Abstract
OBJECTIVES:
To examine the effect of simulation-based seizure management teaching on improving caregiver competence and reported confidence with managing seizures. The authors hypothesized that simulation-based education would lead to a higher level of demonstrated competence and reported confidence in family members and caregivers. Simulation has not been previously studied in this context.
METHODS:
A two-group pre- and post-test experimental research design involving a total of 61 caregivers was used. The intervention was a simulation-based seizure curriculum delivered as a supplement to traditional seizure discharge teaching. Caregiver performance was analyzed using a seizure management checklist. Caregivers’ perception of self-efficacy was captured using a self-efficacy questionnaire.
RESULTS:
Caregivers in the experimental group achieved significantly higher postintervention performance scores than caregivers in the control group in both premedication and postmedication seizure management (P<0.01). Additionally, they achieved significantly higher scores on the self-efficacy questionnaire including items reflecting confidence managing the seizure at home (P<0.05).
CONCLUSION:
Caregivers receiving the supplemental simulation-based curriculum achieved significantly higher levels of competence and reported confidence, supporting a positive relationship between simulation-based seizure discharge education, and caregiver competence and confidence in managing seizures. Simulation sessions provided insight into caregiver knowledge but, more importantly, insight into the caregiver’s ability to apply knowledge under stressful conditions, allowing tailoring of curriculum to meet individual needs. These findings may have applications and relevance for management of other acute or chronic medical conditions.
Keywords: Competence, Education, Family, Family-centred care, Mastery learning, Simulation
Abstract
OBJECTIFS :
Examiner l’effet de l’enseignement de la prise en charge des convulsions par simulation pour améliorer les compétences des soignants et leur confiance déclarée à traiter les convulsions. Les auteurs postulent que l’enseignement par simulation accroîtrait les compétences démontrées et la confiance déclarée des membres de la famille et des soignants. La simulation n’a jamais été étudiée dans ce contexte.
MÉTHODOLOGIE :
Une méthodologie de recherche expérimentale en deux groupes avant et après le test a été privilégiée auprès de 61 soignants. L’intervention consistait en un cours par simulation sur les convulsions donné en plus de l’enseignement habituel sur les convulsions présenté au congé. Le rendement des soignants a été analysé au moyen d’une liste de vérification de la prise en charge des convulsions. La perception d’auto-efficacité du soignant a été saisie au moyen d’un questionnaire d’auto-efficacité.
RÉSULTATS :
Les soignants du groupe expérimental ont obtenu des indices de rendement considérablement plus élevés après l’intervention que ceux du groupe témoin, tant avant qu’après la prise en charge des convulsions par médication (P<0,01). De plus, ils ont obtenu des indices considérablement plus élevés au questionnaire d’auto-efficacité, y compris les questions reflétant la confiance à soigner les convulsions à domicile (P<0,05).
CONCLUSION :
Les soignants qui avaient eu un cours par simulation ont obtenu des taux de compétence et de confiance déclarée beaucoup plus élevés. Ces résultats corroborent la relation positive entre l’enseignement sur les convulsions par simulation au congé et la compétence et la confiance des soignants envers la prise en charge des convulsions. Les séances de simulation donnaient un aperçu des compétences des soignants, mais, surtout, de leur capacité à appliquer leurs connaissances dans des conditions stressantes, ce qui permet d’adapter le cours à leurs besoins. Ces observations peuvent être utiles et pertinentes pour la prise en charge d’autres maladies aiguës ou chroniques.
The use of simulation as a learning modality for supporting family-centred seizure discharge teaching has the potential to positively impact family functioning and well-being (1). Simulation gives caregivers an opportunity to practice managing stressful medical events in a risk-free environment which, in turn, provides health care providers (HCPs) with a window into the family’s ability to engage in traditional seizure discharge teaching. Family-centred care (FCC), acknowledged as the cornerstone of paediatric hospitals around the world, was developed to guide HCPs in the provision of care and teaching to families, acknowledging the family as the unit of care (1,2). Studies suggest a relationship between family-centred care and caregiver satisfaction, more efficient use of health services and improved family functioning in families caring for children with special needs (1–6). As such, there is an expectation that HCPs use a family-centred approach in provision of all health service delivery, inclusive of discharge teaching.
