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Year : 2018  |  Volume : 31  |  Issue : 2  |  Page : 119-124

Hybrid simulation training: An effective teaching and learning modality for intrauterine contraceptive device insertion

Department of Obstetrics and Gynecology, Aga Khan University Hospital, Karachi, Pakistan

Date of Web Publication30-Nov-2018

Correspondence Address:
Iffat Ahmed
Department of Obstetrics and Gynecology, Aga Khan University Hospital, Stadium Road, Karachi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/efh.EfH_357_17

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Background: Hybrid simulation training (HST) is a teaching modality that combines patient interaction using simulated patient (SP) with pelvic model. This provides realism to learners, lacking in manikins alone. This study was designed to compare knowledge, procedural, and communication skills of medical students regarding intrauterine contraceptive device (IUCD) insertion before and after introducing HST and to assess learner satisfaction with this methodology. Methods: This quasi-experimental mixed-method study was conducted at Aga Khan University Hospital, Karachi, from October 2016 to September 2017, for third-year medical students (n = 90). IUCD insertion was introduced to students through interactive session and provision of literature/video clip on IUCD insertion. Students were pretested on objectively structured clinical examination -station (IUCD insertion) using SP and manikin simultaneously. This was followed by practice on manikin and subsequent posttest on same OSCE-station. Learner evaluation of activity was through validated pro forma with both, Likert scale and open-ended questions. Results: Out of the 90 students, 73 completed pre/posttest and evaluation survey. There was significant increase in pre- and post-simulation mean scores for all clinical skills; history taking (5.1 pretest, 8.8 posttest, P ≤ 0.0005), counseling (40.11 pretest, 57.85 posttest, P ≤ 0.0005), procedural (15.16 pretest, 49.09 posttest, P ≤ 0.0005) and total scores (60 pretest, 115.6 posttest, P ≤ 0.0005), when compared using two-sided Wilcoxon signed rank sum test. Overall, activity was assessed as “very good” to “excellent” by 83.5% participants. Themes generated from open-ended questions of evaluation forms were “Process-descriptors,” “Teaching-utility,” “Pedagogic-efficacy” and “Way-forward.” Discussion: HST is an effective teaching strategy with potential to improve competency of medical students. Students acknowledged it, as innovative learning strategy that increased their satisfaction and confidence in performing IUCD insertion.

Keywords: Hybrid simulation, medical students, skills

How to cite this article:
Amerjee A, Akhtar M, Ahmed I, Irfan S. Hybrid simulation training: An effective teaching and learning modality for intrauterine contraceptive device insertion. Educ Health 2018;31:119-24

How to cite this URL:
Amerjee A, Akhtar M, Ahmed I, Irfan S. Hybrid simulation training: An effective teaching and learning modality for intrauterine contraceptive device insertion. Educ Health [serial online] 2018 [cited 2023 Feb 3];31:119-24. Available from:

  Background Top

Pakistan has a low contraception prevalence rate. Nearly 25% of reproductive-aged women have an unmet family planning need.[1] Intrauterine contraceptive device (IUCD) is a highly reliable and reversible long-acting contraceptive method independent of daily concordance.[2],[3],[4] However, medical students have limited opportunities to gain competency in IUCD-insertion and other procedural skills.[5] Health professionals with little experience in IUCD placement are less likely to offer this method to their clients.[3],[6] Training medical students in IUCD insertion can potentially increase the pool of skilled physicians who can offer this cost-effective contraceptive method in community. Provision of community-based contraception is one of the important objectives of Maternal Neonatal and Child Health (MNCH) clerkship conducted for third-year medical students at Aga Khan University Hospital (AKUH), Karachi. This is a 4-week rotation, designed to give students exposure to maternal and child healthcare in primary and secondary level settings.

Traditionally, apprenticeship model has been used to teach procedural skills to medical students, where students learn by initially observing, then performing under supervision and finally independently.[3] Contemporarily, “procedural simulation” is increasingly being recognized as an effective modality to train health-professionals in psychomotor competencies without risk to patients.[7],[8] This has a beneficial effect on the learners' self-confidence and proficiency in technical skills with favorable patient outcomes including improved patient safety.[7],[8] However a gap is recognized between performance on model simulators and doing the bedside procedures on real patients. Real-life situations necessitate good patient communication along with expertise in procedural skills.[9] Hybrid simulation[10],[11] is a strategy that combines patient interaction, using simulated patient (SP), with task-trainer (manikin), to allow both procedural and communication skills training. This brings realism and authenticity to simulation. It is also a relatively cost-effective option compared to teaching on high fidelity simulators[12] which may be an unaffordable option, especially in low-middle income countries (LMIC).

