|Year : 2021 | Volume
| Issue : 4 | Page : 247-254
The need and art of establishing skill and simulation centers to strengthen skill-based medical education: Learning insights and experience
S Archana1, Sathish Raju Nilakantam2, Basavanagowdappa Hathur3, Melanahalli Dayananda4
1 Department of Anaesthesiology and Chief Coordinator, Skill and Simulation Centre, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
2 Department of Hospital Administration and Medical Administrator – Operation Theatre Services, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
3 Department of General Medicine, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
4 Department of Hospital Administration, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
|Date of Submission||08-Jun-2020|
|Date of Acceptance||20-Oct-2020|
|Date of Web Publication||3-Dec-2021|
Sathish Raju Nilakantam
Department of Hospital Administration and Medical Administrator – Operation Theatre Services, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, M.G. Road, Mysuru - 570 004, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Evidence-based medicine seeks to improve medical education, which requires high competency levels in various clinical skills such as examination of patients and execution of clinical techniques on patients by integrating skill and simulation-based teaching and learning as supplementary to traditional methods of bedside clinical teaching. Hence, a safely prepared and controlled environment with trained interdisciplinary teams is very essential in providing such effective medical education to students as well as health-care professionals. The ongoing skill and simulation center project aims to provide teaching, training, and learning in various clinical procedures for both medical students and clinicians. Materials and Methods: The project management cycle framework was used which included the phases of planning, designing, training, and implementation. Having picked the model for the proposed skill and simulation center, that is, redefining medical education with skill and simulation-based teaching, training, and learning, it was decided to establish this skill and simulation center. Results: The functional skill and simulation center unit with the state-of-the-art infrastructure along with a trained multidisciplinary team was achieved. There are also academic programs, which include the demonstration of various clinical and surgical skills and workshops on simulation-based medical education. Conclusion: It was possible to establish a comprehensive skill and simulation center and achieve best practices in medical education by optimal investment in infrastructure and improving the available human resources. Detailed planning is required, across a variety of domains. We hope our experiences shared in this article will help other medical colleges and hospitals across the region, both nationally and globally, toward establishing similar educational facilities.
| Abstract in French|| |
Contexte: La médecine factuelle vise à améliorer la formation médicale, ce qui nécessite des niveaux élevés de compétence dans diverses compétences cliniques telles que examen des patients et exécution de techniques cliniques sur les patients en intégrant l'enseignement et l'apprentissage basés sur les compétences et la simulation en complement aux méthodes traditionnelles d'enseignement clinique au chevet du patient. Par conséquent, un environnement préparé et contrôlé en toute sécurité avec des équipes interdisciplinaires formées est trèsessentielle pour dispenser une formation médicale efficace aux étudiants et aux professionnels de la santé. Le projet de centre de compétences et de simulation en coursvise à fournir un enseignement, une formation et un apprentissage dans diverses procédures cliniques pour les étudiants en médecine et les cliniciens. Matériel et méthodes: Le Le cadre du cycle de gestion de projet a été utilisé, qui comprenait les phases de planification, de conception, de formation et de mise en œuvre. Avoir choisi le modèle du centre de compétences et de simulation proposé, c'est-à-dire la redéfinition de l'enseignement médical avec un enseignement, une formation et une formation basés sur les compétences et la simulation, et apprentissage, il a été décidé de créer ce centre de compétences et de simulation. Résultats: l'unité centrale de compétences fonctionnelles et de simulation à la pointe de la technologie infrastructure ainsi qu'une équipe multidisciplinaire formée a été mise en place. Il existe également des programmes académiques, qui comprennent la démonstration de divers compétences cliniques et chirurgicales et ateliers sur la formation médicale basée sur la simulation. Conclusion: il a été possible d'établir une compétence globale et centre de simulation et atteindre les meilleures pratiques en éducation médicale par un investissement optimal dans les infrastructures et l'amélioration de la disponibilité humaine Ressources. Une planification détaillée est nécessaire, dans une variété de domaines. Nous espérons que nos expériences partagées dans cet article aideront d'autres facultés de médecine et les hôpitaux de la région, tant au niveau national que mondial, en vue de créer des établissements d'enseignement similaires.
