the findings of this study are openly available in the Figshare repository, at https://doi.org/10.6084/m9.figshare.25903786.

Acknowledgement

We would like to thank the students at Lee Kong Chian School of Medicine who participated in this study.

Funding

The authors report that there is no funding associated with the work featured in this article.

Declaration of Interest

The authors report there are no competing interests to declare.

References

Chisnall, B., Vince, T., Hall, S., & Tribe, R. (2015). Evaluation of outcomes of a formative objective structured clinical examination for second-year UK medical students. International Journal of Medical Education, 6, 76–83. https://doi.org/10.5116/ijme.5572.a534

Hilliard, R. I., & Tallett, S. E. (1998). The use of an objective structured clinical examination with postgraduate residents in Pediatrics. Archives of Pediatrics & Adolescent Medicine, 152(1). https://doi.org/10.1001/archpedi.152.1.74

Lee, M. H., Phua, D. H., & Heng, K. W. (2021). The use of a formative OSCE to prepare emergency medicine residents for summative OSCE: A mixed-methods cohort study. Research Square. https://doi.org/10.21203/rs.3.rs-495003/v1

Pugh, D., Bhanji, F., Cole, G., Dupre, J., Hatala, R., Humphrey-Murto, S., Touchie, C., & Wood, T. J. (2016). Do OSCE progress test scores predict performance in a national high-stakes examination? Medical Education, 50(3), 351–358. https://doi.org/10.1111/medu.12942

Townsend, A. H., Mcllvenny, S., Miller, C. J., & Dunn, E. V. (2001). The use of an objective structured clinical examination (OSCE) for formative and summative assessment in a general practice clinical attachment and its relationship to final medical school examination performance. Medical Education, 35(9), 841–846. https://doi.org/10.1046/j.1365-2923.2001.00957.x

*Shanya Shanmugam
Lee Kong Chian School of Medicine,
11 Mandalay Road,
Singapore
Email: shanya001@e.ntu.edu.sg

Submitted: 19 October 2024
Accepted: 28 April 2025
Published online: 1 July, TAPS 2025, 10(3), 84-88
https://doi.org/10.29060/TAPS.2025-10-3/SC3547

Eranthi Weeratunga, Shashika Karunanayaka, Pramudika Kariyawasam & Bimba Wickramarachchi

Department of Nursing, Faculty of Allied Health Sciences, University of Ruhuna, Sri Lanka

Abstract

Introduction: Palliative care nursing (PCN) supports individuals with life-threatening illnesses, aiming to improve the quality of life (QoL) for patients and families. The objective was to assess the necessity of establishing an Advanced Certificate Course in PCN at University of Ruhuna, Sri Lanka.

Methods: A descriptive cross-sectional study was conducted among 220 registered nurses (RNs) using purposive sampling, working at National Hospital Galle. A pre-tested, interviewer-administered questionnaire was used, including questions on prior education or training experiences on palliative care (PC), and its principles, services, and management. Descriptive statistics and the chi-square test were used to analyse.

Results: The majority of the RNs were aged 31-40 years (45.2%), females (86.0%), and married (55.7%). A higher proportion of RNs were nursing diploma holders (67.4%), with 55.7% having less than ten years of nursing experience. Only 11.3% of the RNs had formal additional training on PC, such as workshops and a few training hours. Most RNs correctly identified PC aims: improving survival (59.7%), improving QoL of patients and their families (91.4%), providing relief and pain (93.7%), understanding PC (80.1%), etc. The majority (84.6%) had a good attitude toward palliative caregiving, though only 20.4% had average knowledge of PC. Formal PCN training was significantly associated with PC knowledge (p=0.004).

Conclusion: Limited educational exposure, average knowledge levels, and good attitudes toward PC suggest the need for a PCN course for nurses. Providing a special education programme reduces the current gaps in PC by equipping RNs with the respective knowledge, skills, and attitudes to deliver complex management for patients requiring PC.

Keywords:           Palliative Care Nursing, Sri Lanka, Educational Needs, Registered Nurse

I. INTRODUCTION

Palliative care (PC) is an approach that aims to improve the quality of life (QoL) of patients and their families facing the physical, psychosocial, and spiritual problems associated with life-threatening illnesses (World Health Organization [WHO], 2022). About forty million people need a PC every year in the world, but the majority are from lower-middle-income countries (LMICs) (WHO, 2022). PC is offered by a range of professionals comprising physicians, nurses, support workers, etc., who are equally important, in addition to family members (WHO, 2022).

The major obstacle to improving PC among healthcare professionals (HCPs) and policymakers in LMICs is a lack of education/training (WHO, 2022) and a need for knowledge on PC for nursing professionals, which emphasised in previous findings in Sri Lanka (Meegoda et al., 2018) in addition to less PC content in the undergraduate curriculum (Pesut & Greig, 2018).  Further, less awareness of PC, cultural/social barriers, and misconceptions was found among HCPs; PC education improved nurses’ knowledge, confidence, attitudes, and communication abilities (WHO, 2022).  In Sri Lanka, there is a growing number of non-communicable diseases (NCDs), such as cancers, end-stage renal disease, HIV/AIDS, motor neuron disease, etc., that require comprehensive PC at every stage of the disease process in addition to the rapidly aging population.

PC services in Sri Lanka remain limited due to a shortage of trained HCPs. In response to the rising burden of NCDs, the Ministry of Health has emphasised the need to strengthen PC across all levels of the healthcare system. However, gaps in knowledge, skills, and attitudes among HCPs hinder effective implementation. While universities have introduced theoretical PC education, nursing undergraduates receive minimal practical exposure. Although a one-year post-basic diploma in palliative care nursing (PCN) has been launched for registered nurses (RNs), it is insufficient to meet the growing national demand. The initiation of a new course is of paramount importance, as specialisation in PCN has become an urgent necessity both nationally and internationally. The rising number of patients requiring PC, driven by demographic transitions, underscores this need. In developed countries such as Japan and Australia, the demand for PCN is expected to increase due to aging populations. Nationwide studies in Japan estimated that PC needs will continue to rise. Evidence suggests a growing demand for PC services in Australia, in particular, as the number of Australians aged over 85 continues to increase, the need for PC services has also surged. As a result, the demand for Sri Lankan RNs specialising in PC is expected to rise in these developed countries.

To address the existing gaps in PC knowledge and skills among RNs, we sought to quantify RN’s readiness for specialisation in PCN. The key objective was to assess the necessity of establishing an Advanced Certificate Course in PCN at the Department of Nursing, Faculty of Allied Health Sciences (FAHS), University of Ruhuna (UoR), Sri Lanka, to enhance professional competency and meet the growing demand for PC services.

II. METHODS

This descriptive cross-sectional study was conducted at the National Hospital Galle (NGH), Sri Lanka. The study participants were 220 RNs purposively selected based on having at least one year of experience, surveyed from June to December 2023. Data were collected using a content-validated and pre-tested questionnaire, which had been previously utilised in a Sri Lankan study (Fernando & Prathapan, 2019). The questionnaire comprised sections designed to assess socio-demographic characteristics and knowledge of four distinct domains: basic principles, service organisation, clinical management, and ethical considerations. Additionally, participants’ attitudes were evaluated after obtaining written informed consent. Statistical Package for Social Science (SPSS) 26 software was used; the descriptive statistics, frequencies, and percentages were checked. Further, a chi-square test was used. All results were regarded as statistically significant at p < 0.05.

III. RESULTS

The majority of the RNs were aged 31-40 years (45.2%). The mean±SD age was 36.61 ± 7.47 years. The majority were female (86.0%) and married (55.7%). Of the RNs, 35.7% had a monthly income between Sri Lankan Rupees 50,000 and 74,999. A higher proportion of RNs were nursing diploma holders (67.4%), with 55.7% having less than ten years of nursing experience. Emergency trauma care was the special training received by the RNs (4.5%). Only 11.3% of the RNs had formal additional training on PCN, such as workshops and a few training hours. Most RNs correctly identified PC aims (Table. 1). However, the majority gave incorrect answers regarding general knowledge/concepts of PC principles, such as increasing the life expectancy of terminally ill patients (59.7%) and consultants as ideal coordinators for PC (87.8%). Most RNs agreed that PC offers hope to patients (47.1%) and considered it a basic human right (79.6%). The majority (84.6%) had a good attitude toward PC, though only 20.4% had average knowledge of PC. Knowledge of PC was significantly associated with formal PCN training (p=0.004).

Table 1. General principles of PC among RNs, service organisation, drug management aspects, and ethical concerns

IV. DISCUSSION

This study assessed PC knowledge, management, ethical concerns, and attitudes among RNs in the NHG, Sri Lanka. RNs reported average knowledge and satisfactory attitudes, with age and prior PC training significantly influencing knowledge levels. Compared to the current study, Fernando and Prathapan (2019) reported higher satisfactory scores.

Sri Lankan medical graduates showed limited PC knowledge (37.23%), lower than RNs (20.4%), likely due to curriculum gaps (Fernando & Prathapan, 2019; Prem et al., 2012). While young medical graduates had adequate knowledge of general principles (63%), ethics was the weakest area (19.55%), mirroring findings among RNs.

