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Pal Bikramjit1, Kumar MV1, Nachiappan M1, Soe Htoo Kyaw2, Pal Sudipta3

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Presentation on theme: "Pal Bikramjit1, Kumar MV1, Nachiappan M1, Soe Htoo Kyaw2, Pal Sudipta3"— Presentation transcript:

1 Pal Bikramjit1, Kumar MV1, Nachiappan M1, Soe Htoo Kyaw2, Pal Sudipta3
The effectiveness of high fidelity simulation in undergraduate medical education Pal Bikramjit1, Kumar MV1, Nachiappan M1, Soe Htoo Kyaw2, Pal Sudipta3 Professor, Dept. of Surgery, Manipal Medical College, Melaka, Malaysia Professor, Dept. of Community Medicine, Manipal Medical College, Melaka, Malaysia Lecturer, Manipal Medical College, Melaka, Malaysia

2

3 Introduction Literature review Methodology Results Findings Limitations of the study Conclusion References

4 INTRODUCTION: Benefits Importance Innovativeness Usefulness Purpose of the research Research objectives

5 Introduction INTRODUCTION
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Introduction INTRODUCTION Simulation is not a technology but a technique Replace or augment real experiences with guided experiences Elicit or imitate substantial aspects of real world in a fully interactive manner [1] Simulation is an all-inclusive term encompasses interactive, as well as immersive activity recreation of a part or whole of a clinical experience without putting the patients to the antecedent risks [2]

6 Benefits of Medical Simulators
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Benefits of Medical Simulators To teach therapeutic and diagnostic procedures To develop medical concepts In decision making Simulators have been developed for training procedures ranging from the basics such as blood draw, to laparoscopic surgery [3] and trauma care [4].

7 The importance of simulation in medical education
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education The importance of simulation in medical education It basically animates the curriculum It allows learners to try out and operationalize new knowledge It helps in turning general concepts into practical skills and plan management It imparts an emotional component to the experience It firmly implants new information into memory [5]

8 Innovativeness of high fidelity simulation training solutions
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Introduction Innovativeness of high fidelity simulation training solutions Addresses the number of safety concerns Reduces adverse effects on the patients Replicates clinical case scenarios Repetition of same scenario in a controlled environment Allows practice without risk to patient

9 Usefulness of High Fidelity Patient Simulation [6]
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Usefulness of High Fidelity Patient Simulation [6] To address increasing student enrolment Faculty shortages Limited clinical sites

10 Introduction Literature Review
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Introduction Literature Review 1. According to a study conducted by Bjorn Hoffman - "simulation's ability to address skillful device handling as well as purposive aspects of technology provides a potential for effective and efficient learning” [7] 2. More positive information is found in the article by Kevin Kunkler who opined that, "medical simulators can be useful tools in determining a physician's understanding and use of best practices, management of patient complications, appropriate use of instruments and tools, and overall competence in performing procedures” [8]

11 The effectiveness of high fidelity simulation in undergraduate medical education
3. It is now well recognized that high fidelity patient simulation (HFPS) encourages learning if it is facilitated in appropriate settings [9] 4. High fidelity patient simulators are extensively used to teach diagnostic as well as therapeutic procedures to develop medical concepts that help in decision making [10]

12 Benefits of Facilitated Simulation [11]
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education n Benefits of Facilitated Simulation [11] Encourages to explore emotions and question Stimulates reflective thinking Provides feedback Ultimately reducing morbidity and mortality rates Adds an emotional component to the experience that helps in implanting new information into memory [5]

13 The effectiveness of high fidelity simulation in undergraduate medical education
Current Scenario According to the Institute of Medicine, 44,000 to 98,000 deaths annually are recorded due primarily to medical mistakes during treatment [12]. CDC reported that in the United States, the medical mistakes represents 1.8% to 4.0% of all deaths [13] A near 4% representation of deaths primarily related to medical mistakes is simply unacceptable in the world of medicine. Anything that can assist in bringing this number down is highly recommended and medical simulation has proven to be the key assistant

