The Effects of Early Clinical Exposure On Medical Laboratory ...

Article ID: WMC003926

ISSN 2046-1690

The Effects of Early Clinical Exposure On Medical Laboratory Technology Students: Its effect on Internship Period and their professional Carrier Corresponding Author: Dr. Burhan W Imamwerdi, Assistant professor , Medical laboratory sciences, 75 Panamount Circle NW, T3K0C7 - Canada Submitting Author: Dr. Burhan W Imamwerdi, Assistant professor , Medical laboratory sciences, 75 Panamount Circle NW, T3K0C7 - Canada

Article ID: WMC003926 Article Type: Research articles Submitted on:30-Dec-2012, 11:35:00 PM GMT Article URL: http://www.webmedcentral.com/article_view/3926 Subject Categories:MEDICAL EDUCATION Keywords:Medical Laboratory Technology; Medical internships; On the Job Training; Teaching; Training Techniques; Educational Techniques, Laboratory Scientist, Laboratory Technician. Source(s) of Funding: The researcher would like to thank the deanship of Scientific research of the University of Dammam for their help, support and funding of this study and Dr. Khaled Fikry El-Said Salama for his statistical analysis input. Competing Interests: The author reports no conflict of interest and that I alone am responsible for the content and writing of the article. Additional Files: Full Article with Tables

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The Effects of Early Clinical Exposure On Medical Laboratory Technology Students: Its effect on Internship Period and their professional Carrier Author(s): Imamwerdi BW

Abstract Objective: With the development of the field of medicine, the diagnostic and applied techniques of medical sciences are having a more proactive role in helping this development. In order to address this need, this research proposes Early Clinical Education (ECE) as an innovative learning style that will encourage the strength and depth of learning, develop intellectual skills and enhance integration of theory and practice by extending learning environment from class rooms towards hospital setup. Method: An 18 question questionnaire was implemented on 55 interns and 36 graduates of medical laboratory technology program exposed to ECE in the hospital laboratory setup during the academic years of 2008 to 2012. An additional questionnaire was implemented on 58 hospital lab staff for the same period.

innovative learning style methodology in Medical Laboratory Technology. 2. ECE role in deepening of the knowledge learning, developing technical skills and enhancing the integration of theory and practice. 3. Extending the learning environment from classroom to its realistic professional setup in hospitals. 4. Utilize hospital clinical environment in motivating and fostering student’s professional attitude. Application to Patient Care: 1. ECE role in enhancing student's understanding of medical conditions and enabling them to better retain the knowledge and skills involved for best approaches to lab diagnosis. 2. Exposing students to a wider range of patient’s conditions and assist them to acquire, practice and refine skills involved in a supportive environment that fosters an appreciation of their important role as active lab technologists in a patient healthcare system.

Introduction Results: 95.1% of participants stated that ECE period was a crucial preparatory stage for their internship period with 93.9% of the students expressing significantly higher level of confidence during their internship due to their prior ECE training. 98.8% indicating that ECE had great effect on their professional performance and 90.3% indicating that they would have never performed at the same level without the ECE they experienced in the hospital setup. This outcome was strongly echoed by the professional hospital staff who has been directly involved in the training of our medical laboratory program students test group. Conclusion: Early Clinical Education learning methodology is proposed as an additional innovative learning style to be utilized as part of a structured curriculum or as an additional learning style to any existing curriculum. Advances in Knowledge: 1. Implementing Early Clinical Education (ECE) as an


Since the first clinical laboratory was established at Johns Hopkins Hospital in 1896, the need for the development of medical laboratory sciences became apparent. Gradually this need for laboratory testing was appreciated and medical laboratories occupied a position of much greater importance 1. Currently, one can hardly imagine a health care system without the contributions of clinical laboratory scientists. Concurrently the educational requirements have gradually increased as the body of knowledge has increased in volume and complexity 2. In order to meet this demand, the educational requirements for clinical laboratory science have evolved in tandem with the development and expansion of the scope of the field. Particularly under the continuous scrutiny of the medical laboratory staff performance that are systematically evaluated by local as well as international professionals and accreditation bodies3. Simultaneously, students themselves are becoming more mindful about the quality of their learning. Their

