|ORIGINAL RESEARCH ARTICLE
|Year : 2014 | Volume
| Issue : 3 | Page : 243-248
Implementing a skillslab training program in a developing country
Trung Quang Tran1, Albert Scherpbier2, Jan van Dalen2, Dung van Do3, E Pamela Wright4
1 Medical Education Center, University of Medicine and Pharmacy at Ho Chi Minh City, 217 Hong Bang St, District 5, Ho Chi Minh City, Vietnam, Vietnam
2 Faculty Health, Medicine and Life Sciences Maastricht University, Netherlands
3 Department of Biostatistics, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
4 Medical Committee Netherlands Vietnam, The Netherlands, Weteringschans 32, 1017 SH Amsterdam, Netherlands
|Date of Web Publication||26-Feb-2015|
Trung Quang Tran
Medical Education Center, University of Medicine and Pharmacy at Ho Chi Minh City, 217 Hong Bang St, District 5, Ho Chi Minh City
Source of Support: This research project was funded by the Dutch NPT project
"Strengthening medical skills training at 8 medical faculty/universities in Vietnam"., Conflict of Interest: All of authors do not have any interest in supporting or
against any skill training laboratory (skillslab) involving in this research.
Background: Eight skills laboratories (skillslabs) were established by consensus of Vietnamese medical universities, with international support. A national list of basic skills needed for medical practice and suitable for skillslab training was developed; models, medical and teaching equipment were supplied; learning material was developed and core staff and teachers were trained. This study was designed to assess how closely eight schools in Vietnam came to implementing all recommended skills on list developed by educators of that country, and identify the facilitating factors and barriers to skillslab use within the country's largest school. Methods: Data were collected from reports from the eight skillslabs. Students and trainers from the largest university were surveyed for their perceptions of the quality of training on eight selected skills. Results of students' skill assessments were gathered, and focus group discussions with trainers were conducted. SPSS 16 was used to analyze the quantitative data and cluster analysis was used to test for differences. Results: Only one medical school was able to train all 56 basic skills proposed by consensus among the eight Vietnamese medical universities. Deeper exploration within the largest school revealed that its skillslab training was successful for most skills, according to students' postprogram skills assessment and to students' and trainers' perceptions. However, through focus group discussions we learned that the quantity of training aids was perceived to be insufficient; some models/manikins were inappropriate for training; more consideration was needed in framing the expected requirements of students within each skill; too little time was allocated for the training of one of the eight skills investigated; and further curriculum development is needed to better integrate the skills training program into the broader curriculum. Discussion: The fact that one medical school could teach all skills recommended for skillslab training demonstrates that all Vietnamese schools may be similarly able to teach the basic skills of the national consensus list. But as of now, it remains challenging for most schools in this developing country to fully implement a national skillslab training program.
Keywords: Skillslab, training program, training aids
|How to cite this article:|
Tran TQ, Scherpbier A, van Dalen J, van Do D, Wright E P. Implementing a skillslab training program in a developing country. Educ Health 2014;27:243-8
| Background|| |
Before graduating and starting their work as doctors, medical students must gain competence in a number of skills. The number and selection of skills required will depend on the local context.  Since the 1970s, dedicated skills training centers known as skills laboratories (skillslabs) have been developed. ,,,
Although skillslabs have been effective in Western countries, ,,,,, it cannot be assumed that they will work as well in all settings. Schools in developing countries often adopt Western teaching and learning methods, which may not meet the needs of their individual healthcare systems and cultural norms.  In recent years, skillslabs have been established in many countries. However, because limited resources and experience will affect the choices made by each university regarding skillslab teaching, challenges will arise in training all students to the level required for graduating doctors. Skillslabs vary in their accommodations and resources available, ranging from one room with one manikin to purpose-built structures with a vast assortment of equipment.  For developing countries, fully equipped skillslabs are expensive to set up and to maintain.  In Vietnam, international projects supported the establishment of skillslabs in the country's eight principal state medical schools. Models and medical and teaching equipment were supplied by the projects. Maastricht University provided technical assistance and trained core staff and teachers. A national list of basic skills needed for medical practice and suitable for skillslab training was developed using a Delphi method  among 40 senior teachers of all eight schools based on required standard practice for graduates. Dedicated learning materials were developed, including skills books, videos and self-made models.  These eight state schools, which together produce most of the medical doctors in Vietnam and participated in developing the list, are not yet obliged to use skillslabs in their programs.
Based on self-evaluation of capacity to provide skillslab training, a core team in each university submitted a list of skills that they expected to be able to teach. One way to check whether the skills have been learned is to review the results of skillslab student assessments. However, these results depend on the reliability and validity of the assessment, which is influenced by facilities and the capacity of teaching staff. The students' scores could only be interpreted in relation to the quality of training, which is a result of inputs by both teachers and students.
