Abstract
Background
Debriefing is the core educational component of obstetric crisis simulation training. High-quality structured debriefing improves trainees’ clinical judgment, technical performance and non-technical team skills. However, few specialty-specific debriefing checklists are tailored for obstetric-gynaecology emergency scenarios. General simulation debriefing tools often omit obstetric-specific safety concerns, maternal-focused communication and obstetric team-human-factor challenges.
Aims
This study aimed to develop an Obstetrics and Gynaecology (OBGYN)-specialized simulation debriefing checklist for obstetric crisis team-training, through three steps: (1) generation of an initial item pool; (2) expert panel evaluation of item relevance; and (3) revision and finalization based on expert ratings and comments.
Methods
The checklist was developed following Kern’s six-step curriculum-development framework, guided by the International Nursing Association for Clinical Simulation and Learning (INACSL) simulation standards and the Promoting Excellence and Reflective Learning in Simulation (PEARLS) debriefing model. An item pool was generated from obstetric simulation literature, national obstetric competency frameworks and existing debriefing instruments. Eight obstetric clinicians with at least 3 years of simulation-facilitation or medical-education experience rated item relevance on a 5-point scale; items with an Item-level Content Validity Index (I–CVI) below 0.78 were removed or revised, and the Scale-level Content Validity Index-average (S-CVI/Ave) was computed. Qualitative expert suggestions were collected for item revision.
Results
The initial item pool contained 32 items. After expert evaluation and revision, the final checklist retained 24 items across four domains: technical clinical performance, obstetric-specific communication, team-based human factors, and simulation-facilitation reflection, with an S-CVI/Ave of 0.91. Experts confirmed good specialty relevance and practical feasibility, including use in low-cost table-top drills.
Conclusions
This newly developed OBGYN crisis-simulation debriefing checklist provides evidence of satisfactory content validity based on expert judgement, offering a standardized specialty-specific instrument for structuring and evaluating post-simulation debriefing. Further psychometric testing, including inter-rater reliability and usability research among front-line simulation facilitators, is recommended.
Keywords: Obstetrics and gynaecology, simulation-based education, debriefing, checklist, content validity, obstetric crisis training
Introduction
Simulation-based team training is widely adopted to improve management of life-threatening obstetric crises.1,2 The educational benefit of simulation does not derive purely from scenario drills; structured debriefing is regarded as the most critical learning phase after simulation exercises.3 Well-conducted debriefing facilitates reflective practice, corrects clinical misconceptions, reinforces technical skills and highlights human-factor and teamwork pitfalls that contribute to maternal adverse events.4,5
Many simulation educators conduct debriefing without standardized guiding instruments. Generic debriefing checklists are available, yet most are designed for emergency medicine or general resuscitation scenarios.6,7 They frequently lack obstetric-specific elements: maternal safety prioritization, obstetric consent and counselling, multidisciplinary obstetric team coordination, recognition of simulator artefacts and limitations. Without specialty-tailored guidance, debriefing may overemphasize technical manoeuvres while ignoring obstetric-relevant communication and decision-making gaps.
There remains a shortage of open-access, ready-to-use debriefing instruments specially adapted for obstetric-gynaecology crisis simulation. To fill this gap, the present study reports the development and expert-based content validation of an Obstetrics and Gynaecology (OBGYN) simulation debriefing checklist for obstetric-crisis team training. This project involved expert instrument appraisal only; no trainee or patient data were involved.