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participation in class as well as tutorial discussions and resource utilization in light of the vast electronic educational recourses available to them demands continual improvements and innovations to the programs and its educational environment. In most universities around the world, traditional medical laboratory technology curricula have been based on the model of teaching that kept medical students in classrooms and laboratory settings. However, with the development of new learning methodologies such as task-based, problem-based and outcome-based learning methodologies, few colleges are doing any structural curriculum changes to incorporate these modern medical education techniques4. As such, early clinical exposure (ECE) as an innovative and active experiential learning methodology applied on patient samples in hospital based diagnostic laboratories under direct supervision of practicing laboratory clinical instructors is proposed. This would aid as an ultimate tool for delivering the skills and help molding student`s professional attitude as medical technologists after having successfully acquired their knowledge in a more traditional didactic class based lectures and simulated laboratory setups. The quality of this learning environment has to be maintained as a healthy interactive network of sources within the teaching and learning activities that encourages integration between theory and clinical practice in order to obtain balanced learning outcomes5. Our Medical Laboratory Technology curriculum is based on a formal lectures and practical sessions for the first 2½ years (5 levels) taking place at the college of applied medical sciences class rooms and laboratories. This learning process is assessed by comprehensive practical course handbook and multiple choice assessments with simple essay question formats and the teaching being completely teacher centered, information gathering educational system. To correct the short outcome of this, ECE learning methodology was implemented for levels 6 through 8 to complete the 4 years undergraduate requirements for graduation with the degree of Bachelor of Science in medical laboratory technology. The goal was to shift the educational environment towards a more student centered and task-based learning environment that would achieve higher degree of integration of information and skills previously acquired in their newly introduced hospital environment. Although ECE programs are increasingly widespread in the other applied medical sciences, there is relatively little research performed on the topic in


medical laboratory sciences6-7. Hence the aim of this study was to compare our program's professional outcome levels to similar college graduates in Saudi Arabia without ECE as part of their program, proposing that early clinical exposure experience could make laboratory sciences more perceptible and applicable in the students’ future career. In order to achieve this scientific comparison, hand feedback was gathered from previous current internship students on their educational practical experiences having finished their ECE hospital environment.

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The proposed research question was “The Effects of Early Clinical Exposure for Medical Laboratory Technology Student's: Its effect on their Internship Period and professional Carrier”. The directional hypothesis was that "This early clinical exposure is very crucial in shaping medical laboratory student’s professional attitude and communicational skills and helps in the improvement of our graduates’ professionalism". The null hypothesis for this problem would be that “There is no advantage in this pre-clinical training period over similar academic program graduates who without having the exposure to the early clinical training period would perform the same during their internship period and their professional carrier thereafter”.

Methods Ethical clearance and approval for this study was granted by the deanship of the scientific research of the University of Dammam. Information collected on hard copies was stored in specially designated secure office space with limited access. Data entry and analysis took place on a laptop computer with no access to the network. All data and its analysis were regularly backed up on a designated flash memory for data protection. Two structured five point likert scale questionnaires were developed. The first one was implemented on interns and graduate participants with 4 defined key concept domains as follows: 1. ECE role in professional preparation for the internship period in 4 items with a maximum score of 16. 2. Role of ECE in Soft Skill development necessary for their profession in 5 items with a maximum score of 20. 3. Validity of ECE and its importance in the Medical sciences curricula in 6 items with a maximum score of 24.

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4. The quality of ECE learning methodology evaluated in 3 items with a maximum score of 12. The total score of this questionnaire was 72 for the total 18 questions evaluated. This questionnaire was developed in-house by the researcher and has been piloted on 3 groups of 5 interns and 1 group of 5 professional academicians for its validation. All interns and graduates of our program who have finished their internship in 2008 to 2012 were included in this study. Another structured questionnaire of 9 questions based on a four point likert scale was advised and trialed across 1 group of senior professional laboratory staff employees of an affiliated hospital for its validation. Scores of 3 was designated for exceptionally better; 2 for better; 1 for same as other medical laboratory students and 0 for worst than their peers’ ratings for each of our intern’s theoretical, scientific thinking, practical skills and professional attitude in their work place. These marks were in comparison to the graduates and interns of other laboratory medical technology programs in the Kingdom of Saudi Arabia. Information from laboratory staff, lab supervisors of all the diagnostic labs in the affiliated hospitals in the eastern province of Saudi Arabia who had at least 2 years of interactions with our interns was collected for this study. Data triangulation was applied by utilizing the following primary sources: 1. The Researcher - as a member of the curriculum development committee and the general coordinator of internship affairs of the college. 2. Specially customized questionnaire distributed to non-randomized group sampling from the department of medical laboratory technology of the college of applied medical science’s interns in the eighth month of their twelve month internship period. In addition to the interns from the last four years who could be contacted to voluntarily participate in this study. 3. Another questionnaire was distributed to laboratory staff who have had interactions with our interns in the last two years and lab supervisors of all diagnostic labs in the eight affiliated hospitals in the eastern province of Saudi Arabia. The purpose was to establish a scientific comparison of our intern’s competency and performance levels compared to other interns of other colleges with similar programs but without ECE environment. Data collection took place over three visitations to


