The Efficacy of Hybrid Telesimulation with Standardized Patients in Teaching Medical Students Clinical Lactation Skills: A Pilot Study

Abstract

Introduction:

Medical students lack competencies in clinical lactation. We determined the effect of hybrid telesimulation with a standardized patient (SP) on medical students' clinical performance in lactation support. We assessed students' engagement and satisfaction with the experience.

Materials and Methods:

Undergraduate medical students (n = 13) completed (1) preparatory case scenarios with multiple-choice questions and (2) three telesimulations with SPs wearing a high-fidelity breast model. Students had the option to complete the Encounter Documentation. SPs used the Formative Assessment Rubric (FAR) to evaluate students' interpersonal skills and clinical lactation experts used the Summative Assessment Rubric to evaluate documentation skills. Investigators collected satisfaction data from a focus group and written evaluation. Dunn's multiple comparison and Freidman tests were used to measure differences in FAR scores between cases and telesimulations. Qualitative data were analyzed using thematic analysis.

Results:

Most students (70%) attempted case questions multiple times and scores improved (p < 0.0001) between attempts. FAR scores suggest students were prepared for telesimulations (5.5/6-pt Likert) and interpersonal skills were appropriate (5.4/6), with no differences by case (p = 0.11). FAR scores increased between telesimulation 1–2 (+24.5/114, p = 0.002) and 2–3 (+17.5/114, p = 0.014). Students were satisfied with the experience and would recommend it to classmates (both 4.6/6). Thematic analysis revealed feedback regarding interpersonal skills was helpful.

Conclusions:

Medical students must develop skills to support breastfeeding in virtual settings. Telesimulation can be incorporated into existing curricula to support clinical lactation competencies.

Introduction

Despite growing recognition that breastfeeding supports maternal and neonatal health,¹ undergraduate medical education rarely includes training on breastfeeding physiology, pathology, and clinical management, resulting in a lack of competence in clinical lactation.² Women in the early postpartum period do not want students crowding their rooms and performing repeated physical assessments, which further limits clinical exposure of medical students to the mother-infant pair.³ Clinical skills, including breast assessment and performance of breastfeeding techniques, are the most significant areas of student deficiency.⁴

Simulation allows learners to apply theoretical concepts in a hands-on approach to develop confidence, clinical decision making, communication, and interpersonal skills in a safe environment.^5,6 Current training often includes low-fidelity breast models and breastfeeding patients.^7,8 Hybrid simulation with a trained standardized patient (SP) wearing a high-fidelity breast model and holding a newborn doll emulates a real-life clinical scenario most accurately.⁹

In this mixed-methods pilot study, we determined the effect of a hybrid, on-demand telehealth simulation (i.e., telesimulation) with an SP wearing a high-fidelity breast model on medical students' performance of clinical skills relevant to lactation support. In addition, we assessed medical students' engagement and satisfaction with the hybrid, on-demand telesimulation experience.

Materials and Methods

Pilot study overview

Remote simulation-based learning in clinical lactation was incorporated as a requirement of a 2-week Human Breastfeeding and Lactation credit-bearing elective for third-year medical students at a U.S. medical school in May 2020. Instructors intended for students to interact with breastfeeding patients in an outpatient lactation clinic, but due to COVID-19-related restrictions on in-person clinical experiences, the elective was offered virtually.

Hybrid, on-demand telesimulations

Within the elective, students were assigned to complete the “Lactation Support In a Telehealth Setting” Course (Course, Table 1), an immersive, virtual, asynchronous learning experience. The overarching objective is for the learner to master clinical lactation skills by engaging in deliberate, interactive, and repetitive practice of diagnostic reasoning and patient management in a safe, confidence-building virtual environment. To support this objective, the course features two key components that were required by the students to complete:

Table 1.

Lactation Support in a Telehealth Setting Course Overview

Case 1: Bloody nipple discharge in a lactating woman

Case 2: Breast engorgement in the setting of delayed lactogenesis II

Case 3: Breast milk production and maternal mental health

For each case, the learner completes the following:

1. Preparation	2. On-demand telesimulation	Optional component: Encounter Documentation
Unfolding case scenarios with (10 multiple-choice questions per case): Lactation physiology Clinical decision making Physical assessment Management of clinical lactation concerns	30-minute session includes: SP encounter (20 minutes) Oral feedback from SP on communication and interpersonal skills (10 minutes) Formative Assessment Rubric completed by SP and sent to learner	Written documentation of: (1) Patient summary (2) Problem list (3) Elaboration (4) Next steps Summative Assessment Rubric completed by IBCLC and sent to learner

IBCLC, International Board Certified Lactation Consultant; SP, standardized patient.