PC is a relatively new discipline in Sri Lanka, contributing to limited ethical awareness. Cultural norms favor “hiding bitter truths” over transparency rather than “telling the truth,” which is a fundamental principle in Western healthcare practices, influencing attitudes and ethical concerns (Fernando & Prathapan, 2019).

The medical graduates studied by Fernando and Prathapan (2019) were younger than the RNs in this study. Despite some PC exposure, RNs had fewer opportunities for specialised training, impacting knowledge levels. Nevertheless, their positive attitudes likely stem from empathy-based patient care within the Asian context.

A previous study highlighted insufficient PC preparedness among nurses, attributing it to curriculum deficiencies and inadequate training in pain management (Prem et al., 2012). Female RNs performed better than males, but knowledge gaps remain a global issue. Student nurses and new RNs often feel inadequately prepared to discuss end-of-life issues, death, and other ethical concerns.

Meegoda et al. (2018) emphasised the need for adequate PC knowledge among nurses, as limited PC services worsen cancer care challenges. Heavy workloads and time constraints hinder learning, and 96% of RNs had not attended PC training. In-service programmes were considered beneficial, but specialised training is mainly available in Colombo, restricting accessibility. Distance learning could bridge this gap.

Nurses are vital in PC across various healthcare settings. Skilled PCNs provide essential support to patients and families. WHO (2022) stresses PC’s role in alleviating suffering and advocates its integration into national healthcare. However, LMICs face educational and awareness barriers.

Although Sri Lankan nurses have access to higher education, PC specialisation remains limited, especially in remote areas. With rising NCDs and aging populations, introducing PCN courses is crucial. Establishing a PCN programme aligned with national priorities would enhance patient care and improve career opportunities, particularly for nurses seeking employment abroad. A PCN course at FAHS, UoR, outside Colombo, could improve access to PC education.

A. Limitations

This study highlights the need for PC training, but it has limitations. Sampling bias may affect validity, and self-reported data could introduce response bias.

V. CONCLUSION

Limited educational exposure, average knowledge, and positive attitudes toward PC indicate a need for PCN courses to address existing gaps. RNs at NHG support an Advanced Certificate Course in PCN, emphasising the necessity for specialised training. Expanding PC education will enhance patient care and create new professional opportunities. Future research should assess the impact of PC training on HCP competencies and patient outcomes. Collaboration between the University of Ruhuna and the Ministry of Health is essential for establishing a sustainable PCN course.

Notes on Contributors

EW was involved in conceptual development, data collection/entry/analysis, manuscript drafting, editing, and final correction. SK was incorporated into conceptual development, data collection/entry/analysis, and editing. Data entry/analysis, editing, and final correction were done by PK, and BW was involved in manuscript draft editing.

Ethical Approval

Ethical approval (Ref. No. 83.11.2021) and institutional approval were obtained from the Ethics Review Committee of the FAHS, UoR, and the relevant institutions/authorities.  

Data Availability

Data analysed during the current study will be available from the corresponding author upon reasonable request.

Acknowledgment

The authors are grateful to the Dean, FAHS, UoR, Galle, Sri Lanka, and the Head, Department of Nursing, FAHS, UoR, Galle, Sri Lanka. The Director, Chief Grade Nursing Officer, and all in-charge nursing sisters of the National Hospital Galle are acknowledged for their permission. Ms. Nimesha and Mr. Dilan (11th batch/nursing graduates) are appreciated for their enormous contribution while collecting data despite their busy schedules. All consented RNs were further acknowledged for giving their true opinions and great support to uplift nursing education in the PCN field. 

Funding

The authors received no funding for this study.

Declaration of Interest

The authors declare that they have no competing interests.

References

Fernando, G. V. M. C., & Prathapan, S. (2019). What do young doctors know of palliative care; How do they expect the concept to work? BMC Research Notes, 12(1), 1–6. https://doi.org/10.1186/s13104-019-4462-2

Meegoda, D. L., Fernando, D. M. S., Atulomah, N., Sivayogan, S., & Marasinghe, R. B. (2018). Improvement of nurses’ skills following a hybrid model educational intervention on cancer palliative care. International Journal of Health Sciences & Research, 8(5), 196–203. http://www.ijhsr.org/IJHSR_Vol.8_Issue.5_May2018/IJHSR_Abstract.031.html

Pesut, B., & Greig, M. (2018). Resources for educating, training, and mentoring nurses and unregulated nursing care providers in palliative care: A review and expert consultation. Journal of Palliative Medicine, 21(S1), S50–S56. https://doi.org/10.1089/jpm.2017.0395

Prem, V., Karvannan, H., Kumar, S. P., Karthikbabu, S., Syed, N., Sisodia, V., & Jaykumar, S. (2012). Study of nurses’ knowledge about palliative care: A quantitative cross-sectional survey. Indian Journal of Palliative Care, 18(2), 122–127. https://doi.org/10.4103/0973-1075.100832

World Health Organization. (2022). Palliative care. https://www.who.int/news-room/fact-sheets/detail/palliative-care

*Eranthi Weeratunga
Department of Nursing,
Faculty of Allied Health Sciences,
University of Ruhuna
Galle, 80 000, Sri Lanka
+94 71 440 2662, +94 77 225 8519
Email: eranthiw@ahs.ruh.ac.lk,
eranthiweeratunga@yahoo.com

Submitted: 22 July 2024
Accepted: 4 February 2025
Published online: 1 July, TAPS 2025, 10(3), 80-83
https://doi.org/10.29060/TAPS.2025-10-3/SC3470

Zaitunnatakhin Zamli¹, Rohaini Ramli², Hidayah Sulaiman², Mohd Zulfaezal Che Azemin³, Wan Muhamad Salahudin Wan Salleh⁴, Nurul Asyiqin Yusof⁵, Imran Mahalil² & Azmi Mohd. Yusof²

¹Department of Biomedical Science, Kulliyyah of Allied Health Sciences, International Islamic University Malaysia, Malaysia; ²Department of Informatics, College of Computing & Informatics, Universiti Tenaga Nasional, Malaysia; ³Department of Optometry and Visual Sciences, Kulliyyah of Allied Health Sciences, International Islamic University Malaysia, Malaysia; ⁴Department of Basic Medical Sciences, Kulliyyah of Medicine, International Islamic University Malaysia, Malaysia; ⁵Department of Basic Medical Sciences, Kulliyyah of Pharmacy, International Islamic University Malaysia, Malaysia

Abstract

Introduction: Virtual reality (VR) has been widely used in medical and health sciences education since the late twentieth century. VR complements the conventional teaching and learning (T&L) approach by providing an engaging and immersive 3D spatial learning environment, especially for understanding the orientation of anatomical structures. Despite these advantages, the usability and student preference of highly immersive head-mounted display-based (HMD) and less immersive desktop-based (DB) VR in human anatomy courses have yet to be determined.

Methods: In a cross-sectional study, 49 Year-2 medical students were recruited through a convenient sampling. The participants were asked to identify 15 skeletal system components using the HMD and DB platform with human anatomy VR application. Both applications’ System Usability Scale (SUS) and preference scores were obtained via a self-administered questionnaire. The data were expressed as median [IQR] and statistically analysed using MATLAB R2022b.

Results: Most participants preferred the HMD over the DB platform (p=0.04), especially the male participants (p=0.01). There was no significant difference in overall SUS scores between both platforms (p=0.14). However, when compared within and between genders, females scored significantly higher in the DB than HMD (p=0.02) and higher than males’ DB SUS scores (p=0.03).

Conclusion: The overall usability of HMD was comparable with the DB platform for learning human anatomy. Although most participants prefer to use the HMD, further exploration of why females prefer the DB is needed. Subsequently, VR application developers must consider gender-related adaptions to promote the equitability and inclusivity of the technology for all users.

Keywords:           Human Anatomy, Virtual Reality, Head-mounted Display, Desktop-based Application, Usability, Preference

I. INTRODUCTION

Virtual reality (VR) is a simulated three-dimensional (3D) environment that enables users to explore and interact with virtual surroundings, perceiving them through their senses as if they were in the real world. It has been widely used in various fields, including education, to provide users with immersive, engaging, and experiential learning experiences.

In medical education, VR allows students to manipulate anatomical structures into different planes, sections and orientations in a simulated environment, benefiting learners with low-spatial ability. VR also helps students better grasp the relative size differences of organs and allows students to relate the location and position of the organs with their surroundings, resulting in better memorisation and learning outcomes, with VR groups outperforming control groups in post-test assessments (Kurul et al., 2020). As the current generation is more digitally savvy, most students are easily adapted to VR simulation, which enables them to grasp knowledge from a new perspective. For instance, students can dissect a muscle from the human body, gaining insight into the interaction and innervation of individual muscles during exercise.

However, despite the high acceptability of use in anatomy courses among students, some participants reported simulator sickness symptoms like headaches, dizziness, and blurred vision. These symptoms are more pronounced in females, who tend to experience discomfort in a VR environment (Stanney et al., 2020), potentially due to differences in spatial awareness, sensitivity to sensory stimuli, or physiological responses. In addition, regardless of gender, the mismatch between visual motion and the body’s sensory feedback in VR environments can lead to sensory conflict and an increased likelihood of discomfort.