eight affiliated hospitals in the eastern province of Saudi Arabia where more than 95% of our interns have been training in over the last four years. In the first visit, the intern’s questionnaire was introduced to our students while the laboratory staff and supervisors questionnaire was discussed and distributed to the personal needed to participate in this study. This visit was followed after 4 weeks by a second visit mainly to answer and clarify any enquiries and collect the filled questionnaires if ready or remind the personal to fill the questionnaires and provide extra copies if needed. The third visit was a follow up and collection of the remaining questionnaires in order to maximize the response rate within a set-time frame of time in order to prevent validity problems. Data entry and analysis were conducted using SPSS-16 (Chicago, USA) statistical software.190 individual data were coded, entered after been checked for data entry errors. Three questionnaires were excluded for incomplete entries and missing data upon record verifications. The researcher used descriptive statistics as mean standard deviation and percentage as well as t -test of significance with alpha value of 0.05. The percentage agreement’s score was calculated aggregating the responses of strongly agree with a score of 4 and somehow agree with a score of 3 as agreement scores. Similarly, neither agree nor disagree with score of 2 along with somehow disagree with a score of 1 and strongly disagree with a score of 0 were aggregated to form disagreement scores in favor of the null hypothesis. Questions number 7, 12, 17 and 18 have been structured in a negative statement and hence reverse scored prior to the analysis and interpretation of results.

Results 85 out of total 91 questionnaires distributed to interns and graduates of our college were collected with response rate of 94.4%. Eighty two questionnaires were verified and included in the study after verification. The exclusion of the other three questionnaires was due to data incompletion and discrepancies. All Items Means, standard deviations and standard error of means were calculated as shown in table 1. For the 1st domain of our study evaluating the role of ECE in professional preparation for the internship period as shown on table 2, 95.1% stated that the ECE period was an essential preparation stage for

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their internship period with 93.9% expressing that they even felt more confident during their internship due to their prior ECE training. 97.6% agreeing that ECE had great affect on their professional life performance and 91.5% of them indicated that they would have never performed the same without the ECE time they experienced in the hospital setup. When the role of ECE in development of soft skills necessary for their profession was studied, preparation of log books which is a requirement in the current assessment system was not strongly agreed upon as a valuable skill with only 62.2% of the students indicated the use of logbook preparation during their ECE. While 81.7% of the students agreed on the importance of audio-visual presentation skills for their carrier with great interest in learning research methodologies that was indicated by 89% of interns and 97.4% of newly graduates as this would help their constructive criticism and critical thinking. The validity of ECE and its Importance in the curriculum improvement of medical laboratory technology programs was explored in the third domain with 96.3% indicating that much of what they had performed during their ECE was relevant to their carrier and more than half of participants recommended adding ECE to medical laboratory programs in the other universities. When they were asked for their opinions if ECE time, 92.4% agreed that its benefits over weighed its workload and 84% disagreeing with shortening or cancelling ECE from the current curriculum. Some of the key elements to the success of ECE with the testimony of the student participants were the stimulating nature of the ECE training period that was also echoed by 91.5% of the student’s agreement. There was more demand for student centered education as 51.2% of the students agreed that the current classroom educational environment was not allowing them to actually participate in the formation of their educational process and they felt that this was seen to more proactively during their ECE training with 90.2% approving the current format of the ECE program organization and its time utilization. On two other questions targeting specifically our participating graduates, 88.75% stated that ECE has given them the edge when competing for their current professional curriers. They also expressed that ECE has helped them in better understanding the scientific theories they have acquired during their college education as much as it actually helped them in


