|Year : 2016 | Volume
| Issue : 2 | Page : 118-123
Evaluation of retention of knowledge and skills imparted to third semester MBBS students through basic prehospital care of fracture
Dharmvir Ranjan Bharati1, Partha Nandi2, Ranabir Pal3, Thiruvanthipuram Venkadesan Yamuna4, Andharaj Lokeshmaran2, Gautam Sarker5
1 Department of Community Medicine, Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, Bihar, India
2 Department of Community Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
3 Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
4 Department of Community Nursing, College of Nursing, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
5 Department of Community Medicine, Mata Gujri Medical College and LSK Hospital, Kishanganj, Bihar, India
|Date of Web Publication||5-Jul-2016|
Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
Background: The basics of prehospital care of fracture is essential to the practice of medicine. Objectives: The study was intended to increases the knowledge in the applied aspects of basic prehospital care of fracture and evaluate the posttraining effectiveness of medical students. Materials and Methods: The World Health Organization (WHO) promoted "Injury Prevention and Control--A Handbook for Undergraduate Medical Curriculum" that was used to develop two teaching-learning modules. With the help of "Learning Resources Evaluation Guidelines," resource contents were designed and arranged to develop a teaching-learning module for two groups of third semester Bachelor of Medicine, Bachelor of Surgery (MBBS) students that was focused, compact, and completed within the stipulated time frame. The structured questions were used for evaluation of the cognitive domain while evaluation of the psychomotor and affective domains was done by "do it yourself" simulation exercises on mannequins. Results: For basic knowledge, the differences between pretest and posttest in both groups were statistically significant: the correlation between pretest and posttest was not significant in group 1 but was significant in group 2. For skill, the differences between pretest and posttest in both groups were statistically significant; the correlation between pretest and posttest was not significant in group 1, whereas it was significant in group 2. The second group learnt more at all levels. Conclusions: The study findings evidently pointed out that for optimum learning of all domains in order to bring about a change in the desired direction, there is need for training with a well-structured program to understand practical procedures in near-real life exposure.
Keywords: Fracture, knowledge, prehospital care, skill
|How to cite this article:|
Bharati DR, Nandi P, Pal R, Yamuna TV, Lokeshmaran A, Sarker G. Evaluation of retention of knowledge and skills imparted to third semester MBBS students through basic prehospital care of fracture. Trop J Med Res 2016;19:118-23
|How to cite this URL:|
Bharati DR, Nandi P, Pal R, Yamuna TV, Lokeshmaran A, Sarker G. Evaluation of retention of knowledge and skills imparted to third semester MBBS students through basic prehospital care of fracture. Trop J Med Res [serial online] 2016 [cited 2019 Aug 20];19:118-23. Available from: http://www.tjmrjournal.org/text.asp?2016/19/2/118/185434
| Introduction|| |
An increasing burden of road traffic injuries demands that future doctors should be well-trained and competent in this field. It is the responsibility of medical institutions to strengthen undergraduate medical education to rectify the current deficiency for better patient care.  Fracture is a major cause of premature death and downstream disability because of various etiologies affecting all age groups that need earliest intervention. Out of all interventions, the most important is to provide quality first-aid help to the victims as early as possible for preventing both death and disability. ,, It is worth mentioning in this regard that that orthopedic teaching forms 3.7% of the undergraduate medical curriculum in India.  Students must get education and training with strategies that can enhance learning. The ultimate goal of all communications is to bring about a change in the desired direction of the person who receives the communication. This may be at the cognitive level in terms of increase in knowledge; it may be affective in terms of changing existing patterns of behavior and attitudes and it may be psychomotor in terms of acquiring new skills. , Learning is an intricate observable event involving complex intellectual activities such as critical thinking and the ability to solve problems. In this new millennium, there is an explosion of information wherein learners are experiencing painful learning instead of an escalating scholastic joy. The world is moving to a spick and span vibrant paradigm shift of teaching-learning for need-based education.  Experts in the field of medical education have expressed their vision to bring up a cohort of medical professionals with a passion for intermingled skills.  In the above scenario, we need to increase the competence of prehospital care of undergraduate students.
This study was conducted to achieve the following objectives.
- To increase the awareness and interest on prehospital care of fracture
- To develop a teaching-learning module to increase medical students' knowledge in the applied aspects of basic prehospital care of fracture
- To evaluate the posttraining effectiveness of medical students.
| Materials and Methods|| |
The study was conducted at the Mahatma Gandhi Medical College and Research Institute, Puducherry, India at the Department of Community Medicine between September 1, 2014 and September 23, 2014 among third semester Bachelor of Medicine, Bachelor of Surgery (MBBS) students. The topic and schedule of the teaching-learning was announced 2 weeks in advance. The students were also instructed to gain extra knowledge regarding the topic from the Internet and other available sources.
