A needs assessment for designing and establishing a Center for Clinical Skills Center

Background: Due to the limitations of clinical learning and the consideration of patients’ rights, the emphasis on educating clinical and communication skills and creating attitudes in students has received much attention, which requires an appropriate educational environment. Methods: In a descriptive study, we examined challenges and proposed solutions in a clinical skills center in 2017. The study participants were 60 medical students and 29 faculty members at the Tabriz University of Medical Sciences who were selected randomly and followed for 12 months, from October 2016 to October 2017. The classical modified Delphi technique was used to collect data and study execution in three rounds. Results: From the perspectives of academic board members, the most critical weaknesses included “small and limited educational environment of workshops” (weight of consensus = 212.5), “severe lack of educational facilities such as simulators” (weight of consensus = 158.9), and “lack of adequate facilities for assessing students’ skills” (weight of consensus = 140.9) based on the results. From the perspectives of academic board members, the most crucial weaknesses in the field of management and execution were “lack of adequate constructional infrastructure” (weight of consensus = 239.2), “lack of adequate funding for the clinical skills center” (weight of consensus = 200.1) and “lack of approved organizational chart for clinical skills center” (weight of consensus = 200.1). Conclusion : The main challenges of the Clinical Skills Center of Tabriz University of Medical Sciences included the lack of definition of an organizational chart, lack of sufficient funding to provide educational facilities, lack of standard educational space, and clinical skills evaluation, which the Center for Clinical Skills developed. Most of the center’s problems were resolved by allocating sufficient funds to provide educational facilities and cultivate a culture of interdisciplinary collaboration supported by university authorities.

of developing CLSCs becomes more apparent. Hence, a needs assessment and review of the challenges were required in the current study. Needs assessment is an integral part of strategic planning, during which the needs are identified and acted upon according to their priority. 7 One of the most reliable needs assessment methods is the Delphi technique, through which individuals' opinions are examined in several stages 8 as a consensus-based method. 9 Through this technique, groups' opinions are examined remotely and in a specific location without the simultaneous presence of individuals; what is agreed upon by all constitutes the need. 10,11 The Delphi technique is managed with some questions that are progressively given to individuals, analyzed by a needs assessment instrument, and used in the design of subsequent questions. This is done in several successive steps so that individuals might reach an agreement on their needs. 12,13 Therefore, since the development of clinical skills is a basic element of medical education and an essential part of the core program of medical schools, 14 this study evaluated the educational, directorial, and execution challenges of the clinical skills center of Tabriz University of Medical Sciences from the perspectives of the academic board members and medical students using the Delphi technique to identify strengths and weaknesses, determine opportunities and threats, and provide appropriate strategies.

Materials and Methods
This is a descriptive study using the Delphi technique to examine the challenges and propose solutions in the clinical skills center of Tabriz University of Medical Sciences in 2017. The study participants were students of medical undergraduate and residency courses who had passed clinical skills in the skill lab, as well as members of the academic board of various clinical education departments, the dean of the faculty, and senior educational and executive directors at the Tabriz University of Medical Sciences who were selected randomly over 12 months, from October 2016 to October 2017. The inclusion criteria were medical undergraduate and residency students who had passed clinical skills in the skill lab, instructional faculty members of the clinical skill workshops, and educational and executive directors who were somehow related to the current processes of the clinical skills center. Based on the number of students and faculty members of 17 educational departments and using the Morgan table, the sample size was estimated to be 60 students and 29 instructing faculty members and directors.. The study units' refusal to participate was considered a criterion for exclusion.
The classical modified Delphi technique was used for data collection and study execution in three rounds. In the first round, an unstructured questionnaire, in the form of open-ended questions concerning problems in the current processes of the clinical skills center (strengths and weaknesses) and suggested solutions, was developed for the members of the expert group who had already been selected. This provided a relatively wide range further to explore subject matter to the study participants. A qualitative analysis was performed in the first round, and similar opinions expressed on a single topic were classified into two areas: education and management. Thus, the initially unstructured questionnaire became a structured one, forming the basis of later rounds. In the second round, experts participating in the first round were given the questionnaire obtained from the first round. While expressing their opinions, the individuals were invited to express their critique toward each of the stated sentences and add possible proposals to the end of each section. The third-round quantitative data were analyzed by descriptive statistics techniques. Participants were asked to rate the mentioned variables in each section from 0 (no executability and no priority) to 10 (full executability and high priority). After receiving the participants' answers, the average of the opinions was calculated, and the prioritization of each of the mentioned variables was conducted so that fewer and higher numbers of agreements indicated lower and higher priorities, respectively. Researchers distributed questionnaires to participants in each round; they were asked to complete the questionnaires within 15 days. Afterward, the researchers collected the questionnaires.
Ten professors specializing in relevant fields were surveyed to test the validity of the questionnaire.
To test the reliability of the questionnaire, 30 medical students, faculty members, and medical school administrators were selected using the test-retest method two weeks apart.
Finally, the data of the current Delphi study were analyzed in two stages. The qualitative content analysis with a conventional approach was used to identify the main variables and extract the items of the initially unstructured questionnaire in the first and second stages. The third stage was the beginning of using quantitative methods in which the data were analyzed using descriptive statistics (mean, standard deviation) by SPSS 20.