Mots clés: mannequins, éducation médicale, planification, compétence et simulation, enseignement, formation
Keywords: Mannequins, medical education, planning, skill and simulation, teaching, training
|How to cite this article:|
Archana S, Nilakantam SR, Hathur B, Dayananda M. The need and art of establishing skill and simulation centers to strengthen skill-based medical education: Learning insights and experience. Ann Afr Med 2021;20:247-54
|How to cite this URL:|
Archana S, Nilakantam SR, Hathur B, Dayananda M. The need and art of establishing skill and simulation centers to strengthen skill-based medical education: Learning insights and experience. Ann Afr Med [serial online] 2021 [cited 2022 Oct 4];20:247-54. Available from: https://www.annalsafrmed.org/text.asp?2021/20/4/247/331659
| Introduction|| |
Medical education in India as well as throughout the world has undergone significant changes due to rapid advances in medical technology. Application of the same in modern medicine has challenged the traditional method of clinical skills' teaching, training, and learning. Recent trends in health-care delivery such as encouraging outpatient/day care and other issues such as shortening of hospital stay by enhancing the skills of clinicians in early/quick diagnosis, ethical concerns of practicing on real patients and patient rights, and a disproportionate increase in the number of students as compared to the number of teaching staffs, have not only limited the learning process in medical education but also have led to decline in clinical skills standards among medical students. Sometimes, the fact that the admitted patients are clinically unstable makes them unsuitable for bedside teaching too. These facts will sufficiently support the need of establishing virtual disease models/simulators.
Regardless of these constraints, medical students after graduation from medical colleges should be able to execute certain basic clinical skills and procedures individually at all levels of health-care settings. In any given clinical situation, they should be able to do initial and precise diagnosis, leading to appropriate patient care. Hence, these changes and trends in clinical circumstances have led to the emergence of skill and simulation centers, which, in turn, have become an important educational tool to nurture and acquire the necessary clinical skills which can be problem based, subject specific, and continuum of care driven. The term “clinical skills” involves effective communication, examination, reasoning, and technical and practical procedures which include clinical data interpretation, presentation, documentation, legal consideration, patient management, decision-making, team work, administration, leadership, and professionalism.,,
The skill and simulation center is a state-of-the-art facility that permits medical students and the practicing clinicians with opportunities to learn and obtain clinical skills in a safely prepared and controlled environment. Simulation refers to the artificial representation of a complex real-world process with enough fidelity to accomplish an objective, such as in training or performance testing. Skill- and simulation-based training in medical education is important for making capable and self-reliant health-care professionals and consequently improving patient care and safety and is supplementary to the traditional bedside clinical teaching methods. It offers numerous benefits, for instance, exposure to unique customizable situations, liberty to learn from errors without causing any harm, and become perfect and more confident. The facility of meticulous feedback and assessment makes the simulation center an essential component in medical education.
The skills achieved through the simulation centers and their application in medical care of real patients have stayed a subject of discussion and for additional exploration. However, many studies have revealed that those students who were trained in skill and simulation labs were more competent professionally and were able to perform procedures more efficiently, had better communication skills, and delivered overall better patient care. Previous studies have concluded that training at skill and simulation centers improves procedural skills with significant reduction in medical errors.,,,,
The Indian Medical Council, in its recent gazette has laid explicit rules to accomplish “the Skills of the MBBS graduate.” The guidelines command to have competent medical graduates in clinical and communication skills, research, population health, public health system, ethics, and information management. The Indian Medical Council has instructed all the medical colleges across the country to include the same in their undergraduate and postgraduate (PG) academic curricula.
In this article, we intend to depict our novel endeavor to set up a skill and simulation center, in our medical college-cum tertiary care hospital, Mysuru, South India, with the goal of strengthening medical education and to deliver quality hands-on learning experiences in a safe and realistic environment that are based on medical knowledge, patient safety, evidenced-based medicine practices, and professionalism. The practical challenges and opportunities that developed in this method of establishment are expounded here so that similar initiatives can be encouraged in other institutions.
| Materials and Methods|| |
This study was conducted in a private university-based medical college, which is attached to an 1800-bedded tertiary care teaching hospital located in Mysuru city of Karnataka state in India.
