Seif-perception and manifest competency of performing(selected) core-clinical skills by 2012/2013 final year medical students of the University of Zambia curriculum: A study of how medical students acquire competency in Clinical practical skills

Abstract

Fifty six (56) out of sixty 2012/2013 final year students (93% response rate) participated in a study that sought to determine how Undergraduate Medical Students of the University Of Zambia (UNZA) acquired competency in clinical practical procedures, their levels of knowledge on selected set of skills, and their self-perceived versus manifest competency at the time of graduation. A Multiple Choice Question (MCQ) knowledge test consisting of 48 items was administered to ascertain the level of knowledge on 14 selected clinical practical procedures. Students were also asked to rank their self-perception of competence on 14 selected clinical practical skills using a five-point Likert ranking scheme. For each of the procedures on which students ranked their self-perception, they concurrently rated the frequency of experience using a five-point Likert scale. To measure manifest competency, three selected clinical practical procedures were included in the end-of year Objective Structured Clinical Examination (OSCE) but overall competency on four other practical stations was also studied. Immediately after the OSCE, 10 students were asked to talk through the practical procedures they had performed (Retrospectively Think Aloud Protocols). Additionally, 17 students participated in an in-depth interview on how they acquired competency in clinical practical skills. Traditional, as well as, competence-based curricula specify the clinical practical skills in which medical graduates must be competent in and yet literature has demonstrated that many students graduate without the competency. Such a potential situation is detrimental to patient outcomes and determines success or failure in clinical settings. The context at UNZA concerning such a potential situation had not been studied prior to our study, therefore this study sought to answer the following research questions 1) How do Undergraduate Medical Students of the University Of Zambia acquire competency in clinical practical procedures during clinical years?, 2) What is the clinical practical procedures knowledge level of Final Year Medical Students of the University of Zambia in the last six months of the undergraduate medical education? and 3) How does self-perception of competence compare with manifest-competence in selected clinical practical procedures among University of Zambia Final Year Medical Students in the last six months of training? To answer these three questions, our study applied a non-interventional cross sectional correlation design utilizing the concurrent transformative with concurrent embedded mixed method strategy. The study revealed that: a) Medical students at UNZA acquired and developed competence in clinical practical procedures through four development stages: passive observation to guided performance to unguided performance and finally peer teaching. b) The knowledge levels of clinical practical procedures of the final year medical students were found to be inadequate, represented by a 39% pass rate on a 48-itemMCQ test. c) There was negative correlation between self-perception (moderately competent for most respondents) and manifest competence (barely competent for most respondents) on overall competence on the seven practical stations of the OSCE (Spearman rho -.123) and on two out of the three specific individual procedures included in the OSCE. The correlations (Spearman rho) between self-perceived and manifest competence for the three procedures were: cardiopulmonary resuscitation (-.150); intravenous drug administration (-.521) and nasogastric tube insertion (.128). In literature, there are three main theories of how students acquire clinical competence namely Dave’s (1970) model, Miller’s (1990) triangle and Dreyfus and Dreyfus (1980) model of clinical skills acquisition, while the approach to learning in a traditional curriculum is that of “see one, do one and teach one”. From our study, a new model emerged called “Passive Observation to Peer Teaching Model” of Clinical Procedural Skills Acquisition and Competence Development. When compared to existing models of clinical skills acquisition in particular the three that underpinned our study, the main similarity is that although different terminologies are used to describe different stages of competency development, when considered in totality, the process is progressive in nature, with teaching and assessment related factors nurturing the progress. In addition the model generated from our study can be seen as an expanded version of the “see one, do one and teach one approach” with an expansion of the “doing one” which in our model is first guided then unguided. One notable difference between existing models and the one that emerged from our study is that while existing models (notably Dave’s 1970) focus on actual manipulations to perform a psychomotor skill, our model focuses on the process of developing competency. The benefits of our study to medical education are mostly located in the teaching of clinical practical procedures to ensure that medical students acquire competency. From our study, the following points are noteworthy: a) the pass rates on MCQ knowledge test were high on items from procedures that were formally taught and that formally taught procedures were performed more times with students reporting high self-perception on procedures they had high experience with b) students were more knowledgeable in those procedures where there was a high likelihood of being assessed and consequently practiced more of those procedures in comparison to others, c) majority of clinical practical skills that students never attempted during the three years of clinical medical education are those performed in emergency situations in which trial and error by students is not acceptable due to its negative implications on patient outcomes, and d) irrespective of the mode by which students first learnt clinical practical skills, they essentially had to observe someone perform the procedure before they could attempt. The implications for practice therefore include: a) the need for structured teaching of practical procedures, b) use of alternative innovative teaching/learning avenues such as clinical skills laboratories in addition to bedside teaching and c) inclusion of More Clinical Practical Procedures in the OSCEs. In the light of our finding, we suggested an alternative model for teaching clinical practical procedures in which teaching/learning is more structured, students are accorded more time to observe how experts perform clinical practical procedures, practice under guidance before independent practice and encouraged to teach others as a means to developing competence. We further suggest use of alternative teaching avenues as an adjunct and not a replacement of bedside teaching, and inclusion of more procedural stations during the OSCEs. Our study design’s most significant imperfection was that we could not identically match all the clinical procedures in the self-perception and the manifest competence assessment because the manifest competence was measured in a final examination in which it was undesirable to interfere with the content and number of practical stations. However, three stations were conceded to, in matching of the self-perception and manifest competence. Further, our study was cross-sectional and the numbers were restrictive for statistical generalizations. However, we believe the findings provide enough credibility and fidelity.