Sixth Class Students ' Performance and Confidence Levels Before and After Training in Clinical Skills Laboratories

Background: Acquisition of basic clinical skills by undergraduate medical students is becoming of greater concern. Clinical skills laboratories may provide a comfortable environment for training and may allow students to gain adequate performance level. The aim of this study is to evaluate students' performance and confidence levels before and after training of selected procedural skills; also to explore students' expectation towards skills laboratory training. Methods: Two questionnaires were conducted before and after training sessions in the clinical skills laboratory, school of medicine, University of Jordan, Amman, Jordan. The skills selected for this study: suture practice, venous access, arterial access, intradermal and intramuscular injection, central venous cannulation, male and female urinary catheterization, nasogastric tube placement and rectal examination. Although fifty-seven 6th year medical students filled the first questionnaire at the beginning before training, only 29 students could attend all training sessions, and fill the second questionnaire. Results: For all trained clinical skills, the mean students' performance scores and confidence levels were significantly increased after training (P <0.001). Expectations of students for skills laboratory were high. Conclusions: The students' performance and confidence levels were significantly improved after training in the clinical skills laboratory.


Introduction
The teaching of basic medical knowledge and acquiring the essential clinical skills are important aspects of professional medical practice. 1After being taught the basic medical knowledge during the pre-clinical phase, the students learn the practical clinical skills by interacting with patients throughout clerkships and clinical rotations during their clinical years.4] This is largely limited by time and availability of patients. 5 In the recent years, CSLs have been established in many medical schools around the world [11][12] as they have become an essential part of the training program. 135] In addition, CSLs allow students to learn from mistakes as they perform the first clinical skills on manikins. 14they create a comfortable environment for tutors to demonstrate the clinical procedures step-by-step and to give students the opportunity of performing the skills using manikins 16 as well as repeating them until reaching a good performance level. 17All of these advantages provide optimal training and preparation for clerkships. 7,18  aim of this study is to determine the effectiveness of CSLs on undergraduate medical students assessing their performance and confidence levels, before and after training of some selected procedural skills.In addition, students' expectation and attitude towards CSLs were investigated.

Methods
Evaluation of a training program designed to increase clinical skills on medical students.In the fall of 2015 (November-December), all (n=57) 6th year medical students, who were in the beginning of their surgical clerkship, were invited to participate in clinical skills training.The study was approved by the Institutional Review Board of Jordan University School of Medicine.

Participants and setting
The medical curriculum at the university is divided into two parts: teaching the basic sciences during the first three preclinical years and learning of clinical sciences during clerkships at the last three years.Students directly enroll into clinical rotations after they complete learning the basic sciences.The age distribution was homogeneous and sex ratios were similar.Providing training and data collection was carried out by the same coordinator so that the possibility of any bias that could have arisen from different executives was eliminated.

Original Article
At the beginning of the training, simple clinical background information for each clinical skill was provided by the tutors.
After that, the tutors demonstrated the procedures in a stepby-step manner prior to practice.The students then, under the supervision of the tutors, practiced the skills in similar clinical settings using manikins at the CSL.They were allowed to repeat the procedures as many times as they want until performing the skills competently.This is done by the availability of enough manikins and providing sufficient materials for training.The whole training took place at an interactive skills lab affiliated with Jordan University Hospital which utilized trained simulation patients and different models.

Data Collection
This study was planned as a cross-sectional survey.Data was collected using two anonymous questionnaires, which were modified from previously published studies to compare our results with others.19 The first questionnaire was distributed and collected before the beginning of the training sessions and the second questionnaire after the training was completed.
The first questionnaire consisted of general items identifying the students' attitude, expectations regarding skills laboratory training (SLT), and exploring their confidence level with similar items conducted at the second questionnaire.These were investigated as outcome measures.The questionnaire utilized a rating scale ranging from 1 point to 4 points.In addition, students were asked to self-evaluate their skills on a ten point scale in both questionnaires.

