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Assessing medical student self-efficacy following cardiopulmonary emergency simulation training.

Introduction

The use of simulation in the field of medical education has seen rapidly growing interest in recent years. Simulation can be used to assist medical students in the aim of developing the ability to recognize their own limitations and knowledge. Growing evidence supports the use of simulation training as an important adjunct to clinical skills practice for medical students. (1-4) While myriad factors can be involved in what makes simulation an effective form of training, a particular benefit is the self-confidence and increased belief in ability level developed when given the opportunity to practice complicated and invasive procedures and protocols in a non-clinical simulated setting. (5-8)

Albert Bandura has theorized that the belief a person holds about their capabilities strongly impacts how that individual will behave, and this belief has been termed self-efficacy. (9) According to Bandura's research, self-efficacy beliefs can influence how much one learns and are often better predictors of success at task completion than prior accomplishments, skills, or knowledge. (10) As Maibach and colleagues comment, even clinicians possessing sufficient knowledge and skills might be reluctant to take appropriate action unless they perceive they are confident in their abilities to succeed. (11)

Shukla and colleagues reported that the use of simulation in training third-year medical student techniques involving vascular access, airway management, and chest/abdomen procedures significantly increased students' level of confidence in performing these procedures. (12) More recently, it was found that gynecologic simulation for medical students was an effective way to meet learner goals and improve confidence in performing OB/GYN procedures. (13)

More specifically related to simulation education in resuscitation efforts, it has been demonstrated that simulation programs have led to an improvement in retention of and adhering to Advanced Cardiovascular Life Support (ACLS) guidelines. (14) Recent research involving medical student simulation training for cardiac arrest management yielded findings of increases in confidence and knowledge of medical students regarding resuscitation skills, and higher performance scores and confidence in running a code in a modified, longitudinal simulation ACLS course, versus traditional ACLS curriculum. (15-16)

Despite previous investigations of medical students' confidence following simulation such as these, there is still a need to investigate the impact of simulation experiences on participant confidence or self-efficacy in the ability level for specific medical procedures. Demonstrating the value of a particular simulation training session such as this one on cardiopulmonary emergencies encourages professional accountability in utilization of clinical resources, including faculty, staff and students' training time. Based on prior research of other skills taught to third year medical students, the proposed study hypothesized that participating in simulated scenarios involving emergency cardiopulmonary procedures will lead to increased levels of student self-efficacy in performing such procedures.

Methods

The current research was a prospective study using a pretest-posttest design without a control group. The research assessed students' reported self-efficacy following a hands-on simulated training module. The simulation activities involved in this study were part of the educational program and a required component of the third-year medical students' curriculum. Participants completed a brief self-report measure both prior to and after the simulated training session. Pretest and posttest scores were matched for students so that there was a difference score for each measure from time one to time two. This study was approved by the hospital Institutional Review Board (IRB) and did not require consent from the medical students, as the surveys were anonymous and the simulated training fell into the category of educational training.

Participants included 74 third-year medical students from a large state medical school rotating through each simulation station in groups of 6-7 people.

The intervention used to examine impact on change in self-efficacy was a previously-established hospital Simulation Educational Module for third-year medical students. This module involves scenarios for use of cardiopulmonary emergencies to treat patients. Electrical therapy, as part of this protocol, is a form of electro-medical intervention used to treat heart failure. This involves using a defibrillator to "shock" patients to induce normal heart rhythms.

Students were first asked to complete a Likert-type questionnaire regarding their confidence/self-efficacy in their electrical therapy abilities. Then they were oriented to the simulation module via a verbal introduction. They were given a document outlining learning objectives for the day and descriptions of the six learning stations they encountered during the module. The medical student Clerkship Director announced the availability of participating in the proposed research. Envelopes containing the self-efficacy measures were distributed. After the introduction to the simulation stations, students rotated through six stations (described in Appendix 1). Each session at each station lasted 28 minutes. Each station was set up in individual patient rooms within the Simulation Center.

