Midwifery students’ satisfaction with simulation-based education and associated factors among governmental universities in Amhara region, Ethiopia 2022

An institution-based cross-sectional study was conducted from August 1–30, 2022 among undergraduate midwifery students at governmental universities in the Amhara region. There are ten governmental universities in the region; of these, eight offer a BSc program in midwifery, and seven of these have 3rd and 4th year students (Bahirdar, Gondar, Debre Tabor, Debre Markos, Debre Birhan, Wollo, and Woldia). More than 800 undergraduate midwifery students were enrolled in the regular program in the region. Third- and fourth-year undergraduate midwifery students in the regular program (n = 413) were included in this study. The sample size was proportionally allocated among each university (See supplementary file for the sampling procedure).

The sample size was determined by using a proportion of satisfaction in simulation-based learning among midwifery students taken from a study conducted in Gondar which was 54.2% [22]. The sample size was determined with a single population proportion formula;\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\:n\hspace{0.17em}=\hspace{0.17em}\frac{(\frac{\alpha}{2}{z)^{2}\times pq}}{d^{2}}$$\end{document}

Where,

n- number of sample size.

p- Proportion of satisfaction with simulation-based learning among midwifery students taken from a study conducted in Gondar, 54.2%.

q- Proportion of those who are not satisfied with simulation-based learning (1-p).

d- Permitted marginal error (5%).

Z- Standard normal distribution with a confidence interval of 95%, z = 1.96 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\:n=\frac{1.962^{2}\times0.542\times(1-0.542)}{0.05^{2}}$$\end{document} \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\:n =382$$\end{document}

After adding a non-response rate of 10%=38; the final total sample size was determined to be 420 among the governmental universities in the Amhara region; eight of them provide midwifery in the BSc program. A simple random sampling technique was used to select study participants after the sample size was proportionally allocated among each university.

Proportional allocation, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\:nj=\frac{n\times Nj}{N}$$\end{document}

Where: nj = is the sample size of the jth university.

Nj = is the population size of the jth university.

n = n1 + n2 + n3 + n4… is the total sample size (420).

N = N1 + N2 + N3 + N4… is the total population size (525).

Data were collected using a structured self-administered questionnaire adapted from the National League for Nursing [29–31]. The tool, prepared in English, and has five parts: sociodemographic information, student satisfaction with SBE, SBE practice, design, and environment. Participants were asked to indicate their level of agreement with listed items on a 5-point Likert scale (1: strongly disagree, 2: disagree, 3: neutral, 4: agree, 5: strongly agree) to measure their satisfaction. To assess the internal consistency of the 5 items of the satisfaction measurement tool, a reliability analysis was conducted, yielding a Cronbach’s alpha value of 0.909. A pretest was performed on 5% of the study subjects at Selalie University, and the tool was subsequently modified for the final data collection. Seven data collectors (BSc midwifery) and two supervisors (MSc in Midwifery) were recruited and training was provided on informed consent, confidentiality, participants’ rights, and the objective of the study. None of the data collectors or supervisors was affiliated with the institutions where the data were collected.

Participants were asked to select their level of agreement with listed items on a 5-point Likert scale (1: strongly disagree, 2: disagree, 3: neutral, 4: agree, 5: strongly agree) to measure the outcome variable satisfaction. Students who scored the mean and above for the 5-item Likert scale listed in the Satisfaction of SBE questionnaires were categorized as satisfied, while those who scored less than the mean for 5-items Likert scale listed in the Satisfaction of SBE questionnaires were categorized as unsatisfied [5, 22].

Independent variables such as simulation-based learning practices include questions that measure students’ active learning, time allotment, frequency of SBE, group size, and collaboration during simulation-based education. Students who scored the mean and above for the 7 items listed under the active learning assessment questions were categorized as those with good active learning practices [31]. Similarly, for determining design-related factors, there were domains such as prebriefing, support, debriefing, feedback, and fidelity. Hence, students who scored the mean and above for 5 items listed under the prebriefing domain assessment were considered those with adequate prebriefing. Likewise support during SBE was measured with 4 items listed under support domain assessment and students who scored the mean and above for those questions were taken as students with adequate support. For measuring debriefing there were 2 items listed under debriefing assessment questions and students who answered ‘Yes’ for both were classified as adequate debriefing. Feedback was also measured with 4 items listed under feedback domain assessment and students who scored mean and above for the questions were grouped as having adequate feedback. Fidelity was measured with 2 items listed under fidelity assessment and students who answered ‘Yes’ for both were themed as those with good fidelity in simulation [30]. Learning environment-related factors were measured with questions concerning the availability of skillful assistants and materials, organization of the simulation room, functionality of equipment, provision of checklists, and availability of instructors.

