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Introduction
At present, education in Health Sciences requires interaction with real patients, which is made more complex due to the need to ensure their health safety. For this reason, new teaching methodologies are now being implemented, which help to improve and protect safe care 1,2.
This requires a different way of teaching, where professionals develop critical and reflective thinking and skills that allow them to face different clinical situations while protecting the safety of their patients. In other words, a change in learning strategies, given that, as the article points out, educational models based on the acquisition and development of skills began to be applied in Latin America in the early 2000s 3,4.
The International Institute for Higher Education in Latin America and the Caribbean (IESALC), in 2006, released "The Metamorphosis of Higher Education", a document that shows the main transformations and challenges of higher education, highlighting the need to analyze the training processes that are developed in universities 5. In relation to the above, universities in Latin America, concluded that it was necessary to move toward a curriculum based on competencies 5,6, setting aside traditional class lecturing in favor of approaches incorporating more collaborative, dynamic and personalized learning 7,8.
Working under a competency model puts students at the center and teaches them to develop skills and aptitudes corresponding to their disciplinary work, allowing them to integrate different types of knowledge and learning that bring them as close as possible to the real life context 5. This encourages putting into practice new teaching-learning styles, where not only knowledge is reflected, but also the skills and abilities grouped into competencies that students must acquire to complete their learning process 9.
Clinical simulation is an interactive learning method that replicates real-life situations 10,11. This allows the development of skills and qualities, integrating theoretical and practical knowledge 12,13 as well as human factors, enhancing clinical skills, and where the student is able to face challenging situations in a safe environment, including the possibility of making mistakes, visualizing the mistake and looking for new learning opportunities 14.
The incorporation of simulated clinical practice can be developed in various ways, one of which is role playing. This can be defined as a theatrical representation of a real situation, where there is a simulated or standardized patient, who is an actor trained to play an active role, representing a real story in a simulated context, thus allowing the student to put into practice the theoretical knowledge learned and explore the vulnerability of the patient in a safe space 15. This methodology, applied and supervised by the teaching teams, favors self-learning and autonomous work within the same simulation context 16.
In Chile, clinical simulation is used as a teaching-learning methodology in the training of health professionals, preferably in careers such as medicine and nursing, but it is incipient in nutrition and dietetics careers, representing a potential tool for student learning. It is therefore relevant to learn how those students perceive the use of this tool.
The Universidad Católica de Temuco (UCT) has put into action an educational model based on competencies, adjusted to the current requirements of higher education 17. In this way, the Nutrition and Dietetics career has implemented clinical simulation with dramatization in two subjects of the curriculum (Evaluation of Nutritional Status and Nutritional Care in the Life Cycle) and is used as an innovative student-centered teaching strategy.
Hypotheses. The perception of undergraduate students of Nutrition and Dietetics regarding clinical simulation with dramatization is positive learning strategy and the simulation will be a good educational paradigm based on the acquisition of competences.
Material and methods
Participants
This study was carried out during one year using a quantitative approach with a non-experimental, descriptive design 1. The sample was non-probabilistic for convenience and consisted of 87 undergraduate students.
Instrumentation
A questionnaire was used, with 18 statements divided into 3 dimensions: dimension 1, simulation structure, with six questions reflecting aspects related to its implementation; dimension 2, learning, with seven questions related to aspects of effective communication, trust, learning and respect for diversity; dimension 3, feedback for learning, with five questions, including feedback by the teacher and the simulated patient, as well as their own views with regard to participating in another similar experience again. A five-point Likert scale was used (ranging from 5= Strongly agree to 1 = Strongly disagree). The sum of the points attributed to each item defined the total score, ranging from 18 to 90 points. This questionnaire was designed and applied by the researchers, and its content validity was tested by means of the Delphi method 18.
Ethical aspects
This study was approved by Research Ethic Committee of Universidad Católica de Temuco Chile. Voluntary and informed participation was considered, together with the protection of personal data through the codification of the students’ identities. Participants were informed that they could withdraw from the study at any time.
Data analysis
To determine differences (p < 0.05) between the variables analyzed (gender, university career year and previous experience in simulation) based on observed responses, the following was conducted Kruskal-Wallis test followed by Dunn’s post-hoc test, the analysis was carried out with R software. A Non metric multidimensional scaling (nMDS) analysis was performed to visualize the pattern of responses observed for the different generations based on the set of questions studied calculated from the Bray Curtis similarity matrix, the software PRIMER v6 (PRIMER-E Ltd.) were used for nMDS data analysis.