(1)

Six unfolding case scenarios (two per telesimulation), in which the learner navigates the parts of the case scenario with contextualized multiple-choice questions that they can attempt multiple times to support student-centered and self-directed learning. Student-centered and self-directed learning focus on learning strategies that assist the student in learning from their own experiences to make improvements in knowledge and skills.

(2)

Three telesimulations that occur through video call with a live SP wearing a high-fidelity lactation and engorgement-capable breast model, the lactation simulation model.¹⁰ The telesimulations can be scheduled at any time by the learner. The SP provides oral feedback to students immediately following the encounter in regard to their communication and interpersonal skills.

Although not required, the students also had an opportunity to fill out the Encounter Documentation adapted from the subjective, objective assessment and plan note format.¹¹ Documentation was reviewed by a lactation expert (i.e., physicians practicing breastfeeding medicine certified as an International Board Certified Lactation Consultant [IBCLC]).

Clinical performance

The provision of structured, objective feedback contributes to a learner's self-reflection on performance as well as ultimate learning gains.¹² Immediately following the telesimulation, the SP assessed the learner's performance using the previously validated Formative Assessment Rubric (FAR),¹³ which includes 20 items (19 close ended and one open ended) regarding the learner's performance of communication, interpersonal skills, and teaching. Each close-ended item was rated on a 6-point Likert scale (1 = strongly disagree…6 = strongly agree); thus, the highest score a learner could receive was 114 points (6 points per 19 close-ended questions).

The learner then had the option to complete the 4-item Encounter Documentation Quiz (Documentation), which includes four sections: (1) patient summary, (2) problem summary, (3) elaboration, and (4) next steps for the patient. The previously validated Summative Assessment Rubric (SAR)¹³ was designed for use by an IBCLC to objectively grade the Documentation. The SAR score was determined by completion and correctness of each item.

Medical student engagement with the preparatory materials

In the online learning environment, behavioral engagement can be seen in the actions a learner takes that reflect involvement in learning and academic tasks, such as the time the learner spends on a task and the accuracy of the answers they give during assessments, which often mirror effort, persistence, and attention.¹⁴ For this pilot, engagement was measured by time spent and number of attempts for all unfolding case scenarios, which were automatically tracked for each learner within the learning management system. Multiple-choice questions for the unfolding case scenarios in the Course were automatically graded for accuracy (0/1 point, incorrect/correct) and to further help the student learn from their mistakes.

Medical student satisfaction with the telesimulation experience

Satisfaction with a learning experience is strongly positively correlated with an increase in a learner's perceived gain in knowledge and skill and increases a learner's self-motivation to perform well, especially in a low-stakes simulated environment.^15,16 Upon completion of the elective, students filled out an Elective Evaluation with close-ended items assessing overall satisfaction with the simulation-based learning (i.e., the Course) and whether they would recommend the Course assignment to a peer (both 6-point Likert scale, 1 = strongly disagree…6 = strongly agree).

Other items in the Elective Evaluation included close-ended items on other materials incorporated into the Elective (4-point Likert scales; various response types) and open-ended items pertaining to what went well in the Elective, what could be improved in the Elective, and specifically, how the Course assignment could be improved.

Students participated in a focus group. Focus groups and interviews can help to supplement and interpret the survey responses and allow the participant to delve deeper into their thoughts, experiences, and values surrounding a topic or events.¹⁷ The facilitator referred to guiding questions (Supplementary Table S1) pertaining to the quality of the Course content and delivery, satisfaction with the SP encounter, and the feedback process with the SP and IBCLC. The focus group was conducted through video call, audio recorded, and transcribed using Descript.

Data analysis

Participant demographics (gender, race/ethnicity, and age) were collected from University records. Descriptive statistics were used to calculate averages for the Elective Evaluation, FAR, and SAR scores. Dunn's multiple comparison and Friedman tests were used to evaluate differences between Unfolding Case Scenario scores by attempt and FAR scores by Case and telesimulation number; significance level was decided a priori (α set at 5%). Open-ended responses from the evaluation and focus group were analyzed using a conventional content analysis approach. Qualitative data were independently analyzed by two of the investigators to identify, describe, and quantify major themes. The same investigators cross-checked their work and discussed discrepancies until agreement was reached (code-recode strategy). We tallied the themes to quantify emerging topics per question.

This study was exempt from approval by the University of Michigan Institutional Review Board (HUM00182598).