This study was designed to assess how closely eight schools in Vietnam came to implementing all recommended skills on list developed by educators of that country, and identify the facilitating factors and barriers to skillslab use within the country's largest school.
| Methods|| |
Skills taught in eight medical universities
The staff in charge of the skillslab in each of the eight participating medical universities provided a list of the skills taught there. The eight schools include all the principal state schools offering medical study in Vietnam; they range from large, long-established schools (such as Hanoi, Ho Chi Minh City) and smaller, younger, regional schools (such as Cantho, Thai Nguyen). The eight lists were compared against the national list of skills expected to be taught in the skillslab, which was developed jointly by the same eight schools, to identify the extent to which this nationally agreed training program has been implemented.
Quality of training in skillslab of the largest school
The second part of this study was conducted at the skillslab of the largest medical school, where students' postcourse assessments and the opinions of students and trainers about skillslab training and assessment were collected. From the national list of skills recommended for training in skillslabs, eight skills were selected to cover a range of disciplines and to represent the weight of each discipline in the curriculum. The skills selected were: Heart examination; abdomen examination; ear, nose and throat (ENT) examination; gynecological examination; taking blood pressure; suture technique; lumbar puncture and Pap smear More Details.
First we analyzed the student's postcourse skills assessment. Then we used questionnaires to investigate the main stakeholders' opinions about the perceived quality of the teaching and of the assessment itself. Finally we conducted focus group discussions (FGDs) with teachers to deepen our understanding of their opinions of the teaching and assessment processes.
The routine skillslab assessments of students' performance on the eight selected skills were recorded. The assessments consisted of direct observation of performance using a rating scale and a detailed observation guideline. The way of setting up the skills assessment and rating followed standard protocols used in the schools that provided technical assistance to set up the skills training in Vietnamese schools, as previously documented. ,, The interrater reliability of assessments of students by various raters reached 0.77 after rater training, including expert discussions. Questionnaires were developed based on literature review, and finalized after discussion with trainers and students. The content validity was checked with experts; reliability of each item was improved through trials, revisions and pilot studies. 
For all questionnaires a five-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = uncertain, 4 = agree, 5 = strongly agree) was used to rate the opinions on statements about the training/assessment. Scores below 3 were considered negative, while scores of 3 and above were considered positive.
Students' opinions after a training session
Each cohort of medical students is divided into 30 groups, each with about 10 students. After the training sessions for each selected skill, 11 groups were randomly selected using a list randomizer; all students of the selected squads were asked to answer a 30-item questionnaire covering students (3 items), skillslab training process (13), training aids (8), trainers (5) and difficulty (1). A total of 949 individual student ratings of skills were received, which includes more than one skills rating for some students. The response rate was 90% of 1054 students invited to contribute.
Students' opinions after skillslab assessment
After the sessions to assess learning in the skillslab, we recruited approximately 100 student respondents per skill to complete a questionnaire. Because in skills assessment the number of students assigned for each station (skill) varied, for some skills we surveyed all students and for skills training for larger groups we only surveyed the first completers. The questionnaire included 12 items, 4 about students, 4 about the assessment tools and fo4ur on assessment conditions. We received a total of 801 skill evaluations from students, again with some students providing an evaluation for more than one skill. The response rate was 91% of 880 invited students.
Trainers' opinions after training sessions
After the training sessions on each selected skill, all trainers were invited to answer a 35-item questionnaire on students (4 items), skillslab training conditions (10), training aids (8), trainer (12) and difficulty (1). All invited trainers agreed to answer, making a total of 74 questionnaires completed by trainers after a training session.
Trainers' opinions after skillslab assessments
After a skillslab assessment session, all trainers who had assessed the selected skills were invited to answer a questionnaire with seven items, on assessment tools (4 items) and assessment conditions (3). All of the 53 trainers invited to participate completed these questionnaires.
Focus group discussions with trainers
FGD with skillslab trainers, led by the researcher, provided deeper insights into their views on the quality of the training as revealed by the survey results. The results from the questionnaires were presented to the FGD participants along with the assessment results, and both were discussed and recommendations made.
The FGD discussions were recorded and the verbatim text was made available to three reviewers. The reviewers independently coded the verbatim and identified emerging themes and concepts, as well as representative quotes. Differences of opinion were discussed until consensus about interpretation was reached. As a member checking procedure, a report of the focus group findings was sent to the focus group members and they were invited to submit corrections.
SPSS 16 was used to analyze the quantitative data. For each skill, the mean and standard deviation of the scores of the students' assessment and the percentage of failed students are presented. The mean and standard deviation of the Likert scores on perceptions of students after skill training and after skill assessment are presented. Cluster analysis was used to test for differences in student perceptions of training across the eight different skills, and the scree plot was used to discriminate skills with high scores and skills with low scores. Perceptions of students and trainers of the difficulties of each skill are presented by means and standard deviations. Because perceptions of students are clustered data, the generalized estimating equation was used to compare the perceptions of students and trainers about difficulty.
