The effect of training in different subjects on improving residents’ knowledge and their satisfaction with educational methods - a study in Iran

Abstract

Background

A resident or assistant is a qualified physician who usually practices medicine in a hospital or clinic under the direct or indirect supervision of a physician who specializes in that area. In addition to being learners, they are also responsible for patient care. This study was conducted to investigate the effect of training in different subjects on the improvement of residents’ knowledge and their satisfaction with each of the educational methods used in the Intensive Care Unit (ICU).

Methods

This quasi-experimental intervention study was conducted in 2023 on 90 residents who had completed their training in the ICU. Every month, a group of three residents visited Rasoul -Akram Hospital for rotation. This one-month rotation was divided into 3 periods of 10 days in three different ICUs. Four educational methods were used over a period of 5 months. An initial test was given to each group at the beginning of the training course. Each month, in addition to the scientific and skills training given in the morning sessions and during the visits, four training sessions were given weekly, and at the end of the rotation each group was tested again. The data were analyzed using SPSS (version 25).

Results

The mean scores of the residents improved after the training course, which was statistically significant (P < 0.001). The highest and lowest levels of resident satisfaction with educational methods were associated with training during the visit (3.34) and in the morning (2.23). There was a significant difference between gender and mean residents score in pharmacokinetics and principles of ultrasound (P < 0.05). There was also a significant difference between age and average residents score in pharmacokinetics, principles of ultrasound and principles of sepsis diagnosis (P < 0.05).

Conclusions

Residents were more satisfied with training during the visit. It is recommended that the educational sessions and training during the visit are in line with the educational goals and objectives.

Clinical trial number

N/A. This study is not a clinical trial.

Introduction

The Intensive Care Unit (ICU) is a complex and rapidly changing environment [1] in which critically ill patients are hospitalized [2]. A resident or assistant is a qualified physician who usually practices medicine in a hospital or clinic under the direct or indirect supervision of a specialist in the field [3]. Therefore, while these individuals are considered to be learners, they are also responsible for patient care [4]. Resident training is critical to creating a high-quality medical team, improving the overall level of medical services and ensuring the quality of care [5]. Evidence suggests that factors such as the severity and unpredictability of individual illnesses, restrictions on resident work hours, and the focus on safety and quality of patient care may influence resident training [1]. In this regard, the American College of Critical Care Medicine has developed guidelines for resident training. These guidelines cover clinical training, research and administrative responsibilities [6].

Previous studies have examined various solutions, including providing curricula and increasing the number of educational spaces, with the aim of improving the quality of resident training [7, 8]. The results of the studies show that the traditional methods of education do not meet the needs of today’s medical education, and research has been conducted to evaluate changing educational methods to newer methods such as question and answer learning, case-based learning, group-based learning and learning by changing the way content is presented in the educational environment [9, 10]. According to the search results, there are very few studies that have investigated different educational methods in different educational fields. The types of educational methods used in the form of educational classes, scientific training during the morning, scientific training during patient visits, and patient introduction and explanation of the reasons for choice by the residents, which probably have different effectiveness for each educational field. Totally, educational methods are divided into two categories: Traditional and Flipped Classroom-Based Learning (FC-BL) teaching methods. The traditional method is like the classroom and FC-BL teaching method includes Question Based Learning (QBL), Case Based Learning (CBL), Team Based Learning (TBL). The FC-BL teaching methods are newer teaching methods. Therefore, it seems necessary to conduct a study on the impact of training on improving the knowledge level of residents in different fields and their satisfaction with different methods. The aim of this study was to investigate the effective educational methods in different subjects in order to suggest the most effective method and enough time to teach each subject in the ICU.

Methods

Study design

This quasi-experimental interventional study was conducted in 2023 on residents who were referred to the ICUs of Rasoul-Akram Hospital, Iran University of Medical Sciences, which is a tertiary teaching hospital located in Tehran, Iran, to complete the training course. The residents in this study had specialties in anesthesia, neurology, intensive care, and internal medicine. The sample size was calculated 84 individuals, using G Power software, including test family = exact, statistical test = correlation bivariate normal model, effect size = 0.3 (as moderate effect size), a = 0.05, and power = 0.80 [11]. In this study, the total sample size was 90 residents. The inclusion criteria were Anesthesia, ICU, Neurology, and Internal medicine residents who completed their training in the ICUs of Rasoul-Akram Hospital during the implementation of the study. Residents who withdrew their participation during the study and were unwilling to complete the assessments were excluded from the study.

