Improving Confidence in Performing Clinical Procedures Through Peer-Driven Training Sessions for Preclinical Medical Students

Abstract

Introduction

Preclinical medical students self-report low levels of confidence in performing procedural skills, most often when performing procedures during clinical rotations. Early clinical exposure (ECE) during rotations can increase student confidence in their performance, but resource limitations hinder opportunities for preclinical medical students. A student-led procedure training session (SLPTS) can effectively provide clinical procedure exposure to preclinical medical students outside of the formal medical curriculum, which could increase student confidence prior to the start of clinical rotations.

Methods

We used Kern's six-step curriculum development approach to create an SLPTS, which included presession videos, procedure background, peer demonstrations, and hands-on practice in suturing technique, abscess incision and drainage, endotracheal intubation, and peripheral vein access. Confidence levels were measured before and after the session using a scale of 1–10 (1 = low confidence, 10 = high confidence). Mean changes in confidence (ΔC) were analyzed with a paired t test. We conducted focus groups and analyzed common themes using an inductive coding process.

Results

Among 35 student learners (first year, n = 17; second year, n = 18; survey respondents, n = 31), significant increases in confidence were observed for basic suturing (ΔC = 5.16), abscess incision and drainage (ΔC = 5.39), endotracheal intubation (ΔC = 4.55), and peripheral vein access (ΔC = 5.74; p < .001 for all).

Discussion

The SLPTS effectively provided ECE and increased student confidence in performing clinical procedures outside of the formal curriculum. Collaboration between students and faculty could further integrate such training into the official curriculum.

Educational Objectives

By the end of this activity, learners will be able to:

• 1.Demonstrate an increase in self-reported confidence in performing basic suturing techniques, including simple interrupted suture method and surgical knot tying with a needle drive. They will additionally develop the ability to identify appropriate indications and complications of the procedure.
• 2.Develop improvements in their self-reported confidence in performing an abscess incision and drainage with a single incision method, and in identifying the indications for the procedure.
• 3.Establish peripheral vein access with proper aseptic technique and have increased self-reported confidence in performing the procedure.
• 4.Identify indications for endotracheal intubation and recognize complications such as esophageal intubation while obtaining increased self-reported confidence in performing the procedure.

Introduction

The AAMC has six foundational competencies for undergraduate medical education, one of which is patient care and procedural skills.¹ However, the delivery of procedure teaching in medical schools across the United States varies widely, and medical students often report low confidence in performing procedural skills during their clinical rotations.²

Having early opportunities to receive procedure training during medical school, including hands-on training sessions, is critical to providing students with the confidence to perform procedures during their clinical rotations. Unfortunately, these training sessions are often deterred by limited faculty resources. Compared to traditional lectures, an experimental study by Basukala and Chaudhary found that early clinical exposure (ECE) led to better clinical skills and more positive attitudes in preclinical medical students. Faculty members also agreed that ECE enhances students’ recall and attitudes, though implementing such courses requires significant faculty resources.² Romeo and colleagues also emphasized the significant faculty resource strain required to implement their clinical procedure course for medical students, where attendings and residents served as the instructors.³

One approach to overcoming the barriers to implementing clinical procedure training is to involve medical students in designing, facilitating, and delivering clinical procedure sessions.⁴ Abay and colleagues noted how medical student peer teaching through simulation was a positive educational experience that decreased faculty burden in an emergency medicine clerkship.⁵ There is ample evidence to support the use of peer instructors for medical education. A 2013 randomized controlled study comparing the acquisition of suture skills by novice medical students showed that the student-directed training was similar to the training supervised by a faculty surgeon.⁶ Another randomized, single-blinded controlled trial in Malaysia found that peer instruction was not only effective in the delivery of surgical training, but also effective in providing a desired level of procedural competency when compared to faculty instruction.⁷ In an investigation of medical student views of peer teaching, Bulte and colleagues found that student learners considered peer teachers well suited for the roles of information providers, role models, and facilitators, but less well equipped to fulfill the role of curriculum planners or resource developers.⁸

This student-led procedure training session (SLPTS) provides a framework by which medical students can take ownership of their medical education through a program that can be replicated with minimal faculty resources, as the program was designed and facilitated by medical students. Our training session shows that with appropriate expert review during the planning phases of curriculum design, medical students can fulfill the roles of curriculum planner and resource developer, creating an effective procedure training session with minimal faculty involvement. This will allow medical students at other institutions to overcome some of the barriers that impede their ability to achieve procedural confidence prior to the start of clinical rotations.

