Exploring medical students’ simulation learning experience in Rwanda: a qualitative study

Abstract

Simulation is a valuable technique in training health professionals, but the availability of resources determines which equipment, trainers, and methods to use in each simulation program. Low-income countries face barriers such as a shortage of trained staff and equipment, inadequate infrastructure, and other context-specific challenges in using simulation for training healthcare professionals. This qualitative study, employing semi-structured interviews, aimed to explore medical students’ experiences with learning by simulation in Rwanda, a low-income country. This is among the first studies to explore simulation-based education from student perspectives in Rwanda. Fifteen (n = 15) medical students (male: n = 12; female: n = 3) provided consent to participate in semi-structured interviews. Despite the many challenges faced by medical students as they engaged in simulation-based learning, study participants demonstrated an interest in learning through simulation. They perceived it as essential in acquiring and enhancing procedural skills in a relaxed and no-stakes learning environment. Additionally, learning by simulation methods helps medical students approach patients confidently, especially those with complex and/or less common medical conditions. Study participants identified organizational issues and limited simulation capacity as significant barriers to the effective implementation of simulation-based medical education in Rwanda. They expressed the need to invest more time and resources in simulation for a more impactful simulation-based training program. Integrating standardized simulation into a formal medical curriculum would address most of the organizational issues encountered and lead to a structured and consistent skills training program throughout undergraduate medical training in Rwanda.

Introduction

The growing requirement for patient safety and provider accountability, the advent of competency-based practice, and the rapid expansion of medical knowledge have impacted the faculty’s dedicated time to teach medical trainees in a clinical environment. This challenged the traditional teaching model and called for alternative innovations in teaching with less patient involvement, prompting the medical community to embrace simulation [1, 2].

Simulation is a technique to amplify or replace real phenomena with other experiences that replicate or evoke some real-world aspects in an interactive manner [3]. Initially used in aviation and aerospace [4], simulation gained popularity in medicine towards the end of the twentieth century, and since then, its contribution to healthcare has rapidly increased [1, 5].

Simulation in medical education requires space, equipment, and trainers as prerequisites. However, many aspects need to be considered for a successful simulation experience. The 8 S framework provides an easy way to remember eight factors (Science, staff, support, systems, space, supplies, success, and sustainability) that require special attention for a simulation program to reach its intended goals [6].

Kolb’s model is used in facilitating simulation-based medical education activities where a facilitator guides learners through the cycle by introducing them to the planned activity (briefing), showing them the activity through demonstration, and having them perform the activity by themselves as many times as required, initially with some level of support until they can perform it independently (scenario), and by guiding them through the reflective process on their experience (debriefing). When relating simulation to Kolb’s model, it becomes evident that taking part in a simulated scenario accounts for the concrete experience component only, while debriefing and feedback account for all three remaining components: reflective observation, abstract conceptualization, and active experimentation [7]. Understanding how the 4 phases of Kolb’s cycle are experienced through simulation (briefing, scenario, and debriefing) will give insights into how medical education is optimized through simulation.

There is paucity of data on the use of simulation in resource-limited countries, particularly in Sub-Saharan Africa. Medical schools need to increase student enrollment to meet growing healthcare demands. However, this often results in a lower faculty-to-student ratio and limited patient exposure for students [8]. Due to staffing shortages and limited space, simulation sessions for training medical students in Rwanda are held infrequently and are often led by residents as an additional duty alongside their regular curriculum. Thus, the study aimed to explore students’ expectations regarding engagement in simulation-based education, their perceived benefits of simulation, and the challenges they face. Additionally, the study was intentionally designed to give Rwandan medical students a platform to share their suggestions for the future effective use of simulation in medical education in Rwanda. Findings from this study are expected to inform the efficient and effective utilization of simulation by enabling better resource allocation and curriculum improvements that optimize existing simulation resources.

Materials and methods

Design

This is a qualitative, descriptive study using semi-structured interviews and documents analysis. It sought to understand students’ lived experiences with learning by simulation among a sample of Rwandan medical students.