With the help of "Injury Prevention and Control--A Handbook for Undergraduate Medical Curriculum" by the World Health Organization (WHO), a teaching-learning module was developed for training on cognitive, affective, and psychomotor domains. With the help of "Learning Resources Evaluation Guidelines," resource contents were designed and arranged to develop a teaching-learning module that was focused, compact, and completed within the stipulated time frame. ,,
For the assessment of effectiveness of teaching-learning module, students were evaluated by a set of pretested structured multiple choice questions and Likert's scale-based questions (a total nine questions were there and each one carried 100 marks) for evaluation on the cognitive and psychomotor domains of learning while for evaluation of the psychomotor and affective domains, "do it yourself" exercises on mannequins (only one out of eight procedures for each student and that of 100 marks) was organized.
This teaching-learning module and method of evaluation were developed at the institute with assistance from the faculty members and other experts such as the statistician-linking correlates of fracture to ensure validity, reliability, feasibility, and time management. With help of "Evaluation and Selection of Learning Resources: A Guide,"  two sets of teaching-learning module were developed. The first set consisted of a PowerPoint presentation of 18 slides related to the facts of subject with various different procedures as per the basic skills required to give at the time of prehospital care of fracture. The second set consisted of a PowerPoint presentation of 18 slides related to the facts of subject with various different procedures as per the basic skills required, and eight hands-on exposures on mannequins for different procedures related to various different procedures as per the basic skills required to give at the time of prehospital care of fracture that were included as per the basic skills required to give at the time of prehospital care of fracture.
Two groups of students were selected from third semester MBBS students. At one setting, the first group of 17 students first went through a pretest with of pretested, structured multiple choice questions and Likert's scale-based questions and "do it yourself" exercises on mannequins; thereafter, a 30-min PowerPoint-based lecture class was organized to improve basic knowledge and skills (practical procedures) to administer the basic prehospital care for fracture. After that, a posttest was conducted with the same set of questionnaire and "do it yourself" exercises on mannequins.
In another setting, the second group consisted of 21 students that first went through a pretest with pretested, structured multiple choice questions and Likert's scale-based questions and "do it yourself" exercises on mannequins; thereafter, a PowerPoint-based lecture class was organized to improve the basic knowledge and skills (practical procedures) to administer basic prehospital care for fracture, along with the demonstration by an expert faculty and side by side, hands-on exposure on mannequins for eight different procedures of prehospital care of fracture. After that, a posttest was conducted with the same set of questionnaire and "do it yourself" exercises on mannequins for any randomly selected procedure out of eight practical procedures.
Data obtained after pretest and posttest from both the groups were analyzed with respect to the mean score using Student's t-test by Statistical Package for the Social Sciences (SPSS) (16 evaluation version, SPSS Evaluation version). Scores are reported as means and standard deviation (SD). Statistical significance was assessed at a type I error rate of 0.05.
| Results|| |
Pretest and posttest questionnaires included nine questions and each one carried 100 marks to test the student's basic knowledge on prehospital care of fracture. Students were also asked to demonstrate randomly selected any one out of eight procedures, with 100 marks allotted to each student, for "do it yourself" exercises on mannequins.
For the basic knowledge, among the first group of 17 students, the mean value of pretest was 348.65 (SD = 89.83) while the mean value of posttest was 736.94 (SD = 88.14). The difference between pretest and posttest was 388.29. Among the second group of 21 students, the mean value of pretest for knowledge was 275.71 (SD = 84.37) while the mean value of posttest for the basic knowledge was 798.14 (SD = 92.23). The difference between the pretest and posttest was 522.43. There was a significant difference between pretest and posttest in both the groups at 95% confidence interval [Table 1].
|Table 1: Comparison of pre and post-test for the basic theoretical knowledge on pre hospital management of fracture |
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The correlation between pretest and posttest was not significant in group 1 [Figure 1], whereas it was significant in group 2 [Figure 2].
For the "skill" or basic practical knowledge ("do it yourself" exercises on mannequins), among the first group of 17 students, the mean value of pretest was 37.55 (SD = 17.24) while the mean value of posttest was 68.24 (SD = 19.68). The difference between pretest and posttest was 30.89. Among the second group of 21 students, the mean value of pretest was 24.76 (SD = 9.93). While the mean value of posttest was 79.52 (SD = 12.738). The difference between pretest and posttest was 54.76. The differences between pretest and posttest in both the groups were statistically significant at 95% confidence interval [Table 2].
|Table 2: Comparison of pretest and posttest for basic practical knowledge ("do it yourself" exercises on mannequins) on prehospital management of fracture |
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The correlation between pretest and posttest was not significant in group 1 [Figure 3], whereas it was significant in group 2 [Figure 4].
|Figure 3: Scatter plot for basic practical knowledge in group 1 (r = 0.487, P = 0.047, R Sq = 0.237)|
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|Figure 4: Scatter plot for basic practical knowledge in group 2 (r = 0.542, P = 0.011, R Sq = 0.294)|
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In the first group, the difference between pretest and posttest for the "basic knowledge" and "skill" was 388.29 (SD = 102.783) and 30.88 (SD = 18.811), respectively, while in the second group, the difference between pretest and posttest for the "basic knowledge" and "skill" were 522.43 (SD = 85.26991) and 54.53 (SD = 11.122), respectively [Table 3] and [Table 4]. The "equality of variances" are not significantly different, which means that both the groups were identical at the beginning. This shows that the second group learned more at all three levels of learning as compared to the first group.