The philosophical underpinnings of FCC are built on the premise that caregivers have the abilities and strengths, as well as the capacity, to improve their competence and should, therefore, be afforded opportunities to acquire and/or display competencies (6). This is further supported by the concept of mastery learning (7), in which learners need opportunities to practice the behaviour with supported feedback in real time to achieve competence. Mastery learning refers to the achievement of the required or expected level of knowledge, skill or attitude (7), which is often articulated as competence in medical education (8). From this perspective, HCPs need to adopt a needs-based approach to ensure tailoring of the discharge education to meet individual needs (9). This becomes a useful framework for examining how to optimize seizure discharge teaching to improve caregiver skills and confidence for seizure management at home.
A recent review of randomized controlled trials emphasizes the need for more rigorous research into systematic family-centred teaching initiatives (10). The purpose of the present randomized controlled study was to examine the benefit of using simulation for improving caregiver competence and reported confidence with seizure management. We hypothesized that the use of simulation to supplement traditional seizure teaching administered after the child was hospitalized from an emergency or outpatient clinic visit would lead to a higher level of demonstrated competence and reported confidence in families managing seizures in their children.
METHODS
A two-group pre- and post-test randomized controlled study design was used (Figure 1) (11). Participants were randomly assigned, according to family unit, to one of two arms: a control arm receiving traditional seizure discharge teaching alone; and an experimental arm receiving the traditional seizure teaching and additional simulation-based seizure teaching. Participants in both arms were required to complete an assessment simulation (with performance rated using a seizure management checklist) and a self-efficacy questionnaire pre- and postintervention.
Figure 1).
Study flow diagram
Participants
Participants were recruited between October 2011 and December 2012. Participants were caregivers of a child <18 years of age recently diagnosed and admitted with an “acute seizure disorder” from the emergency department or the outpatient clinic setting. Participants had to be ≥18 years of age, fluent in English and the child had to have been prescribed a rescue medication to stop seizures. Participant consent was obtained before recruitment into the study. Participants were block-randomized according to family unit to one of the two study arms. Simulation training occurred one on one, with additional family members scheduled for discharge teaching with the study coordinator on an ad hoc basis. The study was funded by a grant from the Alberta Children’s Hospital Foundation and approved by the Alberta Children’s Hospital Research Institute for Child and Maternal Health and the Conjoint Health Research Ethics Board in Calgary (Ethics ID: 23930).
Curriculum
Traditional seizure discharge teaching, delivered to participants in both the control and experimental groups, consisted of: pharmacy teaching regarding the administration of the rescue medication; and nurse- and physician-delivered teaching on the recognition of seizures, medication administration and care of a patient during a seizure. The total duration of traditional seizure discharge teaching was variable and dependent on perceived educational needs of each patient. Subjects in the experimental group also received simulation-based discharge teaching focused on assessment and support of the child’s breathing through three phases of seizure management: initial seizure recognition and care; medication administration; and postmedication seizure management, in a mastery learning ‘practice-until-ready’ framework. These sessions lasted between 30 min and 45 min, depending on when the caregiver verbalized confidence. Postsimulation feedback was performed using the advocacy and inquiry debriefing framework developed by the Center for Medical Simulation (12) and directive feedback. In this approach, the facilitator shares their observations and associated point of view, and then probes for the learners to reflect in hopes of uncovering the reasoning for the observed behaviour.
Simulator and setting
For the present study, the Pediatric HAL (Child)® S3005 and (Infant) S3004 manikins (Gaumard®, USA) were used to deliver the simulation-based seizure teaching. The choice of manikin was based on the age of the child. Facilitators verbally expressed clinical findings when manikin limitations impeded seizure realism (eg, colour, movement). The curriculum was delivered in the playrooms at the respective in-patient units at the Alberta Children’s Hospital in Calgary, Alberta.