Study population and setting

Participants in this study were undergraduate medical students at the College of Medicine and Health Sciences of the University of Rwanda. This is the only public medical school in Rwanda and the largest medical school in the country, with 991 students at the time of the study. The medical school has one simulation lab on campus, and only one of the hospitals that serve as training sites has a simulation center. Both facilities are equipped with low-fidelity task trainers and other equipment, including ultrasound machines and surgical instruments. A purposeful non-probability sampling method was used to select participants representative of the study population, and most importantly, those likely to possess more information regarding the topic under investigation.

The first two years of medical school cover basic sciences, where students attend classes regularly and are assigned specific educators for each subject. This is followed by clinical years, during which students are placed in different teaching hospitals and must adapt to the schedules of the clinical departments in which they rotate. Only one of the six hospitals where they rotate has an established simulation and skills training center.

Final year medical students were preferred over other medical students because they are expected to have gained simulation experience during their clinical rotations, making them better suited to provide thorough information for this study’s inquiry. After the study was approved by the University of Rwanda’s Institutional Review Board (No 235/CMHS IRB/2023) and deemed exempt by Ohio State University IRB (2023E0381), an invitation to participate was sent via email with a brief explanation of the study, its purpose, and what was expected from participants. Respondents interested in participating were contacted, given the opportunity to ask questions, and asked to sign a consent form. They were also scheduled for an interview at a convenient time and were informed they could withdraw from the study at any time.

Data collection

Semi-structured interviews were used to gather data. Interviews were conducted virtually via Carmen Zoom, the Ohio State University’s academic audio and web conferencing platform. They were recorded and stored on Ohio State University’s cloud system and on a password-protected personal computer. The interviews were conducted in the participants’ native language, Kinyarwanda, by the principal investigator, who also translated the original transcripts from Kinyarwanda to English.

The Interviews lasted between 20 and 30 min. They consisted of questions about respondents’ experience with simulation and others related to their perception of simulation use in medical education in their specific context. Some examples of open-ended questions asked to participants include: (1) “How did simulation contribute to your learning in medical school?” (2) “Could you tell me about the challenges you faced in learning by simulation?” (3) “What changes do you hope to see in training medical students by simulation in Rwanda?

Data analysis

After collecting and compiling the data in an Excel database, researchers proceeded with analysis and interpretation. Although the analysis was ongoing simultaneously with the collection to guide questions to ask next and identify areas to focus on, more intensive analysis was also done at the end of data collection. Researchers started with open coding, breaking the data into manageable pieces to explore various ideas within the data set.

After the initial (open) coding, codes with shared ideas, patterns, or relationships were organized into potential conceptual categories in what is referred to as focused coding [9] or axial coding [9]. Once conceptual categories were created and described, the interpretive synthesis of data using the inductive process was undertaken.

The interviews were transcribed, translated, and reviewed to ensure they remained accurate throughout the research process. Nonverbals (laughs, pauses, etc.) were added to the transcript to provide the most detailed documentation of what was reported. Additionally, multiple sources of data (students, instructors, and documents, including simulation records and researcher memos) and two different data collection methods (interviews and document checks) were used to confirm emerging findings, a process referred to as triangulation [10].

After the research team agreed on final themes, we also performed member checks, a process by which data and their interpretations are brought to study participants for verification to ensure they are plausible. Finally, we also performed peer examination by asking colleagues and mentors to comment on the findings as they emerge.

Researcher’s positionality and reflexivity statement:

The researcher positions himself as a medical doctor with ten years of training in Rwanda, including six years of medical school and four years of surgical residency. With direct experience of simulation-based education as both a learner and trainer, he brings an insider’s understanding of the Rwandan medical education context. This perspective, while valuable, also carries certain assumptions: that simulation facilities are insufficient for the number of medical students, that learners would be willing to share their perspectives if they believed it might improve training, and that disseminating the study’s findings could help position simulation as a core component of medical education and attract greater investment in its development.

