Simulation-based Boot-camp Improves the Self-ecacy of Newly Inducted Hospital Residents and Interns

Expectation of competence from interns and residents from outset stresses the need for bridging the gap between undergraduate and post-graduate worlds, in terms of clinical skills. Worldwide, simulation-based boot camps ease this transition and equip novice trainees with essential foundation knowledge, technical skills, and effective communication. This study describes the introduction, change management process, and analyzes effectiveness of rst-ever boot camp in Pakistan aimed at improving self-ecacy of PGME interns and residents. A boot camp of 4 days duration was conducted in December 2018 at The Aga Khan University Hospital (AKUH) for newly inducted PGME interns and residents. 40 residents and 68 interns completed a self-administered self-ecacy questionnaire after boot camp. Results There was a signicant overall improvement in self-ecacy of trainees across all skills. Self-ecacy improved most in CVC insertion, hospital management software) and communication, while, least gain was seen in infection control post-boot camp. Boot camp approach has proven to be an ecient, safe, forgiving, experiential learning environment for healthcare professionals and prepares them to thrive in a new hospital setting. Analysis supports effectiveness of boot camp in improving the self-ecacy of new trainees and provides direction for future planning of boot camps.


Introduction
Transition from medical school to hospital environment is a challenging process. This is because healthcare providers (HCPs) are expected and required to be fully functional from very beginning of their training program (1), while new trainees experience a disconnection between academic knowledge and its clinical application (2).
Limited exposure to clinical experience along with a general lack of knowledge regarding basic skills leads to variance in trainee competence and poor patient handling (3,4). Residency program directors report that many new trainees struggle with communication, professionalism, and organizational skills (5). Hospital set-ups are complex training environments where patients are subjected to potential harm at hands of novice trainees. Many studies have reported adverse patient outcomes during trainee change-over periods (5,6).
Ensuring patient safety, training of HCPs before entering into hospital, in a simulated environment is vital (7), where they learn from their errors without fear of harming patients (4,(7)(8)(9). Replication of realistic clinical scenarios through simulation-based education (SBE) is an effective way to gain experience as it minimizes chances of negative learning (10)(11)(12). Furthermore, it exposes learners to challenging behaviors and attitudes which they might experience in clinical settings (12).
"Boot Camps" (BC) help new interns to transition from medical school to residency as it provides a platform to practice basic tasks and to achieve competence (13,14). Moreover, simulation-based BC can equip novice interns and residents with more advanced skills, knowledge, and con dence to deal with complex situations in real-life situations through bene t of practice and feedback integral to high delity SBE (13,15,16). By bringing residents and interns together for BC provides an additional opportunity for vicarious learning and social bonding within group, some of whom may be together for next 5 years.
Aga Khan University's (AKUH) Centre for Innovation in Medical Education (CIME) hosted rst-ever BC for newly hired interns and residents in 2019. Centre's role in any curricular innovation is to be catalyst bringing together faculty, students, technologies, and expertise in SBE to provide solutions to otherwise daunting educational challenges. This BC curriculum included a wide range of basic clinical expertise along with patient safety procedures and soft skills such as communication, administration, and organizational conduct. It provided participants with an experiential learning opportunity aimed at strengthening both knowledge and skills, thus providing a better orientation to the working environment of AKUH.
The study aimed to evaluate the effectiveness of a BC approach to developing clinical skills and knowledge in new interns and residents, through assessing any differences before and after completing the BC.