The establishment of a skill and simulation center requires meticulous planning and close coordination between college/university management and the concerned heads of departments, where the requirement of skill and simulation-based learning is essential along with a curriculum development committee. Prior visits to established simulation centers as well and discussions with experienced staff and stakeholders helped tremendously at this stage. Once the project was initiated, the team members visited many existing skill and simulation centers of other medical colleges to see the infrastructure and obtained feedback from end users regarding mannequins that are to be installed. A concerned in-charge staff for the skill and simulation center was identified in the beginning itself for coordination with various departments and to get their inputs and work smoothly. Success in its execution requires time, efforts, and money. There should be defined organizational goals and objectives, alterations in support resources, and interdepartmental coordination. This stage also involved frequent communications with the principal of the medical college, director of the hospital, and head of the departments of various specialties along with university and hospital administration. Finance, engineering, and maintenance departments were also involved in the team.
Skill-training mannequins, high-fidelity medical simulators, and advanced surgical simulators required by the institution were shortlisted at this time. After comparing the technical specifications of different simulators, suppliers of simulators were finalized and they were also involved in further infrastructure planning. Stakeholders need to give due attention to this important “technological advancement” for improvement of medical education in their own teaching and learning environment. Teaching and ongoing training was stressed on while negotiating and finalizing.
Dedicated space will be required for establishing a full-fledged skill and simulation center. Keeping in mind the equipment we were procuring, an estimated area of 10,000 square ft was required for the establishment of a skill and simulation center. Hence, we identified a separate wing in our hospital campus, where the entire third floor area was designated for simulation center.
In project management cycles, the design segment attentions on meeting initially recognized necessities. Having picked the model for the planned skill and simulation center, that is, redefining medical education with skill and simulation training, the arrangement of the existing space had to be reformed to outfit the new purpose. Professional architects were involved at this stage for adequate space management and infrastructure designing, keeping in mind to have infrastructure on par with international standards. Schematic figures of the planned floor layout were drawn in association with the architectural team, principal, engineering division, and end users of the simulation center. Initial plans were suitably improved in collaboration with the interdisciplinary teams and management staff as new needs arose during construction. Construction work and interior design works were looked after in detail with weekly review meetings and feedbacks. It took 6 months for the whole project to be completed including the installation of mannequins and simulators.
Simultaneously, with the support of the academic curriculum development committee, the teaching and training modules were also designed.
Structure and functional organization of the skill and simulation center
The center is built in approximately 12,000 square-foot area that is designed to serve as a major educational resource and a center of excellence for simulation-based medical education training and research. It offers students with the chance to handle real-life skills and health-related situations in a protected and supported environment before applying these skills in the clinical setting.
The simulation center has the following functional divisions [Figure 1]:
- Reception area – A well-designed reception area at the entrance lobby
- Skill studios – Two skill studios having individual task trainers [Figure 2] and [Figure 3].
- Intensive care unit (ICU) simulation room with a high-fidelity adult patient simulator along with briefing/debriefing areas with a control room.
- Operation theater simulation room having a high-fidelity birthing mannequin with briefing/debriefing areas and a control room
- Pediatric ICU simulation room with high-fidelity neonatal, infant, and child mannequins with exclusive briefing and debriefing areas adjoining the control room
- Audio–visual facilities in all the rooms required for recording and playback sessions
- Surgical simulation suites – Four surgical rooms having advanced surgical simulators
- Exclusive training room for ultrasound imaging
- Large multipurpose seminar hall with facilities to rely scenarios from ICU areas
- The simulation center also has a well-built, board room to conduct webinars and meetings
- Faculty lounge
- Student lounge area with student lockers and restrooms
- The skill and simulation center is furnished with advanced audio–visual framework in each room to capture training during case scenario and permit for debriefing, monitoring, and recording of individual and group exhibitions during a simulation
- HVAC [Heating, Ventilation & Air-conditioning] – fully centralized, for the entire floor
- Fire alarm and safety systems in place
- Adequate storage area to keep consumables.
The skill and simulation center is staffed with a chief coordinator, supporting departmental staff, nursing staff, a receptionist, and a bio-medical engineer.