developing their interest in acquiring more knowledge on many topics covered before. 83.3% of the graduates agreed on the importance of integrating knowledge into practice and how that was systematically achieved through developing their hand on work skills during ECE in hospital environment as indicated in table 3 showing the positive and negative responses in all domains. These encouraging results supports and indorses our recommendation for ECE utilization to reinforce the traditional learning environments present in similar programs that could be utilized as an alternative educational approach. These highly encouraging findings were also echoed by the findings of the second questionnaire collected from 58 staff members with the means, SD and SD of error of mean for the responses with 91.4% of the staff members’ participants listed in table 4. Their input in this study was in the vicinity of their qualitative professional evaluation of our student’s theoretical, scientific thinking, practical skills and professional attitude in the hospital based work place. They were also asked to compare our ECE exposed interns levels to the interns of other colleges in the kingdom not having ECE as part of their structured curriculum and been trained with our interns in the same environment. Table 5 showing the outcome of their professional evaluation which was classified as “being exceptionally better or better” reported as distinguishable performance. While the scores of “being the same or worst performers” been classified together as “needing improvement and development” as equal or unnoticeable performance advantages. 77.60% of the staff members evaluated our interns as distinguishable in their knowledge background in comparison to the other interns; they evaluated their performance with 93.10% of the interns being distinguishable skill performers confirming that their skills were by far better developed due to their prior ECE exposure than the other interns from similar programs without ECE. This was also reflected in their quality and accuracy of work with an overall superiority edge of 82.8% outperformance to the other college’s interns and graduates. There also were other soft skill qualities and skills that our students performed slightly better or the same as their colleagues in dealing with. These skills included

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professional ethics and patient information confidentiality, better resource utilization and dependability in performing designated tasks with limited supervision.

Discussion With the rapid development in the field of medicine and its related diagnostic needs, applied medical sciences is having a more proactive role in helping this process with its hospital based technologies. For the medical laboratory technologies to address these needs, the related educational curricula must develop and accommodate new learning styles which encourage and strengthen the depth of learning, developing intellectual skills and enhance vertical integration of basic laboratory science theories and clinical practices. Even though some laboratory technology and clinical laboratory science departments are still working on improving their traditional curriculum, this study clearly shows that there is great demand for increased clinical exposure even if this means dismantling its traditional educational systems. In our study, there was noticeable observation of our interns’ outperformance when compared with their peers who lacked early clinical exposure element as part of their structured learning environment. This adds to the growing body of evidence that recognition of the importance of the learning environment improves the quality of the education and has significant impact on the student’s perception of the environment as well as their behavior and academic progress9. Because the origin of MLT field is in hospital based clinical laboratories, it is logical to extend the learning environment of such programs to hospitals in order to utilize that environment in motivating students and fostering their knowledge as well as skills in order to improve their professional character This was proposed to take place as early as possible during the program’s academic years through systematic Early Clinical Educational Exposure program in order to develop and maintain as part of the formal curriculum which makes their learning contextual and relevant. Many studies were found and screened in relation to early clinical exposure in medicine, nursing and physical therapy but no studies were found in medical laboratory sciences and technology. Hence, the


outcome of this study provide clear information derived from a three year study on ECE and propose it as an innovative learning methodology that can be applied to other medical laboratory technology curricula to improve its quality and outcome. This study proved hospital based ECE as an ideal natural environment and educational methodology that can strengthen and broaden the cognitive intellectual skills of the medical laboratory students. ECE also proved to be motivating and encouraging students to reflect on their progress towards their future professional roles and responsibilities. These benefits would complement any existing educational curricula of similar medical laboratory technology programs and colleges. As such we strongly voice our recommendation for the inclusion of ECE as part of the formal curricula of other medical laboratory technology programs. Students expectations were satisfactorily met as ECE enabled them to practice the skills needed for their future profession in a new student based learning trend. ECE overcomes the learning limitations students usually face in the short teaching sessions and laboratory practical sessions that were not allowing independent practice of all students. This study also showed that students undergoing ECE training are by far performing better than their colleagues who are lacking this hands-on hospital based educational experience and even having an advantage in securing employment due to this extra experience.

Conclusion Early clinical exposure in the field of medical laboratory sciences provides an integration opportunity of knowledge and laboratory skills in a natural professional environment by creating the clinical setup for an interactive environment not achievable in classrooms and laboratory settings alone. An environment which provides the opportunity to apply educational theories in a simulating practical environment that actually build the student’s confidence and psychomotor among many other soft skills necessary for their professional working setup. The high level of coordination between clinical members of hospital based laboratories and academic faculty members achieves the benefits expected from ECE to the students learning process without compromising the level of patient care and health