At the same time, the researcher acknowledges that his professional authority as a general surgeon may have influenced participants’ responses, highlighting the need for reflexivity in relation to power and privilege. By situating himself within the study and remaining attentive to these dynamics, he sought to approach participants with empathy and respect, fostering an environment conducive to openness. His familiarity with Rwanda’s sociocultural and educational context further informed this stance, supporting both the trustworthiness and depth of the study’s findings.

Results

Participants’ demographic features and experience with learning by simulation

Fifteen medical students participated in the study, including 12 (80%) males and 3 (20%) females (see Table 1). The mean age of study participants was 26.5 years (range = 24 to 32 years). Participants were geographically located in Kigali city (40%) and Southern Province (60%).

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Simulation participation varied broadly. Clinical year exposure averaged 2.46 sessions per student (range 0–6) versus 11.73 in preclinical years (range 1–50; see Table 2). Twelve students (80%) reported most experience in Obstetrics and Gynecology, followed by Surgery (20%).

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The themes identified from the data collected evolved around open-ended questions asked on (1) medical students’ perception of learning by simulation-based activities facilitated by residents, (2) perceived benefits of learning by simulation, (3) challenges and barriers faced by medical students as they engage in simulation-based educational activities, and (4) how Simulation-Based Learning could be improved to help them better achieve their medical training goals. Five themes that emerged from collected data are presented below:

Theme 1: students perceive residents as effective instructors

Sub-theme 1: overall, residents are competent in providing simulation training

All students reported satisfaction with resident-led simulation, noting competence, familiarity with learning objectives, and a relaxed learning environment.

“I do not have any problem with being trained by a resident in a simulation-based learning session because they know what they are doing. We feel more open to them and free to ask questions and give suggestions.” (Student 3).

Sub-theme 2: A small clinical team (residents, faculty) is best to deliver simulation training

Some noted added value in having faculty alongside residents:

“Residents have a lot of knowledge and skills ahead of us…However, expert opinion is always needed, so ideally, having both is more beneficial…” (Student 15).

Theme 2: simulation is critical in the acquisition and enhancement of procedural skills

Sub-theme 1: simulation offers autonomy through skills acquisition

Simulation enhanced skill acquisition and confidence:

“I learned the management of molar pregnancy and abortion…we were encouraged and allowed to practice them and gained more knowledge, skills, and confidence” (Student 10).

Sub-theme 2: simulation offers a relaxed and non-stake learning environment

The safe learning environment allowed repeated practice:

“The good thing with simulation is that you get the opportunity to practice…without the fear to harm anyone.” (Student 3).

Sub-theme 3: simulation offers the opportunity to learn rare procedures

Simulation enabled preparation for rarely encountered conditions:

“The benefit is that we practice rare procedures…if I meet shoulder dystocia… I could do something about its management because we had a demonstration about that.” (Student 14).

Theme 3: Limited simulation capacity and organizational issues are major barriers to learning by simulation

During interviews, the researcher discussed with study participants the challenges they face and what they perceive as barriers to learning by simulation in Rwanda. From that discussion, organizational issues, limited simulation capacity, and restricted access to simulation facilities emerged as the three significant barriers.

Sub-theme 1: organizational issues negatively impact the delivery of simulation training

Sub-theme 1: organizational challenges

Participants reported that time constraints, curriculum structure, trainer shortages, and poor coordination limited learning opportunities.

“Simulation-based educational activities are planned, but the plan is rarely executed…sometimes until the rotation ends.” (Student 6).

Sub-theme 2: limited capacity

Shortages of space, equipment, and staff were reported to constrain learning. One participant, for example, said:

“There are not enough materials…some perform, and others observe because there are not enough mannequins…” (Student 11).

Sub-theme 3: restricted access

Some students reported that scheduled group sessions restricted independent practice:

“We access simulation facilities only in case of planned group sessions. If people could go even at another time, or could borrow materials to practice on independently, that would be helpful.” (Student 9).

However, not all participants agree with that statement. Student 3, for example, pointed out that simulation centers are open to every student for individual practice, but the issue is that no one is permanently assigned there to guide self-directed users. An administrative assistant at one simulation center also confirmed that students are always welcome to use the facility whenever it is available, but sometimes the supplies they need are out of stock.