Training of the interdisciplinary team took place in the skill and simulation center and lasted for 4 weeks. There were periods of didactics, group activities, video-assisted learning sessions, role plays, and brainstorming sessions. Every day ended with 30 min of critical reflection and debriefing. Each participant presented his/her seminars in PowerPoint on various approaches for clinical skill training in the last week of training, to fulfill the requirements for the award of certificates. Facilitators for the training were from the education team of mannequin suppliers who are well versed in education in skill and simulation. More details regarding the teaching and training curriculum and the posttraining evaluation will be published differently. In March 2020, we commenced our skill and simulation center for students in the space designated, with our core ethos being to provide quality medical education in a safely prepared and controlled environment.
The overall expenditure incurred for commissioning this skill and simulation center was 3 million US$ (220 million INR) approximately, which includes the cost of skill trainers, high-fidelity mannequins, and advanced surgical simulators along with creating a sustainable modern infrastructure suitable for simulation-based medical education.
| Results|| |
The state-of-the-art skill and simulation center as a separate division in this medical college and hospital which is private university based, was achieved which functions with the following objectives:
- To incorporate clinical simulation into undergraduate and PG medical education
- To redefine medical education training with simulation-based teaching, which encourages and unlocks opportunities of independent student learning and also for lifelong learning
- To deliver hands-on learning experiences and educational materials explicit to course goals as directed by the syllabus
- To accommodate novel learning requirements of students with various foundations, capabilities, and educational experiences
- To increase students' preparedness before their introduction to clinical training in hospital and for dealing with high-risk cases
- To enrich communication skills, cognitive skills, and psychomotor skills
- To determine the importance of collaboration and team building
- To incorporate clinical skill and simulation into programs such as faculty training and development and continuing medical education.
Simulations and case scenarios were designed to benefit the students for enhancing their skills required for decision-making and problem-solving. Basic life support and advanced cardiac life support, pediatric advanced life support (PALS), neonatal resuscitation program courses, etc., were designed and programmed to be conducted regularly.
Comprehensive clinical and patient care scenarios
The experiences of simulation that our students can learn will range anywhere from neonates to older adults, dealing with their families in more difficult circumstances. These situations can prepare the students for the present clinical reality. Right off the bat in the program, a situation is given that centers around the essentials of clinical practice. This will involve the students to distinguish the fine points of physical evaluation, patient safety, and also the best method of communication with their patients. Taking what they've learned in online coursework and skills lab, our faculty trainers will assess the students on how to adequately examine a patient, or high-fidelity mannequin. As students complete the simulation, instructors/facilitators will assess students to guarantee that they are performing basic skills, for example, techniques of hand hygiene, introducing themselves to the patient and/or patient relative in the room, patient identification, and enlightening their purpose. Practicing these scenarios will help the students to develop, refine, and apply theoretical knowledge into a clinical situation of realistic nature. It will likewise show them the significance of interdisciplinary and team-based care. After training in basic handling, complex case scenarios such as cardiorespiratory arrest, myocardial infarction, acute respiratory distress syndrome, difficult airway, and high-risk obstetric cases are simulated on mannequins to train the students to handle them in real world of clinical practice.
Effective communication plays a vibrant role throughout the patient's health-care experience, and a tremendous bit of the duty falls on the treating doctors.,,,,, Knowing this, it is essential that they are communicating with individuals of cohort during simulation training. This will prepare them to have the certainty to work together with clinical staff's and individual specialists, and nurses during in-hospital clinical pivots. Clinical staff and faculty will have to participate in simulations with other students in cohort, where every one of them will assume explicit jobs. Interdepartmental scenarios are given to encourage team dynamics and resource management.
| Discussion|| |
The aspects of skill and simulation center venture described in this article prove that with administrative and institutional support, it is conceivable to create in-hospital state-of-the-art skill and simulation center. This article also gives emphasis to the value of locally available technical expertise which can be connected in building the capacity for such initiatives in every institution in India and other countries as well. The project took off from little beginnings with orientation workshop to all the faculties. Academic programs also commenced and are ongoing for clinical staffs and medical students both at PG and undergraduate levels. The training of clinical skills can be incorporated anywhere during the phases of preclinical, clinical, house-surgeon training, PG teaching program, and as a part of continuing medical education.
We have been attentive to document our training and educational strategies and programs. Our teaching and training programs, processes, and results are being assessed. Performance appraisals are ongoing, the outcomes of which will be shared in future publications. Inputs to colleagues; the head of the departments; the administration staff of the medical college; and hospital, university, and other important partners have given the basis for program alterations, infrastructural upgrades, and safeguarding policies and checklist documents. Feedbacks are ongoing.
