Global Perspectives

Cultural considerations in simulation-based education

Michelle A. Kelly, Ashokka Balakrishnan & Krishnasamy Naren


The ultimate goals of health professions education are to enhance practice readiness, improve delivery of safe patient care and ideally, improve patient outcomes. Simulation based education (SBE) is now well established as an educational approach, in undergraduate programs and for continuing professional education, that complements existing models in development of core clinical knowledge and skill acquisition for health professions students and clinicians. It is known that the various domains of learning, such as knowledge, the psychomotor, affective and behavioural elements of practice, can be incorporated into holistic patient care simulation scenarios (Kelly, Hopwood, Rooney & Boud, 2016). Ways of determining the impact of SBE are topics emerging in the literature. Increasingly, those who design and deliver SBE are becoming more attuned to the spectra of cultural considerations important for learning and practice (Bahreman & Swoboda, 2016).

Original Articles

An exploratory study of the relationships among physical health, competitiveness, stress, motivation, and grade attainment: Pre-medical and health science students

Marcus A. Henning, Christian U. Krägeloh, Roger Booth, Erin M. Hill, Julie Chen, Craig Webster


This study highlights the use of multi-factor analytical approaches in the investigation of students’ academic performance and their well-being. The aim of the study was to explore the relationships among physical health, competitiveness, perceived stress, motivation, and academic achievement in pre-medical and health science students. Responses were elicited from 339 students preparing for medical and other health science programmes. Questionnaires obtained information regarding gender, age, grade achievement, perceived stress, motivation, physical health, and competitiveness. Due to the subtle gender differences evident in the literature and substantiated by the findings in this study, two structural equation models were generated, one representing male students and the other female students. In general, the illustrated models showed a positive relationship between physical health and enjoyment of competition. Next, physical health was negatively associated with perceived stress, which showed a negative association with self-efficacy and a positive association with test anxiety. Enjoyment of competition was positively associated with self-efficacy. Grade achievement was positively associated with self-efficacy. The models suggest that students, as a whole, experiencing good physical health report less perceived stress and less test anxiety, and more self-efficacy which are associated with positive grade outcomes. These models give insights into how physical health and learning variables may influence grade outcome providing scope for further research into how these relationships impact learning environments, team behaviours, and professional training.

Keywords:            Biomedical and Health Science Students, New Zealand, Motivation, Physical Health, Competitiveness, Academic Achievement

Does empathy manifest in medical students’ palliative care reflective reports?: A qualitative study

Pilane Liyanage Ariyananda


Introduction: Clinical empathy involves the ability to understand problems of patients, their perspectives as well as feelings, and to act based on one’s understanding of the medical problems, in a therapeutic manner. The process of empathy may be divided into the following responses: a) Emotive: the ability to subjectively experience and share another’s psychological state; b) Moral: the altruistic force that motivates the practice of empathy; c) Cognitive: the ability to objectively analyse another person’s feelings and perspectives; and d) Behavioural: Communicative response to convey another person’s perspective.
Methods: The objective of the study was to find out whether Semester 9 medical students of the IMU had documented an empathetic response following their ‘student-patient interaction’ when they visited the Hospice in Seremban and homes of patients who were under palliative care. Following the visit, students submitted a reflective report to their mentors. The author had analysed 58 such consecutive reports that were submitted during the period May 2013 to November 2016.
Results: All 58 students sympathized with the plight of their patients, but only 12 of them had expressed empathy. Expression of empathy in these 12 reports was captured in the following number of instances: Emotive – 5, Moral – 5, Cognitive – 7, Behavioural – 2; some expressing more than one component of empathy.
Conclusion: The study showed that reflective report writing is a ‘window of opportunity’ to find out whether medical students expressed empathy. Its potential as a teaching/learning tool needs further exploration.

Keywords:            Empathy, Palliative Care, Medical Students, Reflective Reports

Healthcare encounters in young children: Impact of Teddy Bear Hospital, Singapore

Ong Lynn, Chua Khoon Han, Soh Jian Yi & Aw Marion Margaret Hui Yong


Background: Teddy Bear Hospital (TBH) was initiated to address children’s fear through role-play. We aim to assess effectiveness of Singapore TBH sessions in decreasing childhood anxiety and enhancing their healthcare knowledge.

Methodology: We performed a cross sectional descriptive study of children (5-8 years) participating in TBH between March and May 2016. Each child completed two multiple-choice questionnaires with pictorial aids. The first survey assessed baseline knowledge and feelings towards healthcare, whilst the second survey assessed the same knowledge and how feelings towards healthcare may have changed after attending TBH.

Results: Data from 334 completed surveys were collected. We excluded 82 children with incomplete data, leaving data from 252 children for analysis; 96 pre-school (38.1%) and 156 primary school (61.9%).

Most children did not have negative feelings towards visiting the doctor or hospital before TBH. Children with positive feelings towards visiting the doctor and hospital increased from 82.5% to 94.4% (p-value <0.001) and 70.2% to 73.4% (p-value 0.035) respectively.

After TBH, majority of children (57.9%) improved scores in knowledge-related questions. Children who answered all knowledge-related questions correctly increased from 81 (32.1%) to 185 (73.4%)  Children in primary school (OR 3.08, 95% CI 1.66 – 5.70) and those who wanted to visit the doctor (OR 3.38, 95% CI 1.08 – 10.55) were more likely to obtain full marks in knowledge-related questions.

Conclusion: We found that most Singaporean children were positive towards healthcare encounters. A TBH experience was able to further increase this number, as well as increase their healthcare knowledge.