Results

Participant demographics

Thirteen third-year allopathic medical students (Table 2) from a public midwestern university participated in the Course. Students had completed most, but not all, required clinical clerkships.

Table 2.

Participant Demographics (n = 13)

Gender	Academic year	Race/ethnicity^a
Female (n = 12) Male (n = 1)	Third year (n = 13)	White (n = 9) Indian (n = 2) Black/White (n = 1) Chaldean (n = 1)

Race/ethnicity categories as defined by the University Registrar.

Student clinical performance

All students (n = 13) participated in three telesimulations and received feedback from the SP. The FAR scores suggest that students were prepared for the telesimulation (5.5/6, Table 3) and the student's behavior during the simulated encounter was appropriate for the Case (5.4/6, Table 2). There were no significant differences in a student's average FAR scores by Case (p = 0.11). The majority of students (n = 8/13) completed Case 1 as their first telesimulation, three students completed Case 2 first, and two students completed Case 3 first. Students' total FAR scores increased between telesimulations 1 and 2 (+24.5/114 points, p = 0.0002) and between telesimulations 2 and 3 (+17.5/114 points, p = 0.01), indicating that the students were able to learn about their performance of communication, interpersonal skills, and teaching and make adjustments to improve with continued practice with a high-fidelity SP.

Table 3.

Average Rating of Medical Students' Performance of Clinical Skills According to Standardized Patient Using the Formative Assessment Rubric (n = 13 Students)

	All cases	Case 1	Case 2	Case 3
The learner seemed… (Likert scale: 1 = strongly disagree… 6 = strongly agree)
Confident	5.2	4.8	5.8	5.0
Knowledgeable	5.3	5.2	5.4	5.3
Relaxed	4.9	4.7	5.3	4.8
Attentive	5.4	5.5	5.5	5.4
Respectful	5.7	5.7	5.6	5.8
Organized	5.1	5.2	5.2	4.9
Prepared	5.4	5.2	5.5	5.6
Professional	5.5	5.4	5.7	5.3
Empathetic	5.2	5.4	5.2	5.2
Friendly	5.4	5.5	5.5	5.3
The learner… (on a scale from 1–6; 1 = strongly disagree …6 = strongly agree)
Concentrated on my chief complaint.	5.2	5.8	5.5	4.3
Used appropriate nonmedical jargon.	5.7	5.6	5.6	5.8
Used clear, organized explanations	5.4	5.5	5.5	5.2
Allowed sufficient time for me to respond	5.7	5.8	5.8	5.5
Used restatement, reflection, and clarification to indicate that he/she was listening to you.	5.3	4.9	5.7	5.4
Utilized the teach-back method to explain techniques or management plan.	4.4	3.3	4.6	5.4
Used a clear voice that was easily understood.	5.8	5.8	5.8	5.7
Maintained comfortable eye contact	5.6	5.3	5.8	5.8
Maintained a range of facial expressions consistent with speech	5.7	5.6	5.7	5.7

Few students completed the Encounter Documentation, because it was not required, so the IBCLC provided feedback through the SAR to only three individuals. On average, students who completed the Documentation received a score of 72% across the three cases. The average score across cases for Summary was 96%, for Problem was 72%, for Elaboration was 45%, and Follow-up was 66%.

Medical student engagement with the preparatory materials

All students (n = 13) completed two unfolding case scenarios in preparation for each telesimulation. The majority of students (70%) attempted unfolding case scenarios more than once and students' performance increased significantly (40%, p < 0.0001) between attempts. On average, learners completed all three scenarios in 82 minutes and all three Documentations (n = 3) in 48 minutes. The total time invested in the Course, including the telesimulations, was under 3.5 hours per student.

Medical students' satisfaction with the telesimulation experience

Eleven students completed the Elective Evaluation. Students were satisfied (4.6/6) with the Course and agreed (4.6/6) they would recommend it to medical school classmates. In open-ended evaluation responses, respondents indicated the unfolding case scenarios supported their self-directed learning (n = 3/9). The respondents also mentioned that the simulated, hands-on approach would result in knowledge retainment (n = 3/9), as one student stated, “The interactive portions of the Course were very helpful and probably will make longer lasting knowledge than some of the readings.” Overall, students found that the SPs' feedback regarding the communication and interpersonal skills was helpful, with one student writing, “SPs were very knowledgeable and did a very good job, better than other simulation experiences I've had so far in medical school.” Students also identified areas for improvement. Students needed more background information or in-depth questions (n = 6/9) to grasp the topics fully. Some students mentioned that the LearnDash platform was clunky (n = 3/9).

