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BRIEF COMMUNICATION
Year : 2010  |  Volume : 23  |  Issue : 3  |  Page : 339

Transfer of Medical Students' Clinical Skills Learned in a Clinical Laboratory to the Care of Real Patients in the Clinical Setting: The Challenges and Suggestions of Students in a Developing Country


1 Dept. Medical Education and Skills Lab, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia
2 Institute for Education, Faculty of Health, Medicine and Life sciences, Maastricht University, Maastricht, The Netherlands

Date of Submission06-Apr-2009
Date of Acceptance15-Aug-2010
Date of Web Publication30-Nov-2010

Correspondence Address:
D Widyandana
Suryatmajan DN I/88 Yogyakarta 55213
Indonesia
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Source of Support: None, Conflict of Interest: None


PMID: 21290355

  Abstract 

Context: Recent studies indicate that medical students may face problems applying clinical skills taught in a skills laboratory setting when they enter their clerkships. This study explores these problems in the context of a developing country, and explores students' suggestions for improving clinical skills training.
Methods: Focus groups discussions (FGDs) were organized with students who had just entered their clerkships. Transcripts of FGDs were digested according to the inductive content analysis protocol.
Results: Clerkship students said to have encountered significant problems when they had to perform clinical skills on patients for the first time, in particular with respect to invasive clinical procedures. Differences in context between skills laboratory and clinic, inadequate supervision and unpredictable responses by patients were most common reasons given. Students suggested creating opportunities to practice clinical skills on patients before entering the clerkships.
Conclusion: Early in their clerkships students may face significant problems when they have to apply skills learned in the skills laboratory on actual patients. Particularly in developing countries, opportunities may exist to follow up on our students' suggestion to arrange for skills training of pre-clinical students in clinical settings.

Keywords: Clinical skills training, skills laboratory, clerkships


How to cite this article:
Widyandana D, Majoor G, Scherpbier A. Transfer of Medical Students' Clinical Skills Learned in a Clinical Laboratory to the Care of Real Patients in the Clinical Setting: The Challenges and Suggestions of Students in a Developing Country. Educ Health 2010;23:339

How to cite this URL:
Widyandana D, Majoor G, Scherpbier A. Transfer of Medical Students' Clinical Skills Learned in a Clinical Laboratory to the Care of Real Patients in the Clinical Setting: The Challenges and Suggestions of Students in a Developing Country. Educ Health [serial online] 2010 [cited 2019 Sep 20];23:339. Available from: http://www.educationforhealth.net/text.asp?2010/23/3/339/101478

Introduction



Mastery of clinical skills contributes to medical graduates' competence; hence many medical schools have installed facilities for clinical skills training ‘skills laboratories’. Skills laboratories offer pre-clinical students opportunities to learn clinical skills in a safe environment and without burdening or endangering patients, with the intention to better prepare students for the clinical years1.



Training within a skills laboratory cannot fully mimic the clinical setting. Consequently, students may encounter problems when they attempt to transfer the clinical skills they learned in the laboratory to the clinical setting1,2. More extensive practice in the skills laboratory and exposing students to patients earlier in the curriculum have been suggested for overcoming this problem3,4.



Most studies addressing this 'transition problem' were performed in industrialized countries1,2,5. Therefore, this study explored problems encountered by early clerkship students performing clinical skills learned in a skills laboratory, within a single school in a developing country. Research questions were: 1) How do students in their early clerkships regard their pre-clinical trainings in the skills laboratory? 2) What are problems encountered by students when they have to translate the skills they learn in skills labs to the care of actual patients? and 3) What suggestions do students have for strengthening their pre-clinical skills training program?



Materials and Methods



This study was conducted at the Faculty of Medicine of Gadjah Mada University (FM-GMU) in Jogjakarta, Indonesia. FM-GMU has a six-year curriculum encompassing four years of pre-clinical education on campus and two years of clinical rotations at all three levels of health care in Indonesia, i.e. primary care centers, secondary care or district hospitals, and tertiary hospitals servicing provinces.