Results
Eighty-nine participants of the study (60 students and 29 academic board members of various clinical education departments, dean of the faculty, and educational and executive directors of Tabriz University of Medical Sciences) completed data collection in all three rounds. Among the 29 academic board members who participated in the study, 9 were professors, 10 were associate professors, and 10 were assistant professors. Of 60 participating students, 40 were undergraduate medical students, and 20 were residency medical students. Cronbach's alpha coefficient of the researcher-made questionnaire was 0.85; 0.70 is considered acceptable for social sciences research. All information obtained from qualitative content analysis in the first two rounds was placed in educational, directorial, and execution areas and three categories: weaknesses, strengths, and suggestions. In the third round (quantitative method), the results were approved or rejected as executable, non-executable, and consensus grades. The educational challenges of the clinical skills center are presented in Table 1.
From the perspectives of the academic board members, senior directors, and students, the most critical weaknesses of the directorial and executive fields are presented in Table 2.
Finally, the suggestions were classified in Table 3 in terms of executability and priority after collecting information.
Based on the results, establishing a center for education, research, and assessment of clinical skills was prioritized and decided in the meetings of deputies and was implemented as follows.

Discussion
Advances in medical science and changes in the provision of health services have necessitated improvements in student education. 15 Establishing CLSCs in medical universities is a response to educational needs and consideration of patients' rights. Due to the type of educational chart and the facilities, CLSCs have a relatively different scope of activities, target groups, and educational resources around the world; they all share the goal of instructing and practicing clinical and communication skills for medical students should be organized and done as soon as possible. 6 According to members of the academic board, senior directors, and students participating in this study, the most critical weaknesses of the clinical skills center of the medical school in the field of education, which was located in an area of about 400 square meters, were the "small and limited educational environment of workshops", "severe lack of educational facilities such as simulators", "lack of adequate facilities for assessing students' skills", "lack of clinical skills course", and "using traditional methods of clinical skills education". Weaknesses in the directorial and executive field were "lack of adequate constructional infrastructure", "lack of adequate funding for the clinical skills center", "lack of approved organizational chart for clinical skills center", and "lack of specialized human resources". Establishing the educational, research, and assessment center of clinical skills was one of the main priorities of this study. Therefore, we became more steadfast in achieving the center's new mission by conducting surveys through an internet search and telephone contacts or physical visits to various clinical skills centers inside and outside the country (Tbilisi, Georgia, Georgia Aci Badem, and Turkey). Almost all clinical skills centers expanded their educational activities for different groups of students and assistants. Meanwhile, the Tabriz University of Medical Sciences has considered the need to improve the physical environment and add experienced human resources as its short-term goals. By the end of the study phase, an educational, research, and assessment center of clinical skills based on new educational and directorial approaches was established in the following executive phases: 1. Estimating the cost of equipment to establish the center based on the new plan and required equipment. 2. Designing a new clinical skills center in an area of 1800 m 2 on two floors with three critical units of education, research, and assessment of clinical skills. լ The educational unit was designed and established, consisting of workshops on trauma care, basic and advanced cardiopulmonary resuscitation, airway management, nursing skills, examination and obtaining medical history, communication skills, diagnostic procedures, model pharmacy, simulated hospital, and electronic library. լ The assessment unit was designed and established, which consists of 30 stations in two halls: A and B (equipped with CCTV camera, test protection room, and quarantine room before and after the test) to hold OSCE, clinical competency tests at the end of general medicine, and other tests and exams. լ The research in education unit was designed and established, which consists of a content production studio (for making distance and multimedia learning software and production of educational content), designing laboratory, manufacturing and repairing educational and medical moulages (designing and manufacturing models, moulages, and teaching aids in the form of knowledge-based projects and student dissertations, the basic maintenance of existing moulages in the center, which leads to increasing their lifespan, self-sufficiency in providing a variety of teaching aids and as a result, currency savings and sales of educational products of the center in long-term), and a unit of research in education (for quantitative and qualitative evaluations of the provided educations in the center and the use of new educational methods such as flipped classrooms). լ The administrative and office unit was designed and established, consisting of the presidency room, think tank (R&D room), management room, educational planning room, certification room, informatics Table 3. Classification of suggestions in terms of executability and priority

Educational Field
Expanding the physical environment of the clinical skills center 9 1 Providing up-to-date medical manikins and educational facilities based on educational goals 8 2 Inviting professors and students interested in holding workshops and educational scenarios 8 6 Allocating educational and executive points for professors cooperating with the center 5 7 Establishing purposeful educational environments 9 3 Establishing a reward system for the presence of learners 4 8 Establishing a dedicated environment for OSCE 8 4 Using modern educational methods 8 5