Instrument development
The new KidSIM-ASPIRE Emergent Seizure Management Checklist (not previously validated) (Appendix 1) was developed by a group of paediatric emergency and neurology nurses, and physicians experienced in emergent seizure teaching and curriculum design. Nineteen items were developed to evaluate caregiver competence through three phases of seizure management: premedication (n=7 items); medication administration (buccal: n=5 items; intranasal: n=6); and postmedication (n=3 items). Each item was scored using a three-point scale with 0 referring to not completed, 1 referring to partially completed and 2 allocated for completed tasks. Further differentiation of each item occurred through the use of a behavioural descriptor. This was performed to minimize subjective interpretation of caregiver behaviours in scoring. The maximum attainable scores were 32 for participants instructed to administer intranasal medication and 30 for participants instructed to use buccal medication. Raters were five emergency educators trained to use the seizure checklist through discussion of items and examples of behaviour with the senior study coordinator. All raters worked with the study coordinator to independently score two participant assessments to ensure all raters were calibrated for the study. After the first assessment, each rater discussed his/her scores with the study coordinator to reach consensus. After the second assessment, scoring was reviewed to ensure adequate calibration of each rater. After raters were calibrated, all remaining performance assessments were scored independently by one rater.
The KidSIM-ASPIRE Parent Seizure Self-efficacy Questionnaire was adapted from the previously validated Parent Asthma Self-Efficacy Questionnaire (13) and consists of 12 items. Each item was developed to examine caregiver confidence in their ability to recognize and provide seizure management. A five-point Likert scale, ranging from 1 (‘not sure at all’) to 5 (‘completely sure’), with an option to check off ‘not applicable’, was used to differentiate between levels of reported caregiver confidence.
Statistical analysis
An analysis of the internal reliability (Cronbach’s alpha) was completed for each evaluation tool. Descriptive statistics were completed using SPSS version 21.0 (IBM Corporation, USA) to present means and SDs for checklist and questionnaire items, and overall aggregate scores for participants in the control and experimental group on both evaluation measures. A χ2 analysis was used to examine differences between characteristics of participants in the control and experimental groups. Paired-samples t tests were used to assess differences between the pre- and post-test participant scores in both groups for both the seizure checklist and the self-efficacy questionnaire. Independent-samples t tests were used to assess differences between the control and experimental group on both evaluation measures. Cohen’s d was used to calculate the effect size and mean differences between pre- and post-test scores.
RESULTS
A total of 61 caregivers were enrolled in the study. Fifteen family units were randomly assigned to each arm (control, n=37; experimental, n=24). There were incomplete data for three participants in the control group and two participants in the experimental group, resulting in the final use of data from 56 participants (control, n=34; experimental, n=22). A χ2 analysis showed no significant differences between the characteristics of the intervention and control groups. Nevertheless, there appeared to be a higher number of control group participants that had to travel distances >20 km from Calgary (χ2[3, 59]=6.95; P=0.073) and more were categorized as having zero to three visits to the emergency department (χ2[2, 59]=5.27; P=0.072]) (Table 1).
TABLE 1.