Data collection

Every month, three groups of three residents visited three different ICUs of the Rasoul -Akram Hospital to complete the ICU rotation (three residents in each ICU). The study duration was 5 months.

During the 5-month study period, four educational methods were used to improve the residents’ knowledge, including educational classes, scientific training in the morning, scientific training during patient visits, introducing patients, and explaining the reasons for the residents’ choice of treatment. All educational methods were used for each resident.

An initial test was given to each group at the beginning of the training course. In educational classes, teaching is one-sided and traditional. The professor explains the subject. In the method of scientific training in the morning, a case with a training objective is presented by the professor, and the corresponding professor plays the role of a leader. First, the resident explains the orders he or she performed on the patient. Then the training is carried out by question and answer and troubleshooting by the professor. In the method of scientific training during patient visits, different specialties are present. After the case or patient has been presented, everything that the patient needs, is practically applied to the patient, and the resident is fully involved. In the method of introducing patients and explaining the reasons for the president’s choice of treatment, before the professor presents her or his orders for the desired case, the resident gives her or his orders, and the discussion and exchange of opinions is carried out in a practical way.

Each month, in addition to the science and skills training given to the residents during morning sessions, patient rounds, and also during visits, four training sessions were given each week, and each group was tested again at the end of the rotation. Then the residents were asked which educational method they thought was best for learning the material, so that each resident’s opinion of all four educational methods was also examined. Residents’ scores were then completed based on the number of points they assigned to each educational method in the different subjects. Finally, after the completion of the specified training courses, the level of residents’ satisfaction was used to compare the educational methods. So that, the residents were asked to express their satisfaction by assigning points to each of the subjects taught. A score of four (very useful), three (fairly useful), two (moderate) and one (ineffective) were used.

In this study, due to the rotation of residents with different specialties in the ICU, the training subjects were selected according to the type of specialty. Furthermore, the subjects of the training courses (pharmacokinetics and pharmacodynamics of drugs in critical patients, ventilator settings, principles of ultrasound for performing procedures and principles of diagnosis and treatment of sepsis) were prepared and revised under the supervision of the educational research group of the ICU of the hospital in order to compare different educational methods on learning. Full versions of the examination questions are presented in the section “Additional materials” section.

Data analysis

Data were analyzed using SPSS software (version 25) at a 5% significance level. After checking the normality of the data, mean and standard deviation were used for quantitative variables and frequency and percentage for qualitative variables. Paired t-test was used to check the mean scores before and after the test. One-way ANOVA was used to compare the level of satisfaction with the rate of increase in scores in different subjects, the level of satisfaction with each of the educational methods and to compare the average scores of the different subjects among the specialties. The correlation test was used to investigate the effect of age, gender, and specialty variables on the level of satisfaction with different educational methods.

Results

A total of 90 residents with a mean age of 35.99 ± 6.178 years participated in this study. Most of the participants were male (53.3%), residents (51.1%) and had an intensive care specialty (46.7%) (Table 1). Figure 1 shows the average score of the residents before and after the training courses. The highest and lowest mean score increase were in the subject of ventilator setting (score = 1.13) and in the subject of pharmacodynamics and pharmacokinetics of drugs (score = 0.80), respectively.

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The level of residents’ satisfaction with the different educational methods used in the different subjects is shown in Fig. 2. There were significant differences between the levels of residents’ satisfaction with the educational methods used in the different subjects (P < 0.001). According to the findings, the highest level of residents’ satisfaction with the educational method was scientific training during patient visits, which was reported in pharmacokinetics and pharmacodynamics of drugs in critical patients (score = 3.5), ventilator settings (score = 3.34), principles of ultrasound for performing procedures (score = 3.49), and principles of diagnosis and treatment of sepsis (score = 3.5), respectively. Also, the lowest level of satisfaction of the residents with the educational method was the scientific training in the mornings, which was obtained in pharmacokinetics and pharmacodynamics of drugs in critical patients (score = 2.26), ventilator settings (score = 2.23), principles of ultrasound for performing procedures (score = 1.9), and principles of diagnosis and treatment of sepsis (score = 2.26), respectively. As can be seen, the highest and lowest levels of satisfaction with educational methods were the same for pharmacokinetics and pharmacodynamics of drugs in critical patients and principles of diagnosis and treatment of sepsis.

