A quasi-experimental design was performed in this study, in which self-reported of pediatric knowledge score of participants were calculated to analyse the effectiveness of this simulation training program.
Hunan Children’s Hospital was a tertiary hospital located in south central China with a total of 1200 beds and more than 2000 medical staffs only doctors and nurses. It is also the national pediatric foreign aid training base of Chinese Ministry of Commerce, has trained more than 1200 international trainees from more than 25 countries mainly from low-resource countries.
The study was approved by Hunan Children’s Hospital ethics commission board, (approving number: HCHLL-208-03) and all written consent were signed by participants.
Pediatric medical staff who volunteered to attend this foreign aid training in two islands of Zanzibar in Apr, 2018 and Oct, 2018 were included in this study. Inclusion criteria were: a) Medical staff of pediatric departments, wards and hospitals in Zanzibar Island, with a total hospital beds over than 50; b) With an English medical education background; c) Obtaining a medical practice certificate; d) Volunteer to participate in this training course and sign the written informed consent; Exclusion criteria were: a)Temporary or un-formal employed staff; b) Residents or nurses who did not finish basic medical training; c) maternal or sick leave more than 1 month during this training year or attending other training program over than 1 months; d) failed to complete all training program; e) the completion rate of the knowledge questionnaire is less than 80% or there is a clear bias on the choices of all answers;
Pre-investigation in Zanzibar: 5 pediatric specialists were sent to Zanzibar to conduct a pre-investigation by focus group interviewing with administration leaders of Zanzibar hospital in order to evaluate the current status of pediatric epidemiology in Zanzibar, and to know the main cause of death under 5 years old, common admitted disease and training requirements, then to determine the training methods based on local phenomenon. Results showing that the common diseases admitted in pediatric wards were pre-term, malnutrition, pneumonia and diarrhea in Zanzibar.
Training team set up: The training team consists of 10 medical doctors and nursing specialists with a title of deputy or above in one tertiary children's hospital, including 5 doctors and 5 nurses, with an English level of IELTS over than 6.5. 5 Medical doctors are responsible for preparation of courseware presentation according to pre-survey result, major in neonatal resuscitation, pediatric basic life support, pneumonia management, nutrition assessment and support, diarrhea and fluid therapy and prevention and control of hospital infection; 5 nurses are responsible for the preparation of training facilities and equipment and other translation task. 3 officers of the International Cooperation Department of children’s Hospital is also equipped to assist and help in recruiting trainees, training venue layout, training implementation and other logistics support.
Appropriate technical curriculum design: The training course is based on the reference of 2017 Neonatal Resuscitation Program (NRP) case training program released by the Canadian Academy of Pediatrics, Pediatric Basic Life Support(PBLS) and Pediatric Advanced Life Support(PALS) of 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendation and "Integrated management of childhood illness (IMCI) strategy for children under five reviewed by the Cochrane database 2016 [26-29]. 6 topics/domains were included in the end, as Neonatal Resuscitation Programm (NRP), Pediatric Basic Life Support (PBLS), Pneumonia management, Fluid therapy, Nutrition assessment and support, and Prevention and control of hospital infection in pediatric wards. The training sites was set in the conference rooms of the central hospitals on the two islands of Zanzibar. Each training program lasts for five days, with 2 days of theory lectures and 3 days of simulation practice.
At the beginning of the training, the teacher will explain the theoretical course in presentation with all trainees in the conference room. A unified explanation of the six domains designed in advance are given, aiming to build a general theoretical framework for the students. Key contents including: I, How to determine and calculate children's fluid requirements, basic principles of diarrhea treatment in children; II, The importance of nutritional assessment for children and how to provide total parenteral nutrition support; III, how to diagnose pneumonia in children, standard treatment process and the main selection criteria of antibiotics; IV, prevention and control of hospital infection in pediatric wards and hand hygiene; V, Steps and implementation process of NRP; VI, PBLS flow-gram processes and key points.
At scenario simulation practice, whole conference room were divided into 5 arears, 5-6 Students and 2 teachers (1 doctor, 1 nurse) were distributed into isolated areas, with a teaching ratio of 2: 5-6, a set of operating tools (including: 1 table, 1 set of neonatal asphyxia resuscitation simulation model,1 set of pediatric basic life support simulation model, 1 set of pediatric venous indwelling model, related medical equipment and appliances). The training process is shown in Figure 1.
Scenario simulation practice
Scenario simulation practice includes four steps: Case selection- Instructor-led technic teaching- Case analysis- Scenario procedure simulation.