Characteristics of participants and children
| Characteristic | Intervention (n=24) | Control (n=37) | χ2 (df), P |
|---|---|---|---|
| Caregiver sex | |||
| Male | 12 | 23 | 0.88 (1), 0.348 |
| Female | 12 | 14 | |
| Relationship to child | |||
| Mother | 9 | 15 | 2.24 (3), 0.525 |
| Father | 9 | 9 | |
| Sibling | 0 | 1 | |
| Other | 6 | 12 | |
| Education | |||
| High school | 7 | 12 | 7.56 (4), 0.109 |
| Trades/certificate | 3 | 1 | |
| University/college | 9 | 12 | |
| Other | 2 | 12 | |
| Middle school | 1 | 0 | |
| Missing data | 2 | 0 | |
| Employment status | |||
| Employed | 12 | 18 | 2.48 (3), 0.480 |
| Unemployed | 1 | 7 | |
| Homemaker | 6 | 8 | |
| Other | 3 | 4 | |
| Missing data | 2 | 0 | |
| Geographical proximity to Calgary | |||
| <20 km to Calgary | 14 | 14 | 6.95 (3), 0.073 |
| >20 km to Calgary | 6 | 19 | |
| Out of province | 2 | 2 | |
| Other | 2 | 0 | |
| Missing data | 0 | 2 | |
| Age of child, years | |||
| <2 | 9 | 9 | 4.77 (3), 0.189 |
| ≥2±5 | 13 | 19 | |
| ≥6±10 | 2 | 3 | |
| ≥11±17 | 0 | 6 | |
| Number of medications the child is taking | |||
| 0–3 | 23 | 34 | 3.51 (2), 0.173 |
| 4–6 | 0 | 3 | |
| >6 | 1 | 0 | |
| Emergency department visits in the past year, n | |||
| 0–3 | 10 | 24 | 5.27 (2), 0.072 |
| 4–6 | 12 | 13 | |
| >6 | 2 | 0 | |
| Number of health care physicians | |||
| 1 | 19 | 26 | 1.38 (2), 0.501 |
| 2 | 3 | 9 | |
| 3 | 2 | 2 |
The overall reliability coefficient (Cronbach’s alpha) for the 10 items reflecting pre- and postmedication seizure management on the KidSIM-ASPIRE Emergent Seizure Management Checklist was α=0.87 for the pretest and α=0.88 for the post-test. Items reflecting medication administration were excluded from reliability analysis because of the lack of consistency between groups in terms of the type of medication used. Medication choice was intra-nasal midazolam or buccal lorazepam, with mode of administration being provider dependent. Independent-samples t tests of mean score differences between groups on the KidSIM-ASPIRE Emergent Seizure Management Checklist revealed no significant differences between groups on baseline performance pretest.
There were significant differences between the groups on the post-test on eight of the 10 seizure management items (Table 2). Paired-samples t tests of mean score differences for participants in the control group from pre- to post-test revealed significant differences for four of the 10 seizure management items, whereas in the experimental group significant differences occurred for eight of the 10 items. Independent-samples t tests of mean score differences between the control and experimental groups revealed significant differences favouring the experimental group for eight of the 10 items.
TABLE 2.
KidSIM-ASPIRE Emergent Seizure Management Checklist pre- and post-test analysis
| Task description | Control pretest | Control post-test | P | Experimental pretest | Experimental post-test | P |
|---|---|---|---|---|---|---|
| Recognizes seizure | 1.76±0.65 | 1.82±0.58 | 0.325 | 1.95±0.21 | 2.00±0.00 | 0.329 |
| Time seizure | 0.35±0.73 | 0.97±0.94 | 0.001 | 0.50±0.83 | 1.95±0.22** | <0.0001 |
| Remains with child | 1.94±0.34 | 1.89±0.47 | 0.571 | 2.00±0.00 | 2.00±0.00 | |
| Protects from injury | 1.29±0.87 | 1.44±0.89 | 0.231 | 1.33±0.86 | 1.86±0.36* | 0.008 |
| Places in recovery position | 0.88±0.98 | 1.15±0.99 | 0.059 | 0.71±0.96 | 2.00±0.00** | <0.0001 |
| Decision to draw-up medication | 0.06±0.35 | 1.55±0.75 | <0.0001 | 0.32±0.75 | 2.00±0.00* | <0.0001 |
| Assess breathing | 0.63±0.94 | 0.84±0.99 | 0.198 | 0.74±0.93 | 1.42±0.77* | 0.002 |
| Assess breathing | 0.13±0.50 | 0.84±0.97 | <0.0001 | 0.10±0.44 | 1.71±0.56** | <0.0001 |
| Observer checks colour | 0.07±0.37 | 0.21±0.62 | 0.161 | 0.10±0.44 | 1.62±0.81** | <0.0001 |
| Places in recovery position | 0.40±0.81 | 0.80±1.00 | 0.012 | 0.30±0.73 | 1.90±0.45** | <0.0001 |
Data presented as mean ± SD unless otherwise indicated. Differences between the control and experimental group:
P<0.05;
P<0.001