Methodology
Planning & Designing of Course Curriculum BC concept is new in Pakistan. Evolving from traditional way of orientation for new inductees, to simulationbased BC was a challenge. Several meetings and discussions were held with inducting committee of Post Graduate Medical Education (PGME) and CIME team to plan content and design of BC. A total of 142 inductees, comprising 80 interns and 62 residents which were divided into 10 groups with approximately 14 participants in each. 10 skills stations were created with a focus on those skills deemed by experienced faculty to be important for new trainees (Table 1). Moreover, participants were certi ed for BLS during BC which previously used to happen after commencement of internship/residency. Each station was carefully planned with subject specialty experts and CIME team following standard approach. Checklists were adopted from Lippincott procedure manual. Participants were given a student booklet as pre-reading, including links to video demonstrations, procedure manuals, and checklists for each skill. Each station was given 2 hours: beginning with demonstration followed by hands-on practice. Multiple task trainers were kept ensuring each participant got ample time to practice. Participants were given checklists for peer feedback and evaluation. They had opportunity to practice again after receiving feedback on performance from peers and facilitators.
Facilitator was to supervise participants, trouble-shoot any technical di culties, clarify learning outcomes, and facilitate learning. They were briefed regarding station content and oriented with task trainer for their station in dry run before BC to ensure consistency.
Study Design, sampling technique, Inclusion/Exclusion Criteria It was experimental design study with purposive sampling technique. All PGME interns or residents newly hired at AKUH, for year 2019, irrespective of gender, enrolled in BC were included in this study, those who failed to complete BC were excluded. Ethics approval by AKU ERC was obtained. Anonymity was ensured and written consent was obtained.
Data Collection & Statistical Analysis 31 item self-e cacy questionnaire (SEQ) was designed based on the principles of self-e cacy (SE) theory by Bandura who de nes it as an individual's belief in his or her capacity to execute behaviors necessary to produce speci c performance attainments. Out of the four key sources of information to determines SE, performance accomplishment provides the optimum evidence and is true re ection of SE as it stems from individual's personal experience as opposed to learning from observing other's experiences, verbal persuasion, and physiological arousal. (17).
Identifying one's SE in task leads to intentional effort to improvise by virtue of behavioral change. It is described that SE is predictor of performance and behavior and therefore, BC was evaluated using SE theory (17,18). Questionnaire was provided to participants after BC. It was retrospective pre and post-test to be lled simultaneously for each of tasks before which a written consent was taken. Along with SE, demographic information was also collected (Supplementary information). Data was entered in SPSS (Statistical Package for the Social Sciences) version 19.0. Descriptive analysis was done for all variables. Based on the same variance, few variables were combined to form four new variables: Infection control, Sahl application, Communication, and Counselling to make the data easy to analyze. Paired T-test was applied to determine if the differences in the SE levels before and after the training were statistically signi cant. Change in SE was also studied considering gender, designation, years of clinical experience, Medical College/University of graduation, name of Hospital of House-job/Internship, using independent T-test.

Results
BC was a four-day program attended by 142 participants and amongst whom 108 (76.05%) consented to ll the SE questionnaire and 34 (23.94%) refused to take part thus were not included in the study.

SE in all Variables
There was noticeable and statistically signi cant improvement in SE of trainees across all skills. Highest pre-SE score was in infection control (74.01) while, lowest was in CVC insertion (20.0). Further details are reported in Table 1.

SE in relation to demographics
Gender demographic was divided into two variables: male and female. There was signi cant association found between performances of adult female catheterization and gender when an Independent T-test was applied, females had higher pre-score (57.70) as compared to males (36.72). Interestingly, males mean SE score difference was higher (41.4) than females (24.2). Similarly, females had a higher mean SE score difference (29.36) as compared to males (23.12) in performing adult male catheterization, however, this result was not statistically signi cant. Signi cant association was also found between performance of lumbar puncture and gender where males improved most (42.34) as compared to females (30.68). While there was no signi cant association found in remaining skills (Table 2).
It was observed that residents had higher overall pre-mean score as compared to interns, as might be expected, however, only few variables had these differences statistically signi cant such as arterial blood sampling , venipuncture, dressing of surgical wound and , dressing of CVC, performing lumbar puncture , SAHL Application and communication skills (Table 2).
Graduation demographic was divided into two: those who graduated from AKU and Externals (who graduated from other universities). It was noted that AKU graduates had higher pre and post mean scores in all skills except combined clinical skills when compared to external graduates. However, these results are statistically insigni cant ( Figure 1).
Newly enrolled residents did their internship from either AKUH or outside AKUH. Internship hospital variable had two possibilities: AKUH and Externals Hospitals. It was found that residents who had done their internship from AKU had higher pre mean and post mean score than those who completed their internship outside AKUH, however, these results were statistically signi cant in only SAHL Application, communication skills and Counselling Skills, while all the rest of the variables were insigni cant ( Table 2).
Newly enrolled residents belonged to multiple specialties, broadly categorized into two variables: Surgery and Medicine. It was seen that in some skills residents from surgery had higher pre-mean scores (Clinical skills, Infection Control) while in SAHL Application, communication and counselling skills medical residents had higher pre-mean scores. However, none of these differences were statistically signi cant (Table 2).

