Can Undergraduate Orthopaedic Student Internship Programme (sip) Improve Student Perception of “Readiness” for Clinical Practice?

Objectives: To validate the effectiveness of the Undergraduate Orthopaedic Student Internship Programme (Ortho-SIP) in preparing final year students for the practice of medicine post-graduation. Methods: A questionnaire based on a five-point Likert scale was given to the students upon completion of different components of the Ortho-SIP. Based on this scale, the number of variable reviews is collated, and individual summated Likert scale scores are calculated the overall improvement to students’ self-confidence, clinical efficiency, and clinical skills. Results: Majority of responses from students who participated in the Ortho-SIP were favourable. 76 % of responses indicated a grade 4 and above (overall mean 3.9) for the quality of their experience in the internship programme. The mean summated Likert scale score for the students is 24.2/30. 83 % of responses indicated that they would recommend or strongly recommend the programme to their colleagues. Conclusion: Students found the scenario case discussions and the practical skill stations relevant and enjoyable opportunities for them to practice clinical skills. We found that according to the students’ self-perception, they were more confident of their post-graduate medical practice and felt that their clinical efficiency and skills had benefited significantly from the programme. Integrating hands-on experiences into the final year of medical students’ education can enhance their learning and preparation for post-graduate practice.


Introduction
Medical students in their final year face the ever-real challenge of translating their knowledge into clinical skills and from the textbooks onto patients. With a change of role, students may be expected to feel a degree of anxiety and a lack of preparation A hands-on approach has been shown by many experiments to be the quickest way to learn and this is especially applicable to skillbased knowledge [7][8][9]. and hence is the recommended method to meet the need of students to pick up the skills quickly and proficiently. Recent literature indicates that clinicians whose skills are acquired through practice and by interacting with a simulation perform better than those whose skills are acquired through information alone [7][8][9][10][11][12]. In 2005, a revised final undergraduate year (Foundation Programme) was designed to focus on practical skills which included three eight-week rotations in medicine, surgery, and primary care. The students were graduates from King's, Guy's, and St. Thomas' [13,14]. The majority of students involved in the study indicated marked increase in confidence and progression in perceived clinical skill competencies. The programme has since been introduced into 25 schools in the United Kingdom [10]. Multiple other studies have also noted that doctors in their first year of practice and students involved in bridging programmes most appreciate the opportunity to shadow seniors and gain their bearings in their new workplace environment before being expected to take on the responsibility [15,16]. Although not for as long a period as the Foundation Programme or the currently compulsory one-year Pre-Registration House Officer (PRHO) in the UK, our SIP shares the same aims to mentally prepare the students by instilling in them the same self-confidence and proficiency in clinical skills. Twenty-three-year-old motorcyclist collided with a lorry, is found to be hypotensive with a bleeding deformed limb.

Description of the Orthopaedic Student Internship Programme (Ortho-SIP)
2 Seventy-year-old lady presents with left hip pain after a fall and is unable to bear weight 3 Thirty-year-old man's hand was crushed by an industrial printer 4 Thirty-nine-year-old man fell from a ladder and complains of neck pain and an inability to move his four limbs.

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Fifty-year-old lady presents with a red, painful, swollen leg and knee.

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Sixty-five-year-old diabetic lady with a foul discharge from her sole and back toe. Seventy-year-old man who had a total hip replacement surgery done five days ago became acutely drowsy and confused at 2 am. the "Venepuncture, Lines and Blood Pressure" station was replaced with a knee aspiration station, to provide the students with as much exposure to clinical skills as possible. Simulation-based clinical skills training provided the students with a safe environment in which they had the confidence to take responsibility. It allowed them to make mistakes, reflect, obtain feedback, and repeat [15].
The 1day foundation skills course was followed by a 4-week student internship which comprised of job-shadowing the junior  (Table 2).