Hybrid simulation training (HST) was therefore introduced to provide medical students opportunity to learn and practice IUCD insertion skill on pelvic model, along with relevant counseling skill on simulated patient (SP). We have traditionally taught the topic on contraception (that includes IUCD) through provision of literature and interactive small-group discussions.

This study was designed to compare knowledge, procedural, and communication skills of medical students regarding IUCD insertion before and after introducing HST and to assess learner satisfaction with the new teaching methodology.

  Methods Top

This was a quasi-experimental, mixed-method, 1-year study, conducted at the Centre of Innovation in Medical Education at the AKUH from October 2016 to September 2017. The study was approved by the ethical review committee.

Study population included all consenting third-year medical students who attended the planned three hour HST workshop. This workshop was designed to teach supervised IUCD insertion as a method of long-term reversible contraception. It was scheduled for the batch of 10–12 students once in every 4 weeks of the MNCH rotation.

At the beginning of clerkship, students were provided reading material on IUCDs as recommended by World Health Organization[13] and sent an internet video link showing demonstration of IUCD insertion. They also had an hour long interactive session on different contraceptive methods, including IUCD, within 2–3 days of the workshop. Students were instructed to read the provided literature, view the video link and prepare fully to actively participate in the small-group session on contraception.

An objectively structured clinical examination (OSCE) station was designed to assess history-taking, procedural and counseling skills of the students. This OSCE station served as pre and posttest of this HST workshop. In order to manage time efficiently, this station was run simultaneously by two faculty members in separate rooms. At the start of the workshop, students were split into two groups of five to six participants each and were individually tested on the OSCE station. Instructions given to the students included; taking focused history, responding to SPs' queries and counseling them about mode of action, efficacy and side effects of IUCD. They also had to dispel the common misconceptions of this method. The SPs had been trained and were given a predesigned script through which they asked questions and discussed misconceptions.[13] Students were then asked to demonstrate the procedure on the manikin, with the SPs sitting behind. SPs were trained to grimace at appropriate times during the procedure. This gave a realist impression of procedure being performed on a real patient. It also allowed the assessment of affective domain through students' response to SPs' reactions. Students were marked on standardized marking scale, designed by principle investigator and validated by three other faculty members. This OSCE (pre-HST test), also served to check the knowledge, skills and counseling technique of the students after traditional teaching and watching the technique of IUCD insertion on the video.

Standard IUCD insertion method with counseling technique was then demonstrated to students. Subsequently, each student was allowed to practice IUCD insertion on the manikin. This was followed by posttest on the same OSCE station. Post-HST test assessed the same competencies of students after HST, to measure the impact of this training. The session ended with debriefing to reinforce student learning.

Pre/post-HST test marking sheet comprised of 25 items. Out of these, two items tested history taking, counseling was tested using 12 items and procedural skills testing consisted of 11 items. Each item was tested on a 7-point rating scale with the score varying from 0 to 6 marks for each item. The anchors for the rating-scale were as follows:

  • 0 = Not done
  • 1 = Very poor performance (incorrect technique)
  • 2 = Poor performance (incomplete history taking/procedural skill/counseling)
  • 3 = Borderline performance (correct technique but could not elicit pertinent history/elicit correct procedure/gain complete trust of the patient)
  • 4 = Clear pass (performs correct history taking/procedural skills/counseling technique including all CRITICAL steps)
  • 5 = Excellent (performs correct history taking/procedural skills/counseling technique including ALL the steps)
  • 6 = Outstanding (performs correct history taking/procedural skills/counseling technique, including all the steps and with PROFICIENCY.

For each item, students could score a minimum of “0” if not performed at all to a maximum score of “6” for an outstanding performance. Thus for a total of 25 items a maximum of 150 marks could be obtained. A similar rating scale is being used university wide for marking students' continuous assessment and for OSCE stations.[14]

Pre/post-HST test marks were compared to objectively assess students' performance before and after introduction of HST.

