A NEW TECHNIQUE FOR CLINICAL SKILLS TRAINING IN OBSTETRICS

Background: Compared to the traditional "eye-to-eye" teaching, technical advances offer a new teaching potential for the improvement of the learning outcomes and professional development in medical studies. In this article, we survey the students’ opinion about the perceived benefit when acquiring theoretical knowledge and practical skills in obstetrics via the application of the HybridLab technique. The aim of the HybridLab training technique is to develop standardized practical skills and to improve long-term memory. Methods: The subjects of the study were 5-year students of the Medical Academy of the Lithuanian University of Health Sciences (LUHS) who were studying the Obstetrics and Gynecology module in 2015. In total, the study included 233 subjects (95% of all 5-year students). The subjects filled out a standardized evaluation questionnaire consisting of 5 statements, which were evaluated using Likert’s 7-point scale. At the end of the cycle, we conducted a qualitative study using an in-depth unstructured interview, where the respondents expressed their opinion about the HybridLab training technique. Results: The analysis of changes in mean self-evaluation scores prior to and after the training cycle revealed significant differences. The greatest changes were observed when evaluating the skills of measuring fundal height in pregnant women (4.62), determining fetal position in the uterus (4.58), and performing FHR auscultation (4.58). Nadisauskiene R, Vaitkiene D, Bariliene S, Andriejaite I, Kliucinskas M, Malakauskiene L, Kemekliene G, Dobozinskas P, Vaitkaitis D, Kudreviciene A MedEdPublish https://doi.org/10.15694/mep.2016.000066 Page | 2 The results of the parametric paired test for dependent variables showed that the students’ overall self-evaluation of their knowledge after the HybridLab training cycle increased by 3.98±2.1 points (p<0.001). The majority of the respondents (35%) named positive aspects of the training. The smallest proportion (10%) of the respondents consisted of those who did not present their opinion. Neutral experience was reported by 17% of the students, 15% of the respondents provided suggestions for the improvement of this training technique, and 23% of the students named negative aspects of the training cycle.


Introduction
The 21 st century, marked by changes and development in technologies, science, education, and medicine, requires novel and modern teaching and learning techniques.Such changes mean that medical education institutions should implement novel teaching techniques to ensure the provision of high-quality medical education.Compared to the traditional "eye-to-eye" teaching, technical advances offer a new teaching potential for the improvement of the learning outcomes and professional development in medical studies.The new techniques include e-learning, on-line or Web-based learning, and problem-based learning (1).Teaching transforms from a teacher-oriented to a studentoriented and activity-based process.According to Mellor C. (2), this strategy stimulates the students to actively use the learning experience instead of being passive listeners.The interactive teaching component stimulates decisionmaking more than mere reading of the methodical material does, and it also helps the learning process to reflect the real situations more closely (3).
In this article, we survey the students' opinion about the perceived benefit when acquiring theoretical knowledge and practical skills in obstetrics via the application of the HybridLab technique.The "eye-to-eye" technique, involving direct communication between the student and the teacher, is time-consuming and requires numerous qualified employees.Students' activity has to be monitored in real time, creating a safe and controlled environment so that patient safety is not endangered.On the basis of distance learning, simulations, and hybrid teaching, we developed an entirely new method of medical studies in a hybrid laboratory (HybridLab).The aim of the HybridLab training technique is to develop standardized practical skills and to improve long-term memory.This model of student training was developed with the aim of standardizing the training process, developing time management and teamwork skills, and learning from successes rather than failures.

Aim:
To evaluate students' opinion about the application of the HybridLab technique for learning the primary assessment of the condition of pregnant women, women in labor, and fetuses.

Objectives:
To determine how students evaluated their knowledge about the primary evaluation of the condition of 1.
pregnant women, women in labor, and fetuses prior to the training cycle.
To evaluate the changes in the students' knowledge about the primary evaluation of the condition of pregnant 2.
women, women in labor, and fetuses after the training cycle with the application of the HybridLab technique.
To generalize the students' attitude towards the HybridLab technique.3.

