To compare both the knowledge and self-reported confidence levels between medical students as the team leaders and followers in shock resuscitation simulation training.
A cross-sectional study was conducted with all fifth-year medical students participating in a shock resuscitation simulation-based training between May 2017 and March 2018. The simulation class was a 3-hour session that consisted of 4 shock type scenarios as well as a post-training debriefing. Medical students were assigned into groups of 4–5 members, in which they freely selected a leader, and the rest filled the roles of followers. Of 139 medical students, 32 students were leaders. A 10-question pre-test and post-test determined knowledge assessment. At the end of the class, the students completed a 5-point Likert scale confidence level evaluation questionnaire. A t-test was applied to compare knowledge scores and confidence levels between the leaders and followers.
At the end of the class, the knowledge scores between the leaders (M=6.72, SD=1.51) and followers (M=6.93, SD=1.26) were not different (t(137)= -0.81, p=0.42). In addition, the student confidence levels were also similar between the leaders (M=3.63, SD=0.55) and followers (M=3.41, SD=0.64) after training (t(137)=1.70, p=0.09).
The knowledge and confidence levels were not different between either the leaders or followers in simulated resuscitation. With time-limit simulation training, we suggested every student may not need to fulfil the leadership role, but a well-designed course and constructive debriefing are recommended. Future studies should evaluate skills and longitudinal effects of the leader role.
Simulation-based medical education has matured, especially in anaesthesiology, emergency medicine, and critical care medicine regarding patient safety and resuscitation skills.
A circulatory shock is a generalized form of acute circulatory failure associated with cellular dysfunction that is life-threatening and results in a high mortality rate.
Our institution provides simulation-based training in shock resuscitation for fifth-year medical students. In our previous study, medical students improved their knowledge and confidence levels in septic shock resuscitation.
Growing evidence shows the importance of non-technical skills. For example, effective team leadership in resuscitation is a contributing factor in the effectiveness of resuscitation. The absence of leadership and poor teamwork was shown to be associated with poor cardiopulmonary resuscitation (CPR) performance and negative clinical outcomes.
We aimed to explore the knowledge and confidence levels between medical students as leaders and followers after the completion of simulation-based shock resuscitation courses. We hypothesized that the role of a leader does not affect the knowledge and confidence levels and that every student needs to play the role of the leader in our course.
This was a cross-sectional study conducted at a university-based medical simulation centre in the Faculty of Medicine at Prince of Songkla University, Thailand. The centre consists of several simulation labs with infant, paediatric, and adult patient simulators; a skills lab; computer-based simulators; multimedia debriefing room; and high-fidelity medical manikins. The simulation system includes simulation software programs for manikin control and respiratory and haemodynamic monitoring. Simulation sessions are digitally recorded for playback and debriefing.
All fifth-year medical students were invited to participate in the resuscitation course from May 2017 to March 2018 during their rotation through internal medicine. There were 8 rotations with approximately 18 students per rotation. A total of 139 medical students were enrolled; 32 students (23%) were leaders. Baseline characteristics of the medical students are shown in
The Ethics Committee of the Faculty of Medicine, Prince of Songkla University, approved the study. A waiver of written informed consent was granted by the Ethics Committee at the Faculty of Medicine, Prince of Songkla University because it was a cross-sectional study involving existing curriculum in an educational setting. The study was conducted according to the Belmont report ethical considerations: all participants data were confidential, no harm would be afflicted upon participants during the study, and their refusal in doing tests or questionnaires in the study would have no impact on their course assessment or grades.
| Variable | Leaders n = 32 | Followers n = 107 | p-value |
|---|---|---|---|
| Mean (SD) | Mean (SD) | ||
| Male, n (%) | 18 (56.2) | 52 (48.6) | 0.45 |
| Grade point average* | 3.26 (0.26) | 3.18 (0.26) | 0.13 |
| Pre-test score† | 5.47 (1.68) | 5.27 (1.94) | 0.60 |
| Post-test score† | 6.72 (1.51) | 6.93 (1.26) | 0.42 |
| Pre-training confidence levels‡ | 2.38 (0.79) | 2.39 (0.79) | 0.91 |
| Post-training confidence levels‡ | 3.63 (0.55) | 3.41 (0.64) | 0.09 |
| Overall satisfaction¶ | 8.75 (1.29) | 8.57 (1.20) | 0.49 |
An independent sample t-test is used to compare means of two groups *Grade point average at fourth year in medical curriculum †Pre-test and post-test scores have maximum scores of 10 points ‡Confidence level: 1 (not at all) to 5 (very confident) ¶Overall satisfaction has a maximum score of 10 points (boring to fun)
All students had already passed a 1-hour didactic lecture on shock resuscitation in the fourth year of the medical curriculum. A 3-hour simulated shock resuscitation course was arranged for all students. The course began with an introduction of the goals and objectives. Students did a pre-test for 10 minutes. Then, teachers provided orientation to the manikins and assigned students into 4 groups corresponding to 4 types of shock resuscitation scenarios. Students freely selected their group and chose one leader; the rest of the students were followers. The resuscitation time consumed 10 minutes, and a 20-minute debriefing for each group was completed after the course. At the end of the class, students did the post-test, self-reported their confidence and gave feedback.