Findings on how simulation-based learning could be improved to prepare medical students in Rwanda for future medical practice

All study participants were asked and agreed to share their opinions on how simulation-based medical education should be implemented so that future trainees can have an improved experience and meet their training goals. The two themes that were developed from that conversation are presented below:

Theme 4: simulation should be integrated into medical curriculum

Participants believed that simulation-based training should be delivered in a structured and consistent manner throughout medical education. Some participants questioned the current curriculum, stating it does not sufficiently emphasize procedural skills. Reflecting on his simulation experience during medical school, Student 9 mentioned that in clinical years, most students are not exposed to learning procedural skills through simulation until the final year. He explained that this creates a hectic and overloaded year, leaving students without the opportunity to absorb and integrate the skills they have learned before graduation.

One of the participants noted that starting to learn procedural skills early in medical training would improve patient outcomes once new doctors are sent to the community to practice independently. He said: “The first step should be integrating simulation into medical curriculum…starting teaching students procedural skills early in the training because this will reduce patients’ adverse outcomes” (Student 12).

Participants view simulation as an alternative mode of learning procedural skills in hospitals, where the large number of medical students and postgraduate trainees limits opportunities to practice those skills.

Additionally, participants proposed that more emphasis be put on the skills they will need in the district hospitals instead of observing procedures only performed at tertiary-level hospitals where they will not be practicing.

Theme 5: simulation capacity and access need to be increased for better learning outcomes

Sub-theme 1: increase capacity

Students highlighted shortages but praised innovative low-cost approaches:

“…we were many students divided into 2 big groups, learning to perform MVA…We used papayas and tree tomatoes to simulate the uterus, and I learned a lot from that training.” (Student 3).

Sub-theme 2: improve access

More centers, open hours, and trained simulationists were recommended:

“…simulation should be used the same way [as a library]…allowing users to borrow some instruments to practice outside training facilities.” (Student 9).

Discussion

This study sought to explore simulation experience among undergraduate medical students in Rwanda. It was conceived to answer questions on how Rwandan medical students perceive the usefulness of simulation in their learning and to hear their perspective on how Simulation-Based Learning could be improved to prepare them for future medical practice. Specifically, the study intended to explore how factors such as the use of residents in facilitating simulation activities, the use of locally resourced training materials, and other factors specific to their learning context influence how they perceive simulation and its benefits.

Asking medical students in Rwanda these questions has become important for two reasons. First, medical students are adult learners who tend to be internally motivated to learn and are interested in the direct application of what they learn [11]. In other words, they will engage in learning activities meaningfully if they perceive them as valuable. Second, medical students’ simulation experience in Rwanda and other countries with comparable resources differs from the experience of students trained in high-income countries in that the simulation methods used in those two settings differ in terms of resources used. Therefore, the available literature does not fully address the questions posed in this study.

Concerning the perceived usefulness of simulation, all study participants expressed a great appreciation for learning by simulation methods. Using residents as facilitators and low-fidelity simulators or improvised materials did not alter their interest in using simulation methods to learn. They acknowledged the contribution of residents in their training, describing them as competent, having a good grasp of content, and offering a relaxed and engaging learning environment. This corroborates findings from other studies that medical students perceive residents as significant contributors to their learning. In a study by Byrne et al. [12] students reported that residents contributed far more than attending physicians in their education by helping them achieve their educational objectives. The rate of participants with a favorable perception towards simulation-based learning found in our study (100%) was superior to the rate reported in studies conducted in India and Pakistan, where the rate of medical students who perceived simulation favorably was 72.5% and 73.9% respectively [13, 14].

