This study evaluates the effects of simulated clinical practice using peer role-plays and a lecture on COVID-19 on medical students’ attitudes to COVID-19 and the burden felt by them due to COVID-19 patients’ care.
This study was approved by the Ethics Committee of Chiba University (approval no. 3425). The study database was anonymized.
CC in the department of respiratory medicine and participants
Medical schools in Japan offer a six-year curriculum, and two years are generally spent in CCs . In Chiba University, with approximately 120 students in each class, students practice in one department and then in another on a rotational basis, every four weeks for two years. The CC begins in December of the fourth year and ends in October of the sixth year.
Groups of 7–11 medical students (4th–5th year) underwent four weeks of training as members of a medical team of doctors and residents in a department of respiratory medicine from December of their fourth year to November of their fifth year. A total of 82 medical students underwent CC in respiratory medicine at Chiba University Hospital between December 2020 and November 2021. During the orientation at the beginning of each group’s CC, informed consent was obtained from the participants for the use of their data for this study.
Between January 2020 and November 2021, students who participated in both the simulated clinical practice and the lecture were included in the study. Students who did not participate in either the simulated clinical practice and/or the lecture, or those with insufficient data from the questionnaire were excluded. Futhermore, medical students did not directly examine patients with COVID-19; rather, they only conducted telephonic interviews and shared information at conferences when they were in charge of these patients. However, the seven students who practiced in September 2021, during the fifth wave of the pandemic in Japan, performed a direct examination of the patients after the simulated clinical practice for COVID-19. Therefore, these seven students were also excluded from the study because of the possible impact of the learning effect of directly participating in the care of patients with COVID-19.
Simulated clinical practice for COVID-19 using peer role-plays
The clinical practices were conducted at the simulation center (Chiba Clinical Skills Center) in the Chiba University Hospital and included seven to eight medical students in the first or second week of the CC. Two of the authors (HK and AK) supervised the practice.
Before the practice, students were briefed about basic IPC, such as wearing and removing PPE and zoning (Fig. 1); they also attended an orientation session.
Students were divided into two groups of four. After their zoning practice of the simulation center, further practice was conducted based on different scenarios pertaining to the admission of patients with COVID-19. We prepared two scenarios with different patient settings and lead lines for the hospital room, and each group participated in the practice according to the two scenarios.
For each scenario, four students were assigned the following roles: a patient, a doctor who wore full PPE, a medical staff who assisted the doctor, and a checker who checked the doctor and the medical staff (Fig. 2). In the role-play, the patient and the doctor could touch each other, but they were considered contaminated and could not touch the clean area and the medical staff. The medical staff could touch the clean area (open the door, push a button, etc.) to maintain cleanliness, while they could not touch the patient and the doctor. As a scenario, we created a fictional patient setting based on an actual acceptance form and prepared a script for each role. During practice, students who played the role of the doctor and the medical staff were supposed to practice how to admit the patient to the ward appropriately without spreading the infection (Fig. 3).
During the debriefing after the practice, the checkers reported the problems, and the students who performed the roles shared their impressions.
Lecture on COVID-19
A lecture on the latest literature available on COVID-19 was delivered to students. It included the following themes: comparison of symptoms/problems associated with COVID-19 and influenza, severe acute respiratory syndrome, middle-east respiratory syndrome, clinical findings and treatment of COVID-19, SARS-CoV-2 vaccine, and ways to deal with information regarding COVID-19. Additionally, the lecture included information literacy as follows. We first introduced the research data showing that false news—which evokes fear, disgust, and surprise—is more likely to spread and did so even before the pandemic . Following this, we provided examples of information that later turned out to be untrue, ranging from rumor-level information to those presented by medical professionals and heads of state. We also pointed out that drugs that show promise in basic research are rarely truly useful and approved by regulatory authorities . These examples emphasized the difficulty of properly handling medical information from any standpoint and revealed the process of medical validation using several drugs/vaccines . The lecture highlighted the importance of not easily trusting information unless medical students experience it first-hand.
The lecture was delivered during the third week of the CC by two authors of this paper (GS, HK).
Quantitative data collection
Quantitative data were compiled using a questionnaire to evaluate the effect of the education program on students’ responses to COVID-19. Questionnaires were created on students’ fear of COVID-19 and their burden in various situations related to COVID-19 patient care. Before the simulated practice and on the last day of the third week of the CC, students responded to the following questionnaire items on the simulated clinical practice and lectures (Table 1): (1a) Are you afraid of COVID-19? (1b) How much care do you take in your daily life to prevent COVID-19? (2) How much of a burden do you consider the following behaviors? Questions (1a) and (1b) were scored on a five-point Likert scale, with scores ranging from 1 [(1a) Not afraid at all; (2b) Not at all cautious] to 5 [(1a) Very afraid; (1b) Very cautious]. In question 2, the following actions are listed: a. Implementation of COVID-19 prevention measures (daily life), b. General practice while taking COVID-19 preventive measures, c. Appropriate use of PPE, including donning and doffing, d. Care of confirmed COVID-19 patients and adoption of preventive measures, e. Handling of information on COVID-19. Additionally, question (2) was scored on a five-point Likert scale, with scores ranging from 1 (Not burdened at all) to 5 (Very burdened). In addition to the above questions, students reported their satisfaction level with the simulated clinical practice and the lecture on the second questionnaire. The questionnaire items were developed based on the students’ sense of burden in the medical treatment assumed from the teaching process.
Qualitative data collection
We conducted focus group interviews (FGIs) with the students to evaluate the effects and advantages of our program on COVID-19. The FGI also aimed to identify what the students learned through our program. On the last day of the third week, students participated in the semi-structured FGIs regarding the advantages of the program, and this qualitative study phase helped us explain the results of the quantitative data.
The students were divided into nine groups (75 student cohorts in total). The criteria for selection specified that all medical students were to be included, as the target population had to be homogeneous to investigate perceptions regarding our education of COVID-19.
FGIs were conducted by two physician researchers (HK and GS), and the interview responses were recorded independently using an interview guide (Table 2). Students were asked the following questions: 1) “What are the advantages of the simulated clinical practice with peer role-playing about COVD-19? Why do you consider these as advantages?” 2) “What are the advantages of the lecture about COVID-19? Why do you consider these as advantages?” The interview guide was validated by the two researchers (HK and GS) before data collection.
The interviews took no longer than 30 min and information on the work impact and fatigue in interviewees were obtained. The interview responses were transcribed verbatim.
The quantitative data are expressed as mean ± standard deviation (SD) unless otherwise indicated. The Wilcoxon signed-rank test was used to compare the degree of burden before and after our education regarding COVID-19. Statistical significance was set at p < 0.05. All statistical analyses were performed using JMP 16.0 (Cary, North Carolina, USA).
Qualitative content analysis
In line with previous studies, qualitative content analysis was performed to analyze the FGI transcripts . Such an analysis comprises descriptions of the manifested content and interpretations of the latent content . HK and CK independently read and coded all the transcripts. Subsequently, they discussed, identified, and agreed on the coding of the descriptors. Inter-rater reliability was measured with the Kappa coefficient (0.8–1.0 = almost perfect; 0.6–0.8 = substantial; 0.4–0.6 = moderate; 0.2–0.4 = fair) .