Directorial Field
Allocating the educational environment in proportion to the volume of students 9 2 Allocating appropriate funds to provide educational facilities 9 1 Establishing production departments and educational innovations in the form of knowledge-based projects and student dissertations 9 3 Proposing an approved organizational chart 4 9 Establishing a unit of research in education 7 7 Establishing a unit of a model hospital 9 6 Establishing a unit of model pharmacy 9 5 Using the capacities of the center to provide practical education to all audiences, including students, staff, and the general public 8 10 Providing specialized nursing staff to meet the challenges of lack of skilled and experienced staff 7 4 Reducing the costs of the center by providing outdated materials such as syringes, sutures, etc. to be used in workshops 7 8 room, and experts' room. 3. Using nurses working at the university as staff to establish a related organizational position (due to the nature of skill lab activities and equipment in the center, nurses were most efficient in performing educational and research activities). 4. Proposing an organizational chart for the educational, research, and assessment center of clinical skills. 5. Public information about using healthy medical equipment in this center for economic savings (such as syringes, angiocath, gloves, etc). 6. Establishing a simulated hospital in an independent environment with wards (triage, resuscitation room, outpatient examination room, laboratory, imaging room, neonatal and pediatric intensive care unit, adult intensive care unit, obstetrics and gynecology ward, and internal ward) to hold educational scenarios and conducting teamwork exercises. 7. Establishing the first model pharmacy in the clinical skills center of the Medical School. 8. Preparation of medical moulages and equipment required for education and holding clinical competency tests (more than 100 types of educational medical moulages). Considering the potential of the educational, research, and assessment center of clinical skills, this center can be used in the following cases: Educating clinical skills to various audiences • Educating skills related to physical examinations and practical semiology to medical students in different courses as well as students of dentistry, pharmacy, midwifery, nursing, health, and other fields of medical sciences. • Educating clinical skills such as suturing, catheterization, cardiopulmonary resuscitation workshop(CPR ), etc., to medical students and other disciplines, e.g., performing CPR courses for pharmacy and dentistry students. • Holding practical education to prepare students for the clinical competency exams.
Educating interdisciplinary skills • Holding skill workshops based on an educational scenario for a group of students of different medical and paramedical disciplines (e.g., a physician, nurse, ward secretary, supervisor, etc., can simultaneously be present in the resuscitation team through an advanced resuscitation workshop). • Using a model pharmacy environment to educate students in medical, pharmaceutical, paramedical, and non-medical departments. Using student capabilities • The goal is to employ and get the students to participate actively (target groups) in various educational programs and research. Decentralized planning, activating students to discover their educational problems, and participating in solving them leads to better and deeper learning. • Through active student organizations, critical educational scenarios will be collected from natural clinical environments, and problem-oriented education will be provided based on the daily needs of the target groups. • Collecting clinical and skill problems in hospital educational settings from students' perspectives and trying to solve them in the form of dissertations and applied research.
Establishing a simulated patient bank This center has the potential to implement first aid training programs to the public through virtual and physical education, concluding training contracts with private and governmental centers, cooperating with pharmaceutical companies and hospital medical equipment stores (educational cooperation and introduction of new medicines and equipment to target groups of programs), creating a bank of clinical test questions at a regional scale, employing members of the academic board and instructors to teach workshops, communication and continuing learning on medical moulages and learning, expanding training to cyberspace, expanding the education center to the universities in neighboring countries, considering the records of the center in holding workshops, holding a student clinical skills Olympiad in order to create healthy competition for students for learning purposes, using corridors to install bulletins of medicines and new equipment for educational purposes, introducing pharmaceutical products and new equipment from private companies, educating clinical skills for specialized and sub-specialized assistants such as ERCP training, endoscopy, or colonoscopy and laparoscopy, and holding education workshops for other audiences even outside the university, such as endoscopy education courses for internal medicine and surgery physicians or prescription and pharmacotherapy workshops for different groups.

Conclusion
The main challenges of the Clinical Skills Center of Tabriz University of Medical Sciences included the lack of definition of an organizational chart, lack of sufficient funding to provide educational facilities, lack of standard educational space, and clinical skills evaluation, which the Center for Clinical Skills developed., Most of the center's problems were resolved by allocating sufficient funds to provide educational facilities and cultivate a culture of interdisciplinary collaboration along with setting up a laboratory for producing educational products supported by university authorities. The following suggestions are presented for improving the educational quality of clinical centers. Therefore, medical universities can take a big step toward improving the educational quality of their clinical skills centers by taking advantage of the results and suggestions of this study.

Suggestions
The following items are suggested to improve the quality of the education provided in the clinical skills center and attract the maximum participation of interested individuals.
• Assigning a course for educating clinical skills • Considering adding educational points for cooperating professors to increase educational motivation to participate • Utilizing volunteer assistants and instructors from other fields, including general practitioners, etc. • Implementing basic and applied education-oriented research in the form of dissertations and contracts with knowledge-based centers. • Providing facilities for transferring real experiences from clinical environments of hospitals to the workshops of the center using fiber optic technologies and also transferring scenario education within the workshops to theoretical classes through the network • Training on animal tissues in the animal lab environment • Integration of clinical skills center education in clinical wards and continuation of education provided in the center on patients as controlled by the instructors of the center • Predicting observation room and debriefing room in designing a skills center • Postgraduate education programs to generate revenue for the center