Hybridlab as a novel teaching technique
The Lithuanian University of Health Sciences (LUHS) and the Crisis Research Center (CRC) created a learning methodology to overcome issues when teaching resources were limited and demands required a standardized practice for skills.CRC created a peer-teaching model that included e-learning modules combined with online checklist driven skills and decision flowcharts that started with simple steps and progressively worked towards complex simulation scenarios.The methodology stressed success-based learning where peer-teachers used checklists to assist the learner down the correct pathway.Based on mastery-learning concepts, learners build automaticity in their skill responses, practicing until competent.Remote faculty provided additional feedback for both learners and peer-teachers after viewing video performances of skills.HybridLab training platform developed by Hybrid Labs, Kaunas, Lithuania was used to combine all the training, evaluation and course management activities.
This special training room at the Hospital of the LUHS Department of Obstetrics, which contains all the equipment for patients'obstetric examination: simple non-computerized dummies and equipment for the examination of the overall condition and the imitation of transvaginal examination (Fig. 1).The room is filmed round the clock with 24 video cameras, and thus there is a possibility to view the material recorded during any time of the day.The solution of any clinical situation is presented with detailed action algorithms in order to ensure a successful solution of the task at the first attempt.The algorithms are compiled using the DRAKON language, which allows for a more rapid assimilation of the learning material and converting the provided information into practical skills.Source: Myhybridlab.com

Methods
The subjects of the study were 5 th -year students of the Medical Academy of the Lithuanian University of Health Sciences (LUHS) who were studying the Obstetrics and Gynecology module in 2015.In total, the study included 233 subjects (95% of all 5 th -year students) (Fig. 2).This study was approved by the decision of Lithuanian University of Health Sciences Biomedical Research Ethics Committee passed at Committee session on November 09, 2015 (protocol No. BE-MF-80).All subjects gave written consent to participate in the study after they were familiarized with its aim and methods.

Fig. 2. The design of the study
In total, 10 obstetric situations were designed for the development of the following basic skills: taking obstetric history, calculation of the term of delivery, evaluation of the overall condition, external examination of the pregnant woman, and auscultation of the fetal heart tones.During this study, we analyzed how the students evaluated their knowledge about the assessment of the condition of pregnant women, women in labor, and fetuses prior to and after the training cycle.The subjects filled out a standardized evaluation questionnaire consisting of 5 statements, which were evaluated using Likert's 7-point scale, where 1 point meant "strongly disagree", and 7 points -"strongly agree".At the end of the cycle, we conducted a qualitative study using an in-depth unstructured interview, where the respondents expressed their opinion about the HybridLab training technique.
Statistical analysis of the data was performed using the software package SPSS 22.0 (Statistical Package for Social Sciences 22 for Windows) for data storage and analysis.All parametric data were expressed as the mean ± SD (standard deviation) and 95% CI (confidence interval).To evaluate the grade changes before and after the training, Paired Samples Statistics and the Wilcoxon nonparametric test were used.Differences between groups were considered to be significant when the level of significance was p <0.05.

Results
Before the training cycle, a total of 191 subjects (78%) evaluated their knowledge about the primary assessment of the condition of pregnant women, women in labor, and fetuses (Fig. 3).The greatest percentage of students agreed with the statements that they knew how to take obstetric and gynecological history (36.1%) and how to measure pregnant women's arterial blood pressure (ABP) (49.7%).Meanwhile, over one-half of the respondents strongly disagreed, disagreed, or partially disagreed with the statements that they knew how to measure fundal height in pregnant women (71.7%), how to determine fetal position in the uterus (75.9%), and how to perform fetal heart rate (FHR) auscultation (74.9%).In general, the students' evaluation of their knowledge about the primary assessment of the condition of pregnant women, women in labor, and fetuses was average -3.48±1.92points.Such mean evaluation shows that the respondents only partially agreed that they knew the primary assessment of the condition of pregnant women, women in labor, and fetuses.After the training cycle, 94 subjects (38%) evaluated their knowledge about the primary assessment of the condition of pregnant women, women in labor, and fetuses (Fig. 4).The subjects presented better evaluations of all statements about the skills than they did before the training, and the mean evaluation score was 6.67±0.847.Such mean value indicates that the subjects strongly agreed that they knew how to perform the primary assessment of the condition of pregnant women, women in labor, and fetuses.Only 2% of the respondents disagreed with the statement that they knew how to take history, and 1% of the students disagreed with the statement that they knew how to measure fundal height in pregnant women, how to determine fetal position in the uterus, and how to measure a pregnant woman's ABP.The analysis of changes in mean self-evaluation scores prior to and after the training cycle revealed significant differences (Table 1).The greatest changes were observed when evaluating the skills of measuring fundal height in pregnant women (4.62), determining fetal position in the uterus (4.58), and performing FHR auscultation (4.58).The results of the parametric paired test for dependent variables showed that the students' overall self-evaluation of their knowledge after the HybridLab training cycle increased by 3.98±2.1 points (p<0.001).
Table 1.Changes in the scores of the students' self-evaluation of their knowledge prior to and after the training cycle In order to clarify the respondents' opinion about training in the HybridLab, a qualitative study was performed, which included 233 students (80%).The obtained responses were distributed into 5 categories: positive aspects, negative aspects, areas of improvement, neutral experience, and no opinion (Fig. 5).2).