While VR modalities show great potential in anatomy education, research comparing highly immersive head-mounted display-based (HMD) with less immersive desktop-based (DB) VR platforms, particularly regarding gender differences in usability and preferences, remains limited. In addition, considering the high cost of VR applications for HMD, addressing this knowledge gap before its development is crucial to ensuring optimal and cost-effective learning outcomes for a diverse student population. Therefore, this study aimed to compare the usability and preferences between DB and HMD platforms in exploring the VR anatomy applications, within and between genders, among medical students.

II. METHODS

Upon their written consent, forty-nine undergraduate medical students (23 males and 26 females, aged 19-21 years) were recruited through a convenience sampling. They were second-year medical students and participated in this study in two sessions. The participants were asked to identify 15 skeletal components (i.e. skull, vertebrae, hyoid bone, sternum, ribs, scapula, clavicle, humerus, radius, ulna, hip bone, femur, patella, tibia, and fibula) using two platforms: a head-mounted display-based (HMD) virtual reality system with the human anatomy VR application (BodyMap v3.2, https://www.mai.ai/bodymap), and a desktop-based (DB) application (Zygote Body, https://www.zygotebody.com/). BodyMap v3.2 is a VR application for exploring the human body in 3D using the Oculus Quest 2 headset, which provides an immersive and interactive experience for anatomy education. Meanwhile, Zygote Body is a web-based platform that offers detailed 3D anatomical models for desktop or laptop exploration.

Each platform was given a time limit of 15 minutes for the participants to complete the task. After completing the task, the participants completed the System Usability Scale (SUS), a 10-item questionnaire designed to measure the perceived usability of both platforms. The SUS score ranges from 0 (very poor usability) to 100 (perfect usability). In addition, the participants were also asked to rate their preference for using each platform on a scale from 1 (do not prefer at all) to 10 (most preferred). The data were expressed as median (interquartile range, IQR), which best represents the central tendency for non-normally distributed data. Normality was assessed using the Kolmogorov-Smirnov test, and the Wilcoxon signed-rank tests were used to compare the median scores of SUS / Preferences within and between genders. All statistical analyses were performed using MATLAB R2022b, with a p-value < 0.05 considered statistically significant.

III. RESULTS

A. Demographic Data

Forty-nine Year-2 IIUM medical students participated in this study. Most of the students were female (n=26, 53%), with a mean age of 20.10 ± 0.37 years old. 

B. Comparison of SUS and Preference Scores between the HMD and DB

There was no significant difference between the median SUS scores between the HMD and DB applications (p=0.14). However, most students preferred the HMD (90, IQR 80.0-100.0) rather than the DB (80, IQR 75.0-90.0) applications (p=0.04).

C. Comparison of SUS and Preference Scores of the HMD and DB within and between Gender

The SUS and preference scores of the HMD and DB applications within and between genders are shown in Figure 1, and individual scores are accessible at https://doi.org/10.6084/m9.figshare.26711965. Based on gender, significantly higher median SUS scores were observed for the DB (85, IQR 77.5-95.0) than the HMD application (75, IQR 59.4-85.6) among the female students (p=0.02). In contrast, the male students had a significantly higher preference score for the HMD (100, IQR 85.0-100.0) than the DB application (80, IQR 70.0-90.0) (p=0.01). A significant difference between gender was only observed in the SUS score, in which the female students scored 85 (IQR, 77.5 – 95.0), and the male students scored 75 (IQR, 58.1 – 86.9; p=0.03) for the DB application.

 

Figure 1. Comparison of SUS and Preference median scores of the HMD and DB application within (A-B) and between genders (C-D). A significant difference of p≤0.05 is denoted as *.

IV. DISCUSSION

This study found that the overall usability scores of the head-mounted display-based (HMD) and the desktop-based (DB) in human anatomy VR applications are comparable. However, a significant gender-related difference was observed in the reported usability scores of the HMD. Female participants reported significantly better usability with the DB than the HMD, likely due to their unfamiliarity with the HMD modality and disadvantage in the 3D spatial ability than males in visualising and manipulating objects in the navigating space. While traditional explanations link these gender differences to brain lateralisation, Bartlett and Camba (2023) challenge this view, suggesting societal expectations and gender roles may shape spatial skills.

Despite this, the study also found that most participants, especially males, prefer the HMD over the DB. This preference might be due to males’ active engagement and early adaptation to the technology, particularly in online gaming, making it more intuitive. This aligns with Deisinger et al. (1997), who found that inexperienced users favoured screen-based projection due to their familiarity with the conventional technology over the HMD. Interestingly, although females perceived DB as more usable, this did not significantly affect their preference for HMD. Many females acknowledged needing more technical help with the HMD but believed they would quickly adapt and prefer it over time. The study’s findings resonate with prior research in medical education, where HMDs are favoured for their immersive experience, enhancing spatial or physical presence and interaction as compared to DB (Yamazaki et al., 2021). However, the effectiveness of HMDs in improving learning outcomes compared to traditional methods remains inconclusive.

Given HMDs’ potential to enhance anatomy education, further research is crucial, especially in complex topics like embryology and neuroanatomy. Developers must focus on high content quality, intuitive user interfaces, and user comfort to ensure a positive learning experience. Gender-related adaptations can promote inclusivity, ensuring that the educational benefits of HMDs are accessible to all users.

Three main limitations of the present study also warrant mention. First, we used the available human anatomy VR applications from two developers, which may have different image quality of VR. However, both VR applications are comparable in terms of content quality. Second, we have not explored their reasons for high preference for utilising HMD when exploring human anatomy VR, potentially limiting our understanding of the user experience (e.g. comfort, immersion, satisfaction, and overall interaction) related to HMD usage. Third, participants’ previous experience using HMD in other platforms, such as gaming, virtual tours, etc, was not determined. Future studies should consider these limitations to understand user experiences with the HMD platform better and identify factors influencing user preferences.

V. CONCLUSION

In summary, this study concluded that the usability of both HMD and DB in exploring the human anatomy VR application is almost similar. As seen in other studies, students tend to favour HMD over DB because of its immersive, interactive, and engaging features. However, at an individual level, gender may influence their perception of its usability and preference. Therefore, it is essential to take gender-related adaptations into account when developing VR applications. 

Notes on Contributors

Zaitunnatakhin Zamli reviewed the literature, designed the study, performed data collection and analysis, and developed the manuscript. The author has read, given critical feedback and approved the final manuscript.

Nurul Asyiqin Yusof reviewed the literature, designed the study, performed data collection and analysis, and developed the manuscript. The author has read, given critical feedback and approved the final manuscript.

Azmi Mohd Yusof reviewed the literature, designed the study, performed data collection and analysis, and developed the manuscript. The author has read, given critical feedback and approved the final manuscript.

Wan Muhamad Salahudin Wan Salleh designed the study and performed data collection, analysis and interpretation. The author has read, given critical feedback and approved the final manuscript.

Mohd Zulfaezal Che Azemin designed the study and performed data collection, analysis and interpretation. The author has read, given critical feedback and approved the final manuscript.

Rohaini Ramli advised on study design and data interpretation. The author has read, given critical feedback and approved the final manuscript.

Hidayah Sulaiman advised on study design and data interpretation. The author has read, given critical feedback and approved the final manuscript.

Imran Mahalil facilitated the data collection process. The author has read, given critical feedback and approved the final manuscript.

Ethical Approval

Ethical approval of this study was granted by the Kulliyyah Postgraduate and Research Committee (IIUM/305/20/4/1/7) and IIUM Research Ethics Committee (IREC) (IIUM/504/14/11/2/IREC2022-194). All participants involved in the study had given their written consent, and their participation was voluntary.

Data Availability

The data of this study data are available at a Figshare repository, https://doi.org/10.6084/m9.figshare.26711965

Acknowledgement

The authors would like to thank the Department of Informatics, College of Computing & Informatics, Universiti Tenaga Nasional, Selangor, Malaysia, for providing equipment, software and logistics support. 

Funding

This study did not receive any funding or financial support.

Declaration of Interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.