Statistical Analysis
Descriptive statistics of the results were computed as frequencies (count and percent), Mean±Standard Deviation and Median depending on the variable studied.Fisher-Freeman-Halton exact test was used for differences between before and after training about distributions of the answers.The differences between before and after training were evaluated using the Mann-Whitney U test with regard to performance score.A P value less than 0.05 was defined as statistically significant.All computations were performed with use of the PASW (ver.18) program.

Results
57 volunteer students (27 female, 30 male) answered the baseline questionnaire and 29 students (14 female, 15 male) answered the follow-up questionnaire.Ages of the students were similar to each other (min 23, maximum 25).

Students' expectations and attitude towards skills laboratory before training
All the invited students (n=57) who were in the beginning of their surgical clerkship attended at the beginning and filled the first questionnaire which was distributed before the training sessions.It contained items exploring students' expectations towards SLT.The students answered these items according to a 4-points Likert scale ranging from strongly agreed to strongly disagreed (Figure 1).
Almost all students strongly agreed or agreed that training in skills laboratory would increase their motivation for learning Training will increase my motivation for becoming a doctor.
Training will increase my motivation for learning other subjects this semester.
Skills laboratory training will make it easier for me to learn clinical skills.
By the end of the course, I will be able to perform clinical skills supervised by a doctor.
I do not have to be afraid to hurt the patient.
I can try each skill as much as I need.
strongly agree or agree percent other subjects (100%), would affect their clinical skills and would make it easier to gain them (98%).In addition, most of them believed that training would increase their motivation for becoming a doctor (94%) and expected that they would be able to perform clinical skills by the end of the course (93%).

Students' expectations and attitude towards skills laboratory after training
At the end of the training, 29 students (50.9%) had completed all training sessions and fulfilled the second questionnaire which also contained similar items that determined the students' perception towards skills laboratory after training.The answers were also according to a 4-points Likert scale ranging from strongly agreed to strongly disagreed (Figure 2).
After training, all students also strongly agreed or agreed that SLT affected their clinical skills (100%).In addition; most students informed that training increased their motivation for learning other subjects (93%) and for becoming a doctor (96%).
These results met what students expected before training.Further, the majority of them believed that skills learnt on manikins could be transferred to patients (79%).
When the students were asked about learning of skills on manikins and on real patients, 13.8% believed that there was no difference, while others disagreed (disagreed or strongly disagreed).This reveals that the majority of students supposed that there was a difference between these two learning environments as the learning on manikins provided a safe and controlled environment to perform skills for the first time.Further, it allowed repeating of the procedures many times.All students stated that training at CSL increased their confidence and outcome (100%).In addition, all of them suggested that SLT should be a part of the medical curriculum (100%).

Confidence level
The students were asked to determine their confidence level about performing the selected procedural skills.Their answers were according to a 4-points Likert scale ranging from Not confident to Able to do independently (Table 1).
Before training the percentage of students who were Not confident was significantly higher (P <0.001) for all selected skills.But after training, for the "Suture practice", "Arterial access" and the "Male and female urinary catheterization" the percentages of students who were somewhat confident, Very confident and Able to do independently were found to be significantly higher (P <0.001).In addition, when we investigated the answers of "venous access", "Nasogastric tube placement" and the "Rectal examination" after training, it was found that the percentage of students who were Very confident and Able to do independently were significantly higher (P <0.001).
After training of "Central venous cannulation", the percentages of students who were somewhat confident and Able to do independently were found to be significantly higher (P <0.001).Furthermore, the percentage of students who were Able to do independently was also significantly higher after the training of "Intradermal and intramuscular injection" (P <0.001).Thus, there is an overall improvement in students' confidence level after training.

Performance level
When we investigated the students' performance level, we asked them to self-evaluate themselves on a 10 points scale before and after training.The mean score for the performance level of each clinical skill was significantly higher after training (P <0.001 for each skill) (Table 2).