Results
The sample was non-probabilistic and consisted of 86 undergraduate students, made up of 74 women (86%) and 12 men (14%). A convenience sampling method was used and the participants were accessed through the teachers of the courses.
The age of the participants ranged between 20-24 years, (69%) and 25-30 years, (31%). All students of the Nutrition and Dietetics career at UC Temuco who were currently enrolled in the subject of Nutritional Assessment (4th semester) or Nutritional Care in the Life Cycle (8th semester), were asked whether they would like to participate voluntarily in the study.
Table 1 shows the central tendency values obtained by the students regarding the variables gender, year of career and prior experience in the use of clinical simulation in any subject, in each of the indicated dimensions. In turn, Table 2 shows that in the three dimensions studied (simulation structure, learning and feedback for learning) high percentages of positive perceptions (86,2 %, 89,9 % and 87,4 %) were reported by the participants in relation to clinical simulation with dramatization as a teaching strategy. The percentages were obtained from the application of a Likert scale, where the students were asked to fill in a questionnaire encompassing the above-mentioned three dimensions and were given a 20-minute deadline to respond. In the non-metric multidimensional scaling (nMDS, Figure 1) a high similarity in the response pattern is evidenced with a stress value <0.2 (good representation in reduced dimensions), this pattern of student responses presents between 87-90% of similarity, among the generations analyzed in this study there is a 10% dissimilarity, which raises a cross-sectional system of questions compared to a group of students from different generations. According to figure 1, a high correlation is observed between the observed response patterns and the evaluated questions (Pearson's correlation <0.2), questions of dimension 1 such as Q1, Q5, Q6 are strongly correlated with the observed response pattern. among students of the 3 generations.
Table 1: Shows the central tendency valuers obtained by the students regarding the variables gender, year of career and prior experience in the use of clinical simulation in any subject, in each of the indicated dimensions.
| Variable | Simulation structure Dimension 1 | Simulation structure Dimension 2 | Simulation structure Dimension 3 | Perception | |
|---|---|---|---|---|---|
| Gender | Male | 4,47 ± 0,39 | 4,31 ± 0,69 | 4,37 ± 0,73 | 4,38 ± 0,54 |
| Female | 4,37 ± 0,51 | 4,48 ± 0,52 | 4,51 ± 0,47 | 4,46 ± 0,44 | |
| University carrer year | 3° | 4,01 ± 0,52a | 4,33 ± 0,48a | 4,24 ± 0,58b | 4,19 ± 0,44b |
| 4° | 4,59 ± 0,34b | 4,64 ± 0,46b | 4,74 ± 0,39a | 4,66 ± 0,35a | |
| 5° | 4,43 ± 0,47b | 4,36 ± 0,62ab | 4,40 ± 0,49b | 4,40 ± 0,48b | |
| Previous exprerience in simulation | Yes | 4,50 ± 0,46a | 4,55 ± 0,50 | 4,61 ± 0,42a | 4,55 ± 0,41a |
| No | 4,23 ± 0,49b | 4,33 ± 0,59 | 4,32 ± 0,60b | 4,29 ± 0,49b |
Statistically significant differences (P < 0.05) are marked with different letters (Kruskal-Wallis test followed by Dunn’s post-hoc test). Descriptive statistics of variables: sex, year of degree and previous experience of having used clinical simulation in any subject. Likert scale was used in each dimension. 1 = totally agree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = totally agree. Average + SD.