14 Purpose of this research
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Introduction Purpose of this research Importance of simulation in training medical students are being recognized by academic institutions around the world In spite of proven benefits, it has so far not been formally introduced as a part of curriculum in medical colleges in our settings There are quite a number of studies on the use of high fidelity simulation Most studies had a smaller number of subjects Highlight of our study: To explore the perception of medical students on the usefulness of HFPS Large cohort of 347 participants in our study We looked at several factors in the use of high fidelity patient simulation Ultimate aim was to define how it may benefit the students in real life

15 Benefits of this research
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Benefits of this research It is hoped that our students will be better prepared for tackling surgical emergencies including trauma as junior doctors May enhance the importance of high fidelity patient simulation in undergraduate medical education and its inclusion in the curriculum in near future

16 To analyze the impact of stressors and its relevance
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Research Objectives To evaluate the effectiveness of simulation-based teaching using a high fidelity simulator in acquisition of knowledge and practical skills, by student perception and performance To analyze the impact of stressors and its relevance To plan future teaching methodology based on the study outcomes

17 METHODOLOGY: Type of study and design Data collection Assessment Data analysis

18 Eligibility criteria for participants Inclusion criteria:
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education METHODOLOGY Type of study and General Design: Quasi-experimental time series design with pretest-posttest interventional study Eligibility criteria for participants Inclusion criteria: Both male and female undergraduate (MBBS) final year students of Melaka- Manipal Medical College (MMMC), Malacca, Malaysia Recruited during their surgical posting Informed consent obtained Exclusion criteria: Students who declined for consent

19 Study period: October, 2015 to September, 2017 (24 months)
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Study population Total number of students enrolled = 375 Number of students completed the course = 347 (92.53%) Drop-out number = 26 Declined to participate = 2 Study area: Clinical Skills Simulation Lab of MMMC Study period: October, 2015 to September, 2017 (24 months) Intervention: METIman Pre-Hospital HI-Fidelity Simulator (Serial number: MMP-0418), CAE Healthcare, USA was used for the simulation sessions

20 Data Collection Procedure
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Data Collection Procedure Pilot study involving 50 students to explore the time management, feasibility,  acceptability and validation of the questionnaires prior to the main study The students were allocated into groups Each group consisted of 12 to 15 students Further divided into three teams of 4 to 5 students Pre-brief: students made aware about the confidentiality of the high fidelity simulation sessions the ethical issues involved shown the environment and the functions of the simulator to avoid stress caused by ignorance of the technology used assured that the program was not part of the evaluation process for the surgical curriculum

21 Methodology: First day
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Methodology: First day Self-assessment of initial background knowledge (Pre-test) about surgical emergencies & trauma care and stressor assessment Briefed about the simulation sessions and expected learning outcomes Interactive lecture on ATLS protocol for management of trauma and surgical emergencies like hypovolemic shock due to hemorrhage (gastrointestinal bleeding, hematuria), head injury, tension pneumothorax, hemothorax and burns

22 Each team then participated in trauma simulation session
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education First day (contd.): Three teams in the group were assigned three different scenarios which were chosen randomly from the conditions mentioned above Each team then participated in trauma simulation session Allocated time for each simulation session: Pre-brief (10 minutes), Simulation (20 minutes) and Debriefing (20 minutes) Post-test I

23 The same team had participated in the simulation of the same scenario:
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education The same team had participated in the simulation of the same scenario: (i) after 1 week (second simulation session) followed by Post-test II (ii) at weeks (third simulation session) followed by Post-test III To test their short to medium term retention of knowledge and practical skills Final debriefing Feedback Subsequent sessions

24 The effectiveness of high fidelity simulation in undergraduate medical education
The progress in applied knowledge, psychomotor skills, confidence and stress reduction was assessed individually for each participant Standardized five point (1 to 5) Likert scale questionnaire was developed for Pre-test and Post-tests Ordinal scale (1 to 5) used by the participants to rate the degree of perception Another set of questionnaires is designed to obtain participant feedback after each session on the relevance and usefulness of the simulation experience and usefulness of briefing and debriefing ASSESSMENT