Learner satisfaction was assessed through a validated pro forma used routinely for evaluation of educational activities at AKUH. The pro forma consisted of Likert scale and open-ended questions. The Likert scale was used to assess the learners' response quantitatively and included following options: “Excellent,” “Very Good,” “Good,” “Average,” and “Poor.” The open-ended questions allowed students' to express their opinions regarding strengths/weaknesses and their suggestions for improvement of the workshop.

Statistical analysis

Quantitative: The individual component marks (history-taking, counseling, and procedural skills) and total marks of pre and post HST test were entered into SPSS software 19 for analysis. Mean and median were computed for the marks obtained by 73 students for history taking (12 marks), counseling (72 marks), and procedural skills (66 marks) separately; as well as for the total marks obtained (150 marks). Comparisons were done between pre- and post-simulation mean scores for these three skills of history taking, procedure performance and counseling, as well as, for overall performance using a two-sided Wilcoxon signed rank test [Table 1].
Table 1: Pre- and post-hybrid simulation training test scores (n=73)

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Participant ratings of the simulation training were reported in terms of proportions and percentages of students (n = 73) [Table 2].
Table 2: Participant ratings of the simulation training components (n=73)

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P < 0.05 was considered statistically significant.

Qualitative: Common issues highlighted through activity evaluation questionnaire (n = 73) and open comments (n = 45) were grouped into trends from which emerged four themes:,” Process descriptors”, “Teaching efficacy, “Pedagogic value” and “Way forward.”

  Results Top

Out of 90 third-year students, 74 attended the workshop and consented to be a part of the study. One student left after the pretest and was not present for the posttest. Seventy-three completed the pre- and post HST-tests and evaluation survey, all containing matching unique identifiers and being eligible for analysis. Forty-five students responded to the open-ended questions.

There was a significant increase in pre and post-simulation mean scores for all three skills; history-taking, counseling and procedural skills when compared using a two-sided Wilcoxon signed rank sum test [Table 1].

Based on their responses to the course evaluation, most participants rated “Activity objectives well-defined,” “Content-coverage in-line with objectives,” “Activity at level of participants understanding,” “Interaction during activity,” “Acquisition of new knowledge” and “Queries responded” items as “Very good” and “Excellent.” 'Time-management' was rated as “Poor” by 8.2% candidates. Overall activity was as rated as “very good” to “excellent” by 83.5% students [Table 2].

Four themes emerged from trends that were identified through open-ended responses of the participants [Table 3].
Table 3: Themes and trends of open-ended responses of medical students with comments (n=45)

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The comments related to the process of the activity were grouped into the trends of 'Hands-on experience' (e.g., “Allowed students hands-on practice…”) “Activity organization” (e.g., ”Excellent and very well organized session”,); “Interactive session” (e.g., ”Really interactive with a lot of learning …”) and “Pre and posttests” (e.g., ”Pretest was a source of detecting mistakes and improving later”). Thus, the theme of 'Process descriptors' emerged.

The second theme “Teaching efficacy” was derived from the following trends; “Facilitators' attributes” (e.g., ”Facilitators were very helpful and patient”), “Effective teaching” (e.g., ”Effectively taught IUCD insertion technique”), and “Teaching resource” (e.g., ”Equipment was good for simulation…;” Video quality could be improved).

Observations on the pedagogic value of this teaching modality were grouped into the trends namely: “Learning-experience” (e.g., ”I feel confident that I have acquired this skill), SP interaction (e.g., “Counseling session with SP … was very helpful,” ”Same SP with same questions was to be evaluated in posttest … more of rote learning” and “Practical value” (e.g., “useful for application in practical life”). This formed the base for the theme “Pedagogic value.”

Participant suggestions for improvement of the workshop formed the basis of the theme “Way forward” that was derived from the trends; “Duration/scheduling suggestions” (e.g., ”Too lengthy and time consuming…keep workshop in morning”) and “Real-patients” ( e.g., ”After practicing on manikin, allow students to perform procedure on real patients under supervision”).