A standardized format of procedures was used for each simulation station. During the six experiential learning sessions, the instructor introduced the knowledge and skills to be demonstrated and practiced by each student during their time in that particular station. Students were then engaged in instructor-guided group practice for the skill unique to that post. Next, students within their group took turns independently practicing the skill or procedure while the instructor observed. Lastly, debriefing occurred at the end of each session. At this time, the instructor highlighted the learning objectives and skills performed, gave general feedback to the group, gave feedback to individuals on their performance of the skill (focusing on strengths the student demonstrated and any improvements that could be made), and emphasized the importance of the skill. Philips Heart-Start Monitor/Defibrillator equipment was used at each station, as well as SimMan (Laerdal, Inc.) high-fidelity mannequins. Additional details unique to each of the six stations are described in the aforementioned Appendix 1.

Following completion of each of the six sessions, the entire group of students was re-convened. They were directed to a marked box in the Simulation Center where they could anonymously leave their post-simulation self-efficacy surveys. Pretest and Posttest evaluations had matching numbers so that each student's time 1 measure could be compared to their time 2 measure.

Participants completed a short, Likert scale self-report measure regarding their confidence in their cardiopulmonary emergency abilities both immediately prior to and immediately following the simulation modules. This measure aimed to assess the subject's self-efficacy, or level of perceived confidence in ability, for completing tasks simulated during the sessions. The self-report instrument is comprised of five items that ask the participant to rate their level of confidence, with each item using a 5-point Likert-scale (scale ratings ranging from Strongly Disagree to Strongly Agree). Participants were instructed to rate their level of confidence in their ability to perform various electrical therapy skills. This self-report measure was constructed specifically and uniquely for this electrical therapy simulation module for medical students based on prior studies that measured other simulated procedure constructs. (14,15) Items on the measure were created specifically for the goals and objectives of the educational simulation session. These included use of AED/BLS (Automatic External Defibrillator/Basic Life Support) with associated rhythm recognition, application of manual biphasic defibrillation, application of external pacing application of synchronized cardioversion, and knowledge of components of the hospital's crash carts and chart documentation.

Data were analyzed using SPSS (version 17.0). Results of the self-efficacy pre and post surveys were compared using means, and standard deviations for each of the five survey items, as well as overall mean scores for pre and post results for the entire group of subjects. The data for each participant was compared, pretest to posttest but only subject numbers were used so that individual participants could be anonymous. Consequently, a series of repeated measures t-tests were used to calculate a P value for each survey item to compare pre and post-test data, and difference scores.

Results

Five individual Likert-scale measures were used to assess self-efficacy in regard to hands-on tasks, both before and after the simulated training module for third year medical students (See Appendix 1). The measures consisted of 1) Automatic External Defibrillator/Basic Life Support Stations (AED/BLS), 2) Manual Biphasic Defibrillation Station, 3) External Pacing Station, 4) Synchronized Cardioversion Station, and 5) Crash Carts and Chart Documentation Station (CCCD). Although not central to the study hypotheses, zero-order correlations among the self-efficacy variables at both pre-simulation (time one, 1a-5a, TotA) and post-simulation (time two, 1b-5b, TotB) were done and can be found in Appendix 2. In general, the vast majority of self-efficacy variables were correlated with one another.

In order to determine the effects of the cardiopulmonary emergency workshop on third year medical student self-efficacy, a series of repeated measures t-tests were performed. Table 1 provides means and standard deviations for all five of the simulation variables and for the sum total of all five variables both before and after the intervention. As depicted in the table, all means increased appreciably from pre-simulation to post-simulation. Separate t-tests for repeated measures indicated significant change on all five efficacy variables from time one to time two. The Total score t-test was significant as the sum of all scores for student self-efficacy improved by nearly eight points on average from the pretest to the posttest, t (74) = 19.38, p <.001. The most pronounced finding for a particular variable was on CCCD, Crash Cart and Chart Documentation, where the mean score jumped two points from time one to time two, t (74) = 18.05, p <.001. Manual Biphasic Defibrillation improved by 1.6 points on average, marking significant improvement, t (74) = 14.29, p < .001. Similarly, the t-test for External Pacing revealed a significant improvement by an average of 1.6 points for medical students, t (74) = 15.34, p <.001. Improvement in the Synchronized Cardioversion variable was also augmented by an average of 1.5, and the repeated measures t-test was significant, t (74) = 14.90, p <.001. The least amount of improvement, relatively speaking, was in the AED/BLS variable, which was still a significant change from pre- to post-simulation (1.3 points) as evidenced by the t-test, t (74) = 13.50, p <.001.