25 For Knowledge Assessment:
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education LIKERT SCALE For Knowledge Assessment: 1 – Very Poor, 2- Poor, 3 – Average, 4 – Good, 5 - Excellent For Simulation Assessment: 1- Strongly Disagree, 2 - Tend to disagree, 3 - Neither agree or disagree, 4- Tend to agree, 5 - Strongly Agree For Stressor Assessment: 1 - No Stress, 2 - Low stress, 3 - Moderate stress, 4 - High stress, 5 - Maximum Stress LIKERT SCALE

26 Microsoft Excel was used for data entry
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Data analysis Microsoft Excel was used for data entry SPSS software (SPSS Inc. Released PASW Statistics for Windows, Version Chicago: SPSS Inc.) for data analysis Descriptive statistics such as frequency and percentage for categorical data, mean and standard deviation for total score of knowledge, simulation assessment and stressor assessment Median, 1st quartile (Q1) ad 3rd quartile (Q3) were calculated for each individual item

27 P-value <0.001 was considered to be statistically significant
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Data analysis (contd.) One-way repeated measure ANOVA with Bonferroni post hoc analysis was used to determine the statistically significant difference in total scores Friedman test was used to determine the statistically significant difference in individual items We checked content and face validity of all assessments For internal consistency, we calculated Cronbach’s alpha coefficient. It was (knowledge), (skills), (stressor) and (feedback) P-value <0.001 was considered to be statistically significant

28 RESULTS: Knowledge assessment Simulation assessment Stressor assessment Feedback assessment

29 The effectiveness of high fidelity simulation in undergraduate medical education
Results Knowledge assessment: Mauchly's test of sphericity indicated that the assumption of sphericity had been violated, χ2(5) = , p <0.001 Greenhouse & Geisser was used to correct the one-way repeated measures ANOVA The total score of knowledge was statistically significant increased over time, F(2.48, ) = , p <0.001 Total score of knowledge assessment progressively increased from 7.99 (SD 3.2) at Pre-test to (2.84) at Post-test III

30 A one-way repeated measures ANOVA
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Results: Knowledge Assessment (Total score) * Table 1: A one-way repeated measures ANOVA * Significant Assessment Knowledge Assessment (Total score) Mean (SD) P-value Pre-test 7.99 (3.28) <0.001* Post-test I 11.66 (2.92) Post-test II 12.52 (2.89) Post-test III 13.33 (2.84)

31 The effectiveness of high fidelity simulation in undergraduate medical education

32 Results: Knowledge Assessment (Pairwise comparison)
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Results: Knowledge Assessment (Pairwise comparison) Table 2: Pairwise comparison of knowledge assessment (total score) with Post-hoc Bonferroni adjustment Between Pre-test And Post-tests Assessment Knowledge Assessment Mean difference (95% confidence interval) P-value Pre-test Post-test I -3.66 (-4.23, -3.10) <0.001* Post-test II -4.52 (-5.16, -3.89) Post-test III -5.33 (-5.99, -4.67) -0.86 (-1.36, -0.35) -1.65 (-2.15, -1.18) -0.81 (-1.24, -0.39)

33 Knowledge Assessment Item
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Table 3: Knowledge assessment (individual item) - Friedman test. * Significant Knowledge Assessment Item 1 – Very poor, 2 – Poor, 3- Average, 4 – Good, 5 - Excellent Knowledge Median (Q1, Q3) P-value  Post-test I  Post-test II  Post-test III ATLS protocol for management of acute trauma 2.0 (1.0, 2.0) 2.0 (2.0, 3.0) 3.0 (2.0, 3.0) <0.001* The management of Hypovolemic Shock 3.0 (3.0, 3.0) The management of Tension Pneumothorax The management of Head Injury 1.0 (1.0, 2.0) The management of Burn Injury 2.0 (1.0, 3.0)