References

Bartlett, K. A., & Camba, J. D. (2023). Gender differences in spatial ability: A critical review. Educational Psychology Review, 35(1), Article 8. https://doi.org/10.1007/s10648-023-09728-2

Deisinger, J., Cruz-Neira, C., Riedel, O., & Symanzik, J. (1997). The effect of different viewing devices for the sense of presence of immersion in virtual environments: A comparison of stereoprojections based on monitors, HMDs and screens. Proceedings of the Seventh International Conference on Human-Interaction Computer, (2), 881-884. https://www.usu.edu/math/symanzik/papers/1997_HCI_Int.html

Kurul, R., Ögün, M. N., Narin, A. N., Avci, Ş., & Yazgan, B. (2020). An alternative method for anatomy training: Immersive virtual reality. Anatomical Sciences Education, 13(5), 648-656. https://doi.org/10.1002/ase.1959

Stanney, K., Fidopiastis, C., & Foster, L. (2020). Virtual reality is sexist: But it does not have to be. Frontiers in Robotics and AI, 7, 476417 https://doi.org/10.3389/frobt.2020.00004

Yamazaki, A., Ito, T., Sugimoto, M., Yoshida, S., Honda, K., Kawashima, Y., Fujikawa, T., Fujii, Y., & Tsutsumi, T. (2021). Patient-specific virtual and mixed reality for immersive, experiential anatomy education and for surgical planning in temporal bone surgery. Auris Nasus Larynx, 48(6), 1081-1091. https://doi.org/10.1016/j.anl.2021.03.009

*Azmi Mohd. Yusof
Jalan IKRAM-UNITEN,
43000 Kajang,
Selangor, Malaysia
Email: azmiy@uniten.edu.my

Submitted: 17 February 2024
Accepted: 25 March 2025
Published online: 1 July, TAPS 2025, 10(3), 65-74
https://doi.org/10.29060/TAPS.2025-10-3/SC3251

Dani R Firman^1,2, Friedo W Dekker^2,3, Eriska Riyanti¹, Sunardhi Widyaputra¹ & Peter GM de Jong²

¹Faculty of Dentistry, Universitas Padjadjaran, Indonesia; ²Center for Innovation in Medical Education, Leiden University Medical Center, the Netherlands; ³Department of Clinical Epidemiology, Leiden University Medical Center, the Netherlands

Abstract

Introduction: To explore the current situation regarding teaching evidence-based practice (EBP) in Indonesian dental schools as a low-middle-income country (LMIC) setting.

Methods: Two nation-wide surveys were administered to all Indonesian dental schools (N=32) to capture the perceived value of the deans about EBP skills and teaching with its resource-related situation, as well as the actual teaching implementation and its challenges by their curriculum teams. The analysis was performed descriptively as national aggregate data.

Results: The response rates were 96.9% and 90.6%, respectively. The deans considered EBP skills to be very important (61.3%) or important (38.7%). However, only 16.1% of deans reported that the implementation of teaching EBP met their expectations. Most schools (75.9%) considered providing training for teachers as the priority plan. Most schools (62.1%) had an independent EBP course in their curriculum, while 86.2% incorporated EBP teaching (also) into other courses. All dental schools employed a lecture strategy for teaching EBP topics, but also used other strategies such as interactive strategies with a wide range of percentages being utilised (10.3 – 89.7%). EBP-specific topics were generally taught with a level of implementation varying from 34.5% to 96.6% in the pre-clinical and from 10.3% to 62.1% in the clinical programme.

Conclusion: The used approach can be considered an effective strategy to provide opportunities for schools to reflect their EBP teaching. This study confirmed the necessity for improvement, especially the need to support faculty development. The deans and their curriculum teams highly value collaborative improvement plans.

Keywords:           National Survey, Evidence-based Practice, Faculty Perception, Low-middle-income Country

I. INTRODUCTION

Evidence-based practice (EBP) is emerging as the standard in clinical dentistry. It integrates the best research evidence with patients’ values, preferences, and clinical experiences (Young et al., 2014). The EBP process involves five key steps in sequence (ask, acquire, appraise, apply, and evaluate). The appraise or critical appraisal skill as part of the steps is related to research capacity still considered as crucial gaps in the LMIC setting compared to high-income country (HIC) setting, and known to hinder EBP development and implementation (Gill et al., 2021). Furthermore, the suboptimal practice of EBP among dental professionals in lower and middle-income countries (LMIC) was suspected due to limited access of web-based subscription database and scarcity of experts as mentor (Minja & Lwoga, 2021).

Potentially, dental schools can play a significant role in promoting EBP implementation in dentistry of such setting by providing the access to evidence, supporting professional development and integrate the EBP teaching and learning in the curriculum. However, institutionalising EBP requires consistent policy and strong administrative support. To understand the current situation of EBP teaching in Indonesian dental schools, we conducted a study exploring the deans’ perceptions about its importance and the need for improvement. We also determined the actual level of implementation as reported by their curriculum teams. The study’s outcomes could inform future interventions to enhance EBP teaching in Indonesian dental schools.

II. METHODS

At the time of the study, in September 2022, there were 32 dental schools in Indonesia, all of which ran a bachelor’s programme (year 1-4) and a clinical programme (year 5-6). A descriptive survey study was conducted online using two sets of Indonesian-language questionnaires in sequence.

The first survey was launched during an in-person national meeting in Surabaya. Only the principal investigator himself participated via Zoom. This first survey aimed to gauge deans’ perceived importance of EBP skills and teaching, along with necessary resource improvements. The questionnaire included demographic items, five-point of Likert-scale questions on EBP teaching value, resources-related, an open-ended item on EBP teaching challenges, and a section for additional comments. Most deans completed the first online survey during that meeting, while those who did not attend the meeting were received the survey’s link via email.

Upon completion for each school by the deans, a second survey was sent to vice dean for academic affairs as corresponding contact using the email address provided by the deans in the previous survey. In the introduction letter, we specifically requested the involvement of their curriculum team of the bachelor and clinical programme as a group response for each school. This second survey gathered data on EBP teaching implementation and challenges more in details. It was translated and adapted from a previous survey used by Gorgon et al. (2013) which was considered relevant to all health professions, including dentistry. The adaptation included a pilot test beforehand to ensure its relevance and clarity.

The study protocol was approved by the Educational Research Review Board of the LUMC (Registry number: OEC/ERRB/20220913/1). Participants electronically consented to both surveys after reviewing the provided information. Respondents with missing or unclear data were contacted for clarification. Five-point Likert scale items, checklist items, and multiple-choice items were analysed descriptively. The open-ended item responses and additional comments were analysed thematically.

III. RESULTS

The first survey’s responses were received from 31 dental schools across Indonesia (96.9%). The schools were located on Java (18), Sumatera (6), Sulawesi (3), and Kalimantan and Bali (2 each). For the second survey, which targeted the curriculum team for each school, the responses were received from 29 schools (90.6%).

A. The Perceived Value of EBP Teaching (The 1^st Survey, n=31)

The deans perceived EBP skills as very important/essential (61.3%) or important (38.7%) for students. Incorporating EBP in the curriculum was seen as very important/essential (51.6%) or important (48.4%). Improving teachers’ EBP teaching expertise was deemed very necessary (54.8%) or necessary (38.7%). Five deans (16.1%) felt their schools met faculty expectations for EBP teaching, while others observed room for improvement (64.5% necessary, 19.4% very necessary). Resources like database access and librarian expertise varied in satisfaction. Most respondents (71%) valued collaboration with other schools on EBP training and implementation (See Appendix 1).

B. The Implementation of EBP Teaching (The 2^nd Survey, n=29)

Over half (62.1%) of participated schools have a standalone EBP course, and 86.2% incorporate EBP in other courses. Lecture-based teaching is the most common EBP strategy, followed by thesis discussions, journal readings, colloquiums, and seminars. Small group discussions and problem-based tutorials are also used. “Critically appraised topics” (CATs) are least used, with only three schools employing this active learning method. Both summative and formative assessments are used. Most schools use a blended approach for EBP courses, with one school offering a fully online course (See Appendix 2.a).

C. Available Resources for EBP Teaching (The 1^st and 2^nd Survey, n=31 and n=29)

Of the participating institutions, only 8 out of 29 dental schools have teachers formally-trained in EBP. Most schools have access to scientific databases, with ScienceDirect being the most accessible (58.6%). Other databases include Web of Science, Cochrane Library, EBSCO Host, CINAHL, and UpToDate, with some schools also subscribing to Springer Link, Wiley, Emerald, and SAGE (See Appendix 2.b). Database access is mostly provided by the university (80.6%), with some funded by faculty budgets (29%) or government institutions (9.7%). Only one school lack subscribed database access (See Appendix 3.a).

D. The EBP Specific Topics Coverage (The 2^nd Survey, n=29)

The five EBP steps (ask, acquire, appraise, apply, evaluate) are taught in Indonesian dental schools, with varying implementation levels from 34.5% to 96.6% in pre-clinic programmes and 10.3% to 62.1% in clinic programmes. The ‘apply’ and ‘evaluate’ steps are least taught in pre-clinic programmes. Interpreting forest plots in systematic reviews is the least covered topic, with only 10 out of 29 schools teaching it in pre-clinic levels, 3 in clinical levels, and 19 not covering it at all. Over a third of the schools (37.9%) do not teach critical appraisal of a systematic review. See Table 1 below for details.