Ethical approval of the project including both scientific and ethical aspects was provided by the University of Medicine and Pharmacy Ho Chi Minh City.
| Results|| |
Skills on the national list to be trained in vietnamese skillslab system
Each of the eight medical universities involved in the project reported how many and which skills it felt confident to teach in the skillslab among the 56 skills on the national list [Figure 1]. One medium-sized university was able to train 56 skills in the national list. Among the other seven schools, four felt confident in the teaching of two-thirds to three-quarters of the skills on the national list, while three skillslabs were confident in their training of fewer than 50% of the basic skills.
|Figure 1: Percentage of skills in the national list of basic skills that are actually trained in the skillslabs of eight Vietnamese medical schools|
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Results of skillslab assessment in the largest medical university
Assessment of students' performance on the eight selected skills used a standard scoring system with a 11-point scale (0 = lowest mark; 10 = highest mark, and 5 = pass) [Table 1]. Students' overall mean score across stations was 7.9 (SD 1.61). On average, 4% (65/1629) of students failed any given station.
The lowest mean score was found for 'heart examination'. High failure rates were seen with 'heart examination', 'taking blood pressure' and 'lumbar puncture'. The skills 'Pap smear' and 'suture technique' produced high marks and almost no failures.
Students' perceptions after skillslab training sessions
Immediately after training sessions, students were asked to evaluate the session. Out of 29 items, students gave 26 a mean score over 3.0, which suggest that on average the students were satisfied with the skill training sessions. There were, however, three items with significantly lower mean scores, all related to the quantity of training aids: Models/manikins (mean score, 2.72), simulated patients (2.82) and medical equipment (2.85).
All three items in which students rated something about themselves received just satisfactory scores, on average. The mean scores for the five items about the trainer ranged from 3.65 to 4.04, indicating general satisfaction with the role of the trainers.
Students identified weaknesses in the training for certain skills compared with others [Table 2]. Training on " heart examination skills" was evaluated significantly lower than other skills in six items. For three skills, the issue of the adequate time for theory and practice teaching was noted.
|Table 2: Students' perception on various aspects of skillslab instruction on the eight selected skills|
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Students' perception after skillslab assessment
Students provided responses not only after training sessions but also after assessment sessions. We received 96-115 completed questionnaires after each of the eight skill test sessions, with the exception of assessment of 'heart examination', for which only 53 students were in the available group, of whom 48 completed the questionnaire. For all aspects of the training program for all eight skills, overall means ranged from 3.37 to 4.15, indicating a positive perception from the students about both training and assessment.
Trainers' perceptions skills training and assessment
Trainers were asked their perceptions on skillslab training after the training sessions and about skillslab assessment after assessment sessions. The mean scores of all aspects of the training program for all skills were above 3; the trainers were positive about their training and the assessment.
The trainers were also asked their perception on the difficulty of each skill they led in the skillslab. The mean scores of item "level of difficulty" for heart examination and lumbar puncture skills were significantly higher than other skills, suggesting that trainers considered those skills more difficult for the students to learn than other skills. For other skills, the trainers considered them not very difficult to learn.
Comparing students' and trainers' perceptions on difficulty of skills
Comparing the rating for difficulty of the eight selected skills between the trainers and students, only for the Pap smear technique were the difficulty scores given by students significantly higher than those given by trainers. For other skills, the levels of difficulty as perceived by students and trainers were similar.
Correlation between the difficulty of skills as rated by students and the students' mean score on assessment
Another consideration is the relation between the perceptions that students have on the difficulty of a technique they are learning and their assessment of their skill on that technique. The equation to predict the assessment results and the difficulty rating by student shows an inverse relation: For each unit increase in difficulty the average score was 1.3 lower [Figure 2]. The coefficient is not significant (P = 0.06).
|Figure 2: Relation between difficulty rating and students' performance scores on assessment for eight selected skills (Gyne exam: Gynecological examination; BP: blood pressure; ENT: Ear, Nose, Throat)|
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Focus group discussions with trainers
A deeper investigation of training in this one university skillslab was conducted with FGDs, when the participants discussed the above-described survey results. One point was that the lowest mean score for 'heart examination' and high failure rates for 'taking blood pressure' and 'lumbar puncture' may be related to the specific result required when students are assessed on those skills. As one trainer noted: "For heart examination students have to recognize a specific heart sound ." Another said, "Having to read the blood pressure of the simulated patient, and to draw spinal fluid (on a model) for lumbar puncture could contribute to students' low scores". In contrast, for other skills, "Students have to perform all steps in the rating scale but there is no specific result to be measured0".
