The participants were interns, who had completed their four-year undergraduate medical program and had their first entry to Otorhinolaryngology postings. They joined the ENT department in batches of 5‒6 every 15-days as a part of compulsory rotatory internship. Every 15-days the study program was repeated for all batches. Written informed consent was taken and all the participants who completed pre-test, post-test and simulation assessment were included in the study. Based on statistical analysis, our study needed a total of 60 students, with 20 students in each simulation group for comparison of scores.

Three clinical scenarios were selected in Otorhinolaryngology set up-tracheostomy tube care, anterior epistaxis management and nasogastric (Ryle’s) tube insertion.

Figure 1.

Participants journey.

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On day 1, the participant batch of 5‒6 interns received a pre-test with a validated questionnaire on three scenarios. The test was conducted without any prior warning to the participants, in an examination environment. The questionnaire included Multiple-Choice Questions (MCQ) and questions assessing knowledge, attitude and confidence in managing these scenarios with modified Likert scale. Following which a 1-hour lecture-based teaching program by an ENT consultant was taken on the three scenarios. The lecture included a PowerPoint presentation of clinical management and performance of the clinical skill with video demonstration.

Later the participants were allotted to Group A (Tracheostomy group), Group B (Nasogastric tube group) or Group C (Epistaxis group) according to their entry to ENT postings. The first batch of interns was allotted to Group A, second batch to Group B, third batch to Group C and similar allocation was followed with subsequent batches. Each group received simulation based hands-on training on mannequins (NW8 Tube Feeding Simulator [NG, OG AND PEG] Kyoto Kagaku Co., Ltd, and NG tube and trach care trainer 375‒10001 Laedral medical) on the assigned scenario. Group A received training on tracheostomy tube care, Group B on Nasogastric Tube (NG) insertion, and Group C on managing epistaxis (Fig. 2).

Figure 2.

Demonstration of anterior nasal packing, tracheostomy tube care and assessment of nasogastric tube insertion with checklist by examiner.

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At the end of 2-weeks, the participants had to demonstrate the management of all the three situations on mannequins under supervision of an ENT consultant. Their performance was assessed with the help of a checklist, thus standardizing the scoring. Three assessors were involved during the post-test simulation-based hands-on assessment to minimize researcher bias. After the candidates had completed demonstration, they received a post-test with same questionnaire as before. Structured feedback was collected at the end of the evaluation and all students received simulation based hands-on training on the other 2 scenarios as well.

The questionnaire was designed by the authors aligning with the objectives of the study. It included modified Likert scale type questions, Multiple Choice Questions and Checklist type of questions to assess the confidence and knowledge of the participants. The questions were validated by a panel of 3 experts, both within and outside the university and were not involved in the study. They evaluated the accuracy and the adequacy of the response options. Both pre and post-test used the same questionnaire and were practical to the concepts taught in the program. The checklist for the evaluation of participants clinical skills were also validated by the same group of experts.

All pre-test and post-test questionnaire assessment responses and simulated demonstration scores were entered separately for each group. Only those participants who had completed both the pre-test and the post-test were included in the analysis. The data were analysed with the IBM SPSS statistics program version 20.0 (IBM, Armonk, NY, USA). Paired t-test was used to compare the mean scores in the pre- and post-test questionnaire. One-way analysis of variance (ANOVA) test and post-hoc Tukey test was used for comparing the three groups.

Comparison of pre-test scores was done on all three scenarios and no significant difference was observed between the three groups as none of the participants had received any form of training on the three scenarios before taking the pre-test.

Group A (Tracheostomy group) showed statistically significant improvement in post-test scores on epistaxis management, tracheostomy care and nasogastric tube care (p =  0.001, 0.001 and 0.018 respectively). Group B (NG tube group) and Group C (Epistaxis group) also showed similar trend in post-test scores. All groups showed significant improvements in the post-test scores regardless of their training method.

The participants had better scores in their confidence levels at the end of the program and these confidence levels were more in the groups which received simulation training (Fig. 4).

Figure 4.

Confidence level of participants in ENT scenarios.

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The participants during their postings in ENT department might have been exposed to these scenarios and this could have lead to bias during assessment. Secondly, the interns were assessed only once on the 15thday from initial training. Repeat assessment after three months would have further validated the study, but since the participants had postings in other departments, our assessment had to be completed within this time frame of 15-days.