| Variable | Pre-training | Post-training | p-value |
|---|---|---|---|
| Mean (SD) | Mean (SD) | ||
| Overall (n=139) | |||
| Test scores * | 5.32 (1.88) | 6.88 (1.32) | < 0.001 |
| Confidence levels † | 2.39 (0.78) | 3.46 (0.63) | < 0.001 |
| Leaders (n= 32) | |||
| Test score * | 5.47 (1.68) | 6.72 (1.51) | < 0.001 |
| Confidence levels † | 2.38 (0.79) | 3.63 (0.55) | < 0.001 |
| Followers (n=107) | |||
| Test score * | 5.27 (1.94) | 6.93 (1.26) | < 0.001 |
| Confidence levels † | 2.39 (0.79) | 3.41 (0.64) | < 0.001 |
A paired sample t-test is used to compare means of two groups *Test scores have a maximum score of 10 points †Confidence level: 1 (not at all) to 5 (very confident)
The Laerdal SimMan high-fidelity patient simulator (Laerdal Medical, Stavanger, Norway) represents a realistic patient in different types of shock. Computer-controlled connections with the manikins showed the haemodynamic and respiratory parameters on a monitor.
Shock scenarios consisted of 4 common types of circulatory shock: septic, cardiogenic, obstructive and anaphylactic shock (an example scenario can be found in
Participants were grouped into four teams for the resuscitation course. Each team consisted of 4–5 members. Students freely selected one student to be a leader. The team members played the roles of leader, nurses, and proceduralist(s). The course instructors assumed the roles of a family member, paramedic, consultant, and lab technician, as needed. Two instructors were present in the room to evaluate team performance and another instructor was in the computer control room.
At the end of each shock scenario, instructors gave an immediate post-action reflection and feedback or debriefing. The debriefing used a standard format,
The students completed a pre-test at the beginning of the simulation course and a post-test at the end of the course. The tests consisted of 10 multiple choice questions to test their knowledge of the four types of shock resuscitation. The validity of the content evaluated by the three subject experts on each item of the tests was greater than 0.6, indicating the tests congruence. Thirty sixth-year medical students were the pilot group for test reliability. Cronbach’s alpha correlation technique was used to ascertain the reliability of the tests, which was 0.81. Task performance was evaluated by two simulation instructors using checklists. At the end of the course, the participants were given a survey questionnaire regarding their attitudes and confidence levels of the simulation course. The confidence levels utilized a 5-point Likert scale that ranged from 1 (not at all) to 5 (very confident).
Descriptive statistics were generated from the test scores and attitude scales. Data were presented as mean and standard deviation (SD). Comparisons between the pre- and post-test scores and pre- and post-course confidence levels were analysed using the independent-samples t-test or paired sample t-test with significance set at a p-value less than 0.05. All statistical analyses were performed using R.
All participants completed the tests and questionnaires. The post-test scores between the leaders (M=6.72, SD=1.51) and followers (M=6.93, SD=1.26) were not different (t(137)= -0.81, p=0.42). The student confidence level as leaders (M=3.63, SD=0.55) was higher than that of the followers (M=3.41, SD=0.64) but not statistically significant (t(137)=1.70, p=0.09). The overall satisfaction in the shock simulation training was high in both groups (
Overall, the knowledge scores of the medical students improved significantly (t(138)=10.55, p<0.001) along with the confidence levels (t(138)=13.83, p<0.001) after training. Both leaders and followers improved test scores and confidence levels after the simulation course (
From our prospective observational study, students taking the role as the leader in our simulation-based training in shock resuscitation course did not gain more knowledge or confidence as compared with the followers.
Simulation-based training creates a safe environment for learning; however, this training requires significant costs and is time-consuming. Previous studies in the simulation of shock management training used various course durations from 5–7 hours
Leadership is a non-technical skill and is an interpersonal skill that is vital and has a significant effect on patient safety outcomes.
Not many studies have focused on leadership skill in shock resuscitation simulation training. Nguyen and colleagues
During emergency situations, an accurate diagnosis and prompt management are crucial. Self-confidence is an important skill in effective decision making.
Our results revealed no difference in the confidence levels between the leaders and followers, with some reasons. First, the groups were small. Everyone had a different role to play but had a chance to express their opinions on the dynamics of the team. Second, constructive debriefing at the end of the simulation provided feedback from everyone concerning their skills and knowledge. Post-simulation debriefing improved the confidence and provided effective learning in the students.
Our study had several limitations. First, we had a relatively small sample size, because we compared participants in the same level and academic year. The number of leaders was less than the number of followers, which may not show different effects. Second, simulation training was conducted in a single centre. Therefore, generalizability should be a concern. Third, we did not survey the personal qualities and behavioural characteristics of the leaders. To understand leadership in detail, there are at least two ways of thinking: styles and situations.
In the setting of our shock simulated training, the role of leader did not affect the knowledge and confidence levels of the medical students during shock resuscitation. Due to time limitations, not every student was able to fulfil the leadership role. A well-designed course and constructive debriefing are recommended in order to improve the confidence levels of medical students. Future studies should assess skills and evaluate the longitudinal effects of the leader role.
The authors gratefully acknowledge Mr Glenn Shingledecker in the International Affairs Department, Faculty of Medicine, Prince of Songkla University for the language correction services.
The authors declare that they have no conflicts of interest.
Appendix 1. Example of shock scenario: Septic shock