Methods
Theoretical Framework and Item Generation
Checklist development strictly followed Kern’s six-step curriculum-development framework.8 Item construction drew upon the International Nursing Association for Clinical Simulation and Learning (INACSL) Healthcare Simulation Standards,9 the Promoting Excellence and Reflective Learning in Simulation (PEARLS) debriefing framework,10,11 published obstetric-simulation literature1,2,5 and national obstetric Entrustable Professional Activities (EPAs).12,13
Item generation was informed by published debriefing assessment instruments and obstetric simulation studies,1,2,5–7 together with core learning objectives for major obstetric emergencies and known human-factor vulnerabilities within obstetric multiprofessional teams.2,5 A structured scoping search was conducted in PubMed and Embase (2000–2025) using combinations of the terms “obstetric simulation”, “maternity crisis simulation”, “debriefing”, “team training”, “human factors”, and “debriefing assessment”. Records were eligible if they described obstetric-crisis simulation training, debriefing frameworks, or debriefing assessment instruments; articles in languages other than English and non-relevant clinical trials were excluded. The reference lists of these key sources were screened to identify additional relevant publications; sources were eligible if they described obstetric-crisis simulation training, debriefing frameworks or debriefing assessment instruments, while general-simulation debriefing tools were also reviewed for transferable elements. An initial item pool of 32 items was generated and grouped preliminarily into four conceptual domains: technical clinical performance, obstetric-specific communication, team-based human factors, and simulation-facilitation reflection. Each item was phrased as an observable evaluation statement for facilitators to use during or immediately after debriefing.
Expert Panel and Content-Validation Procedure
Eight independent experts were invited to participate in content validation. Inclusion criteria were: obstetric-gynaecology clinicians with at least 3 years of experience in simulation facilitation or medical-education curriculum development; this threshold was chosen to ensure sufficient hands-on simulation and curriculum experience to judge item relevance and wording. The panel size of eight is consistent with published recommendations of a minimum of six to ten experts for content validation.14,15 Experts were purposefully sampled through the authors’ professional networks in obstetrics and gynaecology simulation and medical education. The eight experts were recruited from eight hospitals across three provincial-level regions in Eastern China: six hospitals in Jiangsu Province (four in Suzhou and two in Nanjing), one in Shanghai, and one in Hangzhou, Zhejiang. The panel comprised four Chief Physicians and four Associate Chief Physicians, with 15–20 years of obstetric-gynaecology clinical practice and 10–15 years of simulation-facilitation experience. Their educational roles spanned curriculum development, simulation course direction, debriefing training, Objective Structured Clinical Examination (OSCE) examining, simulation facilitation and medical-education research; individual characteristics are summarised in Table 1. Experts worked independently without group discussion, and a single round of expert evaluation was conducted. After receiving the quantitative ratings and written qualitative comments, the research team revised the instrument; no second Delphi-style round was performed. The study was deemed exempt from formal ethics review by the Ethics Committee of Suzhou Ninth People’s Hospital, as it involved only expert evaluation of an educational instrument and no patient or trainee data. Experts participated voluntarily after being informed of the study purpose; written informed consent was obtained, and their ratings and written comments were anonymised and handled confidentially.
Table 1.
Characteristics of the Expert Panel (n = 8)
| Expert ID | Professional title | Clinical experience (years) | Simulation-facilitation experience (years) | Educational role | Institution/Region |
|---|---|---|---|---|---|
| 1 | Associate Chief Physician | 15 | 10 | Curriculum developer | Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China |
| 2 | Chief Physician | 19 | 14 | Simulation course director | Suzhou Ninth People’s Hospital, Suzhou, Jiangsu, China |
| 3 | Associate Chief Physician | 15 | 10 | Medical education researcher | The Fifth People’s Hospital of Wujiang District, Suzhou, Jiangsu, China |
| 4 | Associate Chief Physician | 16 | 11 | Debriefing trainer | Zhongda Hospital, Southeast University, Nanjing, Jiangsu, China |
| 5 | Associate Chief Physician | 16 | 11 | OSCE examiner | Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China |
| 6 | Chief Physician | 20 | 15 | Medical education researcher | Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China |
| 7 | Chief Physician | 18 | 13 | Simulation facilitator | The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China |
| 8 | Chief Physician | 17 | 13 | Simulation course director | Jiangsu Shengze Hospital, Suzhou, Jiangsu, China |
Each expert rated every checklist item using a 5-point Likert-type relevance scale: 1 = not relevant; 2 = somewhat relevant; 3 = moderately relevant; 4 = quite relevant; 5 = highly relevant. Experts also provided open-text qualitative comments for item deletion, merging or re-wording. After ratings were returned, two authors independently reviewed the qualitative comments for each item, grouped recurring suggestions thematically, and reached consensus on revisions; items with I–CVI below 0.78 or judged non-essential were removed, and items with overlapping content were merged.