Methods

A standardized curriculum for the SLPTS was designed by a medical student at Indiana University School of Medicine (Maxwell B. Bohrer) who completed the medical education scholarly concentration program in addition to the core medical curriculum. This scholarly concentration required multiple courses in medical education pedagogy and curriculum design for successful completion. David L. Rodgers, an assistant professor of clinical medicine and doctor of curriculum and instruction, served as mentor for this project. Using Kern's six-step approach to curriculum development,⁹ we created a training session with four clinical procedures (Table 1).

Table 1. Developing the Student-led Procedure Training Session Through Kern's Six-Step Model of Curriculum Development.

Problem Identification and General Needs Assessment

Preclinical medical students (years 1 and 2 in the traditional medical school curriculum, henceforth called MS1 and MS2, respectively) have little exposure to procedural skills that will become vital during their upcoming clinical training years. Opportunities to learn and practice procedural skills are limited by time demands of the curriculum, availability of faculty, and access to training resources.

The preclinical medical school curriculum typically emphasizes fundamental topics, including anatomy and physiology, pharmacology, pathology, and health system science. Procedural skills are often introduced just prior to starting clinical rotations in transitional courses. While these transitional courses introduce procedural skills, the time between introduction and application is short, leaving little time for building confidence and competence. The ideal approach is to introduce procedural skills early enough to permit time for continued practice to build confidence and competence prior to the start of clinical rotations.^10,11 This approach allows the transitional activities to refresh students’ knowledge and skills rather than introduce complex topics and skills immediately prior to clinical rotations. Studies have shown that medical students who are taught procedural skills through adequate simulation-based programs prior to implementing the skills had better performance.^10,11 Additionally, lack of faculty time for instruction may be overcome by other means, including peer teaching.

Targeted Needs Assessment

Target learners are MS1s and MS2s. This group has requisite knowledge on anatomy and physiology related to clinical skills. Their motivation is high, driven by the anticipation of entering clinical rotations where they will be expected to perform certain skills. Knowledge of the target group indicated the learners would be most receptive to active-learning processes, including hands-on practice with feedback.

Learning new, complex clinical skills may be a stressful activity. Learners will respond better in a low-stress environment geared to formative development of procedural skills facilitated by peer teachers, compared to the higher stress of performing in front of faculty.¹² We emphasized a safe learning environment where learners are free to experiment, make mistakes, and learn skills utilizing simulation.¹³ Thus, the goal of this peer-to-peer teaching program is to introduce ECE to preclinical medical students to learn procedural skills well in advance of clinical rotations, which will allow the students to practice these skills in a low-stress environment and could build their confidence and competence in performing clinical procedures. Use of well-prepared peer instructors will reduce dependence on faculty and contribute to a low-stress learning environment.

Educational Strategies

Content validity for clinical skills was established using resources commonly implemented in medical student and resident education and training. Clinical content was reviewed with an expert faculty member in emergency medicine who had also completed a simulation fellowship program. Content validity for educational processes was reviewed by an expert educator who has a terminal degree in curriculum and instruction. Specific educational practices were developed from a review of the literature. A key point in the educational methodology was well-delivered peer-to-peer feedback using the Pendleton feedback model.^14,15 This model is a learner-centered approach to giving feedback in which the learner states what went well, followed by identifying what could have been improved. The teacher then reinforces what went well and provides suggestions for improvement.

Implementation

The SLPTS was implemented electively, outside of the formal medical curriculum, in an evening session separate from the students’ required curricular activities. Preclinical medical students at a regional medical campus were eligible for enrollment, and all eligible students received an email requesting participation in the program. We recruited students to serve in the role of either peer instructor (n = 7) or learner (n = 37). After providing consent for enrollment, students completed a presession survey, created by the lead author (Maxwell B. Bohrer), containing questions about their confidence in performing procedures (Appendix A), similar to the methods used by Klumpp and colleagues.¹⁶ This survey was reviewed by David L. Rodgers, as well the emergency medicine physician who was also present for the peer instructor training session, as described below.