  Discussion Top

Our study demonstrated a considerable increase in the competency level of IUCD insertion in medical students after introduction of HST.[15]

Through HST, students had a comprehensive learning experience with IUCD insertion training on task trainer and communication skill practice through SP interaction. They rated the overall HST experience as excellent [Table 2], Students highly valued the acquisition of knowledge with comprehension of minute concepts through this workshop [Table 2] and [Table 3]. The simultaneous SP interaction further enhanced their communication skills [Table 3]. SP interaction similarly benefited student learning in a study by Young et al.[9] However one student mentioned that using same SP and repeating same questions in pretest, hands on session and post-test lead to 'rote learning'. It needs to be contemplated whether this concern can be addressed through a different set of questions in the posttest.

Students appreciated the teaching methodology including the pre/post-OSCE and the opportunity for sufficient hands-on experience.[16] Brazeau et al. have also employed OSCEs as teaching tools to increase educational impact.[17]

Improvement was observed in students' short-term competencies in all the three domains; cognitive, psychomotor and affective after HST. Others have also reported increase in posttest scores after simulation training.[18],[19] A systematic review by Cook et al. confirmed that technology-assisted simulation training consistently improved knowledge, skills and behavior of learners compared to training without such technology.[20] Our study population was third-year medical students who had no prior clinical exposure to obstetrics/gynecology. They too reported confidence in having acquired the technical skill and its applicability to practical life.[13],[17] Acquiring hands-on skills of IUCD insertion would otherwise not have been possible before graduation.[3] Similar increase in confidence level after simulation-training was seen in other studies.[5],[15],[21],[22],[23],[24] However, further study is needed to determine whether the perceived increase in confidence is sustained long term.

Our students suggested being allowed to perform IUCD insertion on actual patients following HST [Table 3]. This showed their enthusiasm to further perform the procedure in actual settings. This was not seen by Nitsche et al. where simulation training did not show increased student participation in deliveries in real-life situation.[20]

Use of videos including YouTube videos have been employed extensively in health professions education.[25] We had provided students with internet video link on IUCD insertion. However, sometimes problems were faced in downloading the video due to connectivity issues. One student commented on video quality. That can be overcome by preparing a standard video on correct IUCD insertion specifically for this workshop.

Time management was identified as problematic by 20% students [Table 2]. Running OSCE stations as both pre and posttest with assessment on 25 items was very time consuming. This needs resolution through involvement of more faculty members that again has feasibility issues.

Strengths and limitations: The strengths of this study were that a valid assessment tool (OSCE)[26] was used for pre and post-HST tests and was rated by expert faculty members. OSCE assessed all three domains; knowledge, skills and attitude needed to acquire competency for any procedure.[6],[16],[23],[27] Others have used self-perceived assessments by learners which may not be reflective of true clinical skill acquisition[11],[21] and written pre and posttests that assess only the cognitive domain.[18],[19]

Our workshop was a part of the curriculum for all MNCH clerkship students and all consenting participants were included in the study. This made our study more generalizable by removing volunteer bias. Whereas, only volunteering students have been involved in another HST study.[11] In addition, HST can be performed at a relatively low cost with simple manikin and SP, especially in LMIC where purchase of high-fidelity simulators may not be practically possible.[28]

A potential limitation of our study was that, it cannot show difference between learning after traditional teaching as compared to that after HST. However, our data do suggest a rise in competence level after introduction of HST (post-HST test marks) as compared to traditional teaching method (pre-HST test).

Other limitations were that this study was conducted at a single institution and we used a single OSCE station to test all the three skills of history taking, counseling and procedure, at the same time. It was not possible for us to arrange multiple OSCE stations due to limitations of time, availability of personnel and space.

Also, this study may not address long-term students' learning. As our students did not get an opportunity to perform IUCD insertion in actual patients, it cannot be commented whether this enthusiasm would have reflected into practice in actual settings. Transferability of the competency to real life situation needs to be evaluated in future through a prospective follow-up study.

  Conclusion Top

HST may be an effective teaching strategy which has potential to improve competency of medical students. Students acknowledged it as an innovative learning strategy that increased their satisfaction and confidence in performing IUCD insertion.

Other teaching hospitals in LMICs should also consider incorporating HST as a part of their curriculum to improve learning of their students.

Financial support and sponsorship

The workshop was conducted by the Department of Obstetrics/Gynecology at the Center of Innovation in Medical Education (CIME) at Aga Khan University Hospital (AKUH). The pelvic model used for simulation was provided by CIME and the IUCD packs were purchased by the department of Obstetrics/Gynecology, AKUH. No funding/grant was required for the study.

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3]

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