	Pre-clinic		Clinic		Not taught in both programme**
EBP steps and its specific topics coverage (n=29)	Taught*	Not taught*	Taught*	Not taught*
I. Asking clinical question
(1) Formulating clinically questions using the PICO format	22 (75.9)	7 (24.1)	12 (41.4)	17 (58.6)	5 (17.2)
(2) Guided literature search by the clinical questions	20 (69.0)	9 (31.0)	18 (62.1)	11 (37.9)	5 (17.2)
II. Search the evidence
(3) Constructing a focused search with Boolean operator in a database	23 (79.3)	6 (20.7)	7 (24.1)	22 (75.9)	6 (20.7)
(4) Locating clinical evidence using electronic databases	26 (89.7)	3 (10.3)	8 (27.6)	21 (72.4)	3 (10.3)
(5) Utilising a reference manager software	25 (86.2)	4 (13.8)	9 (31.0)	20 (69.0)	4 (13.8)
III. Critically appraising evidence
(6) Study designs and their major strength and limitations	27 (93.1)	2 (6.9)	7 (24.1)	22 (75.9)	2 (6.9)
(7) Assessing the relevance of study design to the question asked	22 (75.9)	7 (24.1)	5 (17.2)	24 (82.8)	7 (24.1)
(8) Hierarchy or levels of evidence	23 (79.3)	6 (20.7)	6 (20.7)	23 (79.3)	5 (17.2)
(9) Difference between narrative, systematic review, and meta-analysis	21 (72.4)	8 (27.6)	4 (13.8)	25 (86.2)	7 (24.1)
(10) Difference between clinical and statistical significance	22 (75.9)	7 (24.1)	9 (31.0)	20 (69.0)	6 (20.7)
(11) Interpreting t tests, chi-square tests	28 (96.6)	1 (3.4)	6 (20.7)	23 (79.3)	1 (3.4)
(12) Interpreting p-value, confidence interval	28 (96.6)	1 (3.4)	6 (20.7)	23 (79.3)	1 (3.4)
(13) Understanding sensitivity and specificity, number needed to treat, odds ratio	28 (96.6)	1 (3.4)	6 (20.7)	23 (79.3)	1 (3.4)
(14) Understanding intention to treat analysis and power calculation	20 (69.0)	9 (31.0)	3 (10.3)	26 (89.7)	9 (31.0)
(15) Use of appraisal tool(s) to assess validity	22 (75.9)	7 (24.1)	7 (24.1)	22 (75.9)	7 (24.1)
(16) Ways in which study validity can be threatened	25 (86.2)	4 (13.8)	5 (17.2)	24 (82.8)	4 (13.8)
(17) Difference between internal and external validity	21 (72.4)	8 (27.6)	3 (10.3)	26 (89.7)	8 (27.6)
(18) Critical appraisal of systematic reviews	18 (62.1)	11 (37.9)	6 (20.7)	23 (79.3)	11 (37.9)
(19) Interpreting forest plots in systematic reviews	10 (34.5)	19 (65.5)	3 (10.3)	26 (89.7)	19 (65.5)
(20) Critical appraisal of studies about intervention (RCTs and clinical trials)	18 (62.1)	11 (37.9)	7 (24.1)	22 (75.9)	9 (31.0)
(21) Critical appraisal of studies about diagnosis (cohort, case-control studies)	21 (72.4)	8 (27.6)	5 (17.2)	24 (82.8)	7 (24.1)
(22) Critical appraisal of studies about prognosis (longitudinal studies)	18 (62.1)	11 (37.9)	5 (17.2)	24 (82.8)	10 (34.5)
IV. Implementation and communication
(23) Communicating the recommendation from EBP process to the patient	14 (48.3)	15 (51.7)	9 (31.0)	20 (69.0)	12 (41.4)
(24) Deciding the clinical decision considering the patient’s value	12 (41.4)	17 (58.6)	11 (37.9)	18 (62.1)	11 (37.9)
V. Evaluation
(25) Evaluation of the EBP implementation (The patient’s outcome and student’s performance through self-reflection)	13 (44.8)	16 (55.2)	9 (31.0)	20 (69.0)	13 (44.8)

Table 1. EBP steps and its specific topics coverage for each programme level (n=29)^b

* n (%)

** n (%) Overlap calculation with the number of not taught on each programme

^b From the 2^nd survey to the curriculum teams

E. Challenges (The 1^st Survey, n=31 and The 2^nd Survey, n=29)

The top three challenges in Indonesian dental schools, as reported by curriculum teams, are a lack of EBP experts (72.4%), insufficient accessible EBP courses for faculty (69%), and students’ inadequate knowledge of statistics and research methodology (65.5%) (See appendix 4). In the open-ended item section, most of the deans expressed the challenges of EBP teaching. Teachers-related factors were considered the most challenging, such as limitation in knowledge and skills, and an overloaded work situation.

F. Action Plans (The 2^nd Survey, n=29)

Most respondents (75.9%) highly valued teacher training. They also preferred incorporating EBP skills into the curriculum (48.3%) and holding faculty meetings to discuss EBP programme development (44.8%) (See appendix 3.b).

IV. DISCUSSION

To our knowledge, this is the first nation-wide survey with very high response rate to report insights of EBP teaching in the South-east Asia region, more specifically in Indonesian dental education setting. Targeting both deans and curriculum teams yielded rich data and stakeholder involvement, potentially fostering acceptance of future EBP improvements at institutional or national levels.

There is a slight gap between the perceived importance of EBP skills for students and the importance of incorporating such skills into the curriculum, which may be related to limited resources. The deans considering room for improvement, especially in teacher expertise. This is echoed by curriculum teams, as less than a third of Indonesian dental schools’ teachers have formal training experience, i.e. training from a well-known academic-based institution or recognised training organisation. This lack of EBP teachers is a top challenge identified by respondents. Deans and curriculum teams agree on the need for improved teacher skills.

The majority of Indonesian dental schools are teaching EBP topics in stand-alone EBP courses as well as incorporated in other regular courses using both face-to-face and online delivery. Lecture-based is the most used teaching strategy among the schools. Our findings suggest that there is room for enhancing the teaching strategy of EBP in Indonesian dental schools towards a more multi-facet, interactive and more authentic setting in the clinical environment as suggested by Howard et al. (2022).

Regarding critical appraisal topics based on the study design (See Table 1, item 18, 19-21), there were very few schools implementing a Critically Appraised Topics (CATs) teaching strategy (See Appendix 2.a). CATs, one-page summaries of evidence on a clinical question, offer active, authentic learning and being recommended in the literature to provide both a critique of the research and a statement of the clinical relevance of its findings. It is crucial to teach critical appraisal skills using the teaching strategy that is supported by the evidence to ensure sufficient development of EBP skills. Many Indonesian dental educators may not be familiar with this CATs teaching method.

The survey reveals that the ‘apply’ and ‘evaluate’ steps of EBP are less addressed than the ‘ask’, ‘acquire’, and ‘appraise’ steps. These five-steps, identical to those in Evidence-Based Medicine (EBM), form the basis of clinical practice and teaching. Key EBM developments like shared-decision making skills, part of the ‘apply’ step, are often overlooked. Hence, it’s vital to teach all EBP steps, ideally in a more authentic clinical setting.

The need for more EBP-trained faculty in most schools highlights the importance of a faculty development programme supported by national collaboration. As a lower-resource country, Indonesia faces challenges in dental education, including limited access to databases and librarian expertise, primarily due to financial constraints, inadequate institutional support, and the absence of national policies prioritising scientific resources. These limitations hinder faculty and students from fully implementing evidence-based practices, widening disparities with high-income countries. To address these issues, a policy brief should be directed to high-level stakeholders, advocating for essential infrastructure, more funding and resource investments for both private and government-funded schools.

This study has limitations. Due to the five-point Likert scale in the first questionnaire were not constructed on the same concept, the reliability test was not feasible. This is also applied for the second questionnaire, which adapted from a previous study, was mostly factual and checklist-based. The value of EBP teaching, reported by deans and curriculum teams, might be socially desirable. However, the results underscore the importance of EBP teaching and the need for improvement. It is worth noting that after the data collection was completed, Indonesia formally transitioned from a lower-middle-income to an upper-middle-income country as of July 2023. This transition suggests a more promising future, with potential improvements in the financial capacity, but it will require the national policy support to be fully implemented.

V. CONCLUSION

This first national survey reveals the state of EBP teaching in Indonesian dental schools, representing Southeast Asian countries. It highlights the need for faculty development and more active, authentic learning experiences but further analysis is required to adopt and adapt these interventions for lower-resource settings. The deans and their curriculum teams highly value collaborative improvement plans. This supports EBP’s vision of using current research to improve Indonesian oral healthcare.

Notes on Contributors

DF is the principal investigator. He designed, analysed, prepared and wrote the manuscript collaboratively with co-authors.

SW and ER made substantial contributions to preparation of the instruments, data collection and editing the final manuscript.

FD and PJ made substantial contribution to the design, analysis, preparation and editing the final manuscript.

All authors read and approved the final version.

Ethical Approval

The study protocol was approved by the Educational Research Review Board of the LUMC (Registry number: OEC/ERRB/20220913/1).

Data Availability

Due to confidentiality of the responses and commitments made with the study participants, also considering the small size data set with its unique data for some variables that might still be traceable to the respondent. Data are available on reasonable request by email to the corresponding author.

Acknowledgement

The authors express gratitude to all participants and schools involved in this study, AFDOKGI and its members for their support and data access, the Research group at the OEC LUMC for their constructive feedback, Universitas Padjadjaran for sponsoring the first author’s PhD scholarship, and Edward Gorgon for permitting the modification and use of the questionnaire.

Funding

This research is part of the first author’s (DF) PhD study, funded by a scholarship from Universitas Padjadjaran, Indonesia (Registry number 3781/UN.6.WR2/KP.10/2021).