Both trainers and students considered heart examination to be the most difficult skill; training in heart examination skills was also evaluated significantly lower than other skills for six items. The trainers suggested that " increasing the training time for this skill would strengthen the weaknesses mentioned by the students and improve their performance".
The trainers also agreed with the students' perception of insufficient medical equipment and models/manikins and suggested that there should be increased opportunity for self-practice. The FGD also had a explanation for the satisfactory score by trainers for those items. " Recent improvements in quality and quantity of the training equipment, models/manikins satisfied the trainers, but in fact, both quality and quantity are still far from meeting the training requirements". The models/manikins were not fully appropriate for training but in assessment they could help students to perform the skills more easily to give better results in assessment.
Regarding the frequency of low scores for learning theory before practice, the trainers also mentioned that, " The skillslab training program was an addition to the existing curriculum; in some cases, the scheduling of the related theory teaching did not completely fit with the skillslab training program". The trainers suggested that, "We need a full curriculum reform to integrate the skills training program in to the existing curriculum".
| Discussion|| |
This study was designed to investigate the capacity of a skillslab in a developing country to train the skills assigned by consensus among eight medical universities. The fact that one university could teach all 56 skills suggests that skillslab training the entire national list of basic skills is possible in this country. That particular university was the first in Vietnam to establish a skillslab, with international support, and has the longest experience, with better trained and experienced teachers running it. It is a medium-sized regional school. The school in which the in-depth study reported here was done is the largest in the country and was the second to set up a skillslab; it was the second highest in number of skills taught using the skillslab. Resource constraints may be one reason for the low proportion of recommended skills being taught in other schools. This interpretation is supported by the students' opinion that the quantity of training aids available even in one of the largest university was insufficient to meet their learning requirements. Insufficient investment for skillslabs in a developing country is understandable and stands in contrast with the often strong investments in developed countries.  Stark and Fortune  suggested that in a first phase of setting up a skillslab in developing countries, it may be easier to let students continue to learn in the clinical environment. However, Hoat et al.  reported the results of an earlier study on skills learning in Vietnamese medical schools; new graduates from schools that already had a skillslab expressed more confidence about skills they had learned than students from schools without one. One way to overcome resource constraints is to use self-made models; , greater availability and relevance as well as lower cost makes such models very useful in a resource-limited setting. The three schools that taught less than 40% of recommended skills were smaller. Younger schools, where human and other resources are limited, may need a longer time to develop sufficient capacity. When capacity to provide training becomes available, all 56 skills in the national list should be trained in skillslabs in all the medical universities.
Training in the skillslab in the one university was apparently successful for most skills, according to the results of student assessment after training and to the students' and the trainers' perceptions. However, based on focus group feedback, curriculum renovation is still needed to integrate the skills training program within the existing curriculum. Also, time allocated for training of one of the eight skills investigated needs to be increased. The issues of inappropriate models/manikins for training could be a problem for any university; the differences between models and human beings have also been a point of criticism of skillslabs in other countries. , It might, however, be a more serious problem in resource-limited settings where the quality of the manikins might be lower.
Students and trainers in the one examined school were satisfied with the role of the trainer. This might reflect a good selection process and training for the trainers. But this praise for instructors might also be a halo effect  and reflect the reluctance within the Southeast Asian culture to criticize,  making the comments about the trainers more positive than students' actual assessments. A deeper evaluation of the quality of the trainers' work still needs to be performed.
The study does have limitations. The focus group participants' openness to respond may have been influenced by their professional relationship with the moderator, who was their senior. We report on the perception of stakeholders and immediate results of skills training but not at the longer term effectiveness of the training. That will require a future, longitudinal study. The data consist of the impressions and opinions of students compared with their performance, while the teachers' performance has not been directly evaluated. Most of the results came from in-depth research of one university, where the data collection and analysis could be controlled by the researchers. From the section reporting the review of skillslab training in the eight schools, it is clear that skillslab training is not yet optimal in some of them. We make the assumption that if skillslab training can be implemented successfully in one university, there is potential for the others to do the same, if they also identify the barriers and obstacles in their particular situations.
| Conclusions|| |
It remains a challenge to implement fully a national skillslab training program in a developing country, at least in the startup phase. In spite of great efforts to establish such a program, there are still many barriers to full implementation. The biggest obstacle recognized by students and trainers was the limited quantity of training aids, providing fewer opportunities for each student to practice. The main issues identified to improve the contribution of the skillslab to the training of medical students of this particular school were to integrate the skillslab training program into the existing curriculum, increase time allocated for training certain skills, ensuring models/manikins were appropriate for the training, and reconsidering the requirements of students for each skill in the skill assessment. Further efforts are needed if the medical schools in this developing country are to make the best use of the skillslabs to improve the quality of their graduates.
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[Table 1], [Table 2]