34 Results: Simulation Assessment
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Results: Simulation Assessment Simulation assessment (as perceived by students): Mauchly's test of sphericity indicated that the assumption of sphericity had been violated, χ2(5) = , p = 0.038 Greenhouse & Geisser was used to correct the one-way repeated measures ANOVA The total score of was statistically significant increased over time, F(2.92, ) = , p <0.001 Total score of simulation assessment progressively increased from (5.19) at Pre-test to (7.57) at Post-test III

35 A one-way repeated measures ANOVA with Bonferroni post hoc analysis
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Results: Simulation Assessment (Total score) Table 4: A one-way repeated measures ANOVA with Bonferroni post hoc analysis * Significant Assessment Simulation Assessment (Total score) Mean (SD) P-value Pre-test 30.12 (5.19) <0.001* Post-test I 52.75 (7.59) Post-test II 52.19 (7.06) Post-test III 52.35 (7.57)

36 The effectiveness of high fidelity simulation in undergraduate medical education

37 Simulation Assessment (95% confidence interval)
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Table 5: Pairwise comparison of simulation assessment (total score) with Bonferroni Post-hoc adjustment (as perceived by students) * Significant Assessment Simulation Assessment Mean difference (95% confidence interval) P-value Pre-test Post-test I (-23.81, ) <0.001* Post-test II (-23.20, ) Post-test III (-23.47, ) 0.57 (-0.54, 1.68) 0.999 0.40 (-0.97, 1.67) -0.16 (-1.26, 0.94)

38 Simulation Assessment Item
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Table 6: Simulation assessment (individual item) - Friedman test * Significant Simulation Assessment Item 1- Strongly Disagree, 2 – Tend to disagree, 3 – Neither agree or disagree, 4 – Tend to agree, 5 – Strongly Agree Simulation Median (Q1, Q3) P-value  Post-test I  Post-test II  Post-test III The session level was appropriate to my present level of knowledge and experience 3.0 (2.0, 3.0) 3.0 (3.0, 3.0) 0.018 It encouraged my active participation 3.0 (3.0, 4.0) <0.001* The training session resembled a real life situation It helps me to think quickly Clinical management more easily learned 3.0 (3.0, 3.5) 0.470

39 Simulation Assessment Item
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Table 6 (contd.): Simulation assessment (individual item) - Friedman test * Significant Simulation Assessment Item 1- Strongly Disagree, 2 – Tend to disagree, 3 – Neither agree or disagree, 4 – Tend to agree, 5 – Strongly Agree Simulation Median (Q1, Q3) P-value  Post-test I  Post-test II  Post-test III Repetition of the scenario during training is essential 3.0 (3.0, 4.0) <0.001* Pausing and teaching during simulation reduced the realism 2.0 (2.0, 3.0) 3.0 (2.0, 3.0) 2.0 (2.0, 2.0) 0.403 The training session was enjoyable 0.001* The facilitator interfered too much during simulation - 1.0 (1.0, 2.0) 2.0 (1.0, 3.0) 0.092 Time for the scenario was adequate 3.0 (3.0, 3.0) 0.205

40 Briefing and De-briefing:
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Table 6 (contd.): Simulation assessment (individual item) - Friedman test * Significant Briefing and De-briefing: 1- Strongly Disagree, 2 – Tend to disagree, 3 – Neither agree or disagree, 4 – Tend to agree, 5 – Strongly Agree Skills Median (Q1, Q3) P-value  Post-test I  Post-test II  Post-test III Time for initial briefing was adequate 3.0 (3.0, 4.0) 3.0 (2.0, 3.0) 3.0 (3.0, 3.0) <0.001* Time for debriefing was adequate - 0.007 Debriefing helped me to learn better 0.225 The debriefing style was effective 0.296

