The Relationship between Experiences Level and Clinical Decision-Making Skill in Midwifery Students: A Cross-Sectional Study.

Background: Development and assessment of clinical decision-making skills are essential in midwifery education because of their role in mothers' and infants' safety. Therefore, the present study's primary objective was to evaluate the relationship between experience levels and clinical decision-making skills using the key features (KFs) examination.
Methods: One hundred and two midwifery students in five different education levels participated in this cross-sectional study through convenient sampling. Twenty KFs questions were designed based on the principles of the KFs examination. The participants' information, including grade point average (GPA), theoretical and practical scores of the obstetrics course, were collected. KFs scores were compared according to students' training semester by one-way analysis of variance (ANOVA). Pearson correlation was conducted to explore the correlation between KFs scores and GPA as well as theoretical and practical scores. All statistical analyses were performed at a significance level of 0.05 (p≤0.05). We used five kinds of effect size calculators, which include mean difference (MD), standardized mean difference (cohend), partial Eta-squared, Cohenf, and partial omega-squared.
Results: There was no correlation between KFs scores and the grade point average, theoretical exam scores, and practical exam scores. KFs scores linearly rose as the learners' level increased with a mean± SD score of 7.61±1.09 during the third semester compared to 11.55 ± 1.89 during the eighth semester (p=0.001). The effect size of this result was large (partial omega square=0.35, partial eta square=0.38 & cohen's f=0.73). The largest SMD was related to the comparison of KFs scores between the eighth and third semester (MD=3.58, SMD=2.554 [CI 95%: 1.719-3.389], p-value═ 0.001), and the lowest was related to the comparison between the third and fourth semesters (MD=0.354, SMD= 0.2 [CI 95%: -0.421-0.821], p=0.987).
Conclusion: Establishing proficiency in clinical decision-making skills is a linear process greatly enhanced by experience, clearly shown by the present study results. Using KFs examination and obtaining extensive evidence to its benefit can allow us to renegotiate proficiency evaluation methods for students in clinical fields. the education curriculum should focus more on identifying clinical KFs skills than merely teaching knowledge about disease processes.

Clinical decision-making is a critical skill for the safety of mothers and infants. The KFs is an approach used to assess the decision-making skill of undergraduate medical and paramedical students. the development and assessment of this cognitive skill are essential in midwifery education.

The promotion of expertise is a linear process, and clinical mental structure develops by expertise and knowledge. Clinical experience has a vital role in clinical decision-making, and it leads to comparing the clinical situations to retrieve mental patterns.

Introduction

Challenging and diverse medical issues of patients (1-3) lead to clinical decision-making as a vital and essential skill for every clinician (4-6). This skill reflects thecognitive process (7), and it is the output of the clinical reasoning process (8) that identifies, integrates, and interprets clinical data for the diagnosis of the disease (5,9). Accordingly, the acquisition of clinical decision-making skills is essential for undergraduate clinical students (10), and its evaluation is the heart of clinical competency assessment (11).

The KFs is an approach used to assess the decision-making skill of undergraduate medical and paramedical students (10). Originating from the First Cambridge Conference on Medical Education in 1984 (12), the KFs approach was defined as an essential step in the process of clinical problem-solving (9,10). The KFs can be related to every step of the clinical reasoning process, from data gathering to patient management (8). Since the skill of clinical reasoning is influenced by experience (5), KFs can be considered one of the distinctive characteristics of experienced medical experts (7) and the discriminating factor between novice and experts in the clinical field (3).

In midwifery, clinical decision-making is a critical skill for the safety of mothers and infants. It has a vital role in reducing the incidence and prevalence of adverse events such as morbidity and mortality rate. Therefore, the development and assessment of this cognitive skill are essential in midwifery education. However, according to our knowledge, there is a lack of robust evidence about improving decision-making skills during clinical and theoretical education in midwifery. Accordingly, we hypothesized that with the advancement of training for midwifery students, the clinical decision-making skills would be improved. Therefore, the main objective of the present study was to assess the relationship between the level of education (semester) with the improvement of clinical decision-making skills using the KFs exam during midwifery education.

Methods

Setting and participants

Bachelor of Science in midwifery in Iran is a four-year program, equal to eight semesters of study after high school. Participants of this study were midwifery students from the Midwifery School of Shiraz University of Medical Sciences who had taken theoretical or practical obstetrics courses during the second term of 2018-2019. One hundred and two students from the third(20 students), fourth(20 students), fifth(22 students), seventh(20 students), and eighth(20 students) semesters enrolled in this study.