The peer instructor group attended a training session 1 week prior to implementing the SLPTS. They received training on how to perform peripheral vein intravenous (IV) access, endotracheal intubation, abscess incision and drainage, and basic suturing procedures (Appendices B–E). These procedures were selected from a list of procedural opportunities, created by the Society of Academic Emergency Medicine, that are commonly encountered by medical students in the emergency department.¹⁷ An emergency medicine physician, who had completed a medical simulation fellowship and serves as the campus simulation champion, was present during the training. To assist with the training session and ensure that proper technique was being instructed prior to the SLPTS, the peer instructors were provided with facilitator guides for each procedure (Appendices F–I), designed by Maxwell B. Bohrer. The peer instructors were provided with these facilitator guides prior to both training sessions. This training session additionally served as our pilot for the SLPTS, in which revisions could be made prior to implementing the SLPTS. Peer instructors additionally received orientation from an expert simulation educator (David L. Rodgers) on providing feedback in the context of simulation-based skills learning activities. No prerequisite knowledge was necessary prior to the training session. All peer instructors were in their first or second year of medical school.

Students in the peer instructor group then facilitated the SLPTS, where they taught their peers the four procedures presented during the initial training session. Each rotation consisted of a brief introduction to the procedure, including indications and contraindications to each procedure, a facilitator demonstration, and student practice time. Author-owned presession videos were made available through digital links that were emailed to the peer instructors and learners prior to the event (Appendices B–E). Each rotation was 30 minutes. The total time for the training session was 2 hours. Each station consisted of one or two instructors and eight learners. Each station was held in a separate room within our institution's simulation center.

The four simulation-based skills stations were:

Station 1: abscess incision and drainage (Appendix F): Following a brief introduction, peer instructors demonstrated how to perform a local anesthetic field block, followed by an incision and drainage utilizing a simulated abscess. Learners then practiced the procedure as the instructor assisted, answered questions, and provided feedback.

Station 2: simple interrupted suturing technique (Appendix G): Following a brief introduction to the procedure, including a summary of baseline suture terminology, peer instructors demonstrated how to perform the simple interrupted suturing technique, carry out the instrument tie, and remove sutures. Peer instructors utilized an overhead camera connected to a screen in the room to ensure optimal viewing. Learners then practiced the procedure as the peer instructor assisted, answered questions, and provided feedback.

Station 3: endotracheal Intubation (Appendix H): Learners were provided a brief introduction to endotracheal intubation, emphasizing that the purpose of the training session was to introduce the physical maneuvers of the procedure. Details regarding intubation medication, specific indications and contraindications, as well as back-up airway options were beyond the scope of the station. Learners observed the peer instructors as they demonstrated the procedure, utilizing a self-constructed video laryngoscope for the simulation,¹⁸ which was connected to a screen in the room, allowing learners to visualize the anatomy of the mannequin as the peer instructor demonstrated the skills. Learners then practiced the procedure via direct laryngoscopy as the peer instructor assisted, answered questions, and provided feedback.

Station 4: peripheral vein IV access (Appendix I): Learners observed the instructor perform the peripheral vein IV access procedure on a task trainer arm. Learners then broke into groups and practiced the procedure as the peer instructor assisted, answered questions, and provided feedback.

Each guide included facilitator instructions with station activity outline, station-specific educational objectives, supplies and equipment, station setup, and information resources.

Evaluation and Feedback

We evaluated the session using a one-group presession/postsession quantitative survey (Appendix A) and by analyzing feedback from the postintervention focus groups (Appendix J). The Indiana University Institutional Review Board approved the project as exempt from further review (protocol 17409). All students consented to their participation.

Quantitative data analysis

Learner survey responses regarding their confidence levels in performing each of the procedures, obtained prior to and after participation in the student-led training session, were recorded using a secure data collection tool (Appendix A). Each survey consisted of questions regarding students’ level of confidence in performing the procedures on a scale of 1–10 (1 = low confidence, 10 = high confidence). Using a paired t test with a 95% confidence interval (95% CI), the mean change in confidence levels for all four skills from presession to postsession was measured using Microsoft Excel data analysis tools.

