ORIGINAL RESEARCH PAPER

Year : 2009  |  Volume : 22  |  Issue : 2  |  Page : 57

Students' Perceptions of the Effectiveness of a Professional Skills Program in Preparation for Clerkship Training

E Al-Jishi¹, NA Khalek², HM Hamdy^2
1 Ministry of Health, Bahrain
² University of Sharjah, United Arab Emirates

Correspondence Address:
E Al-Jishi
po box 12
Bahrain

Source of Support: None, Conflict of Interest: None

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1

PMID: 20029743

Context: The goal of the Professional Skills Program at Arabian Gulf University, Bahrain, is to prepare medical students for the clerkship phase. In the six-year integrated problem-based learning (PBL) medical program, the Professional Skills Program is introduced in years two to four. The aim of this study was to evaluate program effectiveness as perceived by the students in the clerkship phase.
Method: Students' perceptions were obtained using a mailed questionnaire. Close-ended questions were assessed using a 5-point Likert scale. Students were also asked to comment on areas of strengths or suggestions for improvement. The questionnaire was piloted with a group of students in the clerkship years. Results were analyzed in relation to the different domains of the program.
Results: Students were positive about their clinical skills training in preparing them for their clerkship in relation to three levels of Kirkpatrick outcome measures. This was particularly true for the domains of physical examination and procedural skills. However, they indicated some areas in need of program development, particularly in the history-taking domain.
Conclusion: The students' opinions generally support the effectiveness of the Professional Skills Program training in preparing them for the clerkship phase. Program evaluation has helped us to plan for further development of the program.

Keywords: Professional skills, program effectiveness, clerkship, Kirkpatrick Model

Introduction



Over the past three decades, emphasis has been placed on the importance of early introduction of clinical training in the undergraduate medical curriculum. Clinical Skills Laboratories (CSL) have been established not to replace clinical experience, but to allow the early practice of not only routine skills but also difficult, painful or embarrassing procedures in a safe, supervised and ethical environment. Clinical skills centers are now seen to be complementary to real patients' encounters in conventional clinical settings (Whipple et al., 2006). A good skills training program should define the teaching goals, allow opportunities for considerable practice and provide regular feedback (Remmen et al., 1998). Simulation is a fundamental educational tool in these centers, attempting to represent some characteristics of the real task and to incorporate them into an effective training environment (Patrick, 1992). The transformation and application of learned skills in the lab to students' performance in the clerkship phase of the curriculum and, eventually, in real life is an important educational rationale – a rationale that needs to be tested since these centers provide a different context for learning, which can never capture the real world setting (Boulay & Medway, 1999).



Studies have shown that basic clinical skills training, running through the pre-clinical phase of the curriculum, can have a substantial effect on outcomes by facilitating skills training during the clerkships (Remmen et al., 2001). However, studies of the effectiveness of these programs have focused more on the learning of skills as a short-term outcome (Williams et al., 2007). The aim of this study was to assess the effectiveness of a Professional Skills Program (PSP), as perceived by students in preparing them for their clerkship phase of study.



Study Context



The College of Medicine and Medical Science at the Arabian Gulf University (AGU) offers a six-year integrated problem-based learning (PBL) curriculum. Year one is a foundation year, followed by integrated problem-based learning of organ systems in years two, three and four (pre-clerkship phase). This is then followed by a clerkship phase in years five and six. Clinical skills training, through the PSP, runs horizontally and vertically in the pre-clerkship phase coordinated with the integrated organ systems blocks. The aim is to assist students in developing competencies in a spectrum of skills related to the expected future medical practice. The main components of the PSP are communication and interviewing skills, history-taking and clinical reasoning skills, physical examination skills and procedural skills (Hamdy et al., 2001). Different modalities of simulation including models, videos, demonstration, role-plays and simulated patients are used. Exposure to real patients also takes place at the end of each block after completing the training in the skills lab. The aim of encountering a real patient is to assure students that they can transfer what was acquired in the lab into practice.