High-fidelity medical mannequins in brief
Advanced birthing simulator [Figure 4]
Normal labor to various high-risk obstetric case scenarios can be created here to train the students.
High-fidelity adult patient simulator [Figure 5]
This simulator displays a varied series of physiological symptoms and signs as well as pharmacological response to different classes of medications. It can also be used for advanced simulation training such as bed-side ultrasound, ventilator management, monitoring of patient, and video debriefing.
High-fidelity infant and neonatal simulators [Figure 6] and [Figure 7] have features required for training neonatal resuscitation, PALS, securing airway, connecting to ventilator, and other complex cases. Pediatric simulator is a realistic full-body simulator for pediatric emergencies. It allows learners to focus on a broad range of clinical scenarios to gain experience of life-threatening pediatric cases.
Time given to training on these hi-fidelity mannequins is extremely helpful. It teaches how to respond to extreme circumstances that may happen on the fly, care for patients of all ages, and communicate effectively with a real-life patient. Importance is also given for crisis resource management in individual specialties.
Advanced surgical simulators [Figure 8] and [Figure 9]
They are used to train faculty and PGs of surgical specialties, ranging from laparoscopy, colonoscopy, endoscopy, endoscopic retrograde cholangiopancreatography, arthroscopy, hysteroscopy, etc., Ultrasound simulators are also installed to train them in basic and advanced ultrasound imaging.
Briefing / debriefing areas with a control room [Figure 10]
For a successful simulation experience, briefing before simulation training is of utmost importance. As it orients and prepares the participants before the start of the simulation, which guarantees that the simulation experience is consistent and provides the maximum benefit to the participants. Debriefing is the intentional discussion following the simulation experience that allows participants to achieve a clear understanding of their thought processes and actions to enhance learning outcomes and promote their clinical performances in the future. Post simulation debriefing is considered not only as one of the most effective components of Simulation Based Education but also as the cornerstone of the learning experience in the simulation of medical education settings.
Challenges stood and opportunities provided by the skill and simulation center
Some of the challenges that we have been experiencing in running the skill and simulation center from its beginning, include cost required to be invested in such centers, adjusting with the realism of simulators, and time fixed for simulation training and teaching along with asset and resource availability and accessibility.
The initial and recurrent price of procurement and maintenance of disposable consumables for all the simulators is high and has to be planned well in financial allocation. Recurring cost also includes maintenance from HVAC, electricity, and staff allowance, to mention a few.
Incorporating time slot for simulation-based teaching, in undergraduate and PG medical curriculum, is a challenging task, with balancing all other curricular requirements. As the efficiency of the center is dependent on these, we are continuously evaluating them. More innovative teaching components need to be established for dedicated training of the students and other specialists, highlighting on approaches toward communication and case-based clinical case scenarios.
Our skill and simulation center opens up prospects for enhanced teaching, training, and learning of health-care staffs of various levels as they get extensive introduction to the varied clinical case scenarios, demonstrations, and treatment methodologies used. Such a dedicated unit may produce enhanced and various opportunities for research, focusing on clinical care and skills, curriculum development for medical education, and improvement on professional performances in modern medicine.
For future medical academicians, health-care professionals, and researchers from developing countries, for example, India, the challenge is to create cost-effective and more viable models of teaching and training which vertically incorporate the tertiary health-care and primary health-care systems for the future clinicians. Such models may inevitably remove the locus of care from specialists to the primary health-care arena, saving truly necessary human resources. We trust this paper will give useful experiences to clinicians working in various medical colleges to stem further research around there and promote the expansion of such facilities across the country.
