Near-peer interprofessional simulation training in an undergraduate setting

Abstract

To assess the effectiveness of near-peer educators to improve human factors education for medical and nursing students managing an unwell simulated patient. 12 medical and eight nursing students volunteered. Doctors and nurses qualified for less than 2 years were used to run and debrief the sessions. Self-assessment Likert-scale questionnaires, focussing on topics related to human factors along with differences between near-peer and senior-led simulation sessions, were used before and after the intervention. The results showed an improvement in every question for topics related to human factors. The highest post-programme scores were in escalation of care and knowing professional role or limitations. Students scored near-peers highly in relation to relevance to practice, content covered and approachability. The post-programme questionnaires show students prefer near-peer to senior-led simulation sessions. The interprofessional nature was well received. Our project differs from traditional undergraduate simulation, where students can act out of the role they are training in. Near-peer educators appear to be more approachable and cover content more relevant to clinical practice compared with senior staff. Improvements were seen in every human factor related field.

Interprofessional education has been shown to be effective in improving knowledge, teamworking and communication.^{1 2} Interprofessional education has been defined as ‘students from two or more professions learning about, from and with each other to enable effective collaboration and improve health outcomes’.³ Near-peer training in simulation appears to be beneficial to both medical and nursing students. However, there is little research into interprofessional education ran by near-peer educators. We defined near-peer as professionals within maximum of 5 years of study.^{4 5} We conducted a near-peer interprofessional simulation programme to evaluate potential benefits to undergraduate students.

Aim

To assess the effectiveness of using near-peer educators, in order to improve human factors education for medical and nursing students managing an unwell simulated patient.

Methods

Six third year medical students, six fourth year medical students and eight final year nursing students volunteered. Junior doctors and nurses, all qualified for less than two years, volunteered to run and debrief the sessions. The programme was conducted using the University of Exeter Medical School simulation suite in Cornwall. Ethical approval was not required for this project.

Likert-scale questionnaires were given to the students before and after the programme (figure 1). The questionnaire was adapted from previous work undertaken by the Simulation Team at the Royal Cornwall Hospital looking at human factor development in simulation in maternity units,⁶ although no formal piloting of this version of the questionnaire took place with the students. Scores were generated based on self-assessment of ability or confidence in each field with 10 being highly confident and 1 being not confident. Scores were then collated and a mean average figure generated for each question. The scale for questions related to the near-peer versus senior-led sessions was graded from 5 (for senior led) to 0 (for neutral) back to 5 (for near-peer). We deliberately avoided using a negative figure in an attempt to avoid biasing the student’s opinion. When calculating the mean with these questions, we took the senior-led score as a negative number and the near-peer led as a positive number. Due to the subjectivity of the questions and small sample size, mean averages were calculated as recommended in the article by Sullivan.⁷ Pretest scores and post-test scores were then compared with assess improvement.

Figure 1.

The questionnaire given to the students before and after the 6-week programme.

The questions focused on aspects related to human factors as well as differences between near-peer and senior-led simulation sessions. Human factors have been defined as ‘enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities and application of that knowledge in clinical settings’.⁸ The areas of human factors explored were escalation of care, knowing your role and limitations, knowing the role and limitations of other team members, prioritising tasks, communication skills as well as recognising and anticipating potential complications. These were selected as important based on the authors’ personal experiences of managing unwell patients as junior doctors.

Students were involved in two scenarios each week for the 6-week programme. Each week had a different focus (airway/breathing, shock, chest pain, reduced consciousness, abdominal pain and cardiac arrest), although the main learning objectives were good quality A–E assessments with appropriate escalation of care and effective handover. The junior doctors and nurses were taught how to run the manikin and were used in the role of the ‘helpful healthcare assistant’ in the scenario to help guide the students if required. The debriefers were given a talk at the start of the programme focussing on human factors and simulation debriefing. They were encouraged to use an advocacy inquiry style⁹ when debriefing the simulations.

Results

The results showed an improvement in every score for aspects related to human factors (table 1). The largest improvement between pretest and post-test scores for medical students was in knowing their professional role and limitations within the team (mean average increase of 4.08), and for nursing students was in knowing the role and limitations of others within the team (mean average increase of 2.63). The highest post-programme questionnaire scores for both sets of students were in escalation of care (mean average score of 8.33 for medical students and 8.38 for nursing students) and knowing their professional role and limitations within the team (mean average score of 8.0 for medical students and 8.5 for nursing students). Smaller scale improvements in human factor related questions were noted for the nursing students (range of 1.19–2.63 compared with a range of 2.76–4.08 for medical students).

Table 1.