Discussion

The cardiopulmonary emergency workshop was designed as part of a simulation-based skills series to prepare medical students for a required end-year Advanced Cardiac Life Support (ACLS) certification course. Medical students midway through their third year have also commonly had inpatient and emergency room exposure to code situations during their clinical clerkships, mainly as observers. This perspective lends curricular and practical relevance to learning basic emergency skills, with students eager for a more active role during future critical care encounters, as well as specific skills preparation for their upcoming ACLS course. Similar to other research, (15-16) we found improvements in medical students' confidence in skills related to cardiac arrest management following simulation. For our study, survey questions assessing confidence in resuscitation focused on a subset of ACLS skills through our workshop devoted to electrical therapy skills and documentation. Furthermore, several additional stations beyond what are typically used in ACLS simulation training were added for this focused workshop with WVU medical students. The present study was comprised of actively-practicing EMS professionals and provided small group skills training and feedback in a supportive and effective manner. This opportunity for focused, individualized practice of high-stakes, invasive interventions was reflected in significantly improved self-confidence following the workshop, lending further evidence to the ideas that hands-on experience and constant feedback from professionals makes for an efficacious learning experience.

The uniformly positive results from medical students' self-efficacy reporting are similar to previous studies of simulation in medical education. (12-13,17-18) In particular, this data suggests that a well-designed simulation-based skills workshop is an effective tool for raising confidence in cardiopulmonary emergency and lifesaving skills for third-year medical students. Students received training appropriate to their clinical readiness, with pre-test scores reflecting middling baseline self-confidence with emergency procedures. The students were receptive and engaged participants in this workshop, and their evaluations reflected recognition of their own improvement.

Additionally, when the medical students completed the surveys, it involved taking a few moments to reflect on their level of confidence in succeeding at these new tasks. This likely led to self-reflection of their ability level, as well as possible reflection upon what has been learned during this module. An extensive body of literature in the Education and Adult Learning fields has demonstrated that self-reflection leads to deeper learning of material, as well as longer retention of new information. Further, this study found what numerous studies have concluded: simulation is an effective means of learning for medical students. (15) Future study might include additional follow-up interviews with former students, reflecting on the value of simulation training during their medical education at a later time in their careers.

Limitations

One limitation in the present study may be the short time lapse pre- and post-workshop, with possible loss in self-efficacy happening sometime days or weeks following the training. Student confidence and self-efficacy were measured just moments following the workshop and there was little time for their knowledge to fade. If cardiopulmonary emergency skills are not reinforced over time, it may stand to reason that those skills and confidence thereby will diminish. Finally, although it is a standard model for measuring success in clinical training, the self-efficacy reporting tool is limited to documenting a learner's confidence. Further study will be needed to document sustained clinical benefit, following our early clinical learners into the patient care setting.

Another limitation is the lack of a control group in the current study. Since the medical students participated as a required part of their training, there was no control group and thus no way to compare the 74 medical students who received the intervention to another group. A future project is planned where students will receive an educational session only on cardiopulmonary emergencies and that group can be compared to the current group who received the hands-on simulation.

Conclusion

A simulation-based cardiopulmonary emergency skills workshop is an effective tool for teaching critical care techniques to third year medical students. This workshop successfully prepared students to gain confidence in performing invasive, lifesaving clinical skills in a supportive, low-risk setting. Students reported significantly increased self-efficacy, indicating that these skills sessions are a valuable use of student time, faculty time, and hospital resources. Based on the results of this project, the cardiopulmonary emergency skills workshop will remain a required curricular component for our third year medical students.