Discussion
The hybrid teaching format is rapidly spreading in the sphere of education worldwide.The attractiveness of its idea lies in that it allows for combining the traditional teaching techniques formed by centuries of pedagogical experience with modern technologies (4).According to B. R. Turk et al. (5), the science of medicine stimulates students to develop the sense of social responsibility as well as to assimilate and apply intellectual and practical skills such as communication, analysis, and problem solving.The most important skill is the ability to apply knowledge and skill in a real workplace.It is the development of this skill that our hybrid training technique is based upon.In this study, we analyzed the students' attitude towards the novel HybridLab training technique and the change in the students' evaluation of their knowledge.
With the help of the simulations of the HybridLab, students learn to work in a team, to manage the situation, and to make decisions.In addition to that, they also improve their doctor-patient communication skills (6).Not only does working in the HybridLab provide the possibility to learn the standardized clinical skills, but it also develops distance learning skills.When learning via the traditional technique (one teacher and a large groups of students), not all students have enough time to practice -they more frequently only observe the procedures instead of performing them.Clinical simulation-based training of practical skills in small groups is more efficient and promotes the students' self-confidence (7).Meanwhile, in the HybridLab, the group consists of only 3 students, and each student receives adequate attention: the information is accessible via the internet, students may prepare for the work at home, and each student learns practical skills by performing them independently until he or she achieves the desired result.According to S. Hubackova and I. Semradova (8), all students appreciate the possibility of choosing a convenient time and place offered by distance learning, and thus the ability to select a convenient time and to gather a desirable team stimulates the students to create learning-friendly environment.
When asked to express their opinion about the HybridLab technique, over one-third of the students mentioned only positive experience.A study conducted by A. L. Nazarenko (4) showed that 60% of the students had a positive attitude towards the hybrid learning technique.The study revealed a number of various reasons for the students' positive or negative attitude.The students like virtual learning environment because of the easy access to the learning material, interactive communication during the course, and the possibility to try a new method (4).In our study, the students identified overall positive subject-based and emotional experience as the main positive aspect of this technique.According to L. Hsu and S. Hsief (9), hybrid learning contributes to self-education and metacognitive learning outcomes.Also, a large group of students stated that they appreciated the meaningfulness of the acquired experience.One of the main characteristics of the simulation is that it provides the learners with the possibility to acquire concrete experience ('know how') without having any effect on the patients.This opportunity to learn from the experience without any associated harm is seen as a "moral imperative" (10).The students also positively evaluated the methodical material used to prepare for the simulation.
Negative aspects of HybridLab training were pointed out by 23% of the respondents.The majority of the negative responses were associated with aspects related to instructors, such as delayed evaluation, a lack of feedback, and the absence of instructions.A study conducted by N. Makhdoom (1) showed that one of the most prominent negative characteristics of hybrid training was the absence of personal teacher-student communication.An appropriate balance between "eye-to-eye" classes and e-teaching depends on such factors as the desired learning outcomes, the level of the students' knowledge, technological resources, and the evaluators' experience (1).The students also criticized the methodical material, the algorithms, and the situations.
The usefulness of this novel training technique is reflected not only by the students' favorable opinion about the training, but also by their positive evaluations of the acquired knowledge.In general, after the training cycle, the score of the students' evaluation of their knowledge about the primary assessment of the condition of pregnant women, women in labor, and fetuses was 6.67±0.847points, compared to only 3.48±1.92points before the cycle.The slightest change (by 2.75 points) was observed in the evaluation of the statement that the respondents knew how to measure a pregnant woman's ABP.This was the best-evaluated statement before the training cycle because the students had already acquired practical skills during physical examinations undertaken in other clinical departments.Before the training cycle, the students also presented better evaluations of their history-taking skills, and thus the change in the evaluation score was 3.36.The students had been taught clinical examination and interview procedures in other subjects, whereas in the obstetrics cycle, the focus was placed on the aspect of medical history associated with the menstrual cycle, sexual life, and fertility.Only a very small percentage of the students presented negative evaluations of the HybridLab training, complaining about an excessive cognitive load.

Fig. 1 .
Fig. 1.The design of the study

Fig. 4 .
Fig. 4. Self-evaluation of knowledge after the hybrid training cycle Fig. 5. Categories of responses about the HybridLab training cycle and the frequencies of these categories in an indepth unstructured interview