The reliability coefficient for the 12-item KidSIM-ASPIRE Parent Seizure Self-efficacy Questionnaire was α=0.92 (Table 3). In the control and experimental groups, pretest mean item scores on the self-efficacy questionnaire were lowest for knowledge of rescue medication side effects (item K) and highest for carrying rescue medications at all times (item F). On the post-test, self-efficacy questionnaire mean scores for participants in the control group were lowest for managing the seizure at home (item B) and highest for following directions for administration of rescue medications (item G). In the experimental group, mean item scores on the post-test self-efficacy were lowest for item B and highest for knowing when to telephone 911 or drive the child to the emergency department (item G). Paired-samples t tests supported significant differences in pre- to post-test mean scores in both groups (P<0.001; Cohen’s d=0.70 to 2.47). Independent-samples t tests revealed significant differences favouring the experimental group in five of the 12 items.
TABLE 3.
KidSIM-ASPIRE Parent Seizure Self-efficacy Questionnaire pre- and post-test analysis
| Item | Pretest | Post-test* | Effect size** Cohen’s d (95% CI) | Pretest | Post-test* | Effect size** Cohen’s d (95% CI) | |
|---|---|---|---|---|---|---|---|
| A. | How sure are you that you know when your child is having a seizure? | 2.91±1.38 | 4.27±0.99 | 1.01 (−0.47 to 2.47) | 3.06±1.61 | 3.94±1.25 | 0.61 (0.12 to 1.10) |
| B. | How sure are you that you can manage your child’s seizure at home rather than calling 911 or driving your child to the emergency department? | 1.95±1.09 | 4.36±0.85 | 2.47 (1.68 to 3.25) | 2.12±1.22 | 2.39±1.40** | 0.21 (−0.27 to 0.68) |
| C. | How sure are you that you know when to call 911 or drive your child to the emergency department when they are having a seizure? | 3.50±1.37 | 4.86±0.35 | 1.36 (0.70 to 2.02) | 2.85±1.56 | 4.12±1.25** | 0.90 (0.40 to 1.40) |
| D. | How sure are you that you can protect your child from harm when having a seizure? | 3.05±1.53 | 4.59±0.67 | 1.30 (0.65 to 1.95) | 2.76±1.48 | 4.06±1.32* | 0.93 (0.42 to 1.43) |
| E. | How sure are you that you can place your child in the recovery position during a seizure? | 2.20±1.61 | 4.85±0.37 | 2.27 (1.47 to 3.06) | 2.50±1.54 | 3.88±1.53** | 0.90 (0.40 to 1.40) |
| F. | How sure are you that you will carry the rescue medications on you at all times? | 3.85±1.35 | 4.60±0.68 | 0.70 (0.06 to 1.34) | 3.72±1.51 | 4.47±0.80 | 0.62 (0.12 to 1.12) |
| G. | How sure are you that you can follow the directions for administering the rescue medication correctly? | 3.65±1.32 | 4.76±0.44 | 1.13 (0.40 to 1.85) | 3.03±1.61 | 4.57±0.82 | 1.21 (0.66 to 1.59) |
| H. | How sure are you that you can draw up the correct dose of rescue medication when your child is having a seizure? | 3.44±1.46 | 4.69±0.60 | 1.12 (0.37 to 1.87) | 3.07±1.62 | 4.38±1.02 | 0.97 (0.42 to 1.51) |
| I. | How sure are you that you can administer your child’s rescue medications during a seizure? | 2.78±1.44 | 4.67±0.49 | 1.76 (0.99 to 2.53) | 2.66±1.40 | 4.38±0.90 | 1.46 (0.88 to 2.04) |
| J. | How sure are you that you can administer the rescue medication if your child has seized for longer than 5 min? | 2.65±1.54 | 4.71±0.59 | 1.77 (0.97 to 2.56) | 2.30±1.49 | 4.33±1.00 | 1.60 (1.02 to 2.18) |
| K. | How sure are you that you know the common/emergent side effects of your child’s rescue medications? | 1.94±1.44 | 4.35±0.93 | 1.99 (1.17 to 2.81) | 1.45±0.99 | 3.69±1.20 | 2.04 (1.40 to 2.67) |
| L. | How sure are you that you can assess your child’s breathing during a seizure? | 1.85±1.31 | 4.45±0.76 | 2.43 (1.61 to 3.24) | 1.88±1.17 | 4.48±1.42** | 2.00 (1.40 to 2.59) |
Data presented as mean ± SD unless otherwise indicated. P<0.001 from pre- to post-test for all items;
P<0.05;
P<0.01 between group post-test scores. Mean effect size difference calculated using Cohen’s d, in which 0.20 to 0.49 = ‘small’, 0.50 to 0.79 = ‘medium’ and >0.80 = ‘large’ effect size difference
DISCUSSION