41 The effectiveness of high fidelity simulation in undergraduate medical education
Table 6 (contd.): Simulation assessment (individual item) - Friedman test * Significant Affective: 1- Strongly Disagree, 2 – Tend to disagree, 3 – Neither agree or disagree, 4 – Tend to agree, 5 – Strongly Agree Skills Median (Q1, Q3) P-value  Post-test I  Post-test II  Post-test III I want to have further sessions on the simulator 3.0 (3.0, 4.0) 4.0 (3.0, 4.0) <0.001* I feel that simulation is essential to train in trauma management - Learning Outcomes: I have achieved all my learning objectives 3.0 (2.0, 3.0) 0.110 Confident of managing trauma scenario in real life 2.0 (2.0, 3.0)

42 Results: Stressor Assessment
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Results: Stressor Assessment Stessors assessment (as perceived by students): Mauchly's test of sphericity indicated that the assumption of sphericity had been violated, χ2(5) = , p <0.001 Greenhouse & Geisser was used to correct the one-way repeated measures ANOVA The total score of stressors was statistically significant increased over time, F(2.824, ) = , p <0.001 Total score of stressor assessment progressively decreased from (SD 8.16) at Pre-test to (9.59) at Post-test III

43 Results: Stressor Assessment (Total score)
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Results: Stressor Assessment (Total score) Table 7: A one-way repeated measures ANOVA with Bonferroni post hoc analysis * Significant Assessment Stressor Assessment (Total score) Mean (SD) P-value Pre-test 27.41 (7.32) <0.001* Post-test I 25.98 (8.16) Post-test II 24.92 (8.71) Post-test III 24.54 (9.59)

44 The effectiveness of high fidelity simulation in undergraduate medical education

45 (95% confidence interval)
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Table 8: Pairwise comparison of stressor assessment (total score) with Bonferroni Post-hoc adjustment (as perceived by students) Assessment Stressor Assessment Mean difference (95% confidence interval) P-value Pre-test Post-test I 1.43 (0.19, 2.66) 0.013 Post-test II 2.49 (1.17, 3.80) <0.001* Post-test III 2.87 (1.38, 4.36) 1.06 (-0.13, 2.25) 0.114 1.44 (0.15, 2.73) 0.019 0.38 (-0.82, 1.6) 0.999

46 Stressor Assessment Item:
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Table 9: Stressor assessment (individual item) - Friedman test * Significant Stressor Assessment Item: 1 – No stress, 2 – Low stress, 3 – Moderate stress, 4 - High stress, 5 – Maximum stress Stressors Median (Q1, Q3) P-value  Post-test I  Post-test II  Post-test III Difficulty in understanding the content 3.0 (3.0, 4.0) 3.0 (2.5, 4.0) 3.0 (2.0, 3.0) 3.0 (2.0, 4.0) 0.127 Need to do well (self-expectation) 4.0 (3.0, 4.0) < 0.001* Competition due to working in a team 0.001* Shortage of time during training session Feeling of incompetence in managing patient

47 Stressor Assessment Item
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Table 9 (contd.): Stressor assessment (individual item) - Friedman test * Significant Stressor Assessment Item 1 – No stress, 2 – Low stress, 3 – Moderate stress, 4 - High stress, 5 – Maximum stress Stressors Median (Q1, Q3) P-value  Post-test I  Post-test II  Post-test III Death of the simulated patient 4.0 (3.0, 4.5) 4.0 (3.0, 5.0) 4.0 (3.0, 4.0) 0.001* Conflict with other students 3.0 (2.0, 3.0) 2.0 (2.0, 3.0) < 0.001* Need to participate in scenario 3.0 (3.0, 4.0) 3.0 (2.0, 4.0) 0.016 Participation in debriefing 0.009 Not knowing my role in the team