Item-level Content Validity Index (I–CVI) was calculated for each item (proportion of experts assigning score 4 or 5). Items with I–CVI < 0.78 were excluded.14–16 To account for the possibility of chance agreement, modified kappa statistics (κ*) were calculated for each item following the method of Polit, Beck and Owen.17 The Scale-level Content Validity Index-average (S-CVI/Ave) was computed for the overall instrument according to standard methodology.14,15 Revisions were implemented according to quantitative results and written expert feedback.
Final Instrument and Supplementary Material
After revision, the final 24-item OBGYN simulation debriefing checklist was produced. The instrument can be applied both for high-fidelity maternal-manikin simulation and low-resource table-top obstetric crisis drills. The full editable checklist file is supplied as supplementary appendix for open reuse by international obstetric educators.
Results
Item Screening and Revision
From the initial pool of 32 items, 8 items were removed or merged following expert quantitative ratings and qualitative feedback. Items were removed when I–CVI was below 0.78 or when experts judged them as not essential to the target construct; items with overlapping content were merged on expert recommendation. After revision, 24 items remained in the final checklist, distributed across four domains (Figure 1):
Domain 1: Technical clinical performance (8 items): covers recognition of obstetric deterioration, appropriate emergency intervention, adherence to obstetric clinical guidelines.
Domain 2: Obstetric-specific communication (6 items): maternal-centred counselling, risk disclosure, consent-related discussion, inter-professional hand-off within obstetric teams.
Domain 3: Team-based human factors (6 items): team resource management, role allocation, closed-loop communication, situational awareness in obstetric crisis.
Domain 4: Simulation-facilitation reflection (4 items): reflection on simulator limitations, recognition of scenario-embedded pitfalls, alignment of debriefing discussion against predefined learning objectives.
Figure 1.
Flow diagram of checklist development from the initial 32-item pool to the final 24-item instrument (single-round expert review with an I–CVI threshold of 0.78; items below threshold or with overlapping content were removed or merged).
Content-Validity Indices
For the final 24-item checklist, all individual items achieved I–CVI ≥ 0.80, and the S-CVI/Ave was 0.91, indicating strong expert-judged content validity.14,15 Domain-level mean I–CVI values were: technical clinical performance 0.91; obstetric-specific communication 0.92; team-based human factors 0.92; and simulation-facilitation reflection 0.91.Item-level I–CVI values and retain/remove/merge/revise decisions for all 32 initial items are presented in Table 2; modified kappa (κ*) for each item is reported in Table 2. The structure of the final 24-item checklist by domain is presented in Table 3.
Table 2.
Item-Level Content Validity Results for the 32 Initial Items (Eight Experts; 5-Point Relevance Scale; I–CVI = Proportion Rating 4–5; Threshold ≥ 0.78). The S-CVI/Ave of the 24 Retained Items was 0.91
| Item no. | Initial item (abbreviated) | Domain | I-CVI | κ* | Decision (retain/remove/merge/revise) |
Reason for decision |
|---|---|---|---|---|---|---|
| 1 | Recognise obstetric deterioration markers | Clinical performance | 1.000 | 1.000 | Retain | I–CVI ≥ 0.78; retained |
| 2 | Review performed emergency interventions | Clinical performance | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 3 | Identify deviations from evidence-based guidelines | Clinical performance | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 4 | Reinforce correct crisis decision-making | Clinical performance | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 5 | Explore missed clinical cues | Clinical performance | 1.000 | 1.000 | Retain | I–CVI ≥ 0.78; retained |
| 6 | Address technical-procedural gaps constructively | Clinical performance | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 7 | Reflect on prioritisation of emergency clinical goals | Clinical performance | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 8 | Discuss simulated patient safety outcomes | Clinical performance | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 9 | Review maternal-centred counselling | Communication | 1.000 | 1.000 | Retain | I–CVI ≥ 0.78; retained |
| 10 | Explore risk-disclosure communication | Communication | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 11 | Reflect on consent-related discussion points | Communication | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 12 | Evaluate inter-professional hand-off communication | Communication | 1.000 | 1.000 | Retain | I–CVI ≥ 0.78; retained |