Declaration of Interest

The first author (DF), an assistant professor at the Faculty of Dentistry, Universitas Padjadjaran, which participated in this study. DF also had ties until 2020 with AFDOKGI, the association of Indonesian dental schools, as a dental education consultant. 

References

Gill, P. J., Ali, S. M., Elsobky, Y., Okechukwu, R. C., Ribeiro, T. B., Soares dos Santos Junior, A. C., Umpierre, D., & Richards, G. C. (2021). Building capacity in evidence-based medicine in low-income and middle-income countries: Problems and potential solutions. BMJ Evidence-Based Medicine, 26(3), 82–84. https://doi.org/10.1136/bmjebm-2019-111272

Gorgon, E. J. R., Basco, M. D. S., & Manuel, A. T. (2013). Teaching evidence-based practice in physical therapy in a developing country: A national survey of Philippine schools. BMC Medical Education, 13(1), Article 154. https://doi.org/10.1186/1472-6920-13-154

Howard, B., Diug, B., & Ilic, D. (2022). Methods of teaching evidence-based practice: A systematic review. BMC Medical Education, 22(1), Article 742. https://doi.org/10.1186/s12909-022-03812-x

Minja, I. K., & Lwoga, E. T. (2021). Evidence based dentistry among dentists in low- and middle-income countries: A systematic review. The East African Health Research Journal, 5(2), 129–136. https://doi.org/10.24248/eahrj.v5i2.662

Young, T., Rohwer, A., Volmink, J., & Clarke, M. (2014). What are the effects of teaching evidence-based health care (EBHC)? Overview of systematic reviews. PLOS ONE, 9(1), e86706. https://doi.org/10.1371/journal.pone.0086706

*Dani R Firman
Jalan Sekeloa Selatan I,
Kota Bandung, Jawa Barat 40132,
Indonesia
+62222534985
Email: dani.firman@unpad.ac.id / d.r.firman@lumc.nl

Submitted: 30 April 2024
Accepted: 25 September 2024
Published online: 1 April, TAPS 2025, 10(2), 82-85
https://doi.org/10.29060/TAPS.2025-10-2/SC3345

Sethapong Lertsakulbunlue & Anupong Kantiwong

Department of Pharmacology, Phramongkutklao College of Medicine, Thailand

Abstract

Introduction: Very Short Answer Questions (VSAQs) minimise cueing and simulate actual clinical practice more accurately than Single Best Answer Questions, as multiple-choice options might not be realistic. Phramongkutklao College of Medicine has developed a Self-Marked VSAQ (SM-VSAQ) for formative assessments. This study determines the validity and reliability of the SM-VSAQs.

Methods: Ninety-four third-year pre-clinical students took two occasions of 10-question SM-VSAQ exams regarding cardiovascular drugs. Each question consisted of two steps: (1) clinical vignettes with questions and (2) expected answers with scores, self-marking, and feedback comprehension. Scores ranged from 0.00 to 1.00 in 0.25 increments, though not every increment was applied to all questions. A distribution of the rating agreement between students’ and teacher’s ratings was presented to determine criterion-related validity and inter-rater reliability.

Results: Criterion-related validity revealed 90.64% and 93.19% of the ratings demonstrated exact agreement between students’ and teachers’ ratings, with an inter-rater reliability of 0.972 and 0.977 for the first and second occasions, respectively (p=0.001). The exact agreement was relatively lower on the first occasion for questions with more diverse expected answers (85.11%, r=0.867, p=0.001) and drugs requiring their specific full names for a perfect mark (74.47%, r=0.849, p=0.001). While questions with specific guides do not require complex answers, they received a higher exact agreement.

Conclusion: The SM-VSAQ format effectively combines guided answers with the VSAQ model. The agreement with teacher-rated is excellent. Marking discrepancies rooted in misconceptions underscores the importance of teacher feedback in improving self-grading in formative assessments. Regular self-assessment practice is recommended to enhance grading accuracy.

Keywords:           Very Short Answer Question, Self-assessment, Medical Education, Undergraduate, Pharmacology

I. INTRODUCTION

Very Short Answer Questions (VSAQs) emerge as a relatively novel assessment format, addressing the constraints of traditional examination methods like Single Best Answer Questions (SBAQs), Constructed Response Questions (CRQs), and Modified Essay Questions (MEQs) (Sam et al., 2018). Although SBAQs are widely adopted in medical education globally, they are prone to cueing effects, leading examinees to depend on contextual clues, promoting a recognition-based learning approach (Sam et al., 2018). Moreover, the absence of multiple-choice options in real-life scenarios diminishes the relevance of SBAQs to medical practice.

Conversely, while CRQs and MEQs better mimic real-life situations, they suffer from rater dependency and significant evaluation time. Whereas VSAQs, free-response questions with 1–5 word answers, lessen rater dependency and evaluation time. Evidence indicates that VSAQs outperform SBAQs in discrimination, validity, and reliability in undergraduate assessments. Their open-ended nature prevents recognition-based learning and cueing. Additionally, VSAQs adeptly pinpoint common errors, often missed by SBAQs, and offer valuable feedback opportunities for educators (van Wijk et al., 2023).

Feedback is crucial for supporting and enhancing learning. Despite its longstanding importance in medical education, effective feedback is frequently deemed insufficient (Kuhlmann Lüdeke & Guillén Olaya, 2020). Self-assessment, enabled by formative exams, allows learners to identify their learning needs (Gedye, 2010). To improve feedback in formative assessments, Phramongkutklao College of Medicine (PCM) developed the Self-marked VSAQ (SM-VSAQ) format, which pairs a VSAQ with possible answers and a marking guide. Students may assess their understanding and pinpoint study areas through SM-VSAQ, enhancing feedback. Although VSAQs offer several benefits, challenges remain in grading the tests, as they may require a longer time. The self-graded format could address this issue in low-stakes examinations. This study assesses whether the SM-VSAQ with partial credit format, utilizing the marking guide, would achieve valid and reliable ratings compared with the teachers.

II. METHODS

Ninety-four third-year pre-clinical students participated in two 10-item SM-VSAQ during a cardiovascular pharmacology course. The exams covered antihypertensive, antiarrhythmic, antianginal, antithrombotic drugs, heart failure drugs, rational drug use, dyslipidaemia treatments, and drugs for atherosclerotic cardiovascular disease (ASCVD). The second SM-VSAQ sessions vary by changing the clinical vignette, the question, or both while maintaining the same underlying blueprint as the first session. Difficulty levels align with the Thai Medical Competency Assessment Criteria. Students had attended lectures on these drug groups before the exams. The VSAQ was content-validated by three professors for relevance, difficulty, feasibility, and simplicity using the Item Objective Congruence method with all over 0.67 of 1.00, indicating acceptable content validity. This approach ensured comparable difficulty.

The formative test was administered through Google Forms under examination conditions within a one-hour timeframe. Ethical approval was obtained from the Institutional Review Board, Royal Thai Army, and the waiver of the requirement for participant consent was deemed unnecessary following national regulations. An information sheet was provided on the first page of the Google Form. This initial test was conducted a day after they completed all lectures. After receiving teacher-led feedback and having time to review, students took a second parallel formative test ten days before the summative exam.

The SM-VSAQs featured four components for each question: clinical vignettes and questions on the first page, answers with scoring guidelines on the next page after they’ve answered, and a self-scoring option with feedback on answer comprehension. Scores ranged from 0.00 to 1.00 in 0.25 increments, though not every increment was applied to all questions. After the students completed the exam, they provided open-ended feedback on the pros and cons of the format. Examples of the format are shown in supplementary figures 1 and 2.

The self-rated, according to the marking guide, were exported into a Microsoft Excel spreadsheet to facilitate teacher ratings of the VSAQ answers. Using the ‘filter’ function in Microsoft Excel, the range of answers for each question was examined, and marks were awarded (Sam et al., 2018). Minor misspellings or alternative correct spellings were considered correct. Three pharmacology professors, who assigned scores, reviewed student answers that fell outside the guide. Consensus-determined scores require agreement from at least two of the three professors.

The data analyses were performed using StataCorp, 2021, Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC. Consistency reliability was analysed using Cronbach’s alpha. Criterion-related validity was demonstrated by the distribution of the rating agreement between student and teacher ratings, presented as frequency and percentages. Inter-rater reliability was calculated using Pearson’s correlation.

III. RESULTS

Cronbach’s alpha for the SM-VSAQ was 0.741 and 0.721 on the first and second occasions, respectively. The teacher-rated alpha was 0.766 initially and 0.735 on the second. Criterion-related validity was assessed through agreement analysis (Supplementary Tables 1 and 2). Table 1 summarises the results of the agreement analysis. 90.6% and 93.19% of the ratings showed exact agreement between the students’ and teachers’ ratings, with an inter-rater reliability of 0.972 and 0.977 for the first and second occasions, respectively. The exact agreement is relatively low on the first occasion of Drugs used in heart failure (85.11%) and Anti-angina drugs (74.47%). Conversely, antithrombotics and drugs used in ASCVD received a high exact agreement of 96.81%. Example of questions with high and low agreement is demonstrated in supplementary figures 1 and 2. Additionally, content analysis of student’s feedback revealed that they perceived that the format helps identify knowledge gaps, encourages review of missed topics, and aids in recognizing their current knowledge level (Supplementary Table 3).