Kathleen P. Bors, MD

Assistant Professor, Department of Family Medicine, West Virginia University School of Medicine--Charleston Division, Charleston, WV

Elise A. Drake, PhD

Senior Educator, Charleston Area Medical Center Health Education and Research Institute, Charleston, WV

Scott A. Fields, PhD

Associate Professor, Department of Family Medicine, West Virginia University School of Medicine--Charleston Division, Charleston, WV

Corresponding Author: Kathleen Bors, MD, 3200 MacCorkle Avenue SE, 5th Floor, Robert C. Byrd Clinical Teaching Center, Depart. of Family Medicine, Charleston, WV 25304. Email: kbors@hsc.wvu.edu.

Appendix 1

Cardiopulmonary Emergency Learning Stations

Heart Start Defibrillator Station:

Students were introduced to the monitoring and therapy interventions utilized with the Philips HeartStart Monitor/Defibrillators. Students had the opportunity to physically manipulate and practice with this equipment.

AED/BLS (Automatic External Defibrillator/Basic Life Support) Station:

Students were instructed on delivering shock therapy to a patient and on starting CPR. Students had the opportunity to apply these skills and use equipment to provide electrical shocks to the mannequin.

Biphasic Defibrillation and Synchronized Cardioversion Station:

Students were instructed on using hands-free and/or paddle defibrillators. They had the opportunity to use these devices on the mannequin.

External Pacing Station:

Students were instructed on skills and interventions used in external pacing for electrical therapy. They had the opportunity to use equipment to practice stimulating the heart rate (via electrical conduction pathway).

Crash Cart and Chart Documentation Station:

Students were familiarized with identical crash carts to those currently used throughout the hospital. They had the opportunity to practice chart documentation of cardiac arrest. Medical and legal implications of documentation were discussed and emphasized.

Pediatric Defibrillation:

Students were instructed on special procedures and equipment used in electrical therapy of infants and children. Students had the opportunity to use the monitor and defibrillator equipment to apply electrical shocks to the pediatric mannequin.
Appendix 2
Student Self-Efficacy Pre-Post Simulation Zero-Order Correlations

       Time 1

1a     2a   3a        4a        5a        TotA      1b

1a     --   .50 (a)   .44 (a)   .47 (a)   .23 (a)   .65 (a)
2a          --        .76 a     .79 (a)   .60 (a)   .87 (a)
3a                    --        .73 (a)   .64 (a)   .84 (a)
4a                              --        .62 (a)   .89 (a)
5a                                        --        .73 (a)
TotA                                                --
1b
2b
3b
4b
5b
TotB

       Time 2

1a     2b        3b        4b        5b        TotB

1a     .42 (a)   .37 (a)   .35 (a)   .33 (a)   .40 (a)   .41 (a)
2a     .34 (a)   .34 (a)   .34 (a)   .39 (a)   .28 (a)   .38 (a)
3a     .14       .20       .27 (a)   .27 (a)   .21       .25 (a)
4a     .33 (a)   .34 (a)   .43 (a)   .45 (a)   .23 (a)   .40 (a)
5a     0.15      .22       .20       .24 (a)   .19       .23
TotA   .34 (a)   .37 (a)   .40 (a)   .42 (a)   .33 (a)   .42 (a)
1b     --        .79 (a)   .73 (a)   .75 (a)   .72 (a)   .88 (a)
2b               --        .70 (a)   .79 (a)   .77 (a)   .90 (a)
3b                         --        .82 (a)   .74 (a)   .91 (a)
4b                                   --        .70 (a)   .88 (a)
5b                                             --        .91 (a)
TotB                                                     --

Notes: N = 75; (a) Significant, p < .05; Self Efficacy Variables: 1.
AED/BLS, 2. Manual Biphasic Defibrillation, 3. External Pacing, 4.
Synchronized Cardioversion, 5. CCCD. Total Variables: TotA = Total of
Time 1 Variables. TotB = Total of Time 2 Variables. a= Time 1, b =
Time 2.


Acknowledgements

The authors would like to thank several individuals for their time and assistance with this research: Charleston Area Medical Center Simulation Staff and Faculty Instructors, with special thanks to Barbara McKee, Dave Matics, and Chris Melton for facilitating the simulated training modules. We also wish to thank Dana Kelly and Charissa Davis, from the West Virginia University Charleston Division Student Services Department, for their assistance in organizing and implementing the simulation modules and collecting data.