48 Stressor Assessment Item:
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Table 9 (contd.) : Stressor assessment (individual item) - Friedman test. * Significant Stressor Assessment Item: 1 – No stress, 2 – Low stress, 3 – Moderate stress, 4 - High stress, 5 – Maximum stress Stressor Median (Q1, Q3) P-value  Post-test I  Post-test II  Post-test III Lack of appreciation to my contribution in the team 4.0 (2.0, 4.0) 3.0 (2.0, 3.0) < 0.001* Stress as instructor is observing 4.0 (3.0, 4.0) 3.0 (3.0, 4.0) Stress as fellow classmates are observing 3.0 (2.0, 4.0) 0.001*

49 The effectiveness of high fidelity simulation in undergraduate medical education
Table 10: Descriptive statistics of feedback assessment at the end of training course 1 – Strongly disagree, 2 – Tend to disagree, 3 – Neither agree or disagree, 4 – Tend to agree, 5 – Strongly agree Feedback Item Median (Q1, Q3) Could you get the best out of this training? 4.0 (4.0, 4.0) Simulated training sessions better than didactic teaching 4.0 (4.0, 5.0) I was able to participate actively Debriefing is better after simulation I would prefer a chance to correct wrong actions during a scenario I would prefer a chance to correct wrong actions after a scenario 4.0 (3.0, 4.0)

50 FINDINGS: Knowledge assessment Simulation assessment Briefing and Debriefing Stressor assessment

51 The study showed that HFPS had made a difference
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Our main objective was to determine usefulness of HFPS as a teaching or learning tool for management of surgical emergencies The study showed that HFPS had made a difference in enhancing the knowledge and skills over time in management of trauma and surgical emergencies as perceived by our students Learning and skills had significantly improved with each session of simulation learners’ attitudes were supportive of simulation

52 The effectiveness of high fidelity simulation in undergraduate medical education
The study corroborates the findings of Wayne, Barsuk, O’Leary, Fudala, & McGaghie (2008) who showed that internal medicine residents had increased knowledge and skills using simulation technology and deliberate practice [14] Participants in one study (Okuda et al., 2009) felt simulation based teaching was a reliable tool for assessing learners by providing good feedback on performance which was similar to our observation [15]

53 The effectiveness of high fidelity simulation in undergraduate medical education
In a study by Founds, Zewe, & Scheuer (2011), participants felt that high fidelity simulators can present simulations that were closer to real life situations which was similar to opinion of most of our students [16]. The study revealed that simulation sessions with high fidelity simulators encouraged active participation of students who need further sessions on simulation for better understanding of clinical problems and knowledge acquisition

54 The effectiveness of high fidelity simulation in undergraduate medical education
Findings The finding in one of the main area of study: “Clinical management more easily learned” was not satisfactorily documented (p < 0.470). It showed that simulation did not always help in better understanding of management of clinical problems

55 Findings: Briefing and Debriefing
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Findings: Briefing and Debriefing The time for briefing was adequate but participants felt that Time for debriefing was inadequate and Debriefing did not help them to learn better This was an area of utmost concern to us as we concluded that there was a definite lacuna in our debriefing process We planned to rectify our shortcomings and deficiencies in this matter

56 The effectiveness of high fidelity simulation in undergraduate medical education
Findings: Stressors The drop in stress was significant at week II and III but flattened out in week IV which might be due to participants’ increasing adaptability to simulated atmosphere This is similar to the findings by Lasater who reported that stress tend to decrease with continued practice [17]. Similarly, the study by Ghazali DA, Ragot S, Oriot D (2016) revealed that stress declined over time with the repetition of simulation sessions [18]. Fauquet-Alekhine P. et al. (2014) also observed that progressive simulation sessions helped to reduce stress of the students [19]..