Also, contrary to findings by Muhumuza et al. [15] where some medical students in a low-income country exhibited skepticism towards the transferability of skills learned by simulation in a clinical setting, learning by simulation using low fidelity methods was deemed by participants from this study to be important in the acquisition of the knowledge and skills valuable for clinical practice. Another study by Masoth et al. [16] found that using high-fidelity simulation methods to teach Advanced Trauma and Life Support (ATLS) to medical students did not lead to superior outcomes compared to low-fidelity methods. However, it resulted in overconfidence in students assigned to the high-fidelity group in the trial. Another systematic review of randomized controlled trials found no difference in using high- or low-fidelity simulation methods to teach cardiac auscultation [17].

It is true that low-fidelity simulation methods do not give a representation close to real clinical scenarios as high-fidelity ones do, therefore careful selection of scenarios suitable for simulation using low-fidelity simulation methods can facilitate the acquisition of skills among trainees.

In addition to knowledge and skills acquisition, participants reported other benefits of learning by simulation, such as a relaxed and no-stakes learning environment and the opportunity to learn how to perform less common procedures. Similar findings were reported in previous studies [18, 19].

This is significant in Rwandan undergraduate medical education because medical students are trained in referral hospitals that routinely treat patients with complex medical conditions, whereas many patients are treated at the District Hospital level. Because most medical conditions are treated at the district level, and only patients with complex conditions are referred to a superior level, there are many procedures performed in District Hospitals that are rarely seen in referral hospitals. Yet, medical students are trained to be sent to District Hospitals as general practitioners. Simulation can be used to prepare them to manage medical conditions they will encounter in District hospitals that they do not often see in referral hospitals where they are trained. It can also help them practice skills they learn during their brief time in the district hospitals for their clinical rotation.

In addition to the benefits of using simulation methods to train medical students, this study explored challenges associated with learning by simulation in Rwanda. Participants identified significant barriers such as organizational issues such as poor planning, lack of structure, and insufficient time allocated to learning by simulation.

Participants felt that fewer learning opportunities are planned, and even when they do, students are given little time to practice because of their enormous number and the short time allocated to those sessions. This can seriously impact the quality of learning and prevent the achievement of intended learning goals because procedural skills are mastered and integrated through repetitive practice, which is one of the benefits of learning by simulation [20].

Also, with less time allocated to simulation training, students lose the opportunity to receive feedback and improve their performance. How often and how much feedback should be delivered in simulation-based learning to maximize its impact is unclear. However, the literature suggests that high-frequency intermittent feedback results in better performance [21]. In simulation, debriefing and feedback are essential to experiential learning because they take the learner through reflective observation, abstract conceptualization, and active experimentation [7]. By conducting brief simulation sessions without a debriefing phase, learners are only involved in the first phase of Kolb’s experiential learning cycle (concrete experience) and miss the opportunity to reflect on, conceptualize, and experiment with what they learned for better integration in their skill set.

Consistent with findings from this study, shortage of training time, staff, space, and equipment were identified in the literature as a barrier to simulation, especially in countries with limited resources [14, 22]. Other barriers not previously reported in the literature include delayed introduction of procedural skills training activities, inappropriate timing of simulation-based educational activities, and restricted access to some simulation centers in case of individual practice.

Medical students shared their perspectives on how Simulation-Based Learning could be improved to help them learn better. They recommended integrating simulation into the curriculum, increasing capacity, and improving access. Structured and early exposure to simulation, particularly for procedures relevant to district hospitals, would allow students to consolidate skills before graduation. Creating additional centers, maintaining open access, and training simulationists to support both group and individual practice were emphasized.

Findings from this study reveal that participants had widely varying exposure to simulation during pre-clinical years, with some having fewer than three simulation activities and others participating in more than 30.

Considering the entire medical training, the average student’s exposure to learning by simulation in clinical years decreased significantly by 79%, dropping from 11.73 participations per student in preclinical years to 2.46 in clinical years. The variation in preclinical years can be explained by the fact that participants attended two medical schools during their preclinical years—some at the University of Rwanda and others at the University of Gitwe—before the schools merged in 2018. The curriculum structure and availability of trainers may have contributed to the differences in simulation exposure during preclinical and clinical years.