|Table 3: Comparison of the effectiveness between training module no. 1 for group 1 and training module no. 2 for group 2 on the "basic knowledge" for prehospital management of fracture |
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|Table 4: Comparison of effectiveness between training module no. 1 for group 1 and training module no. 2 for group 2 on the "skill" for prehospital management of fracture |
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| Discussion|| |
The fundamentals of prehospital care of fracture are essential to clinical practice for primary care physicians. The optimum treatment for managing a fracture at the site of injury may not be sufficient as most medical schools do not have formal prehospital care training in the teaching-learning curriculum. We need to strengthen training for future physicians to prepare them to respond effectively in an event of fracture in a prehospital setting at the graduate level. 
It was evident from the results that pretraining knowledge regarding prehospital care of fracture was inadequate. After hands-on training on mannequins, student knowledge and skills improved more as compared to those who were not exposed over the same. Researchers reported that after the BLS training, students' knowledge and skills improved.  Others also reported that a simulation-based intervention enhanced more skills in recognizing and handling emergencies.  Educational studies also advocated that practicing basic life support (BLS) on mannequins enhanced students' skills in recognizing and handling emergencies.  Other research groups have also stressed the importance of reinforcement to attain adequate cardiopulmonary resuscitation (CPR) skills and maintain continued competency in the technique. , The above scenario calls for multipronged educational intervention programs at all levels that should be feasible, acceptable, and can easily be monitored.
In a South Indian study, very few students had good knowledge about first aid irrespective of whether they were earlier trained or not indicating that apart from the training at graduate level, medical programs need to be reinforced periodically with refresher training workshops. 
The knowledge of prehospital care in suspected fractures by immobilization in road traffic accidents was good in about 44% students in two studies conducted at Karachi, Sindh, Pakistan. , The use of simulation techniques using mannequins as educational and assessment tools has been reported. A study from New Zealand reported that a great majority of the students felt that the simulations were a logical appraisal of their abilities; the research group recommended the incorporation of simulation-based workshops in the undergraduate curriculum both for education and assessment of competence in emergency management. , A training program evaluated the positive effect of training of Chinese paramedics in the China-America Union Pre-Hospital Emergency Care Training Program on the emergency medical knowledge and skills in fracture care and stabilization, and transportation. 
In the undergraduate medical curricula, learners are trained in hospital emergency settings under supervision and the umbrella care of all the infrastructural supports. However, managing an emergency at the site of the accident remains questionable. , Medical courses and curricula are changing their educational programs and teaching strategies globally to groom them with the philosophy of lifelong self-directed learning.  We need to provide the learners the best learning tools available for their methodical perception, and germane skills as medical science is moving toward skill-based social science from knowledge-based social science in line with the "Best Evidence Medical Education." 
The Medical Council of India has stretched the possibility for ground-breaking approaches for skill development and creation of appropriate attitudes with all endeavors to give confidence to use active methods of teaching-learning.  As an essential component of evaluation, assessment is an educational tool that serves manifold functions such as feedback to learners on areas of strength or weakness that can provide the facilitator insight on the usefulness of an agreed approach. 
To sum up, the results of this study clearly indicate that for the maximum learning at all levels of the domain and to bring about a change in the desired direction of a person, there is a need to trained students with well-structured, organized "hands-on training on mannequins" to understand the practical procedures in mimicked situations to achieve the maximum outcome in real life. Further, the level of knowledge about prehospital care was not sufficient among a majority of the learners that pointed out the need for formal training in the medical curriculum.
Strengths of the study
Ultimately, we have to enhance the proficiency of the medical graduates who as primary health practitioners have to be competent to provide prehospital care to the last man on the road and thus, enhance the quality of health care in India. Our study generated awareness about further research in medical education in other departments too. Moreover, no study on this topic has been reported so far in this region though research in teaching-learning in undergraduate medical courses is much needed in Southeast Asia.
Limitations of the study
The results from our study should be viewed within the context of various limitations. First, a small sample was used for the assessment of effectiveness of newly developed study module. Second, due to time constraints, each student was examined for only one practical procedure for skills by "do it yourself" exercises on mannequins against eight procedures. Third, there is a need to modify the teaching-learning module for better comparison with other published reports in the next phase of study. Fourth, the results show the trends from one medical institution.
Future directions of the study
With the encouraging results on constructive gains and acceptability by the students and faculty, we hope to continue the study every year. Further, we hope to propose to the authorities to bring about a change in the medical curriculum and teaching methods. We feel that similar studies are needed with inputs from the multidisciplinary sources available in our country, along with larger study participants for more significant results. Our overall impressions underline the fact that medical students are not adequately prepared in the prehospital care of fractures.
The authors acknowledge the guidance and support of the following: Faculty of the Orthopaedic Department and Community Medicine and the third semester MBBS students of Mahatma Gandhi Medical College and Research Institute (Pondicherry, India).
Financial support and sponsorship
Conflicts of interest
No conflicts of interest, financial or otherwise, are declared by the authors.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]