Firstly, Case selection and design. Before the training, the experts of the training team would select some typical cases according to the training content, transcript cases, and compile the case information into a reminder case-card. Case selection criteria were children younger than 16 years old, length of hospitalization <2 weeks, without congenital disease or any other surgical requirements etc. Cases including changes in the illness condition who require basic life support, new admitted patients required neonatal pulmonary resuscitation, different types of children with pneumonia, diagnosed hospital infection, diarrhea and malnutrition. For each topic at least 4 cases were selected with a total of 30 case card were made. In the process of case selection, patient privacy should be taken into consideration, without true personal information appearing on the case card such as name, hospital number and family address. The case card would be distributed to the trainees before simulation practice, encourage them to analyze and make consideration about the cases in advance.
Then case information of case-card was interpreted by the teachers, and students were invited to try to propose specific clinical treatment plans and related clinical technical skills. Then teachers would summarize and analyze the case details, give and introduction and diagnosis of all involved diseases, offer standardized treatment plans and related skill procedures. The aim of this process was to help students focus on each individual characteristic, build one comprehensive diagnosis and treatment plan, Strengthen their sense of cooperation, critical thinking ability and comprehensive ability on disease diagnosis and treatment.
Secondly，Instructor-led procedure teaching. The teachers will select cases that includes all procedures required for systematic teaching, emphasis on standard skill procedures and assessment indicators in the form of one-to-one procedure demonstration. The procedures including: Apgar scoring, newborn care, positive-pressure ventilation, endotracheal intubation and use of laryngeal mask, chest compression, administration of medications, placement of peripheral vein catheter and hand hygiene, and treatment plan determine.
Thirdly, Case analysis. The case information of case card was asked, and students were invited to try to propose specific clinical treatment plans and related clinical technical skills designed for the case. Summarize and analyze case details, introduction and diagnose of involved diseases, standardized treatment plans and related skill procedures. Focusing on each changing individual, which requires comprehensive diagnosis and treatment. Strengthen the teamwork awareness, problem thinking ability and comprehensive diagnosis and treatment ability of medical staff.
In the end, Scenario simulation practice. Participants would simulate the clinical treatment process in pairs, make treatment plans and perform clinical procedures according to the instructor/teacher who acts as the debriefing facilitator, judge if the trainees making correct judgements. If the judgments were correct, procedures would be carried out smoothly. If not, simulation stopped and the teacher would revise it correctly then guide the students in right way. They are going to work together as a team to follow the NRP and PBLS flow diagram. During simulation not only the case study was assessing but also the procedure learning was taught by giving one-on-one teaching method and detailed instructions. Trainees alternate roles and perform procedures one-by-one. The simulation training ends until all trainees have completed all procedures. On-the-spot correction and Q & A for the specific problems of students were conducted during the practice.
Throughout the scenario simulation process, participants are taught to evaluate and analyze cases while emphasizing continuous correction and improvement of the students' correct procedure skills. All skill procedure items are first taught to the students in a demonstration form, and then the students are instructed to rotate through repeated exercises until they have mastered all the essentials of the procedures.
Self-designed questionnaire of pediatric knowledge was distributed to test the score of all trainees’ before and after training. Participants were asked to finish the questionnaire anonymously and independently. General characteristic of the trainees and pediatric knowledge were included in the questionnaire. The questionnaire was formulated by 10 pediatric specialists and was revised by three rounds of Delphi method.
Characteristics of trainees including gender, date of birth, occupation, education level, and working years; Pediatric knowledge questionnaire is a questionnaire that includes 50 multiple choice questions. Knowledges are about neonatal resuscitation; pediatric fluid therapy; nutrition support and evaluation; pneumonia management, pediatric basic life support and prevention and control of hospital infection in pediatric ward, contains a total of 50 questions, 2.0 points per each question, all questions are not weighted, with total score of 100. The higher score is, the better of pediatric knowledge is. A passing grade required answering 80% or more of items correctly .
SPSS 22.0 software was used for data analysis. Quantitative data satisfying the normal distribution and homogeneity of variance were expressed by mean (standard deviation). Comparison between the two groups was performed by independent sample t test. The training effect was defined as the difference in scores of the pediatric knowledge questionnaire before and after training, and the paired sample t test was used for analysis. Qualitative data are expressed as percentages (%), and comparisons between groups are made by chi-square test. P value less than 0.05 is considered as statistically significant.