The focus group revealed that students were satisfied with the quality of the experience. Six of the nine students indicated the learning objectives for each telesimulation aligned with their experience with the SP during the simulated encounter. Students confirmed four separate times through the duration of the focus group that the Course provided them an opportunity to practice a real-life clinical situation. In alignment to the written feedback from the Elective Evaluation, students in the focus group mentioned that more background content would have been helpful to prepare for the cases and SP encounter (n = 4/9 students). See Supplementary Table S1 for more focus group responses.

Discussion

Medical education lacks an adequate breastfeeding curriculum and clinical immersion to meet core breastfeeding competencies.^2,7 Engaging, realistic learning experiences such as the hybrid telesimulation must be explored and implemented to support the deliberate and repetitive practice of clinical skills in maternal-child care.^18,19 The use of a trained actor who is wearing a high-fidelity breast model engages the student in an environment they would encounter when working with real patients. Given the average time students took to complete the telesimulations and the asynchronous, self-directed modalities, it is feasible to incorporate the Course into an already existing curriculum as an assignment required for diverse learners to complete on their own dedicated time.

High-fidelity simulation with an SP is the gold standard for medical education in regard to knowledge acquisition and skill transfer to patient care⁷; even so, virtual patient encounters and low-fidelity simulation are often used in medical education to develop diverse clinical skills such as clinical reasoning, communication, teamwork, and conflict management, in general and in relationship to clinical lactation.^18,20–22 High-fidelity simulation with a live SP is superior to the traditional virtual patient or low-fidelity simulation since it mimics real-life simulations more closely. This allows students to more easily suspend disbelief, facilitating mastery of clinical knowledge and skills, by mimicking a real-life situation more closely than a computer-generated simulation.⁹ The hybrid telesimulation in this pilot study is innovative because live, web-based patient simulations (telesimulations) have never been applied in the field of lactation. In this pilot study, investigators evaluated the feasibility of this approach for teaching clinical lactation skills.

Medical students were satisfied with the hybrid telesimulation largely because learning objectives and preparatory materials were delivered to the students in a scaffolded approach before encountering the SP.²³ Furthermore, satisfaction with a learning experience motivates students to perform well and positively correlates to an increase in a learner's perceived gain in knowledge and skill, which is especially significant when preparing for and engaging in a simulated experience.²⁴ Since the debrief is the most important aspect of the simulated learning experience, we hypothesize that the formative and summative feedback provided to the medical students contributed to their high level of satisfaction with the telesimulation experience.²⁵

Limitations

Given this was a pilot of an educational intervention that was placed in a breastfeeding elective course, the sample size was small, it was limited to a single institution, and there was potential selection bias in regard to the demographic makeup of the cohort. The cohort was nearly all women, and because the course was elective, may have been made up of more motivated learners. However, the selection bias was lessened due to the prospective and novel nature of the intervention and the cohort was exposed to all of the same education materials. The investigators did not obtain demographic data in regard to breastfeeding experience. Despite these limitations, the evaluation helped to define value, practicality, and feasibility and supported the acquisition of hands-on, counseling, and documentation skills relevant to lactation support.

Conclusion

The level of engagement provided by the telesimulation with an SP supported medical students' development of clinical skills, while fostering the maturation of interpersonal skills. Lactation telehealth is an important modality for mothers with limited access to health care. Health care trainees must have opportunities to immerse in telehealth interactions to prepare them for the full spectrum of effective counseling and clinical skills. In summary, use of a telesimulation teaching model approximates hands-on clinical experience, is acceptable to students, and improves students' clinical lactation skills.

Footnotes

Acknowledgments

We wish to acknowledge the contribution of Matthew Goblirsch, Camila Khan, Kelly Loberger, Emily Wilson, Sabina Sheikh, Julie Eggleton, Megan Martinez, and Rachel Jalfon for their assistance with the development of the multiple-choice questions and SP scripts for the Course.

Disclosure Statement

The authors of LiquidGoldConcept, Inc. (LGC) co-developed the Course and evaluation instruments and were involved in the study design and execution, data analysis, and manuscript writing. AS is the President, Chief Executive Officer, and a shareholder of LGC. SAC is the Chief Operating Officer and a shareholder and employee of LGC.

Funding Information

The validation of the content within the “Lactation Support in a Telehealth Setting” Module was partially funded through a grant obtained by the University of Michigan School of Public Health from the Association of Teachers of Maternal and Child Health's Innovative Teaching Award.

Supplementary Material

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Supplementary Material

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