Table 2: Dimensions studies
| ITEM | Frecuency | ||
|---|---|---|---|
| N | % | Average | |
| Dimension 1: simulation structure | |||
| Q1. The simulation is related to the contents developed in the subjects taken | 86 | 100 | 4,85 ± 0,36 |
| Q2: The information previously provided in the clinical file is related to the assigned case | 81 | 94,2 | 4,70 ± 0,46 |
| Q3: The information provided allowed me to put my performance into practice | 80 | 93,0 | 4,75 ± 0,43 |
| Q4: The characterization of the patients favors the case to be simulated | 72 | 83,7 | 4,57 ± 0,50 |
| Q5: I consider the time allotted to carry out the simulation adequate | 59 | 68,6 | 4,56 ± 0,50 |
| Q6: The materials and infrastructure resources used favor the development of the simulation | 67 | 77,9 | 4,60 ± 0,49 |
| 74 | 86,2 | 4,67 ± 0,11 | |
| Dimension 2: learnings | |||
| Q7: Working with simulation has allowed me to integrate the theoretical - practical content in my performance | 79 | 91,9 | 4,76 ± 0,43 |
| Q8: The simulation strategy allowed me to develop the learning results of the evaluated subject | 75 | 87,2 | 4,57 ± 0,49 |
| Q9: The simulation has favored my clinical reasoning and decision making | 79 | 91,9 | 4,62 ± 0,49 |
| Q10: The simulation has favored effective communication with the user and/ or family member who accompanies him | 74 | 86,0 | 4,59 ± 0,49 |
| Q11: The simulation has allowed me to develop confidence and security in my performance | 74 | 86,0 | 4,62 ± 0,48 |
| Q12: The simulation has allowed me to respect the cultural and social diversity of people | 78 | 90,7 | 4,68 ± 0,47 |
| Q13: Simulation as a teaching method has favored my own learning | 82 | 95,3 | 4,67± 0,47 |
| 77 | 90 | 4,65 ± 0,06 | |
| Dimension 3: Learning feedback | |||
| Q14: the teacher´s feedback after the simulation has been carried out contributes to my learning | 78 | 90,7 | 4,79 ± 0,40 |
| Q15: Feedback from the simulated patient after the simulation has been done contributes to my learning | 61 | 70,9 | 4,69 ± 0,46 |
| Q16: He would like to participate in the simulation again in others subjects | 80 | 93,0 | 4,80 ± 0,40 |
| Q17: The simulation has been a motivating activity in my professional training process | 77 | 89,5 | 4,66 ± 0,47 |
| Q18: The simulated cases are consistent with the level of proffesional training in which I find myself | 80 | 93,0 | 4,73 ± 0,45 |
| 75 | 87,4 | 4,73 ± 0,06 | |
| Perception of clinical simulation with dramatization in each of the dimensions | |||
| Perception of clinical simulation (%) | |||
| Simulation structure | Learning | Feedback for learning | |
| 86,24 | 89,87 | 87,44 | |
R Core Team (2014) R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria URL https://www.R-project.org/
Discussion
The three dimensions studied in this study, simulation structure, learning and feedback for learning, report a high level of positive perceptions which reflects that the simulation strategy is an educational tool in health-related careers that enhances the clinical competencies of the students as well as the relevant theoretical and practical skills and abilities in their learning process, promoting integration of the knowledge acquired in previous subjects 6.
This finding is corroborated by different international educational entities, showing that clinical simulation in the training of health professionals has a positive impact as a teaching-learning methodology 19.
Working on the dramatization with a standardized patient facilitates the teaching process by enhancing clinical reasoning and decision-making in different clinical situations, where the student gets to interact with the patient, focusing not only on the procedure but also on establishing a relationship with him/her. This contributes to the confidence that learners develop when facing a real user 9,19. As proposed by Harder 20, simulation significantly improves patient safety.
This strategy allows immediate feedback from the teacher, which is well accepted by students since it allows them to correct mistakes and to improve and reinforce the skills, abilities and knowledge acquired, and this is consistent with what was noted in the research of Ávila et al. 19.
As Moya et al. 21 suggest, clinical simulation as a teaching methodology can contribute to the training of health science professionals, affording students a closer view of reality as well as bolstering their self-confidence while ensuring patient safety, thus significantly improving their perception of this methodology. As stated by Harder 20, simulation has proven to be effective in enhancing safety competencies in the different disciplines
As similarly proposed by Zambrano 13, this strategy makes it possible to integrate theoretical and practical concepts through the deployment of skills and qualities.
It is an important part of the process to have controlled and safe simulated scenarios, as close to reality as possible, allowing students to make mistakes and learn from those mistakes, focusing on their self-reflection and self-evaluation for their own learning.
Our results are consistent with the various studies regarding the evaluation of clinical simulation as a teaching method, together with what is expected from its development in the enrichment of skills, knowledge, techniques and good performance.
Conclusion
Continual evaluation of the direct participants and their views regarding the method is essential for the improvement of the model and its contribution to the training process 14,22, and should include asking them their opinion on a regular basis.
It is also relevant to deepen the students' perception regarding clinical simulation in order to identify opportunities and improvements in the strategy, thus enriching the learning process.
In this study the undergraduate students of Nutrition and Dietetics found that the clinical simulation with dramatization was a positive learning strategy. The results obtained are a valuable contribution to the training of students in the health sciences, especially in the nutrition career, where clinical simulation is used today, but in an incipient way. Our results demonstrated that the simulation will be a good educational paradigm based on the acquisition of competences.