Before beginning the analysis procedure, the acquired data were reviewed for completeness. A template format was prepared, and the coded data were entered into Epi-Data version 4.6.0.4 and then exported to SPSS version 26 for analysis (http://www.epidata.dk/download.php↗). Descriptive analysis was employed to describe the percentages and distributions of students’ sociodemographic characteristics and factors associated with their satisfaction with SBE. Binary logistic regression was used to examine the association of independent variables with the dependent variable. Bivariable analysis was conducted to select candidate variables for multivariable analysis at a P-value less than 0.2. Model fitness test was assessed using the Hosmer-Lemeshow goodness-of-fit statistic. Multicollinearity was checked with the variance inflation factor (VIF) test. Crude and adjusted odds ratios (AOR) with corresponding 95% confidence intervals were computed, and a P-value < 0.05 was considered to indicate statistical significance. Finally, the results were presented using tables, figures, and text.

A total of 413 midwifery students participated in this study, resulting in a response rate of 98.33%. Among the respondents, 195 (47.2%) were male. For most of the participants, the ages of 345 (83.5%) were in the range of 20–24 years with a mean age of 22.94 years (SD ± 2.003). In addition, 168 (40.7%) were in their third year, while 245 (59.3%) were in their fourth year (Table 1).

Among the 413 undergraduate midwifery students in Amhara region universities, 350 (84.7%) were satisfied (scoring mean and above) with their simulation-based education. To check for the internal consistency of the 5 items of the satisfaction measurement tool, reliability analysis was conducted, yielding Cronbach’s alpha value of 0.909.

For the five-item Likert scale, 68 (16.5%) participants strongly agreed that the teaching methods used in the simulation were effective. One hundred (24.2%) of them also strongly agreed that the simulated teaching materials were motivating and beneficial to their learning. Moreover, the overall mean SBE score was 3.63 ± 0.991 (Table 2).

The majority 352 (85.2%) of study participants agreed that using simulation activities made their learning time more productive. Two hundred seventy-one students (65.6%) demonstrated overall good active learning practice in SBE. More than half of them, 222 (53.8%), reported that the time allotted to practice a certain procedure was adequate. Two hundred ninety-nine (72.4%) participants exhibited good collaboration practice in SBE (Table 3).

With respect to SBE designs, 291 (70.5%) participants reported that there was adequate prebriefing. Only 250 (60.5%) of midwifery students felt that adequate support was given in simulation education. In addition, 278(67.3%) reported that there was adequate debriefing of SBE. Two hundred twenty-nine (55.4%) of the students reported that the feedback given after simulation-based learning was adequate. The students also indicated that there was good fidelity of simulation-based education 291 (70.5%) (Table 3).

The majority of the respondents, 384(93%), reported that instructors were available during their simulation learning. In addition, 276(66.8%) stated that lab assistants were skillful. Two hundred seventy-nine (67.6%) students agreed that their learning environment had the necessary materials for conducting simulation learning. Three hundred thirty-five (81.1%) of them also noted the presence and provision of checklists in the simulation room. Two hundred ninety-nine (72.4%) students reported that the simulation room and materials were well organized (Table 3).

After controlling for the effects of other covariates, fifteen variables (year of study, active learning, collaboration, adequacy of sessions, prebriefing, support, debriefing, feedback, fidelity, instructor availability, skillful lab assistants, availability of materials, provision of checklists, functionality of materials, and organization of rooms) that were significantly associated with satisfaction with SBE according to the bivariable analysis (with P-value less than 0.2) were fitted in the multivariable logistic regression model for further investigation. Among these predictor variables year of study, support, instructor’s availability, and provision of checklists were significantly associated with students’ satisfaction with SBE.

This study revealed that the odds of being satisfied with SBE among 4th-year midwifery students were 2.93 times higher than 3rd-year students [AOR: 2.93; 95% CI (1.53–5.63)]. The result also showed that the odds of being satisfied with SBE among students with adequate support were 2.90 times higher than students receiving inadequate support [AOR: 2.90; 95% CI (1.21–6.92)]. The odds of being satisfied with SBE among students with available instructors in a simulation learning environment were 2.86 times higher than those students with no instructors during simulation [AOR = 2.86, 95%t CI (1.07–7.59)]. In addition, the odds of being satisfied with SBE among students in a simulation learning environment where checklists were provided were 2.32 times higher than those students in a simulation learning environment where checklists were not provided [AOR: 2.32; 95% CI (1.14–4.73)] (Table 4, Table 5 and Table 6).

This study was conducted at the regional level using a large sample size and probability sampling method to minimize selection bias and to ensure its generalizability to midwifery students studying at universities found in different regions of Ethiopia. To minimize information bias, a pretested, valid, and reliable questionnaire was used to collect data. Study participants were also limited in the use of exclusion criteria to those who were in clinical practice during the data collection period to reduce recall bias. Similarly, the objective of the study was clearly described to the study participants, and the confidentiality of their responses was assured to encourage them to provide their genuine response. In addition, data quality was maintained throughout, and an appropriate statistical analysis method was used with a strong model goodness of fit test. However, further research using qualitative approaches should be used.