Materials, Survey Design, and Implementation

First, the clinical issues that midwifery students must be proficient in, based on the obstetrics course’s educational goals, were identified. Next, each case’s most prominent issues were extracted. Then, 20 clinical scenarios with a question to identify KFs were designed by one experienced associate professor of gynecology and obstetrics (N.A) and one expert in midwifery education (So.D); they were expert in designing KFs test. In addition So.D was Ph.D of medical education. These scenarios were then reviewed, edited, and approved by a ten-member panel of experts in the midwifery field. All of the KFs scenarios confirmed by M.A (expert in medical education).

Each clinical scenario was followed by 12, 16, or 20 clinical option identifying statements (Appendix 1). For every four clinical options, there was only one correct answer. Therefore, each clinical scenario could have 3, 4, or 5 correct KFs. Every clinical scenario question had one point (each correct answer carried 0.2 or 0.25 or 0.33 points based on the total number of correct KFs present in that scenario). Negative points were not given to incorrect options. The final KFs score result was calculated out 20 points (1 point per clinical scenario). The following example demonstrates a typical KFs scenario followed by 12 clinical alternatives which had only three correct options. Therefore, in this scenario, if students identify all three correct KFs, they will get one point. If they identify only two correct options, they will get 0.66 points as one correct KFs identification carries 0.33 points (Text Box 1).

Text Box 1. KFs sample scenario

A 23-year-old woman, with GA: 38WK, having sudden onset pain in the upper right quadrant which started the night before referred to the clinic. She had nausea and vomiting and fever of 38.5 C and blood pressure of 130/80 mm of Hg. In the CBC test, WBC was 19,000.

What are next best steps to make a proper diagnosis? You are allowed to select 3 items.

A) Evaluation of Uterine contractions

B) Evaluation of Urine protein levels (Correct)

C) Evaluation of Abdominal ultrasound (Correct)

D) Diagnostic laparotomy

E) LFT (Correct)

F) OB Sonography

G) Laparoscopy

H) Fibrinogen level evaluation

I) Taking the family history

J) PR

K) RR

L) Vaginal exam

The KFs exam was conducted at the end of the academic semester in summer 2019. Before starting the exam, N.B educated participants on how to answer the questions. Besides, we wrote test instructions on the first page of the test sheet (Appendix 1).

Other markers of students’ academic performance were collected from Dean’s office for the second term of 2018-2019. Students’ GPA was calculated at the end of the semester, which ranged from 0 to 20. In the midwifery curriculum, students of the third and fourth semesters usually have theoretical and practical exams. Students in the fifth semester have only theoretical exams, while students of the seventh and eighth semesters have only practical exams. All theoretical and practical course scores were collected from the final exam, ranging from 0 to 20.

Statistical analysis

Our primary hypothesis was that with the advancement of training for midwifery students, the decision-making skill would improve. For our primary and secondary purpose, we analyzed the data using Stata and MedCalc. For the descriptive analysis of the data, we used descriptive statistics. For calculating the correlation, we used the scatter plot and the Pearson test; the interpretation of the correlation size is according to Table 1.

Table 1

Interpretation of correlation (13)

Size of Correlation	Interpretation
0.00 to.30 (0.00 to -0.30)	Negligible correlation
0.30 to 0.50 (-0.30 to -0.50)	Low positive/negative correlation
0.50 to 0.70 (-0.50 to -0.70)	Moderate positive/negative correlation
0.70 to 0.90 (-0.70 to -0.90)	High positive/negative correlation
0.90 to 1.00 (-0.90 to – 1.00)	Very high positive/negative correlation

The ANOVA test was performed to analyze the differences between the students’ KFs scores in different semesters, as there were five groups. To find the difference of KFs scores from one semester to another, we used Scheffe as a posthoc test. We used five kinds of effect size calculators which included mean difference (MD), standardized mean difference or SMD (cohend) (<0: adverse effect, 0-0.1: no effect, 0.2-0.4: small effect, 0.5-0.7: intermediate effect, >0.8: large effect), partial Eta-squared (<0.010: no effect, 0.010-0.059: small effect, 0.060-0.110: intermediate effect, >0.110: large effect) (14), Cohenf (<0.13: no effect, 0.14-0.19: small effect, 0.40-0.69: moderate effect, >0.70: high effect) (15) and partial omega-squared (0.01-0.05: small effect, 0.06-0.13: moderate effect, >0.14: large effect) (16).

Results

One hundred and two midwifery students participated in this study from the third (20 students), fourth (20 students), fifth (22 students), seventh (20 students), and eighth (20 students) semesters in this cross-sectional study. According to each semester, the results of the descriptive statistics related to the KFs, GPA, theoretical exam scores, and practical exam scores are described in Table 2 (all scores are from a total of 20 points).