Focus group discussions (FGDs) were planned with a random sample of 30 fifth year students out of the full class of 162; these students had begun their clerkships less than one semester earlier. This subset was found not to differ from the rest of the year class as judged by their scores on the final undergraduate OSCE taken six months earlier (Student t-test; p=0.615). Students participating in FGDs were assigned to one of three groups that each assembled twice for about 90 minutes. They were reimbursed transportation costs, rewarded with a free lunch, and assured confidentiality with respect to their individual statements. FGDs were guided by three principle questions: “What is your opinion about skills lab training as preparation for your clinical rotations?”; “What problems did you encounter with respect to skills in your first clerkships”; and “How could the problems be solved?” Eventually 21 students participated (9 females and 12 males). Nine students who did not show up had coincident obligations during their clinical rotations. All sessions were audiotaped and transcribed verbatim.



FGD transcripts were analyzed following the ‘inductive content analysis protocol’ of Elo & Kyngäs6. The first author briefed two skills laboratory teachers and a research assistant on the protocol. The protocol includes open coding, creating categories and abstractions. The three coders worked independently in identifying categories, then the lists of categories were grouped within higher order categories to reduce the total number of categories6. Eventually a meeting with all four reviewers was held to reach agreement on categories of comments extracted.



The research assistant discussed the final set of categories and illustrative quotes with some individual students drawn randomly from the group of 21. This checking process was concluded after the fourth student because no new comments on the set of categories and quotes emerged with the third7. The protocol for this study was approved by the ethics committee of FM-GMU.



Results



The coding procedure highlighted 57 statements, which were grouped into three categories and ten sub-categories.



Opinions on the effectiveness of pre-clinical skills training with respect to performance in clerkships



Clerkship students stated that clinical skills training in the skills laboratory had had a significant positive effect on their preparation for the clerkships; they had found it more difficult to perform clinical skills which had not been taught in the skills laboratory.

“..practice in the skills lab proved very important for me in the clerkships, although I only practiced on manikins and simulated patients. But anything is better than nothing (...) It gave me some confidence.” (FGD I/2/1&3)

However, students perceived skills trainings as a kind of game; they couldn’t imagine how skills training related to clinical reality, for instance because there was no risk of harming patients in the skills laboratory. Moreover, for most students the time gap between training in the skills laboratory and entering the clerkship had been over six months, permitting time for newly learned skills to be forgotten. Comments were also made with respect to the management of the skills laboratory, e.g. about instructors from the clinic coming late and about the need to repair or replace certain manikins.



Problems encountered when performing clinical skills on patients for the first time



Students needed time to adapt to the clinical setting; they did not from the outset feel emotionally ready to meet patients. Students said that the first time they had to apply a clinical skill in the hospital with the stress of the situation, they forgot everything they learned in the skills laboratory.



Students reported that they met many challenges during clinical rotations: an unstructured learning program, an overload of administrative duties, increased responsibility, lack of supervision (by residents and nurses), differences between clinical procedures taught in the skills laboratory and as performed by their supervisors, and differences in equipment used in the skills laboratory and in the clinic.

“…if we do all the steps in accord with the skills lab standard, it will take a long time, and the patient or supervisor may become angry…” (FGD II/1/1; II/2/1;II/3/7)

These circumstances made students anxious when they attended patients for the first time. Students had also noted that communicating with patients was different than exercises performed with peers and simulated patients in the skills laboratory. For example, communication with patients was impeded by patients’ local dialect and terminology and their sometimes unexpected responses. In addition, some patients, particularly children and their parents, often did not cooperate.



Clerkship students shared that performing invasive procedures, in particular, caused problems. Students became anxious when the reality of the clinical setting proved to be different from the setting of their training. Differences between manikins used in the skills laboratory and live patients, e.g. varieties in human anatomy and the risk of bleeding, were identified by students as most important in this respect.

“…in the dummy the place to insert the needle is very clear, but with real patients it’s so different, we don’t know where the blood vessel is...” (FGD I/1/2; II/3/2).

Students became aware that invasive procedures can potentially harm patients, which on one hand enhanced their empathy but also their fear of being prosecuted for malpractice. To prevent the latter, students tried to obtain informed consent from patients before performing procedures. Moreover, students realized that if they would fail to perform an invasive procedure properly it could increase costs for the patient, because the materials used are generally for single use only.