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Table 2 shows the relationship between residents’ satisfaction with the different educational methods used and the increase of scores in different subjects. According to the findings of this study, there was a significant and negative difference between the residents’ satisfaction with the morning teaching method and the increase in scores of the pharmacokinetics and pharmacodynamics of drugs (P = 0.02). Also, there was a significant and positive difference between the residents’ satisfaction with the educational method during the morning with the increase in the scores of the principles of ultrasound to perform the procedure (P < 0.001).

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Table 3 shows the relationship between the average scores of residents in different subjects by gender. There was a positive and significant difference between the average scores of residents in the subject of pharmacokinetics and pharmacodynamics of drugs (P = 0.04) and principles of ultrasound to perform the procedure (P = 0.009) in terms of different gender. In other words, male residents get higher scores than female residents in the above subjects. According to the results of one-way ANOVA test, in the principles of ultrasound to perform the procedure subject, there was the significant relationship between the average scores of residents after training courses with gender (P = 0.007). So that, male residents get higher scores than female residents in the principles of ultrasound to perform the procedure subject. In addition, in ventilator setting subject, there was a significant relationship between the average scores of residents before training courses with gender (P = 0.03), which shows that male residents get higher scores than female residents in this subject.

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Table 4 shows the average scores of various subjects according to the age of the residents. There was a positive and significant difference between the age of the residents with the mean scores of principles of diagnosis and treatment of sepsis (B = 0.19, P = 0.043), principles of ultrasound to perform the procedure (B = 0.18, P = 0.02), and pharmacodynamics and pharmacokinetics of drugs in critical patients (B = 0.19, P = 0.03).

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The relationship between the average scores of the residents in terms of specialties is shown in the Supplementary Section (S1). According to this, in the subject of principles of diagnosis and treatment of sepsis, there was a significant relationship between specialties and the mean scores after training courses (P = 0.02). In the subject of principles of ultrasound to perform the procedure subject, there was a significant relationship between specialties and the average scores before (P = 0.047) and after (P = 0.02) training courses. Also, there was a significant relationship before (P = 0.001) and after (P = 0.008) training courses in ventilator settings subject.

Table 5 shows the level of satisfaction of residents with different educational methods in different subjects by gender. According to the findings, there was no significant relationship between the level of satisfaction with the educational methods in different gender group (P > 0.05).

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Table 6 shows the effect of resident age on satisfaction with different educational methods in different subjects. According to the findings, in the subject of pharmacokinetics and pharmacodynamics of drugs, there was a significant and positive relationship between age and satisfaction with teaching by expressing the reasons for the residents’ choice of treatment (B = 0.32, P = 0.002). There was also a significant and positive relationship between age and satisfaction with training during visits in the subject of ventilator settings (B = 0.28, P = 0.008), and principles of sepsis diagnosis and treatment (B = 0.22, P = 0.03).

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The mean level of satisfaction with different educational methods in different subjects by specialties is shown in the Supplementary Section (S2). The findings show that in the subject of principles of ultrasound for performing procedures, there were significant relationships between residents’ level of satisfaction with scientific training in the morning (P = 0.049) and scientific training during patient visits (P = 0.016). Other findings show that the residents’ specialties did not affect their average score and satisfaction in different subjects is shown in the Supplementary Section (S3).

Table 7 shows the effect of age, gender and specialty variables on the average scores of residents. According to the findings, there was a significant and positive difference between the age and the average score of the residents in the subjects of pharmacokinetics and pharmacodynamics of drugs, principles of ultrasound to perform procedures, and principles of diagnosis and treatment of sepsis (P < 0.05). There was no significant relationship between specialty and the average score of the residents in various subjects (P > 0.05). In addition, there was a significant and positive difference between gender and the average score of the residents in the subjects of pharmacokinetics and pharmacodynamics of drugs and the principles of ultrasound to perform the procedure (P < 0.05).

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Discussion

The aim of this study was to investigate the effective educational methods in different subjects in order to suggest the most effective method and enough time to teach each subject. According to the findings of this study, the residents’ scores increased in all subjects after the training courses, which is consistent with the previous study [12, 13]. The reason for the difference in score increase can be attributed to the type of educational method chosen according to the nature of the subject. Also, due to the rotation of residents with different specialties in the ICU, the most needed topics (according to the type of specialty) are often covered [14]. This may also be one of the reasons for the difference in the average score increase. The study by Bossaer et al. shows that students’ scores did not increase after the training, which contradicts this study [15]. The reason for this difference may be due to the educational method used, the type of study, and the different specialties involved. In this study, the highest average score increase was in the subject of ventilator setting. It can be said, because of its nature and the need to teach theoretical topics, the course was effective.