Survey Development
In order to assess the students' self-perception of "clinical readiness", a prospective review of the Ortho-SIP effectiveness using customized student questionnaires on a five-point Likert scale was conducted. Self-perception of "Clinical readiness" is defined as a demonstration of confident, effectively performed clinical skill.
The questionnaire was hence designed to determine the students' perception of their confidence, clinical effectiveness, and level of proficiency of their practical skills. The "clinical readiness" is then quantified by the mean obtained from the summated individual Likert scale score measuring improvement of student confidence, clinical effectiveness, and clinical skill enhancement. These surveys were conducted immediately after the 1-day foundation skills course, as well as after the 4-week job-shadowing experience, and also into their post-graduate surgical practice. A score of 1 referred to no benefit gained, 2 to below average, 3 to average, 4 to a good experience, and 5 to a significantly beneficial experience. The survey also included questions for students to assess the usefulness of each individual component of the Ortho-SIP, for the administration to make improvements to the programme at the time. There are no major changes to the programme between the years that could affect the students' learning through the Ortho-SIP.

Data Analysis
As each year's gender and race ratios were uniform, we found it acceptable to analyses the data according to years. To measure the success of the programme as an education tool, only scores of 4 and above were considered significant and only responses that indicated 4 and above were counted into the number of favourable reviews [18]. The individual summated Likert scale score assessing Responses indicate that an above average (grade 4 and above) increase in confidence, clinical effectiveness, and skill enhancement was experienced by 87 % of students due to the foundation skill course and 78 % of students due to the job-shadowing experience.
The mean of the summated individual Likert scale scores measuring students' confidence, clinical effectiveness, and clinical skill enhancement is a 24.2 upon 30. 83 % of students responded that they would recommend or strongly recommend the Ortho-SIP to their colleagues [19,20] (Table 3).

Discussion
All components were rated a grade 4 and above (beneficial to significantly beneficial) by at least 75% of students, indicating that the contents of the programme were able to engage and benefit most of the students. as well as hands-on experiences through simulation makes the best combination of learning [7][8][9][10][11][12]. Simulation complements the experiential learning in wards and a combination of procedural experience and skill programmes increases self-reported confidence [14,15]. Students also felt that two weeks would have been long enough to "Rotation to each ward would be more beneficial so that we can see a variety of cases." These results cohere with that of other studies in that, although job-shadowing on the whole value-adds to the students' learning, there is a limit to the benefit derived from job-shadowing compared to the time spent.16 At the same time, not all students appreciate the opportunity to job-shadow [16].
Responses also showed that the job-shadowing was carried out more efficiently when organized into teams, as they could learn more by working with Registrars and Consultants. This coheres with the results of previous studies that indicate that the jobshadowing during the transition year is best facilitated in teams, where students can interact with members of allied healthcare [2,4,13,14,16].
"Team-based management seems preferable for patient care and junior staff teaching." "Team-based system will be better for our learning." "The House Officers being ward-based, had difficulty rounding with the consultant. Although it was different for the team-based organization, it offered a different experience. I must say most of us had difficulty adjusting to this system and felt that the team-based organization was a more organized approach." The 82% of students who would recommend the Ortho-SIP is a reflection of how the components of the programme are not redundant, as they felt that future years of medical students should also have the same beneficial experiences.
The overall positive feedback from this study gives support for the importance and effectiveness of implementing a programme that helps medical students transit from their final year to working in hospitals as housemen [1,2,[4][5][6]13,14]. It also gives credit to a more hands-on approach when educating students -allowing them to learn by having them carry out the procedures and immersing them, with some guidance, in the environment that they will eventually work in.

Limitations of the Study
While the Likert scale can reflect the level of effectiveness of each component of the programme, it may not be able to establish cause and effect, as it would not be able to reflect the actual factors that contributed to the success of the different components of the programme. As the different surveys were conducted at different times, not all the participants were available to give feedback, hence there may be unaccounted for discrepancies in the results of the surveys. However, the surveys represented at least 75% of the participants and hence can still be considered a reliable source.
Though the overall response rates are high, there is a potential for a non-response bias. Students who chose not to respond to the surveys may have had less favorable experiences during the Ortho-SIP than those who did respond.

Conclusion
In conclusion, we found that our Ortho-SIP is beneficial for final year students. Not only did they enjoy being able to translate their medical knowledge into practical skills, they were able to do so proficiently and learn from their seniors how to do so in a hospital setting. This in turn led them to have more self-confidence and project "clinical readiness" for when they enter their post-graduate medical practice. This gives credence to the importance of having a transitional programme for students in their final year, as well as the incorporation of simulation and shadowing.