Qualitative data analysis

At the conclusion of the SLPTS, learners were divided into seven groups of five participants per group. In each group, learners participated in 15-minute focus group interviews, which were recorded, manually transcribed, and analyzed for common themes identified throughout the discussions using an inductive coding process. Peers of the student learners (first- and second-year medical students) moderated the focus groups using a set of guiding questions to initiate conversation. Maxwell B. Bohrer created the focus group guide, which was reviewed by David L. Rodgers as well the seven focus group moderators prior to implementation in the SLPTS. Maxwell B. Bohrer reviewed and categorized the data, ensuring a comprehensive interpretation of the findings.

Results

Quantitative Data Analysis

Forty-four learners participated in the SLPTS, of whom seven served in the peer instructor role and 37 were part of the learner group (MS1, n = 18; MS2, n = 19). The group consisted of 21 female participants and 16 male participants. Of the 37 students who enrolled in the educational program, two did not complete the presession survey, and two who completed the presession survey were unable to attend the training session and thus did not complete the postsession survey. Additionally, two learners who completed the presession survey and attended the session did not complete the postsession survey. Thus, a total of 31 learners completed both the presession and postsession surveys regarding confidence levels and were included in the quantitative data analysis. Thirty-five SLPTS student learners attended the postsession focus groups.

The 31 student learners included in the quantitative data analysis showed significant increases in confidence after participating in the SLPTS. Statistically significant improvements in mean confidence levels in performing all four procedures (p < .001 for all) were noted by the survey respondents (Table 2). The largest improvement in confidence was seen in the peripheral vein IV access station, where we observed a mean difference between presession and postsession confidence scores of 5.74 (95% CI 4.84 to 6.64). The smallest improvement in confidence was seen in the intubation station, with a mean difference in confidence scores of 4.55 (95% CI 3.62 to 5.48).

Table 2. Change in Confidence of Learners in Performing Four Procedures (N = 31).

Qualitative Data Analysis

We identified three themes from the SLPTS focus group discussions: (1) high level of organization; (2) creation of a comfortable learning environment; and (3) effective peer teaching. For each theme we identified additional subthemes (Table 3).

Table 3. Qualitative Data Analysis (N = 37) From Focus Group Session.

Theme 1: high level of organization

Learners appreciated the aspects of the SLPTS that highlighted the attention to detail paid to its design and implementation. Learner feedback emphasized the efforts made to incorporate a variety of learning styles throughout the curriculum design process. The learners indicated that the program felt highly organized, given the attention to detail in creating presession videos, visual aids, as well as peer-led demonstrations for each procedure. One student mentioned, “having all different types of learners, where some people learn by seeing it, hearing it, or doing it, the resources available accommodated all of those needs.” Most students expressed that the time spent at each station was adequate. One student commented, “compared to past sessions that we have had, in effectively the same amount of time, we got to do more things, more repetitions, more variety in what we were doing.” However, a few students mentioned that they might have benefitted from more time at each station. Having adequate supplies was critical; as one student stated, “having enough supplies was a huge thing, it was just very well thought out, there were plenty of supplies for everyone.” The program received praise regarding the content, with one student commenting, “I have gotten more hours out of these 2 hours than I have in my entire clinical contact hours.”

Theme 2: creation of an optimal learning environment

As the most prevalent theme overall, learners indicated that an optimal learning environment was created during the training session. Student feedback demonstrated that the SLPTS was a question-friendly atmosphere with reduced intimidation compared to faculty-led training sessions. The atmosphere created in the SLPTS promoted question-asking by student learners, with one student stating, “I felt more comfortable asking questions that I would have otherwise been hesitant to ask.” Learners found the safe learning environment to be ideal for an introductory procedure training session, with one student mentioning that “when there is a faculty member teaching, it is great because they have a vast amount of knowledge, but when there is a peer teaching, I can be comfortable.” Ultimately, learners agreed that this experience was one that should be included in their formal medical curriculum.

Theme 3: effective peer teaching

Overall, learners reported that peer teaching was an effective method for receiving an introduction to the clinical procedures taught in this session. Moreover, learners were happy with the level of preparation made by their peers but found certain instructors to be more prepared than others. One student commented, “I feel like having someone closer to our age, you know MS1s/MS2s, they understand kind of how you're thinking or the anxiety that you have when learning something new because they just went through that recently, so I feel that they're better equipped to teach us,” thus showing that intellectual proximity of peer instructors to the learners was beneficial to the educational experience. Additionally, the session created a positive change in many of the learners’ perspectives of peer teaching. One student stated, “I didn't think it was going to be very useful, but I was proven wrong.”