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services provided to the society in hospitals. The positive results were not limited to students only as the data from this study demonstrated that interns who participated in ECE have by far out performed their peers from other medical laboratory technology programs who have studied similar theoretical course contents but only administered in a traditional educational class and lab based learning environment alone. These results were echoed and supported by the feedback from the professional bodies surveyed in support of this research’s hypothesis. Based on the results of this study, a strong recommendation for the inclusion of early clinical exposure in similar curricula with a greater focus on the clinical skills and implementation environment is made as this improves the student’s performance and preparation for their professional currier. This study expands our understanding of ECE and its effect on the advancement of the student’s comprehension and skills gained during their academic life. It also serves as an evaluation and reflection opportunity to acknowledge the strengths of a medical training program and to identify its weaknesses as potential developing points to focus and work on for the enhancement of the learning environment.

Association. 2003;91(3): 303-310. 2. Sathishkumar S, Thomas N, Tharion E, Neelakantan N, Vyas R. Attitude of medical students towards Early Clinical Exposure in learning endocrine physiology. BMC Medical Education 2007;7(1):30 3. Dornan T, Bundy C. What can experience add to early medical education?: Consensus survey. British Medical Journal 2004 October 9;329(7470): 834-837. 4. Dunn SV, Burnett P. The development of clinical learning environment scale. Journal of advanced nursing. 1995;22(6):1166-1173. 5. Wenrich M, Jackson M, Scherpbier A, Wolfhagen I, Ramsey P, Goldstein E. Ready or not? Expectations of faculty and medical students for clinical skills preparation for clerkships. Medical Education Online. 2010 Aug 6;15.doi:10.3402/meo.v15i0.5295. 6. Wartman S, Davis A, Wilson M, Kahn N, Sherwood R, Norwalk A. Curricular change: Recommendations from a national perspective. Academic Medicine. 2001;76(4): S140-S145. 7. O'Brien-Gonzales A, Blavo C, Barley G, Steinkohl D, Loeser H. What did we learn about early clinical experience? Academic Medicine. 2001;76(4):S49-S54. 8. Harden R. AMEE guide no.21: Curriculum Mapping: A tool for transparent and authentic teaching and learning. Medical Teacher. 2001;23(2):123-137. 9. Audin K, Davy J Barkham M. University Quality of Life and Learning: an approach to student wellbeing, satisfaction and institutional change. Journal of Further Higher Education.2003;27(4): 365-382.

Further study of the effect of ECE programs implementation in other applied medical science programs will provide a clearer picture of its importance and its great impact in preparing a more professional laboratory scientists among other allied medical technologists with a call for revising the existing curricula and the addition of ECE in it as this will surely revitalize the medical laboratory science profession.

Acknowledgements The researcher would like to thank the deanship of Scientific research of the University of Dammam for their help, support and funding of this study and Dr. Khaled Fikry El-Said Salama for his statistical analysis input.

References 1. Delwiche F. Mapping the literature of clinical laboratory science. Journal of Medical Library


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Illustrations Illustration 1 Table 1: Individual domains items Mean scores and Standard Deviation for the 82 Interns and Graduate participants.

Domains Domain 1: ECE role in professional preparation for the internship period

Domain 2: Role of ECE in Soft Skill necessary for the profession

Domain 3: Validity of ECE & its Importance in the Curriculum

Domain 4: Quality of ECE program

Items I felt more confidants during my internship period having gone through the clinical rotations. Clinical rotations prepared me for my internship period. I do not think the clinical rotations had any effect on my professional life performance *. I would have performed the same during my internship with or without the early clinical rotations training I had*. The clinical rotation period helped me to learn the art of constructive criticism & critical thinking. My critical thinking and problem solving skills were developed during my internship period and not during the clinical rotations. Log Book preparation during clinical rotation was useful. I found power-point presentation preparations during my early clinical rotations very useful. I prefer learning research methodology during my early clinical rotation over log booking or presentations. The professional enjoyment outweighs the stress of studying MLT. The early clinical rotation exposure benefit overcomes its workload. Much of what I have performed in clinical rotations was relevant to my career in MLT. I was rarely bored in the early clinical rotation period I prefer shortening the period of MLT studies by cancelling the early clinical rotations * I recommend adding early clinical rotation to all MLT programs of the colleges in the kingdom The teaching process and technical coaching during the early clinical rotations were often stimulating The teaching process was Student cantered were students did most of the teaching process / providing the teaching material * The early clinical rotation time was put to good use (organized & Utilized well)

Mean (out of 4)

Std. Deviation

3.61 3.56

T - test

P - value

0.871

128.7