Table 2

GPA, Theoretical Exam Scores, and Practical Exam Scores

variable	Semester 3N=20	Semester 4N=20	Semester 5N=22	Semester 7N=20	Semester 8N=20
GPA	15.82 (1.29)	15.68 (1.83)	15.32 (1.26)	15.85 (1.05)	17.61 (0.99)
Theoretical Exam Scores	15.23 (1.37)	14.73 (1.23)	14.86 (1.89)	-	-
Practical Exam Scores	18.04 (0.35)	18.00 (1.16)	-	17.91 (0.47)	18.12 (0.63)
KFs total score	7.61 (1.09)	7.96 (2.22)	8.81 (2.23)	8.81 (2.23)	11.55 (1.89)

KFs scores increased as they continued their training from the third to the eighth semester. The lowest and highest KFs mean scores were related to the students in semesters three (7.61±1.09) and eight (11.55±1.89), respectively (Table 2 & Fig. 1).

Fig. 1

Comparison of the total KFs scores according to educational semester (p<0.001, adj R-squred= 0.35, root MSE=1.94)

Comparison of the KFs total scores according to educational semesters

There is a non-significant correlation between the practical exam scores and KFs scores (0.241) and a low positive correlation between the theoretical scores and GPA and KFs scores (0.426 & 0.354), respectively.

There was a statistically significant difference (p≤0.005) in KFs scores according to their educational level (semester) according to ANOVA analysis (Figs. 1 & 2).

Fig. 2

Values of partial omega square (0.35), partial eta square (0.38), and cohenf (0.73) show the high effect of experience (semester level) on KFs scores. The largest and lowest mean difference (MD) were between the third, eighth(3.58), and fourth (0.354) semesters, respectively. The largest SMD was related to the comparison of KFs scores between the eighth and third semester (MD=3.58, SMD=2.554, CI 95%: 1.719-3.389, p-value=0.001), and the lowest was related to the comparison between the third and fourth semesters (MD=0.354, SMD= 0.2, CI 95%: -0.421-0.821, p=0.987). The post-hoc Scheffe test results showed a statistically significant difference in the students’ KFs scores in seven and eight compared to those of the students in semesters three, four, and semester eight compared to those of the students in semesters five. There was also a statistically significant difference in KFs scores of students in semester seven compared to KFs scores of the students in semester three (p<0.05) (Fig. 2).

Discussion

Decision-making is acognitive process (7), and it is the output of the clinical reasoning process (8) that plays an essential role in the accurate diagnosis and management of diseases (5,17). Thus, medical education institutes’ fundamental responsibility is to lead medical and paramedical students from the path of memorizing information to becoming analytical problem solvers who approach clinical cases in the best possible manner (18). Identifying KFs of clinical scenarios can lead to successful clinical reasoning and clinical decision-making under the influence of knowledge and experience (19). Development and assessment of clinical decision-making skills are essential in midwifery education because of their role in mothers’ and infants’ safety. Therefore, the present study’s primary purpose was to assess the relationship between clinical experiences and the improvement of clinical decision-making skill using the KFs examination.

The promotion of expertise is a linear process (20), and clinical mental structure develops by expertise and knowledge (21). Clinical experience has a vital role in clinical decision-making (22), and it leads to comparing the clinical situations to retrieve mental patterns (3,22). The present study confirmed that clinical experience had a meaningful and substantial effect on clinical decision-making skills. In this regard, the results of the present study confirmed that students in higher levels of midwifery considerably recognized more KFs than students in the lower levels. Therefore, comparing the KFs scores of students at various educational levels of midwifery at the Bachelor of Science level with the grades from the KFs examination supports the above notion. The results of the present study confirmed a meaningful difference between the lower and higher-level students in clinical decision-making ability with a substantial effect. Pairwise comparison, according to the semesters, indicated a small to substantial effect of the role of experiences in clinical decision-making, and experience of more than one semester showed considerable change and larger effect on the total score of KFs. Although, due to the small sample size, these effects are not statistically meaningful at each level (except the comparison between the eight and third to fifth semesters as well as the seventh and third to fourth semesters). In future studies, the role of experiences in the decision-making needs to be assessed by a larger sample size in order to get confirmatory results.

clinical scenarios with a question to identify KFs were designed according to all of the topics taught at three and four semesters by the theoretical and practical curriculum. We expected all of the student acquired good scores. But, the highest KF scores were achieved in the eighth semester; however, it was still lower than 75% of the total score (total score of KFs test was 20), indicating that midwifery students were not as competent to identify KFs as they should be. These results might be due to the direct result of inattention to teaching clinical decision-making skills and helping students to identify key signs and symptoms of correct disease diagnosis. On the other hand, the GPA, theoretical exam scores, and practical exam scores were much higher than 75% of the total score, which indicates that our educational system is paying more attention to theoretical and practical skills and does not adequately address clinical decision-making skills. Since midwifery graduates tend to have a great number of sensitive cases of women and their delivery issues, their competency in clinical decision-making skills and correct, timely identification of illnesses can play a vital role in reducing undesirable consequences and elevating health indicators in Iran. It is imperative that the weaknesses of midwifery students’ education in diagnosing and treating illnesses be identified and addressed; besides, educational institutes should not resort only to theoretical and practical skills in their curriculum. Educational policymakers and clinical teachers must develop and assess midwifery students’ decision-making skills.