Submitted: 30 April 2024
Accepted: 25 September 2024
Published online: 1 April, TAPS 2025, 10(2), 86-90
https://doi.org/10.29060/TAPS.2025-10-2/SC3551

Ozlem Tanriover¹, Sukran Peker², Seyhan Hidiroglu², Dilek Kitapcioglu³ & M. Ali Gülpınar¹

¹Department of Medical Education, School of Medicine, Marmara University, Türkiye; ²Department of Public Health, School of Medicine, Marmara University, Türkiye; ³Department of Medical Education, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Türkiye

Abstract

Introduction: This study aimed to identify the emotions experienced by medical students during the quarantine period, explore their coping strategies, and determine whether the pandemic affected their learning behaviours.

Methods: In this descriptive study, data were collected through an online questionnaire. The study included quarantined medical students enrolled in a distance education program at a medical school during the pandemic. The Positive and Negative Affect Scale was used to assess the emotional spectrum of the participants.

Results: The majority of medical students in the sample experienced predominantly negative emotions. Students with higher negative affect scores struggled with stress management and were less able to employ emotional regulation strategies, which adversely affected their learning behaviours.

Conclusion: Emotions should be explicitly addressed in medical education, and students should be supported in managing their emotions as part of their professional development and well-being.

Keywords:           Coping, Emotions, Emotion Regulation, Medical Student, Pandemic, Stress

I. INTRODUCTION

Medical education has long been a significant source of stress for students. The COVID-19 pandemic introduced additional challenges with social distancing, home confinement, and online learning, further intensifying this burden (Fegert et al., 2020). In Turkey, the Council of Higher Education suspended face-to-face education on March 26, 2020, shifting all theoretical and some practical medical courses online. This move removed students from campuses and hospital settings to protect public health. As a result, medical students from all years, including those close to graduation, were quarantined and separated from their academic routines.

Quarantine, a measure to prevent disease spread, often leads to frustration, boredom, and heightened distress (Brooks et al., 2020). Medical education is already emotionally taxing, and the pandemic amplified these challenges. While many studies have explored the emotions of healthcare workers and students on the front lines, little is known about how medical students in Turkey, confined at home, experienced and coped with this period. This study aims to explore their emotional experiences, coping mechanisms, and changes in learning behaviours during quarantine.

II. METHODS

This descriptive study utilised an online questionnaire sent via Microsoft Forms to medical students from a university in Istanbul. Participants included both preclinical and clinical students, all engaged in distance learning due to the pandemic. The survey was distributed in June 2020, with participation being voluntary and anonymous. The study ran from mid-June to the end of July 2020.

A. Ethical Approval

The study was approved by the School of Medicine Ethical Committee (No. 09.2020.657). Consent was obtained from all participants before data collection.

B. Data Collection

The questionnaire gathered sociodemographic data and inquired about online education experiences. The Positive and Negative Affect Scale (PANAS), developed by Watson et al. (1988) and adapted to Turkish by Gençöz (2000), was used to assess emotions. The PANAS contains 20 adjectives rated on a five-point Likert scale, with scores ranging from 10 to 50 for both positive and negative emotions. High positive scores reflect engagement and energy, while high negative scores indicate distress.

C. Statistics

Statistical analysis was conducted using SPSS 20.0. Normality was tested with Kolmogorov-Smirnov and Shapiro-Wilk tests. Descriptive statistics were presented as medians (IQR) for non-normal data and frequencies for categorical data. The Mann-Whitney U test was used for two-group comparisons, and the Kruskal-Wallis test for comparisons across more than two groups. A p-value < 0.05 was considered statistically significant.

III. RESULTS

A total of 145 students participated in the survey, with a slight female majority (57%, n=83). The participants’ ages ranged from 20 to 27 years (mean=21.4, SD=1.99), and most (93%, n=135) lived at home with their families. Students attended an average of 4-6 hours of online lectures per day during quarantine. Emotions such as “interested,” “alert,” and “enthusiastic” had low scores, while 63.4% reported feeling distressed, followed by 40.7% upset and 39.3% irritable.

The PANAS total score comparison showed that students aged 22-25 scored significantly higher than those aged 18-21 (51.7 vs 48.1, p=0.028). Similarly, positive affect (PA) scores were higher in older students (p<0.001). Students living alone had higher total PANAS scores (59 vs 49, p=0.008) and PA scores (31.7 vs 23.6, p<0.001) than those living with their families.

A. Coping Strategies

Most students (65.5%) coped with stress using distraction activities like watching TV, while 8.3% sought emotional support. A minority engaged in substance use or denial (4.9%), and 8.3% reported being unable to cope. Those who made an effort to cope had higher PA scores (24.6 vs 21.2, p=0.036) and lower negative affect (NA) scores (25.3 vs 29.5, p=0.01).

B. Changes in Learning Behaviour

About 74.5% of students reported changes in their study methods during the pandemic, though no significant differences in PANAS scores were observed. When asked about adapting to online learning, 33.7% of students reported difficulty adjusting, while 17.3% used self-motivation, and 11.5% created study programs with peers.

C. Emotion Regulation

Cognitive reappraisal was the most common strategy used by 65.5% of students to manage emotions, while 8.3% used expressive suppression. Nearly 25% reported no effective emotion regulation strategy, and 1.4% felt they didn’t need one. Those who used emotion regulation strategies had significantly lower NA scores (p=0.017).

Submitted: 6 May 2024
Accepted: 12 September 2024
Published online: 7 January, TAPS 2025, 10(1), 48-52
https://doi.org/10.29060/TAPS.2025-10-1/SC3349

Craig S. Webster^1,2, Antonia Verstappen¹, Jennifer M. Weller¹ & Marcus A. Henning¹

¹Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland, New Zealand; ²Department of Anaesthesiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand

Abstract

Introduction: We aimed to determine the extent to which non-technical skills and attitudes acquired during undergraduate interprofessional simulation in an Advanced Cardiac Life Support (ACLS) course translated into clinical work.

Methods: Following ACLS simulation training for final-year nursing and medical students, we conducted a 1-year follow-up survey, when graduates were in clinical practice. We used the Readiness for Interprofessional Learning Scale (RIPLS – higher scores indicate better attitudes to interprofessional practice), and nine contextual questions with prompts for free-form comments. RIPLS scores underwent repeated-measures between-groups (nurses vs doctors) analysis at three timepoints (pre-course, post-course and 1-year).

Results: Forty-two surveys (58% response) were received, demonstrating translation of non-technical skills and attitudes to clinical practice, including insights into the skills and roles of others, the importance of communication, and improved perceptions of preparedness for clinical work. However, RIPLS scores for doctors decreased significantly upon beginning clinical work, while scores for nurses continued to increase, demonstrating a significant interaction effect (reduction of 5.7 points to 75.7 versus an increase of 1.3 points to 78.1 respectively – ANOVA, F(2,76)=5.827, p=0.004). Responses to contextual questions suggested that reductions in RIPLS scores for doctors were due to a realisation that dealing with emergency life support was only a small part of their practice. However, the prevailing work cultures of nurses and doctors in the workplace may also play a part.

Conclusion: We demonstrated the translation of non-technical skills and attitudes acquired in undergraduate simulation to the clinical workplace. However, results are tempered for junior doctors beginning practice.

Keywords:           Work Culture, Translation, RIPLS, Simulation, Advanced Cardiac Life Support, Undergraduate Education, Skills and Attitudes, Patient Safety

I. INTRODUCTION

Preparing undergraduate healthcare students for their future roles in the clinical workplace is a central concern for modern healthcare educators and is of critical importance for the maintenance of adequate healthcare services throughout the world (Barnes et al., 2021). Modern healthcare is inherently multidisciplinary, yet much of the training received by healthcare practitioners remains siloed within professional groups, and this is particularly the case at the undergraduate level. The use of simulation in healthcare has become increasingly important in recent years as a way to offer safe and immersive training. Conducting simulation with interprofessional healthcare teams allows those who will work together to be trained together, and can have the double benefit of promoting the acquisition of technical and non-technical skills in participants, while also allowing insight into the skills, roles and knowledge of other team members from different professional groups (Jowsey et al., 2020).

We previously reported on the development and evaluation of an interprofessional Advanced Cardiac Life Support (ACLS) course for undergraduate nursing and medical students in their final year at the University of Auckland, aimed at increasing technical resuscitation and non-technical teamwork skills (Webster et al., 2018). The evaluation study, using a mixed-methods design and recruiting 69% of the entire year’s student cohort, demonstrated significant improvements in scores on the Readiness for Interprofessional Learning Scale (RIPLS) over the course of the training day, and important interprofessional and attitudinal insights into the skills and knowledge of other team members related to communication, teamwork, leadership, realism, and professional roles. Medical and nursing students both reported that such insights would not have occurred during uniprofessional simulation and felt that the course had better prepared them for work in the clinical context. At the end of the training day we invited participants to take part in a further follow-up survey timed to occur approximately one year later, at a time when participants would typically be working clinically.