Keywords:            Teddy Bear Hospital, Singapore, Hospital Role-play, Childhood Anxiety, Educational Tool

Short Communications

Patterns of reflective thinking and its association with clinical teaching: A pilot study

Christie Anna & Lian Dee Ler


Aims: The evidence on how reflection associates with clinical teaching is lacking. This study explored the reflection pattern of nursing clinical instructor trainees on their clinical teaching and its association with their teaching performance.

Methods: Reflection entries on two teaching sessions and respective teaching assessment data of a cohort of Registered Nurses participating in the National Healthcare Group College Clinical Instructor program (n=28) were retrieved for this study. Reflection entries were subjected to thematic analysis. Each reflection statement was coded and scored according to topics in relevance to three clinical teaching phases – preparation, performance and evaluation. Teaching assessment scores were then used to group the participants into different performance group. Reflection patterns derived from the coding scores were compared across these groups.

Results: Participants’ reflections focused on the performance phase (57% of reflected items), followed by preparation (30%) and evaluation (13%) phases. To assess the reflection pattern of trainees with differing teaching performance, participants whose teaching assessment scores were already high from first teaching session were classified into Consistently High group (score>22). Remaining participants were further categorized based on their improvement in teaching assessment scores into Higher Change (score difference>1) and Lower Change (score difference≤1). Compared to Lower Change group, participants in the Consistently High and Higher Change groups had higher trend of reflection focus on performance (57% and 59% vs 48%) and evaluation phases (14% and 14% vs 8%), but lower on preparation phase (29% and 27% vs 44%).

Conclusions: The finding suggests a possible role of reflection in teaching performance of nurse clinical instructors, warranting further investigation.

Keywords:            Registered Nurses, Clinical Instructor, Reflective Thinking, Clinical Teaching, Reflective Journal

Perceptions of Do Not Attempt Resuscitation (DNAR) amongst nurses in an Asian modern ageing society

Li-Phing Clarice Wee


Objectives: Do Not Attempt Resuscitation (DNAR) orders have been used in hospitals worldwide for the past 30 years, but are still considered to be a challenging and difficult area of practice. Nurses being the frontline healthcare professionals should be involved during the decision-making process and are required to have good understanding of the DNAR order, in order to provide effective and efficient care. Our aim was to investigate: nurses’ involvement during decision-making process, level of understanding of issues surrounding DNAR orders; and how they perceive care for patients with DNAR orders.

Methods: A descriptive crossed sectional study design using electronic questionnaires was adopted for the study.  The study was conducted among 400 nurses at a tertiary hospital in Singapore.

Results: This study showed that 44.5% of nurses reported physicians did not involve them in decisions for DNAR orders; only 8% felt that they should be involved in the decision-making process. Even if they did not agree with the order, 63.2% would still comply whilst 21% of them were willing to discuss this further with the treatment teams. Most agreed that antibiotics, intravenous fluids, oxygen therapy and artificial feeding were appropriate for patients with DNAR orders. Majority (57.1%) expressed uneasiness in discussing end of life issues with patients even in specialty areas.

Conclusion: Nurses should be encouraged to advocate for their patient and take part in the decision-making process. Communication between the medical team and nurses can be improved and there is an obvious need for further improvement in education and collaboration in this area.

Keywords:            Do Not Attempt resuscitation, End-of-Life, Withdrawal, Palliative Care

Family medicine post-graduate examination reforms in Singapore: A value-driven practical and contextual approach

Lim Mien Choo Ruth, Keith Tsou Yu Kei, Chooi Peng Ong, Sabrina Wong Kay Wye, Gilbert Tan Choon Seng, Winnie Soon Shok Wen, Joanne Quah Hui Min & Marie Stella P. Cruz


This paper describes the revision of a national post-graduate medical examination to incorporate formal quality assurance and psychometrics. We discuss the considerations and rationale leading to the new format, challenges faced and lessons learned in making the change. The processes described were successfully implemented in the 2015 examination administration. We continue to reflect on and analyse these processes to improve the examination.

Keywords:           Post-graduate, Examination Reform, Quality Assurance, Psychometrics, Family Medicine, Standardised Patient

Personal View

An overview of how to encourage the Standardised Patient (SP) teaching methodology – from the perspective of a SP and SP Trainer

Wu Jiansheng


As one of the first generation of Standardised Patients in China, perhaps Asia as well, I have been working in the clinical skills training centre in West China Medical School of Sichuan University for 25 years. I would like to share with you how I joined this little-known and somewhat mysterious field, participated in this form of teaching, and progressed from a normal SP to a SP trainer. It is noted that the Standardised Patient (SP) was first introduced by Howard Barrows in 1963 (Pan & Luo, 2017). In 1993, West China School of Clinical Medicine, Sichuan University was the first to do the training courses and trained the first group of SPs. In 2003, China Medical Boar (CMB) America organized a “Student Evaluation Plan Program”; 8 Chinese medical schools joined and imported the training programme to China.

Fostering student engagement using online, collaborative reading assignments mediated by Perusall

Seow Chong Lee & Foong May Yeong


One of the biggest challenges at engaging undergraduates effectively in Biology modules is large class size (Wood, 2009). Typically, the class size of an undergraduate Cell Biology module in our institution ranges from 200 to 300 students. Instructors of large class modules traditionally teach didactically by simply disseminating facts, which become outdated quickly in this growing field of science. Furthermore, using didactic instruction, it is difficult to help students develop skills such as critical-thinking expected of our university graduates.