Discussion

In this educational intervention, we have described a peer-to-peer teaching SLPTS that may have distinct advantages over programs designed by faculty. Students showed a significant increase in their confidence in performing all four procedures following participation in this SLPTS, consistent with previously described utilization of peer- and near-peer teaching within the medical education literature. Similar increases in confidence among MS1s and MS2s have also been demonstrated in faculty-led procedure training sessions.¹⁶ Analysis of themes from the focus group discussions showed that the procedure training session had an effective design and adequate resources.

Having a high level of organization was of utmost importance as we prepared for the implementation of the SLPTS. Previous literature has reported that programs designed and developed by medical students have a high level of efficacy.^19,20 However, no previous studies have evaluated the efficacy of a procedure training program that is not only facilitated by medical students as peer instructors but also designed in its entirety by medical students. The study from Bulte and colleagues on student views of peer teaching showed that peer teachers were equipped to facilitate training sessions, providing their peers with information, but did not have the skill set to plan and develop the resources needed for such a training session.⁸ With this in mind, a significant amount of time was devoted to the preparation of facilitator guides, original videos utilizing the same materials that would be used during the SLPTS, as well as in-person demonstrations. Contrary to findings from the Bulte and colleagues study, the qualitative results obtained from focus groups showed that the resources and overall organization of the SLPTS were consistently appreciated as one of the program's greatest attributes.

Similar to previous studies comparing peer teaching to faculty teaching,²¹ the creation of an optimal learning environment was an aspect of our curriculum that is somewhat unique to student-led training sessions. Learners can often feel stressed during training sessions led by faculty members. Although peer instructors do not have the level of knowledge held by faculty members, learners found the safe learning environment to be ideal for an introductory-level procedure training session.

Consistent with the findings of research by Lockspeiser and colleagues,²² our learners indicated that the session was successful due to the intellectual proximity of peer instructors to the learners, a distinct advantage over faculty-led training sessions. While some students doubted that the training session would be beneficial to their procedure skills, there was overwhelmingly positive feedback regarding the value that this session provided to their educational experience. The positive change in perspective on the use of peer instructors outlined from students within the focus groups is a key component of adult learning theory, specifically transformative learning theory as described by Mezirow.²³ Learner beliefs that led to doubts on the peer instructors’ capabilities and course outcomes were challenged as the experience unfolded. This exemplifies Mezirow's concept of a disorienting dilemma, as prior beliefs evolved based on the experience until a new belief was adopted.

The reasoning behind this feedback may be attributable to several factors. First, as described earlier, the intellectual proximity of a medical student peer instructor to their learner audience may provide the opportunity to recognize specific needs and desires within their curriculum. Faculty-developed programs may be reused year-to-year with minimal changes that may not account for the evolving medical student demographics and state of medical education. Additionally, faculty members may rely on end-of-course evaluations as their primary method of feedback from students, which may not be representative of the feedback that would be given by students immediately after a specific educational session. Using this model, medical students at other institutions can implement their own SLPTS, allowing them to increase their procedural exposure and take ownership over their medical education.

This educational training program is limited in its ability to provide objective evidence for improvement in students’ skills to perform clinical procedures, because there was no formal assessment performed before and after the training session. However, previous studies have shown that a student's level of confidence in performing a procedure is associated with their actual ability to perform the procedure following training.²⁴ Thus, change in confidence may be an appropriate surrogate for procedure performance to evaluate the efficacy of student instruction. An additional concern is that peer instructors may teach improper procedure techniques. This concern was mitigated by requiring all peer instructors to participate in a training session prior to the SLPTS, in which an emergency medicine faculty member was present to ensure proper technique was taught. This faculty member additionally reviewed the facilitator guides and provided suggestions for revision prior to implementing the SLPTS.

Future research should be conducted to measure skill acquisition using a standardized assessment tool in a head-to-head study comparing peer instructors with faculty instructors. A standardized method of assessing a student instructor's procedural skills could also be useful, ensuring that all instructors begin with a desired level of competence prior to the SLPTS. Comparing student learners in their clinical years who participated in the SLPTS to those students who did not participate, in order to evaluate long-term changes in confidence and objective procedural skill retention, could provide further support for this method of educational delivery. Following student learners throughout their medical career and measuring the impact of this training session on specialty selection is another area of interest that could be evaluated.

Funding Statement

None to report.