- The skill and simulation center established here strictly applies just to this institution only
- Depending on the available infrastructure and local resources, hospital size, and levels of teaching and care, other medical colleges and teaching hospitals can adjust this plan and layout only after suitable changes according to their necessities
- Simulation can only imitate however not reproduce reality. Although the benefits of simulation-based skill lab teaching are broadly acknowledged, there is scanty exploration on its long-standing viability and effectiveness.
| Conclusion|| |
Teaching clinical skills in simulation centers is a fundamental connection between medical students and staffs for their training and learning and to gain adequate clinical experience and has demonstrated to be an effective tool for evaluating critical thinking, technical skills, and group conduct. It is possible to establish a comprehensive skill and simulation center and achieve best practices by careful planning and optimized investment on infrastructure and procuring the right material from right vendors. We also make recommendations for setting up similar units in other medical colleges of India and abroad as well. The skill and simulation lab will provide better chances for a more comprehensive medical education and improved student-centered training and focused inter-disciplinary research. Careful coordination between the vendors, interior designers, bio-medical engineers, clinicians, and all stakeholders is the key factor in establishing a skill and simulation center in any health-care institution.
Areas of interest for future research
- To study the impact of skill and simulation training on academic performances of medical students at preclinical level and clinical level in comparison with the current methods of teaching
- Cost analysis of skill- and simulation-based training for various categories of health-care professionals
- Functional evaluation to know the utilization patterns of our skill and simulation center
- To study the perceptions and experiences of staffs and students who underwent training from our skill and simulation center
- To design and use new innovations and learning objectives in the teaching of clinical skills.
The authors wish to express their heartfelt gratitude to the management and administration of JSS Academy of Higher Education and Research, Mysuru, for establishing this skill and simulation center. The completion of this project could not have been possible without the participation and assistance of all the supporting team members whose contributions are sincerely appreciated and gratefully acknowledged.
Financial support and sponsorship
Financial support was provided solely from institutional and/or departmental sources.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dhaliwal U, Supe A, Gupta P, Singh T. Producing competent doctors The Art and Science of Teaching Clinical Skills. Indian Pediatr 2017;54:403-9.
Remmen R, Scherpbier AJ, Derese A, Denekens J, Hermann I, van der Vleufen CP, et al
. Unsatisfactory basic skills performance by students in traditional medical curricula. Med Teach 1998;20:579-82.
du Boulay C, Medway C. The clinical skills resource: A review of current practice. Med Educ 1999;33:185-91.
Bradley P, Postlethwaite K. Setting up a clinical skills learning facility. Med Educ 2003;37 Suppl 1:6-13.
Datta R, Upadhyay K, Jaideep C. Simulation and its role in medical education. Med J Armed Forces India 2012;68:167-72.
Al-Elq AH. Medicine and clinical skills laboratories. Fam Community Med 2007;14:59-63.
Herrmann-Werner A, Nikendei C, Keifenheim K, Bosse HM, Lund F, Wagner R, et al
. “Best Practice” skills lab training vs. a “see one, do one” approach in undergraduate medical education: An RCT on Students' long-term ability to perform procedural clinical skills. PLoS One 2013;8:1-13.
Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: A case-control study. Chest 2008;133:56-61.
Lund F, Schultz JH, Maatouk I, Krautter M, Möltner A, Werner A, et al
. Effectiveness of IV cannulation skills laboratory training and its transfer into clinical practice: A randomized, controlled trial. PLoS One 2012;7:1-10.
Peeraer G, Scherpbier AJ, Remmen R, De winter BY, Hendrickx K, van Petegem P, et al
. Clinical skills training in a skills lab compared with skills training in internships: Comparison of skills development curricula. Educ Health (Abingdon) 2007;20:125.
Lynagh M, Burton R, Sanson-Fisher R. A systematic review of medical skills laboratory training: Where to from here? Med Educ 2007;41:879-87.
Ziv A, Ben-David S, Ziv M. Simulation based medical education: An opportunity to learn from errors. Med Teach 2005;27:193-9.
Akaike M, Fukutomi M, Nagamune M, Fujimoto A, Tsuji A, Ishida K, et al
. Simulation based medical education in clinical skills laboratory. J Med Invest 2012;59:28-35.
Bugaj TJ, Nikendei C. Practical clinical training in skill labs: Theory and practice. GMS J Med Educ 2016;33:1-21.
Upadhayay N. Clinical training in medical students during preclinical years in the skill lab. Adv Med Educ Pract 2017;8:189-94.
Juliano JM, Liew SL. Transfer of motor skill between virtual reality viewed using a head-mounted display and conventional screen environments. J Neuroeng Rehabil 2020;17:48.
Hannafin NM, Phillips R. The flipped classroom applied to the clinical skills lab setting. J Healthc Commun 2017;2:1-3.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]