The results from the questionnaires given by the medical and nursing students as well as the change in score

		Near-peer				Human factors
		Approachable	Content covered	Relevance to practice	Overall debriefing	A–E assessment	Escalation of care	Own role and limitations	Role of other team members	Prioritising tasks	Communication	Recognise and anticipate
Medical students	Pretest	1.92	0.25	1.17	0.42	4.92	5.00	3.92	3.92	4.50	3.92	3.50
	Post-test	2.58	3.50	4.00	3.08	7.67	8.33	8.00	7.08	7.17	7.17	7.50
	Change	+0.67	+3.25	+2.83	+2.67	+2.75	+3.33	+4.08	+3.17	+2.67	+3.25	+4.00
Nursing students	Pretest	−0.38	−1.25	0.13	−2.00	5.88	6.88	6.88	5.25	6.00	5.94	5.25
	Post-test	2.63	3.50	3.50	3.13	7.75	8.38	8.50	7.88	7.38	7.13	7.13
	Change	+3.00	+4.75	+3.38	+5.13	+1.88	+1.50	+1.63	+2.63	+1.38	+1.19	+1.88

In the post-programme questionnaire, both sets of students scored near-peers highly in relation to being relevant for practice (mean average of 4.0 for medical students and 3.5 for nursing students) and the content covered (mean average of 3.5 for both medical and nursing students).

The nursing students preferred senior-led sessions at the start of the programme (range of −2 to 0.13), but preferred near-peers by the end (range of 2.63–3.5).

Discussion

The smaller scale improvements seen with the nursing students are potentially due to the lack of nursing staff involved in the debriefing sessions. Furthermore, the fact that the initial pretest scores of the nursing students were higher may have impacted results, as the post-test scores of both students are largely equivocal.

The fact that both sets of students scored near-peers highly in relevance to practice and content covered suggests students can gain information more relevant to their upcoming job role. However, senior members of staff have significantly more clinical and teaching experience and this expertise will be absent in junior staff members.

As medical and nursing schools are separate organisations, students often get little exposure to working within an interprofessional team. This can lead to students acting out of the role they are training to become (ie, a medical student acting as a nurse). The interprofessional nature of our course was clearly well received by the students. This may help explain why there were large improvements for both sets of students in knowing their own professional role and limitations as well as the role and limitations of others within the team. Additionally, there is a current lack of near-peer nurses involved in nursing school education. This may be a key factor for why the nursing students preferred senior-led sessions in the pretest scores.

Although the results are encouraging, the project was only with a small number of students. Consequently, no statistical analysis has taken place. Furthermore, the students all volunteered as they either wanted more experience with simulation or had previously enjoyed it. Anxiety has been linked to poor performance in a simulation environment and may impact on educational gains.^{10 11} The enthusiasm of the volunteered students may not be matched by other undergraduates who may have anxiety around simulation training and consequently benefit less from the programme.

Furthermore, improvements may be associated with the students completing simulation programmes. We did not have a control group for comparison and therefore ultimately it is difficult to comment on how much of the improvements are related to the near-peer and interprofessional components of our projection, and how much is related to simulation training alone.

The debriefers were largely made up of junior doctors (eight in total). Unfortunately, only one nurse of the original eight who expressed an interest was able to attend sessions. Reasons quoted as being unable to attend included tiredness, work obligations and life commitments. There was a lot of interest in volunteering from the junior doctors potentially related to requirements for teaching in their portfolio. Factors affecting teaching in junior doctors and nurses would benefit from further investigation.

One aspect we did not look into were the potential benefits for the junior doctors and nurse involved as debriefers. We were fortunate to have a regular group attending most sessions and although not assessed qualitatively, it was clear that their confidence in teaching and running debriefs improved during the course. This is an unanticipated benefit of the course and would benefit from further investigation. If a positive correlation was found, this would likely help in recruiting junior doctors and nurses as debriefers.

Conclusion

Overall, the results of the programme suggest that near-peer educators are felt to be more approachable and cover content more relevant to clinical practice compared with senior members of staff. Near-peer educators are becoming more popular in medical schools and are utilised in clinical placements in ad hoc teaching. This project adds evidence of their potential effectiveness within medical and nursing education, although further research is required.

Improvements were seen in human factor related fields, with the largest improvements seen in students recognising their own roles and limitations as well as their role within a team. This may be due to the interprofessional basis of the project which differs from traditional methods of undergraduate simulation, where students often act out of the role they are training in, adding to the overall realism of the scenarios.

There are likely to be added benefits to the junior doctors and nurses involved as debriefers, which we did not explore. This would benefit from further investigation.