The increased level of competence with regard to seizure management in the experimental group provides important information about the creation and dissemination of seizure teaching. Although there was potential for participants in both groups to have received some traditional seizure teaching before enrolling in the study, the lack of significance between the groups at baseline suggests randomization was effective for equalizing any differences. Furthermore, the low scores on most behavioural items on the KidSIM-ASPIRE Emergent Seizure Management Checklist suggests that either seizure-management behaviours were not addressed previously in traditional discharge teaching, or participants may not have heard and retained teaching, which is possible. Literature on learning theory highlights the challenge that occurs when information is both delivered and/or accessed in a stressful context; learners often feel unsuccessful because they cannot retrieve the information although sometimes there is memory of receiving it (14,15). For participants in the control group, the low mean scores for timing the seizure, placing the child in the recovery position and postmedication assessment suggests a gap in this type of education in our traditional seizure teaching. In contrast, the high scores attained by participants in the experimental group on the same items suggest that caregivers who receive a simulation-based seizure curriculum with feedback that provides opportunities practice and master these behaviours are more likely to retain and apply the skills in a realistic seizure scenario.
In medical education, there is evidence to support improved HCP skills with simulation-based curricula compared with traditional approaches (16–18); however, there are few available studies investigating discharge teaching for caregivers to make a comparison. Nonetheless, the higher performance scores by participants in the experimental group are supported by the theory of deliberate practice (19), as well as experiential (20) and mastery learning theories (21). In all of these theories, the acquisition of desirable characteristics are reliant on the provision of opportunities with focused learning objectives to experiment with knowledge and behaviours in realistic contexts inclusive of real time with feedback from educators. The baseline simulated seizure scenario provided a window into the caregivers’ abilities to apply knowledge of seizure management in a stressful situation (needs-based approach). Observations were discussed with the participants to expose either gaps in knowledge or conceptualization, followed by additional opportunities to experiment with new concepts, with ongoing feedback. Caregivers were given opportunities to experiment with seizure management until they verbalized confidence and readiness for post-teaching assessment.
In previous studies examining FCC, the focus has been on the relational quality of the partnership and information sharing between the HCPs and the family, with no specific attention devoted to the learning modality. The importance of providing a family-centred approach has been endorsed by studies examining chronic illness, although there is limited evidence supporting the same approach in acute illness. From an FCC perspective, the strength of engaging simulation is supported by its capacity to identify the areas that challenge caregivers in the provision of competent seizure management. Simulation provides an objective window into real caregiver needs and supports closing of these performance gaps through deliberate practice and mastery learning in a safe, harm-free environment. If the caregiver is able to effectively demonstrate seizure management in a simulated context, HCPs can feel more confident that the family may be more successful in a real seizure event. Delivering traditional seizure teaching without the support of simulation leaves HCPs dependent on what caregivers verbalize to be their needs, without a more formalized assessment of actual needs. It leaves HCPs at risk for missing the mark with teaching content, and philosophically defeats a family-centred approach.
