To sustain and continue improving the maternal and newborn health gains in Bihar, India, it is imperative to invest in novel, impactful and long-lasting continuing eductation methodologies for the local workforce. To our knowledge, this is the first study to evaluate knowledge, self-efficacy, and simulation facilitation and debriefing skills of a third generation of nurse mentor simulation educators in India, and one of the few studies globally. By analyzing before and after simulation educator training data, we found that the simulation educator training conducted by NMS (second generation educators trained by PRONTO Master Trainers) led to increased simulation facilitation knowledge and self-efficacy among AMANAT-jyoti NM (third generation educators) in Bihar. Analysis of simulation videos showed that primary health clinics had the appropriate physical infrastructure to conduct simulation training, and that the AMANAT-jyoti NM had developed basic skills to conduct simulations and debriefs at their assigned clinic. In short, almost 700 nurse mentors were able to perform simulation and debriefing according to simulation training best practice for novice educators.14
In this assessment, we found that some simulation facilitation skills such as communicating via whiteboard and the use of simulation supplies during simulated scenario were widely adopted. Similarly, some debriefing practices such as sitting in a semicircle to foster a welcoming environment and delivery of the debrief following the Diamond approach (description, analysis and application) were commonly implemented. However, advanced simulation skills such as rapid adjustment of blood flow and formulation of questions in a constructive manner were observed less frequently. Both of these findings are consistent with Benner’s novice to expert framework that argues that simulation and debrief facilitation abilities require practice and that competency is achieved after 2 to 3 years of practice and feedback on their facilitation skills from more experienced simulation educators.14 Notably, despite the common infrastructure challenges in Bihar’s health facilities, all the primary health clinics under study used an appropriate area to conduct simulations. Nurse mentors tended to conduct the majority of the simulations in classrooms settings as opposed to labor rooms, which would be considered the gold standard for in-situ obstetric and newborn emergency simulation training. Most likely, the labor and delivery rooms were occupied with patients when the training took place.
The video analysis showed mixed results in key aspects of the simulation setup and fidelity for the postpartum hemorrhage scenario. For example, 28% of the simulations did not use any fake blood during the scenario as instructed in the simulation guide. The reasons for this could include: lack of knowledge on how to make simulated blood, lack of supplies, or lack of understanding about the importance of fake blood for adding to the realism of the scenario. A positive finding was that there were no scenarios in which the patient actress laughed during the scenario. The patient actress role is typically performed by an actual nurse at the facility as opposed to a hired actor, this suggests the educators were able to communicate the importance of role play to recreate the emergency and to control the seriousness of the scenario.
The close educator to participant speaking ratio was a surprising finding, as novice debriefers tend to exhibit more didactic characterists and spend more time speaking than participants.15 This result contrasts with a previous study that argued that in countries such as India with a high power distance index (PDI) defined as “acceptance of inequality in distribution of power in a certain society” and a measure of hierchical structures, educators tend to speak for longer periods of time than in countries with a low PDI. 16 This study however did not account for debriefer experience. We hypothesize that novice debriefers in high PDI countries like India are less confident and therefore may tend to speak less than more seasoned debriefers.
We have yet to assess the impact of third generation of training on maternal and neonatal outcomes. However, PRONTO simulation and teamwork trainings in India and elsewhere have been shown to increase the use of evidence-based practices and to increase the identification and management of maternal and newborn complications.17,5,18