Methods



The conceptual framework of the study was based on modification of the Kirkpatrick Model of measuring effectiveness of educational programs (Kirkpatrick, 1998):

• Level 1: Reaction = participants’ satisfaction;
  
  
• Level 2: Learning = participants’ knowledge acquisition, improved skills or changes in attitude;
  
  
• Level 3: Behavior = changes in participants’ on-the-job behavior;
  
  
• Level 4: Results = final change at the organizational and population levels.

The measurement of students' perceptions of the effectiveness of the PSP in preparing them for their clerkship corresponds to levels 1 to 3 of the Kirkpatrick Model.



An internally-developed questionnaire was used in collecting students' opinions on clinical skills training. It was comprised of five main domains: Communication (five items); History-taking (nine items); Clinical Reasoning (three items); Physical Examination (nine items); Procedures (three items). Items were assessed on a 5-point Likert scale (1 "strongly disagree" to 5 "strongly agree"). In addition, each item included space for free comments on areas of strength and suggestions for improvement. Face and content validity were tested through a focus group discussion with 20 students in the clerkship phase. Hence, the discussion explored students’ understanding of meanings in the questionnaire and reduced ambiguity, particularly as their mother tongue was Arabic and not English. In addition, the questionnaire was piloted on 15 other students in year five, who were excluded from the study group.



Following institutional ethics approval, the questionnaire was sent by mail and e-mail to 110 clerkship students, including those who participated in the focus group discussion. All had successfully completed the first two clerkship rotations in year five (20 weeks). Data were analyzed using the Statistical Package for Social Sciences (SPSS – version 10.0). For analysis purposes, strongly agree and agree responses were combined as agree; strongly disagree and disagree were combined as disagree. Frequencies and percentages were compiled for each questionnaire item. The reliability of the questionnaire was measured using Cronbach's alpha.



Results



Out of the 110 students, seventy-one (64.5%) responded to the questionnaire. The questionnaire was found to be reliable according to Cronbach’s alpha (0.88). In relation to the Communication Skills domain, students’ assessments were positive, particularly with respect to patient dialogue (78%) and establishment of eye contact (86%). On the other hand, 45% of students agreed that the communications component was ‘sufficient’ (Table 1). Similarly, training in History-Taking Skills was considered sufficient by 24% of the respondents. Eighty percent of students expressed the need for training with real patients in this domain.



Table 1:  Students' Perceptions of the Professional Skills Program at Arabian Gulf University







Concerning physical examination skills, the students agreed that integrating theory with skills examination training was important (83%). Sixty-one percent of students pointed out that using stimulated patients was a valuable experience and more authentic than the simulators.



Within the Procedural Skills domain, 82% of the students agreed that there was a need for more procedural skills, with 32% of students agreeing that there was enough time devoted to this set of skills.



Students' written comments pointed to some of the strong areas in the program, while at the same time indicating areas for improvement (Table 2). Some students reported that the program improved their ability to establish a good relationship with the health team (e.g. “my previous experience during skills training helped me to approach the residents and nurses easily during clerkship training”). Moreover, students expressed their need for feedback sessions about their performance considering end-of-rotation assessment not being sufficient (e.g. “I wish to have feedback immediately after each training session”). In addition, students noted the inconsistency in the method of training among the different trainers and suggested training sessions for the trainers (e.g. “I like the method of teaching which is used by our tutor during cardiovascular system sessions - I wish all tutors will use the same method”; “I felt that some tutors are not aware of how to teach us”). Some students recommended revisiting the clinical reasoning training session continuously with each organ system introduced and not limiting it to year two, which is at the beginning of the PSP.



Table 2:  Students’ perceptions of areas of strength and suggestions for improvements in the Professional Skills Program at Arabian Gulf University







Discussion



Overall, the clerkship students seemed to value the training received in the PSP, which helped them in establishing good rapport with patients and improved their physical examination skills. However, students found that training in the history-taking domain was not sufficient. They were dissatisfied with the inadequate supervision and limited feedback by the tutors. The program lacked integration between communication skills, history-taking training and clinical reasoning. This needs to be continually revisited with each organ system using different written scenarios in order to increase student exposure to and level of familiarity with clinical scripts, which may improve their recognition and analytical reasoning.