The findings regarding caregiver-reported self-confidence were congruent with our findings from the seizure checklist. In social learning theory, the greatest determinant of behaviour is intent to act (21). When self-efficacy is conceptualized as a belief in one’s capability to produce a desired effect, we see that self-efficacy becomes a mediator of competence. Reports of caregiver self-confidence provide insight into caregiver beliefs about the actions required to achieve competent seizure management. From a theoretical stance, caregivers who reported feeling more confident would have a higher likelihood of engaging in that behaviour. The fact that both groups reported a significant improvement in their confidence postcurriculum is consistent with literature on FCC and chronicity. Caregivers reported being more confident with care when they perceived a benefit from HCP teaching (1,22,23). However, what was notable was the disconnect in improvement between caregiver-demonstrated competence and reported confidence in the control group; although caregivers reported significantly improved confidence, competence did not significantly improve. This highlights a disconnect between knowledge acquisition and the application of knowledge presenting a great opportunity for engaging simulation.
The use of simulation as a learning modality has been heavily endorsed for use in HCPs education (16); however, to our knowledge, the present study was among the first to examine its efficacy for supporting FCC, in this case traditional seizure teaching in this population of caregivers. The need for developing assessment tools to support reliable and valid score interpretation is well documented in medical education, but nonexistent for assessing caregiver behaviours in a seizure management context. As such, the KidSIM-ASPIRE Emergent Seizure Management Checklist provides an evaluation tool with evidence to support both reliability and a dimension of construct validity – its ability to discern differences in caregiver seizure management behaviours. The significantly higher scores related to seizure management behaviours demonstrated by participants who received the simulation-based curriculum were congruent with the teaching focus. The next step would be to conduct a multicentre, randomized trial across various paediatric institutions, with a slightly modified instructional design, to further examine the impact of learning from inclusion of simulation-based discharge teaching.
The present study had several limitations. The first was the small sample size and the unequal number of participants in each arm. When we randomly assigned participants according to family unit, the family units in the control arm asked for more family members to undergo the training than in the experimental arm. We did not believe that it would be appropriate or ethical to allocate one family member to the intervention group and another to the control group; therefore, we decided to keep family units together. The second limitation rests in the evaluation tool. The KidSIM-ASPIRE Emergent Seizure Management Checklist needs to be modified to include items that are generically relevant for administration of any kind of antiseizure medication. This would enable us to complete reliability analysis on the complete checklist. It may also have provided more insight into differences between the control and experimental group related to having another opportunity to practice delivering a medication in a real emotional context. The third limitation of the study was the lack of formal assessment of inter-rater reliability, which may have influenced performance scoring. Study rigour would be enhanced had we completed a formalized process with statistical analysis of inter-rater reliability. The fourth limitation was the lack of control of traditional seizure teaching. The final limitation resides in the sustainability of our findings over time by having participants be evaluated over time intervals.
CONCLUSION
The present study was the first to examine the value of using simulation-based education with family teaching for improving caregiver competence with seizure management. Simulation as a learning modality provides a unique window into needs of caregivers securing the use of a needs-based assessment to inform seizure teaching. It also provides a venue, congruent with the principles of FCC, for deliberate practice with guided feedback. Our findings suggest a benefit for caregiver competence and confidence in managing seizures when traditional seizure discharge teaching administered after a child’s hospitalization is supplemented with simulation-based seizure curriculum. In addition, our results reinforce the importance of developing a standard for seizure teaching that includes initial recognition and care, medication administration and postmedication care.
Appendix 1. KidSIM-ASPIRE Emergent Seizure Management Checklist
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