Discussion
BC was introduced as unique concept not only in AKU but also in Pakistan. Arranging such intense activity with such many participants was very challenging. Execution of this concept was only made possible because our Centre provided suitable learning spaces for smooth management of these dynamic stations rotating every 2 hours and its' live-video technology helped in supervising multiple stations to ensure quality. Aiming to train 142 participants in basic skills also came with a cost that all was budgeted extensively during the planning phase. Each station had at least one and a maximum of 3 facilitators, who were briefed in detail regarding their stations and oriented with task trainers individually before BC. Successful execution of this rst BC was only possible because of extensive and rigorous pre-planning. It resulted in improvement of SE of the participants throughout all skills ranging from clinical, hospital management system (Sahl application), and soft skills such as counseling and communication.
Amongst clinical skills, in infection control showed smallest improvement which could mean that skill was too basic for participants and that it didn't offer for 'new' learning opportunities for participants. Having highest pre-boot camp SE (Table 1) would support this conclusion. Whereas, low pre-boot camp scores in CVC insertion indicate a lack of previous experience in this specialized skill, therefore with an appropriate teaching strategy highest gain in SE was witnessed.
Relationship between gender of participants and SE was not signi cant. It was noted that females tended to have a higher pre-boot camp SE score in performing female catheterization (p-value 0.002, Table 2) and lower for male catheterization. A possible explanation for this nding can be due to institutional policies requiring same gender urinary catheterization, (19), leading to decreased exposure and practice as students, hence, less pre-training SE.
Since BC was structured for both interns and residents with same curriculum content, a signi cant difference in pre-boot camp SE was recorded, with residents being more e cacious than interns ( Table 2). As residents entered their program with at least one year of clinical internship experience, difference between two groups can thus be explained.
SE scores according to graduate college and internship hospital, low pre-boot camp SE scores with most improvement in Sahl application are explained by induction of trainees who either graduated or did their internship from outside AKUH and therefore were not familiar with system as opposed to participants internal to AKUH. Similarly, part of communication category included paging technique, using hospital SBAR notes for giving/receiving patient's hand over, therefore, trainees who previously did their internship within AKUH had higher pre-boot camp scores as compared to the externals (Figure 1).
In a study conducted in a north Indian medical college, nal year students were recruited for a BC. Majority of participants agreed that after activity they could counsel patient con dently and had improved their communication skills (20). In another study, interns of general surgery had reported self-improvement in their interpersonal skills and communication after attending BC (21). Similarly, there has been evidence of improvement in learner's clinical skills, knowledge, and con dence as reported in a meta-analysis by Blackmore et al (2014) (1). In another systematic review, Neylan et al (2017) studied effectiveness of boot camps and concluded that although BC positively affect con dence level of medical graduates entering hospitals, none of studies measured objectively clinical performance of interns (22).
In conclusion, this BC was successful in preparing new inductees for their clinical training, as evidenced by above results. It also highlighted areas of learning that were successful that could be developed as stand-alone workshops or adapted for incorporation in any future BC. This analysis supports that BC provide an effective, safe, forgiving experiential learning environment for HCPs and prepare them to thrive in a new hospital setting. This study also highlights effectiveness of SE measurement as an evaluation tool in determining the effectiveness of teaching-learning strategy used in BC educational design.

Limitations
Participants might have had recall bias while rating themselves in SE. Qualitative method can be employed in future and through interviews, in-depth insight into participants' learning can be achieved. It may be valuable to survey participants again after commencement of their internship/residency to assess exact impact of BC on their e cacy to perform tasks. Since these results are calculated for a speci c population, it cannot be generalized. Whereas, there has not been any BC for newly inducted doctors in Pakistan as per information of authors, this study was one of its kind. It can serve as a national example for other universities and teaching hospitals to adapt and introduce into their programs. Availability of data and materials: The data that supports the ndings of this study are available on request from the corresponding author. The data are not publicly available due to ethical considerations.

List Of Abbreviations
Competing interests: There are no competing interests.
Funding: All the consumables were funded by PGME while no nancial bene ts were given to any of the authors.
Authors' contributions: MIR initiated the idea, analyzed & interpreted the data and wrote the abstract, introduction and discussion of the manuscript. CD provided supervision in execution of the research and interpretation of the data.and reviewed the manuscript. AA supervised the research, collected data and reviewed the manuscript. FK performed data analysis and wrote results. MSA entered the data on SPSS.   Figure 1 Pre and Post mean scores in relation to Graduation

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. SupplementaryInformation.docx