57 “Seeing a patient die” is significantly more stressful [20]
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education The stressors showed significant drop in scores with repeated simulation sessions (p < 0.001) except in the category of “Death of a simulated patient” The highest stressor score in our study was noted in “Death of the simulated patient”, which is similar to the finding by Lasater (2007) who reported that students experienced maximum stress during simulation in relation to the anticipation of an unexpected event [17] “Seeing a patient die” is significantly more stressful [20]

58 The next two high stressor scores in our study were:
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Findings: Stressors The next two high stressor scores in our study were: “Feeling of incompetence in managing patient” “Need to do well (self-expectation)” “Competition due to working in a team” showed moderate stressor score in comparison low score in Cato’s study [21]. The stressor score in the category “Participation in debriefing” showed moderate level all throughout the simulation training course

59 The effectiveness of high fidelity simulation in undergraduate medical education
Mary Louis Cato, in her study, had shown that the possibility of making a mistake during simulation sessions led to maximum stress followed by being observed on camera and performance in front of faculty and friends [21] The same was observed in our study where the students perceived very high stress when the faculty and colleagues were present during the simulation sessions.

60 The effectiveness of high fidelity simulation in undergraduate medical education
Presence of peers during simulation sessions may result in increased stress [22] Boostel Radamés et al. (2018) study also showed that the participants in high fidelity patient simulation had increased perception of stress related to interpersonal relationships with patients, faculty and colleagues [20]

61 There was significant improvement in the following areas:
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education There was significant improvement in the following areas: ATLS protocol for management of Acute Trauma The Management of Hypovolemic Shock The Management of Tension Pneumothorax The Management of Head Injury

62 The participants strongly agreed that:
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education The participants strongly agreed that: The session level was appropriate to their current level of learning It encouraged active participation of the participants Need further sessions on simulation for better understanding of clinical problems, knowledge acquisition and perfecting clinical skills Simulation is essential to train in trauma management

63 Limitations of the study:

64 Limitations of this study
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Limitations of this study The study was conducted on the information provided by students. There is a chance of selection bias due to volunteer nature of inclusion criteria The participants' interpretation of the questions and subjective nature in reporting their perception may result in reporting bias The study dealt with some variables like simulation course implementation, curricular integration, faculty expertise and student characteristics which might had influenced the findings

65 Limitations of this study
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Limitations of this study The standard assessment for knowledge and skills with MCQ and OSCE respectively were not used. The findings were as perceived by the students during simulation sessions Lastly, this is a single center study and only included the final year medical students and consequently the findings may not be applicable to other settings

66 Conclusion:

67 The effectiveness of high fidelity simulation in undergraduate medical education
Conclusion Students’ favorable perception on high fidelity patient simulation in this study indicated that there is a valid need for its mandatory inclusion in undergraduate medical curriculum Simulation based medical education may be helpful in preparing students to cope and respond more satisfactorily to stressful events in real clinical practice It is hoped that this will translate into improved patient care and healthcare safety when these students progress as junior doctors further down their career path

68 Plan for future research study
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Plan for future research study Encouraging results and students’ active participation in this study helped us to plan a Randomized Controlled Study: “A prospective randomized controlled trial on the effectiveness of high fidelity simulation in undergraduate medical education in comparison to conventional educational methods” It has started in October 2018 and the pilot study with 56 students has been completed. The main study is scheduled to start in March 2019 and will involve about 200 students

69 Declaration of Interest:
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Ethical Approval: Duly taken from the IRB & IEC, Melaka-Manipal Medical College Acknowledgements: The final year MBBS students of Melaka-Manipal Medical College who had participated in this research project The Faculty of the Department of Surgery The lab assistants and technicians of Clinical Skills Lab The Management of Melaka-Manipal Medical College Declaration of Interest: The authors have not received any funding or benefits from industry or elsewhere to conduct this study and have no conflicts of interest

70 References:

71 The effectiveness of high fidelity simulation in undergraduate medical education
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72 The effectiveness of high fidelity simulation in undergraduate medical education
References 5. Richard, L.L. (2007). Simulation: The New Teaching Tool. Annals of Emergency Med, 49(4), 6. Schoenig, A.M., Sittner, B.J., Todd, M.J. (2006). Simulated clinical experience: nursing students’ perceptions and the educators’ role. Nurse Educ., 31 (6), 7. Hofmann, B. (2009). Why simulation can be efficient: On the preconditions of efficient learning in complex technology based practices. BMC medical education, 9(1), 48. 8. Kunkler, K. (2006). The role of medical simulation: an overview. Int. J. Med. Robotics Comput. Assist. Surg., 2(3), 9. Issenberg, S.B., McGaghie, W.C., Petrusa, E.R., Lee, G.D., Scalese, R.J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach, 27(1),