Our aim in the present study was to determine the extent to which the non-technical skills and attitudes acquired during the undergraduate interprofessional ACLS simulation course translated into the clinical work of the former course participants.

II. METHODS

We conducted a 1-year follow-up survey comprising a further RIPLS questionnaire and nine additional contextual questions, with quantitative response scales and prompts for explanatory free-form comments (see Supplementary Table 1). The survey was mailed to participants who had elected to supply their contact information, along with a post-paid return envelope. All participants gave written informed consent to participate. One postal and one email reminder was also sent if a reply was not forthcoming.

The RIPLS is a validated questionnaire comprising 19 questions using 5-point Likert response scales (anchors, 1=strongly disagree to 5=strongly agree), and yielding a possible total score from 19 to 95 points where higher scores indicate a greater willingness to engage in interprofessional practice (Parsell & Bligh, 1999). In the present analysis, RIPLS responses from each participant in the 1-year follow-up survey were paired with their own corresponding RIPLS scores at two previous time points and underwent repeated-measures between-groups (nurses vs doctors) analysis at three timepoints (pre-course, post-course and 1-year). Responses to quantitative ratings on contextual questions used identical 5-point Likert scales and were summarised along with exemplar quotations from the free-form comments (Supplementary Table 1).

III. RESULTS

Between August 2014 and November 2015, 42 survey responses were received, representing a 58% response rate from the 73 participants who elected to give contact information for the follow-up survey. Two nurses were not working clinically at the time of the survey, and their responses were excluded from analysis – resulting in a total of 14 nurses and 26 doctors being included in the present study. All doctors were working in hospitals at the time of the 1-year survey, as were 71% of nurses. The remaining nurses were working in primary healthcare or general practice. RIPLS data did not significantly depart from a normal distribution (Shapiro-Wilk test, p=0.22), therefore parametric analysis was conducted using SPSS v.27 (IBM SPSS Statistics, Armonk, New York).

A one-way repeated measures ANOVA demonstrated a significant interaction effect between time point and professional group (F(2, 76)=5.827, p=0.004), demonstrating that at the 1-year time point mean RIPLS scores for doctors fell significantly by 5.7 points, while mean RIPLS scores for nurses continued to increase by 1.3 points (Figure 1).

 

Figure 1. RIPLS scores for nurses and doctors paired over three time points

The results of the contextual questions in the present study (1-year time point) demonstrated strong support by nurses and doctors for the value of the interprofessional ACLS course in general terms and more specifically in terms of feeling part of the team, better understanding the skills and roles of others, and feeling more confident in clinical practice – with all mean responses ranging from high 3’s to >4 (see Supplementary Table 1 for complete summary). Participants strongly agreed that the interprofessional ACLS course should continue to be offered (with an overall mean score of 4.68 out of 5). The single reverse-scored question asking whether ACLS training would have been more effective if conducted uniprofessionally demonstrated strong disagreement with an overall mean score of 1.65. Exemplar quotations from free-form comments provided a context for the quantitative results in terms of demonstrating that the ACLS training better prepared doctors and nurses for emergencies, helped to improve their communication, and was a realistic form of training – for example, stating “Much more ‘real life’ when other professions involved” (doctor) and “Interdisciplinary teamwork is huge in the real world…” (nurse).

Despite the largely positive findings, exemplar quotations also allowed some insight into why doctors’ RIPLS scores were high at the end of the ACLS course, but then fell significantly upon entry into clinical practice at the 1-year time point. Exemplar quotations suggested that once in the clinical workplace junior doctors better appreciated that the technical skills in the ACLS course made up only a small part of their scope of practice, stating that there “are many things… you are unable to do and it is important to know what level of knowledge and ability other individuals may have” and that ACLS “does not make up a large part of my clinical practice” (Supplementary Table 1).

IV. DISCUSSION

Our results demonstrate the translation of non-technical skills and attitudes acquired during undergraduate interprofessional simulation training to the clinical workplace. Our findings show particular benefits for nurses, and reinforce the value of the interprofessional ACLS course as an important part of the undergraduate curriculum. While the overall evaluation of the ACLS course was positive, the differential response in RIPLS scores between nurses and doctors upon entry into the clinical workplace is an intriguing result which clearly warrants further research.

We know of no previous study that has followed the same cohort of undergraduate participants after an interprofessional simulation course up to the point where they have entered the clinical workplace. The ability to pair responses for the same participants across all three time points in our study is a strength, as this avoids the variability that would be present if there were different participants at each time point, and so gives us more confidence in our findings.

Our results suggest that the significant reduction in RIPLS scores upon entry into the clinical workplace for junior doctors may be due to a realisation that the technical skills learnt in the ACLS course make up only a small part of a doctor’s domain of practice. However, recent research into the experiences of junior doctors during interprofessional collaboration suggests that the interaction effect in RIPLS scores across professional groups may also be a consequence of the different work cultures of nurses and doctors. Evidence suggests, including from our own University, that doctors typically believe that they should take individual responsibility for their clinical work, while nurses have a more collective view of patient care (Horsburgh et al., 2006; van Duin et al., 2022). Thus, the prevailing workplace cultures could reinforce and promote nurses’ willingness to work interprofessionally (hence explaining the increase in their RIPLS scores), while for doctors the prevailing individualistic work culture may reduce their willingness to work interprofessionally (hence contributing to the reduction in their RIPLS scores, Figure 1).

Further work to investigate this intriguing interaction effect, and the dynamics of work cultures and professional identity formation, would likely involve mixed-method research, perhaps using observation, interviews or focus groups and quantitative measures such as RIPLS (Jowsey et al., 2020). In addition, such studies conducted with clinicians at various levels of experience within a hospital could potentially yield insight into the state of the prevailing clinical work cultures and may allow some estimate of whether incoming graduates with interprofessional training could change these cultures, and when a critical mass of such graduates may allow this to happen. In the meantime, our results suggest that prevailing work cultures may represent a challenge for interprofessional teamwork initiatives, at least in medicine.

V. CONCLUSION

Our follow-up study demonstrated the translation of the non-technical skills and attitudes acquired during undergraduate interprofessional simulation training to the clinical workplace in terms of insights into the skills and roles of others, the importance of communication, and perceptions of preparedness to deal with emergencies. However, these results appear to be tempered for junior doctors beginning clinical work likely due to realisations around the applicability of ACLS training to their scope of practice and the influences of their prevailing workplace culture.

Notes on Contributors

Craig S. Webster was involved in the conceptualisation of this study, data analysis, writing and revision.

Antonia Verstappen was involved in data collection and analysis, writing and revision.

Jennifer M. Weller was involved in the conceptualisation of this study, writing and revision.

Marcus A. Henning was involved in the writing and revision of this paper.

Ethical Approval

This study was carried out in accordance with all regulations of the host organisation and with the approval of the Human Participants Ethics Committee of the University of Auckland (reference number 9073). All participants gave written informed consent to participate.

Data Availability

The complete data set for this study is openly available on the Figshare repository, https://doi.org/10.6084/m9.figshare.25750230

Funding

This study was conducted without funding.

Declaration of Interest

All authors have no potential conflicts of interest.

References

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Horsburgh, M., Perkins, R., Coyle, B., & Degeling, P. (2006). The professional subcultures of students entering medicine, nursing and pharmacy programmes. Journal of Interprofessional Care, 20(4), 425-431. https://doi.org/10.1080/13561820600805233

Jowsey, T., Petersen, L., Mysko, C., Cooper-Ioelu, P., Herbst, P., Webster, C. S., Wearn, A., Marshall, D., Torrie, J., Lin, M. P., Beaver, P., Egan, J., Bacal, K., O’Callaghan, A., & Weller, J. (2020). Performativity, identity formation and professionalism: Ethnographic research to explore student experiences of clinical simulation training. PLoS One, 15(7), e0236085. https://doi.org/10.1371/journal.pone.0236085

Parsell, G., & Bligh, J. (1999). The development of a questionnaire to assess the readiness of health care students for interprofessional learning (RIPLS). Medical Education, 33(2), 95-100. https://doi.org/10.1046/j.1365-2923.1999.00298.x

van Duin, T. S., de Carvalho Filho, M. A., Pype, P. F., Borgmann, S., Olovsson, M. H., Jaarsma, A. D. C., & Versluis, M. A. C. (2022). Junior doctors’ experiences with interprofessional collaboration: Wandering the landscape. Medical Education, 56(4), 418-431. https://doi.org/10.1111/medu.14711

Webster, C. S., Hallett, C., Torrie, J., Verstappen, A., Barrow, M., Moharib, M. M., & Weller, J. M. (2018). Advanced cardiac life support training in interprofessional teams of undergraduate nursing and medical students using mannequin-based simulation. Medical Science Educator, 28(1), 155-163. https://doi.org/10.1007/s40670-017-0523-0

*Craig Webster
Centre for Medical and Health Sciences Education
School of Medicine, University of Auckland
Private Bag 92-019
Auckland 1142, New Zealand.
Email: c.webster@auckland.ac.nz