Previous studies in other medical sciences that assessed decision-making in undergraduate students with KFs examinations showed the same results (6,23). These results might be due to the widespread use of the multiple-choice question exams with one possible answer, which does not evaluate the student’s qualifications in synthesizing information and analyzing symptoms leading to sound clinical decision-making – an essential skill in effective medical practice (17). This study found an ignorable correlation coefficient between the KFs total scores and the theoretical scores. These results are probably due to the final exams’ nature, which considers the students’ knowledge at the level of memorizing information and does not evaluate their analytical skill or clinical decision-making potential. Similar to our results, Zamani et al. (17) showed a low to moderate correlation coefficient between the KFs examination and the multiple-choice test given to the obstetrics course. In this regard, Valerie et al. (8) show that there was a negligible low positive correlation between KFs scores and the National Board of Medical Examiners Subject Examination (NBME-SE) scores. Besides, there was no meaningful correlation between the KFs total scores and practical exam scores. These results could be because the practical exam is not only a measure of their capability for diagnostic reasoning and gathering useful information, but it also takes into consideration a combination of various clinical merits, including knowledge base, practical skills, competence in identifying differential diagnosis, correct diagnosis, patient management, and communication skills.

Study Limitations

Our study had several limitations. Firstly, the cross-sectional design did not allow testing and confirming a casual hypothesis. In addition, external validity is limited due to convenience sampling. Another limitation is that we did not control potential confounders/covariates that could affect clinical decision-making skills. The other limitation of the present study was the low sample size, which prevented us from presenting a prediction model. This small sample size also prevented us from reaching confirmatory results compared to the semesters mentioned in this study. Not having theoretical scores of the students in semesters seven and eight and the students’ practical scores in the fifth semester were barriers to using the linear regression model. Utilizing this type of examination (KFs) method may be challenging to adopt because of the teachers’ unfamiliarity with its design. This problem can be easily solved by training teachers and involving them in KFs designing. Thus, despite the difficulty of the design, implementation, and scoring, this test introduces a new perspective on assessing and evaluating students’ cognitive skills.

Conclusion

Proficiency in clinical decision-making is determined by clinical experience, responsibilities a student is given (number and variety of patients taken by the student), educational techniques, and evaluation methods for students’ theoretical and clinical skills. KFs can play a significant role in evaluating students’ clinical decision-making potential and can be used as an assessment tool to predict students’ success in specialized clinical tests. There is an urgent need for numerous, precise, and in-depth studies using various clinical reasoning and clinical decision-making assessment tools to examine midwifery students’ ability to identify and gather key information to diagnose patient conditions. This can be accomplished using the KFs examination, which is capable of providing a possible prediction for the weaknesses, which, in turn, can be used for making new policies in the educational system for students’ evaluation.

We hope that the evidence provided by this study will pave the way for changes in teaching and evaluation systems in clinical sciences, especially the midwifery major. We hope our results are the start of a movement to assess and psychologically analyze various clinical reasoning testing methods such as CRP, script concordance, and puzzle test. We hope that researchers perform other clinical reasoning tests to check the relation of decision-making skills and experiences level in health profession sciences especially midwifery students. In the future, researchers may use the abundant evidence provided by these studies to complement or replace the current traditional testing systems with these assessment methods. We suggest that various clinical reasoning skill tests, especially the KFs examination, be given to students of this field at four levels of expertise: Bachelor’s, Master’s, Doctoral, and instructor level. Simultaneously, evaluating the test results at all the mentioned levels will provide substantial and precise evidence regarding this test’s potency in differentiating the levels of expertise among students and practitioners.

Acknowledgment

The authors would like to thank the professors and students at the midwifery School of Shiraz University of Medical Sciences for their help in conducting this study.

Ethics approval and consent to participate

Since this study was conducted on humans, first, the Research Ethics Committee of Shiraz University of Medical Sciences approved this study with the code of IR.SUMS.REC.1396.s403. Besides, the students were assured that their information would remain confidential, and before conducting the study, written informed consent was obtained from all the students.

Conflict of Interests

The authors declare that they have no known competing financial interests. So.D and S.D are siblings; it could not have any influence on the work reported in this paper.

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