73 The effectiveness of high fidelity simulation in undergraduate medical education
References 10. Cooper, J.B., Taqueti, V.R. (2008). A brief history of the development of mannequin simulators for clinical education and training. Postgrad Med J., 84(997): 11. The INASCL Board of Directors (2011). Standard I: Terminology. Clinical Simulation in Nursing, 7(4S), s3-s7. 12. To Err Is Human: Building a Safer Health System. Institute of Medicine (IOM) Kohn, L.T., Corrigan, J.M., Donaldson, M.S. (Eds.). (2000). To Err Is Human: Building a Safer Health System. Institute of Medicine (US) Committee on Quality of Health Care in America. Washington (DC), National Academies Press (US). 13. "How Common Are Medical Mistakes“. wrongdiagnosis.com Retrieved November 30, 2008. 14. Wayne, D. B., Barsuk, J. H., O’Leary, K. J., Fudala, M. J., & McGaghie, W. C. (2008). Mastery Learning of Thoracentesis Skills by Internal Medicine Residents Using Simulation Technology and Deliberate Practice. Society of Hospital Medicine, 3(1),

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References 15. Okuda, Y., Bryson, E. O., De Maria, S. Jr., Jacobson, L., Quinones, J., Shen, B., & Levine, A. l. (2009). The utility of simulation in medical education: What is the evidence?. Mount Sinai Journal of Medicine, 76(4), 330–43. 16. Founds, S. A., Zewe, G., & Scheuer, L. A. (2011). Development of high fidelity simulated clinical experiences for baccalaureate nursing students. Journal of Professional Nursing, 27(1), 5–9. 17. Lasater, K. (2007). High-fidelity simulation and the development of clinical judgment: students' experiences. J Nurs Educ., 46(6), 18. Ghazali, D.A., Ragot, S., Oriot, D. (2016). Salivary Cortisol Increases after One Immersive Simulation but the Repetition of Sessions does not Blunt it. Ann Clin Lab Res., 4(2), 83.

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References 19. Fauquet-Alekhine, P., Geeraerts, T., Rouillac, L. (2014). Characterization of anesthetists’ behavior during simulation training: performance versus stress achieving medical tasks with or without physical effort. Psychology and Social Behavior Research, 2(2), 20. Boostel, R., Felix, J.V.C., Bortolato-Major, C., Pedrolo, E., Vayego, S.A., Mantovani, M.F. (2018). Stress of nursing students in clinical simulation: a randomized clinical trial. Rev Bras Enferm [Internet], 71(3), 21. Cato, M.L. (2013). Nursing Student Anxiety in Simulation Settings: A Mixed Methods Study. Dissertations and Theses. Paper /etd Portland State University. 22. Alhedaithy, A., Mesmar, R., AlBawardy, N., AlOmari, A., Munshi, F., Lababidi, H., Georgiou, E. (2018). Stress Among Medical Students during Simulation Training at King Saud bin Abdulaziz University for Health Sciences. The Egyptian Journal of Hospital Medicine, 71(4), Page

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Final year medical students participating in a simulation session at clinical skills lab of MMMC

77 Feedback and Evaluation or visit the kiosks next to registration
The effectiveness of high fidelity simulation in undergraduate medical education The effectiveness of high fidelity simulation in undergraduate medical education Feedback and Evaluation Your kind feedback and evaluation are highly solicited Please leave your feedback at or visit the kiosks next to registration Contact details: Dr. Bikramjit Pal; Professor of Surgery, Melaka-Manipal Medical College, Malacca, Malaysia

78 The effectiveness of high fidelity simulation in undergraduate medical education

79 The effectiveness of high fidelity simulation in undergraduate medical education
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