Physical examination skills were considered satisfactory by the majority of the students. They indicated that the coordination between the problems in the PBL curriculum and related knowledge and training in the PSP program implemented at AGU emphasized the relevance of the knowledge and increased its retention. The majority of students agreed that there was no need for training on real patients prior to the clerkship phase within this domain. This was mainly due to the poor supervision when sent to hospitals and to difficulties encountered during the implementation. Practicing physical examination on simulated patients helped students to acquire the needed physical examination skills. Although clinical skills centers provide a ‘different’ context for learning, which can never be captured in the real-life setting (Boulay & Medway, 1999), students were satisfied with the training received in this particular domain.



Our study revealed that key factors for program success are clear objectives, availability of teaching staff feedback and high fidelity simulators. An important problem identified by students was the lack of consistency and standardization of history-taking and physical examination techniques between the faculties. This has been addressed by developing checklists, which describe in detail the techniques of history-taking and physical examinations. Logistics of implementation, such as time-tracking and group size, were important factors which influenced students' opinions and satisfaction.



The acquisition of skills in charting, summary presentations and defining patient problems are important skills that medical students should acquire through training. The General Medical Council Education Committee of the United Kingdom (1993) recommended that "medical students should be able to demonstrate an ability to synthesize the patient data and present a good quality written report.” Similarly, Busari and colleagues (1997) state that "PBL curriculum students should be able to apply their knowledge and use clinical data to reason diagnosis” (Busari et al., 1997). In our program, clinical reasoning skills are introduced early and training takes place through workshops in year two. However, our students indicated that there is still a need to extend the training throughout the program.



Limitations of our study included, first, that all findings reflect self-reports. Actual changes or progress in skills development would require future study. Second, while respectable, our response rate by students could have been higher. The response rate was influenced by the timing of the questionnaire administration during the academic year.



Overall, students’ feedback was constructive, identifying areas of strength as well as suggestions for improvement. The study has led to important changes in the program, particularly related to increased standardization of examination techniques, emphasis on improving reasoning and history-taking skills with each body system and introduction of modern high fidelity simulators.



References



Boulay, C. & Medway, C. (1999). The clinical skills resource: A review of current practice. Medical Education, 33, 185-191.



Busari J.O., Scherpbier A.J., & Boskuizen H.P. (1997). Comparative study of medical education as perceived by students at three Dutch universities. Advances in Health Sciences Education, 1, 141-151.



General Medical Council Education Committee. (1993). Tomorrow's Doctors: Recommendations on Undergraduate Medical Education. London: General Medical Council.



Hamdy, H., Greally, M., Grant, I.N., El Shazli, H., Nayar, U., Rajab, K., AL-Rommi, K., Mohammad, A.M., Al-Awadi, A., & Al-Refai, A.M. (2001). Professional Skills Programme in a problem-based learning curriculum: Experience at the College of Medicine and Medical Sciences, Arabian Gulf University. Medical Teacher, 23, 214-216.



Kirkpatrick, D.L. (Ed.) (1998). Evaluating Training Programs: The Four Levels San Francisco, Berrett-Koehler, Publisher Group West.



Patrick, J. (Eds.) (1992). Training: Research and Practice. San Diego: Academic Press, 487-511.



Remmen, R., Denekens, A., Scherpbier, C., Van Der Vleuten, C., Hermann, I., Van Puymbroeck H., & Bossaert, L. (1998). Evaluation of skills training during clerkships using student focus groups. Medical Teacher, 20, 428-432.



Remmen, R, Scherpbier, A., Van Der Vleuten, C., Denekens, J., Derese, A., Hermann, I. Hoogenboom R., Kramer A., Van Rossum H., Van Royen P., & Bossert L. (2001). Effectiveness of basic clinical skills training programs: A cross-sectional comparison of four medical schools. Medical Education, 35, 121-128.



Whipple, M.E., Barlow, C.B., Smith, S., & Goldstein, E.A. (2006). Early introduction of clinical skills improves medical students comfort at the start of third-year clerkships. Academic Medicine, 81 (10 supp), 540-543.



Williams, R.G., Klamen, D.L., Mayer, D., Valaski, M., & Roberts, N.K. (2007). A sampling strategy for promoting and assessing medical student retention of physical examination skills. Academic Medicine, 82 (10 supp), s22-25.