References

(1.) Takayesu J, Farrell S, Evans A, et al. How do clinical clerkship students experience simulator-based teaching? A qualitative analysis. Simulation in Healthcare 2006; 1: 215-219.

(2.) Scalese R, Obeso V, Issenberg S. Simulation technology for skills training and competency assessment in medical education. Journal of General Internal Medicine 2008; 23(Suppl 1): 46-9.

(3.) Okuda Y, Bryson E, DeMaria Jr S, et al. The utility of simulation in medical education: What is the evidence? Mt. Sinai Journal of Medicine 2009; 76: 330-343.

(4.) Baker C, Pulling C, McGraw R, et al. Simulation in interprofessional education for patient-centred collaborative care. Journal of Advanced Nursing 2008; 64: 372-379.

(5.) Laschinger S, Medves J, Pulling C, et al. Effectiveness of simulation on health profession students' knowledge, skills, confidence and satisfaction. International Journal of Evidence Based Healthcare 2008; 6: 278-302.

(6.) Deering SH, Hodor JG, Wylen M, et al. Additional training with an obstetric simulator improves medical student comfort with basic procedures. Simulation in Healthcare 2006; 1: 32-34.

(7.) Dayal AK, Fisher N, Magrane D, et al. Simulation training improves medical students' learning experiences when performing real vaginal deliveries. Simulation in Healthcare 2009; 4: 155-159.

(8.) Bambini D, Washburn J, Perkins R. Outcomes of clinical simulation for novice nursing students: Communication, confidence, clinical judgment. Nursing Education Perspectives 2009; 30: 79-82.

(9.) Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychological Reviews 1977; 84: 191-215.

(10.) Bandura A. Self-Efficacy: The Exercise of Control. New York: W.H. Freeman; 1997.

(11.) Maibach EW, Schieber RA, Carroll MF. Self-efficacy in pediatric resuscitation: Implications for education and performance. Pediatrics 1996: 97: 94-99.

(12.) Shukla A, Kline D, Cherian A, et al. A simulation course on lifesaving techniques for third-year medical students. Simulation in Healthcare 2007; 2: 11-15.

(13.) Nitchman C, Bartz D, Johnson N. Gynecologic simulation training increases medical student confidence and interest in women's health. Teaching and Learning in Medicine: An International Journal 2014; 26: 160-163.

(14.) Schwid HA, Rooke AG, Ross BK, Sivarajan M. Use of a computerized advanced cardiac life support simulator improves retention of advanced cardiac life support guidelines better than a textbook review. Critical Care Medicine 1999; 27: 821-4.

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Table 1. Result of Pre- and Post-Simulation Self-Efficacy Survey

                                             Mean [ + or -]
                                           Standard Deviation
Question                 Pre-simulation     Post-simulation     P value

I am confident in my    2.9 [+ or -] 0.9     4.2 [+ or -] 0.6    < .001
ability to use the
AED/BLS with
associated rhythm
recognition.

I am confident in my    2.6 [+ or -] 0.9     4.1 [+ or -] 0.7    < .001
ability to apply
manual biphasic
defibrillation with
associated rhythm.

I am confident in my    2.5 [+ or -] 0.8     4.1 [+ or -] 0.7    < .001
ability to apply
external pacing with
associated rhythm.

I am confident in my    2.6 [+ or -] 0.9     4.1 [+ or -] 0.7    < .001
ability to apply
synchronized
cardioversion with
associated rhythm
recognition.

I am confident in my    2.1 [+ or -] 0.8     4.1 [+ or -] 0.7    < .001
knowledge of
components of the
crash carts and chart
documentation.

Five Question Total     12.8 [+ or -] 3.4    20.6 [+ or -] 3.0   < .001
Score

Notes: Results based on 1 = strongly disagree, 2 = disagree,
3 = neutral, 4 = agree, 5 = strongly agree; N = 75.
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Title Annotation:Scientific Study
Author:Bors, Kathleen P.; Drake, Elise A.; Fields, Scott A.
Publication:West Virginia Medical Journal
Geographic Code:1USA
Date:Jan 1, 2016
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