According to the results, the highest and lowest levels of resident satisfaction with the educational methods used in all relevant subjects were associated with scientific training during patient visits and morning training, respectively. Bedside training is the most common form of resident training [1]. The results of previous studies were consistent with this study [16, 17]. Another study reported that residents were dissatisfied with inadequate bedside teaching [18], which contradicts the findings of this study. In general, the factors that influence the satisfaction with the training are the level of the hospital, the time of the training and the amount of exposure to the case [19]. Also, the reasons for the difference in the results of these studies can be attributed to the different scientific level of the senior doctors, teaching by doctors with less experience, the lack of a performance evaluation system leading to a lack of educational initiative, and the existence of a dry and inflexible organizational system for managing residency training [20]. Since the training during patient visits is the most effective training method from the residents’ point of view, it is suggested to increase the teaching time of the mentioned this method.

The findings of this study showed that the level of satisfaction with training during the morning in the pharmacokinetics subject was low. This subject deals with the effects of drugs on the body and their mechanism of action. Therefore, it is obvious that the topics related to this subject cannot be properly explained through morning training and that other training methods are needed, such as holding training classes. For this reason, residents’ satisfaction with this educational method decreases, and as a result, it leads to their interaction decreases [21]. In general, the strengthening of residents’ educational skills is accompanied by an increase in their self-confidence, which leads to the transfer of their knowledge to their peers [2].

Other findings from this study showed that gender had an effect on residents’ average scores in some subjects. Evidence suggests that men and women rely on different cognitive-emotional regulation strategies and achieve different levels of satisfaction [5]. The results of the study showed that men had a better interpretation of the learning environment, which can be attributed to cultural differences in society [18]. In fact, people of different genders have different evaluations of the educational program, which are subsequently associated with different satisfaction and scores [5, 22]. Previous studies have mentioned the influence of gender on learning style [18, 23]. This leads to different scores between residents according to gender. As a result, it can be said that female residents need more support in the educational environment, which may be more due to the cultural conditions of the society and family responsibilities.

Other findings showed that age had an effect on residents’ scores. One of the reasons for this may be that most residents gain experience as they get older. The results of the study showed that the more experience the residents had, the more satisfied they were with the training program [22]. More experienced residents may have a lower cognitive load and exert less mental effort when performing a skill [24]. Another study indicated that the ability of residents in higher years may explain the difference in grades in different years [18]. Overall, the difference in the relationship between the age of residents and the type of educational method in different subjects may be attributed to the increase in their experience, more learning by residents during their years of study and more rotations they had in the early years of study [22].

The present study is the first study that investigated different educational methods in residents with different disciplines in critical patients. Although, it has some limitations. First, the duration of the study was short, which may have limited the ability to evaluate the effectiveness of the educational methods applied to residents. Second, the sample size varied between specialties, which may have influenced the results and limited the comparability of the outcomes between groups. Third, it was not possible to study four educational methods separately in different specialty groups, which may have limited the ability to assess their individual effectiveness.

Totally, the duration of the ICU rotation was too short to adequately improve residents’ knowledge. Since the most effective educational methods, according to the residents, were scientific training during patient rounds and also introducing patients and explaining the reasons for the residents’ choice of treatment, it is recommended that the duration of these educational methods be extended. Moreover, it may not be practical to provide the same duration for all educational methods in different specialties, and adjustments should be made to meet the specific needs of each specialty.

Conclusions

The findings of this study showed that the highest level of satisfaction of the residents was during the visit. The variables of gender and age of the residents were associated with improved scores and learning, suggesting that new educating and learning methods should be developed that take these factors into account and provide educational and innovative opportunities for all groups. Due to the different specialties of ICU residents, it seems that there is a need for a residency education program that is aligned with the specialty courses of each discipline in order to provide the necessary skills for effective training. It also, seems that the same time and educational method is not suitable to improve the knowledge of residents in all ICU skills. Furthermore, the choice of educational method should be related to the nature and type of specialized courses, which in this case is related to increasing resident satisfaction and advancement.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

Abbreviations

ICU:

Intensive care unit

QBL:

Question based learning

CBL:

Case based learning

TBL:

Team based learning

FC-BL:

Flipped classroom-based learning

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