Discussion
In this study we investigated the effectiveness of CSLs on the acquisition of basic clinical skills by undergraduate medical students in the course of SLT, and we also explored students' perception towards skills training.Our results showed that Training increased my motivation for learning other subjects this semester.
Skills learned on a manikin can be directly transferred to patients.
There is no difference in learning skills on a manikin and on a patient.
Skill training in the skills laboratory increased my confidence when I will perform such skills on patients.
Skill training in the skills laboratory increased my outcome.SLT has a valuable effect on students' performance level and it increased their outcome confirming previous findings by Remmen et al. 7 In addition, students perceived skills training highly to increase their motivation for learning and for becoming a doctor.Before the training sessions, our data showed lower overall performance scores by medical students.This is probably * Different letters which are located on the percentages indicate significant differences between before and after.
due to the limited hands-on experience of basic skills during clerkships, as the students become anxious and fear harming patients when they have to apply first actual performance on real patients. 23In addition, limited exposure to patients and limited opportunity to practice the clinical skills during clinical rotations may also have a role.] This indicates that adequate basic skills training cannot be achieved only by clerkship experience. 8 a systematic review, our results which showed that students' scores after training were significantly higher and there was an increase in their proficiency as well.This finding suggests that SLT leads to improvement in students' skills compared to the traditional "see one, do one" approach provided by bedside teaching. 13 fact, CSLs facilitate skills training and create a safe and controlled environment for medical students to acquire basic clinical skills; they also allow students to receive feedback about their performance and give the opportunity to repeat the procedures until they become competent before progressing to clerkships.Thus, SLT prepares undergraduate students more effectively to perform practical skills in the actual clinical practice and increases patients' safety. 18,26  results showed that a majority of the students believed that the skills trained in CSL could be transferred to patients.This confirms other findings revealing that basic clinical skills such as intravenous cannulation and nasogastric intubation can be transferred from skills laboratory settings to be applied to real patients. 13,18 hus, the gap between preclinical and clinical phase can be overcome.
The fact that a number of students who were in the beginning of their surgical clerkship failed to complete the training sessions constitutes a limitation of our study.Having detected the presence of some students who disagreed or strongly disagreed with many of the questions constitutes another limitation.Additionally, other limitations may include the fact that the differences between different levels of medical school were not evaluated, the lack of randomization, and the diminished number of participants during the follow-ups.
In conclusion, the overall picture of this study reflects the deficiencies of medical students in acquiring adequate competence in performing basic clinical skills during their clerkships.We have shown in the present study that students' performance was significantly improved after training in the CSL.This underlines the need for skills lab implementation in medical schools and to be an integral part of the medical curriculum.Further studies should be undertaken to investigate the maintenance of skills performance after skills laboratory training and transference into real practice.

Figure 1 .
Figure 1.Students' expectations towards skills laboratory before training (n = 57) (My expectations for skills laboratory training are) Abualhayja'a AM, et al.Sixth Class Students' Performance and Confidence Levels Before and After Training in Clinical Skills Laboratories

Figure 2 .
Figure 2. Students' expectations and attitude towards skills laboratory after training (n=29) (My expectations for skills laboratory training are) Abualhayja'a AM, et al.Sixth Class Students' Performance and Confidence Levels Before and After Training in Clinical Skills Laboratories All 6th year students who only participated in surgical internship were included for this study.The practical course included eight basic clinical skills, chosen for this study, were Skills lab training should be part of medical school programs.Abualhayja'a AM, et al.Sixth Class Students' Performance and Confidence Levels Before and After Training in Clinical Skills Laboratories

Table 1 .
Comparison of before and after training responses.
Lynagh et al. showed that clinical skills training at the CSL lead to improvements in performance level compared to traditional training. 11This goes parallel to Abualhayja'a AM, et al.Sixth Class Students' Performance and Confidence Levels Before and After Training in Clinical Skills Laboratories

Table 2 .
. Descriptive values of performance score tof clinical skills on before and after training.