Opinions on opportunities to practice clinical skills during the pre-clinical program in health care settings



To get familiar with applying clinical skills on patients, all participating students welcomed opportunities to practice clinical skills in a health care setting prior to entering the clerkships. Some students said such exposures would facilitate transfer of clinical skills from the laboratory to the clinical setting. That statement was based on students’ experience in 2006 helping earthquake victims.

“…in the emergency situation after the earthquake we gained experience by helping victims,… …It gave us experience and improved our confidence early in our clerkships…”(FGD I/2/2)

Some students mentioned that training in health care settings may be difficult to implement because such field activities must fit with their tight academic schedule on campus. Furthermore, one student advised that pre-clinical students should only be assigned responsibilities matching their level of competence.



Discussion



This study finds that the pre-clinical program at FM-GMU does not optimally prepare students to perform clinical skills in their later, clinical rotations. Students found it difficult to apply clinical skills on patients for the first time, and they encountered problems communicating with patients.



These findings are consistent with those from other studies that have found that students have difficulty transferring clinical skills from the pre-clinical to the clinical setting. Students become anxious when it comes to applying clinical skills on patients for the first time2. Moreover, uncertainty about their responsibilities, high work load and inadequate supervision may negatively impact students' performance5. As also noted by Sarikaya et al., problems encountered with the transfer of clinical skills learned in the skills laboratory to the clinical setting were most prominent with respect to invasive procedural skills2.



Some issues emerged in this study that may be specific to developing countries. Manikins that poorly resemble the human body and that may be worn out may negatively affect the effectiveness of training in the skills laboratory. Financial limitations of the country’s health insurance system also affected students, because if they failed to successfully perform a procedure involving disposable materials it could increase costs for the patient, who often could not afford it.



To mitigate problems with the transfer of trained clinical skills to the hospital setting, students suggested to include exposure of students to patients within the pre-clinical program. Early patient encounters may provide pre-clinical students with a more accurate picture of the clinical setting and increase their motivation to study3. Offering such opportunities may particularly be readily available in developing countries where medical schools usually have many primary health centers nearby8. Those health centers may be involved in clinical skills training of pre-clinical students4.



One study weakness is the small number of participating clerkship students who were confined to only three discussion groups. On the other hand, the findings of the three groups were very similar. A second weakness is that the findings of this study were based on comments from students of only one school and some may reflect the particular situation of students of this school.



In conclusion, pre-clinical skills training may not adequately prepare undergraduate students for performing clinical skills in the hospital setting. Students of this study suggested arranging patient contacts during the pre-clinical phase of their studies to bolster their clinical skills and prepare for interactions with real patients prior to entering the clerkships. In a subsequent study we will explore the suitability of various clinical settings (e.g., primary, secondary and tertiary health care) to offer such opportunities to pre-clinical students.



References



1.Smith B. From simulation to reality – breaking down the barriers. The Clinical Teacher. 2006; 3:112-117.



2.Sarikaya O, Civaner M, Kalaca S. The anxieties of medical students related to clinical training. Journal of Clinical Practice. 2006; 60:1414-1418.



3.Dornan T, Littlewood S, Margolis SA, Scherpbier AJJA, Spencer J, Ypinazar V. How can experience in clinical and community settings contribute to early medical education? A BEME systematic review. Medical Teacher. 2006; 28:3-18.



4.Diemers AD, Dolmans JM, Santen MV, Luijk SJV, Noordman AMBJ, Scherpbier AJJA. Students perceptions of early patient encounters in a PBL curriculum: a first evaluation of the Maastricht experience. Medical Teacher. 2007; 29:135-142.



5.Prince KJAH, Boshuizen HPA, van der Vleuten CPM, Scherpbier AJJA. Students opinions about their preparation for clinical practice. Medical Education. 2005; 39:704-712.



6.Elo S, Kyngäs H. The qualitative content analysis process. Journal of Advanced Nursing. 2008; 62:107-115.



7.Fraenkel JR, Wallen NE. How to Design and Evaluate Research in Education. 8th edition. New York: McGraw-Hill; 2009.



8.Stark P, Fortune F. Teaching clinical skills in developing countries: are clinical skills centres the answer? Education for Health. 2003; 16:298-306.




 

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