It is essential to note that only planned simulation-based educational activities conducted in simulation centers and other designated areas, whether temporarily or permanently, were considered in this study. This means that students participated in many other educational activities using simulation that were not reported in this study. An example would be a student learning heart auscultation on another student in a changing room or at home. This accounts for simulation because one of the students is acting as a simulated patient.

Overall, the study confirms that simulation-based learning is highly valued by Rwandan medical students and has significant potential to strengthen clinical training. Realizing this potential requires attention to organizational efficiency, resource allocation, and curriculum integration, as well as sustained efforts to expand simulation capacity and access. Adequate exposure, repeated practice, and structured feedback are essential for effective skill acquisition and completion of the experiential learning cycle [7, 20, 21].

Conclusion

Medical students perceive simulation as an essential teaching modality in Rwandan medical education, helpful in learning procedural skills in a relaxed, no-stakes environment. Innovative low-cost solutions, such as locally sourced simulators, were viewed not as a workaround, but as practical strategies to enhance training in limited-resource settings. In addition to resource constraints, the impact of simulation on medical education in Rwanda is hindered by limited exposure to simulation-based educational activities due to organizational issues such as a delayed introduction of skills training in medical training and fewer and/or inopportune simulation-based educational activities in clinical rotations. The early introduction of simulation methods, regularity and consistency in use, timely feedback, and repetitive practice can significantly enhance skills acquisition and retention, confidence, and readiness to practice at the end of medical training.

Limitations

One of the limitations of this study is that interviews were conducted in participants’ native language and translated into English. The researcher acknowledges that there is a possibility that the meaning of participant views could have been modified to some extent. To minimize this, the researcher performed member checking to ensure the original idea from the participant was maintained after translation. Also, the interviewer’s positionality might have influenced participants’ responses.

Additionally, the study was qualitative in nature and, therefore, did not measure the impact of learning by simulation or the impact of reported benefits of simulation on skill acquisition. It did not make causal inferences on any variable reported in the findings.

Another limitation is the generalizability of the findings, as the study was conducted with a small sample size of 15 participants from a single institution. However, although participants were medical students from one medical school, they were involved in clinical rotations at the three largest hospitals in the country, which was important in capturing diversified simulation experiences. Also, findings from this study suggest that obstetrics and gynecology was the department that used simulation to train skills. This finding might not reflect the actual use of simulation by the clinical department in Rwanda because it happened that students participated in a simulation training on safe abortion and contraception that was not embedded within the formal curriculum and might have influenced their responses. However, it is also possible that the Department of Obstetrics and Gynecology frequently uses simulation methods to train students because it encompasses both surgery and primary care.

Lastly, since participation in this study was voluntary, there is a potential for selection bias. Those who decide to participate may be interested in simulation or perceive it as useful. Therefore, despite the researcher’s effort to recruit a sample representative of the medical student population, this study’s findings do not necessarily reflect the views of all Rwandan medical students.

Recommendations

The findings from this study suggest several implications for the Rwandan medical education community.

Study participants demonstrated low confidence and insufficient exposure to procedures required of a medical professional after completing medical school. This is partly due to the organization of their curricular activities in clinical years, where they spend two years learning by observation and rarely practice the skills they have learned until they reach the fifth and final year of their training. Moreover, the large number of students compared to the training staff and hospital workload compromises the implementation of planned hands-on teaching sessions in the already overloaded final year.

To address this challenge, the current organization and implementation of the educational program need to be reviewed and adjusted so that medical students can begin practicing essential skills early in their training through simulation methods. Additionally, the findings of this study suggest that better learning opportunities for students can be achieved without necessarily relying on more scarce resources, but rather through improved curriculum design, pedagogical principles, and local innovative solutions. Simulation should be used with well-defined, clear learning goals, and consistency and regularity should be maintained throughout medical training.

Lastly, with the increasing number of trainees, multiple training sessions in smaller groups should be scheduled throughout clinical rotations, and a designated training staff member should be assigned to coordinate simulation-based learning activities to ensure students have opportunities for repeated practice and feedback.

Data availability

Additional data generated from this study are available from the corresponding author upon reasonable request.

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