| 13 | Address communication with patient/next-of-kin | Communication | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 14 | Discuss obstetric-specific language/barriers | Communication | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 15 | Review team-resource-management behaviours | Human factors | 1.000 | 1.000 | Retain | I–CVI ≥ 0.78; retained |
| 16 | Explore role allocation and clarity | Human factors | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 17 | Analyse closed-loop communication | Human factors | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 18 | Discuss situational awareness | Human factors | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 19 | Consider hierarchy-related team dynamics | Human factors | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 20 | Highlight team coordination success/failure | Human factors | 1.000 | 1.000 | Retain | I–CVI ≥ 0.78; retained |
| 21 | Reflect on simulator hardware limitations | Facilitation reflection | 1.000 | 1.000 | Retain | I–CVI ≥ 0.78; retained |
| 22 | Discuss simulator-generated artefacts | Facilitation reflection | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 23 | Review scenario-embedded pitfalls | Facilitation reflection | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 24 | Align debriefing with predefined learning objectives | Facilitation reflection | 0.875 | 0.816 | Retain | I–CVI ≥ 0.78; retained after minor wording revision per panel comments |
| 25 | Interpretation of maternal vital-sign abnormalities | Clinical performance | 0.625 | 0.553 | Merged | Merged into Item 1 (content overlapped recognition of deterioration markers) |
| 26 | Review of uterotonic drug administration technique | Clinical performance | 0.625 | 0.553 | Removed | Too clinical-content-specific; checklist should assess debriefing quality rather than drug knowledge |
| 27 | Debriefing on fetal heart-rate tracing interpretation | Clinical performance | 0.500 | 0.472 | Merged | Merged into Item 1 (fetal-tracing discussion covered under missed clinical cues) |
| 28 | Family presence during operative delivery | Communication | 0.500 | 0.472 | Merged | Merged into Item 13 (family presence overlapped with next-of-kin communication) |
| 29 | Informed consent for emergency caesarean section | Communication | 0.375 | 0.368 | Merged | Merged into Item 11 (consent discussion content duplicated) |
| 30 | Use of interpreters and language barriers | Communication | 0.375 | 0.368 | Merged | Merged into Item 14 (interpreter/language content duplicated) |
| 31 | Review of team leadership behaviours | Human factors | 0.250 | 0.249 | Merged | Merged into Item 16 (leadership behaviours covered under role allocation/clarity) |
| 32 | Facilitator self-review of own debriefing performance | Facilitation reflection | 0.125 | 0.125 | Removed | Duplicated Item 24; insufficiently actionable for peer assessment |
Table 3.
Structure of the Final 24-Item OBGYN Simulation Debriefing Checklist by Domain
| Domain | Number of items | Items (from Supplementary Appendix 1) |
|---|---|---|
| 1. Technical clinical performance | 8 | 1. Recognise obstetric deterioration markers 2. Review performed emergency interventions 3. Identify deviations from evidence-based guidelines 4. Reinforce correct crisis decision-making 5. Explore missed clinical cues 6. Address technical-procedural gaps constructively 7. Reflect on prioritisation of emergency clinical goals 8. Discuss simulated patient safety outcomes |
| 2. Obstetric-specific communication | 6 | 9. Review maternal-centred counselling 10. Explore risk-disclosure communication 11. Reflect on consent-related discussion points 12. Evaluate inter-professional hand-off communication 13. Address communication with patient/next-of-kin 14. Discuss obstetric-specific language/barriers |
| 3. Team-based human factors | 6 | 15. Review team-resource-management behaviours 16. Explore role allocation and clarity 17. Analyse closed-loop communication 18. Discuss situational awareness 19. Consider hierarchy-related team dynamics 20. Highlight team coordination success/failure |
| 4. Simulation-facilitation reflection | 4 | 21. Reflect on simulator hardware limitations 22. Discuss simulator-generated artefacts 23. Review scenario-embedded pitfalls 24. Align debriefing with predefined learning objectives |
| Total | 24 | Full checklist in Supplementary Appendix 1 |
Qualitative expert feedback highlighted key strengths: the checklist adds obstetric-specialty components absent in generic debriefing tools;6,7 items are observable and practically usable for busy clinical educators; adaptable across high- and low-resource teaching environments. Suggested revisions included simplifying several complex-worded items and adding one statement prompting facilitators to discuss simulator artefacts during reflection. All major suggestions were incorporated.
The complete OBGYN simulation debriefing checklist is available as Supplementary Appendix 1; the anonymised expert rating matrix (8 experts × 32 items) is available as Supplementary Appendix 2; the final items are also summarized by domain in Table 3.
Discussion
Principal Findings
This study developed an open-access, obstetric-specialized debriefing checklist for obstetric-crisis team simulation and obtained content validity evidence for the instrument based on expert judgement. Several debriefing-related assessment instruments have been published for general simulation contexts.6,7 However, most existing checklists focus on emergency medicine or resuscitation training and lack obstetric-specific items, and many obstetric simulation-related tools are designed to measure trainee performance rather than to evaluate the quality of facilitator-led debriefing sessions. Although PEARLS and other debriefing frameworks are widely cited in simulation education,10,11 few studies have transformed these general frameworks into a complete, expert-content-validated checklist tailored for obstetric crisis scenarios.6,7,10,11 Our instrument integrates obstetric-unique clinical, communication and human-factor considerations within a single unified tool, which differentiates it from previously published instruments. The content validity evidence obtained here supports the relevance of the 24 retained items to obstetric crisis debriefing; whether the checklist improves facilitator debriefing quality or trainee learning outcomes was not assessed in this study and remains to be tested.
The instrument was designed for real-world obstetric-teaching contexts. Potential applications include guiding debriefing for high-fidelity maternal-manikin simulation and for table-top obstetric crisis drills in resource-limited teaching institutions; providing the full checklist as open supplementary material allows obstetric educators to adopt, adapt and modify it according to local clinical guidelines and training requirements. Actual implementation of the checklist is expected to vary across institutions, countries and educational systems, and such variation should be examined in future studies.
Limitations
This study has several limitations. First, the validity evidence obtained is limited to content validity based on expert judgement; reliability (eg, inter-rater reliability), construct validity, criterion validity and real-world effectiveness were not assessed. Second, the expert panel comprised eight obstetric clinicians, which is adequate for content validation but limits the generalizability of the results across institutions, countries and educational systems. Third, a single round of expert evaluation was performed, and additional rounds (eg, a Delphi process) might have yielded further refinement. Fourth, the checklist was developed for obstetric emergency-focused simulation, and additional adaptation would be required before use in elective gynaecology simulation scenarios. Finally, we have not yet collected feedback from trainees receiving debriefing guided by this checklist,18,19 consistent with instrument-development best-practice principles and established translational frameworks for simulation-based education.
Implications for Medical-Education Practice
Obstetric simulation facilitators may use this checklist for two main purposes: first, as a pre-session preparation guide to structure debriefing plans before simulation drills; second, as a post-session self-assessment instrument for facilitators to reflect on the completeness and specialty appropriateness of their own debriefing performance. Educators should note that this checklist serves as a guiding framework rather than a rigid scoring scale; facilitator clinical-educator judgement remains indispensable.20 These suggested uses are potential applications of the instrument; their effectiveness in improving debriefing quality or learning outcomes has not been evaluated and should be examined in future implementation studies. When conducting debriefing, instructors are reminded to explicitly address simulator hardware artefacts which may distort clinical presentations.
Conclusions
The 24-item OBGYN simulation debriefing checklist provides evidence of satisfactory content validity based on expert judgement. It offers a specialty-specific, open-access guiding instrument to standardize post-simulation debriefing for obstetric-crisis team training, usable for both high-fidelity manikin simulation and low-cost table-top team exercises. Further psychometric testing—including inter-rater reliability, construct validity and usability—and implementation studies are required before broader claims regarding the checklist’s validity or effectiveness can be made.
Acknowledgments
The authors sincerely thank all eight obstetric medical-education experts who participated in the content-validation evaluation of this checklist.
Funding Statement
No funding was obtained for this study.
Ethical Approval
The study was deemed exempt from formal ethics review by the Ethics Committee of Suzhou Ninth People’s Hospital (Suzhou, China), as it involved only expert evaluation of an educational instrument and no patient or trainee data. All experts provided informed consent, and their responses were anonymised and handled confidentially.
Disclosure
The authors report no conflicts of interest in this work.
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