Simulation capacity building in rural Indian hospitals: a 1-year follow-up qualitative analysis

Abstract

Introduction

The benefits of simulation-based medical training are well described. The most effective way to plant and scale simulation training in rural locations remains undescribed. We sought to plant simulation training programmes for anaesthesia emergencies in two rural Indian hospitals.

Methods

Two Indian consultant anaesthetists without experience in medical simulation underwent a 3-day course at the Boston Children’s Hospital’s (BCH) Simulator Program. They returned to their institutions and launched simulation programmes with an airway manikin and mock patient monitor. The 1-year experience was evaluated using individual, in-depth interviews of simulation facilitators. Three staff members (responsible for facilitating medical simulations over the prior year) at two rural hospitals in India were interviewed. None attended the BCH training; instead, they received on-the-job training from the BCH-trained, consultant anaesthetist colleagues.

Results

Successes included organisational adoption of simulation training with exercises 1 year after the initial BCH-training, increased interdisciplinary teamwork and improved clinical competency in managing emergencies. Barriers to effective, local implementation of simulation programmes fell into three categories: time required to run simulations, fixed and rigid roles, and variable resources. Thematic improvement requests were for standardised resources to help train simulation facilitators and demonstrate to participants a well-run simulation, in addition to context-sensitive scenarios.

Conclusion

An in-person training of simulation facilitators to promote medical simulation programmes in rural hospitals produced ongoing simulation programmes 1 year later. In order to make these programmes sustainable, however, increased investment in developing simulation facilitators is required. In particular, simulation facilitators must be prepared to formally train other simulation facilitators, too.

INTRODUCTION

The scarcity of trained surgical and anaesthesia personnel ^1–3 in rural Indian hospitals often results in non-speciality trained physicians and non-physician providers managing clinical cases, in particular emergencies, for which they may not have received formal training. Simulation-based teaching has been shown to be effective in teaching and refining new skills and knowledge and can facilitate training of medical staff. ^{4 5}

The benefits of simulation-based training on clinical skills, team-based care and crisis coordination are well described. The skills and teamwork benefits arising from simulations have been demonstrated throughout high-, middle- and low-income countries. ^{6 7} To spread the benefits of simulations, the Boston Children’s Hospital’s (BCH) Simulator Program (SIMPeds) has even extended its reach to spread simulations to neighbouring community hospitals through its SIM Network. ⁸

The most effective way to plant simulation training programmes in rural settings, however, remains undescribed. Therefore, we sought to qualitatively describe the obstacles faced in developing and implementing simulation programmes in two rural Indian hospitals. In particular, we examined the 1-year experience of the seeding of simulation training programmes from BCH SIMPeds to two rural hospitals in India.

METHODS

Training of simulation facilitators

As an initial step, two Indian consultant anaesthetists without experience in medical simulation travelled to Boston and underwent a customised 3-day simulation ‘train-the-trainer’ course at the BCH SIMPeds. This training provided knowledge and practice with experiential approaches to teaching and learning, including core skills and situational instruction using simulation, as well as advanced debriefing techniques in both individual and team-based learning. ⁹ All training of these individuals, referred to as ‘primary facilitators’, was based on the SimZones approach to simulation-based education pioneered at BCH, described extensively earlier. ⁹ As the participants in the training had many years of experience teaching procedures and emergency management, the curriculum focused on the conceptual aspects of simulation, grounded in psychological safety, adult learning theory, and a structural framework that lends itself to maximising learning and reflection on and in practice. Emphasis was placed on using SIMZones, in particular Zone 1 and Zone 2, in order to formulate the appropriate design, delivery and debriefing activities to enhance knowledge retention and skill acquisition.

These primary facilitators then returned to their respective hospitals in India: the Tribal Health Initiative and Gudalur Adivasi Hospital (table 1). Both are located in rural areas, primarily serving tribal communities. Each hospital employs approximately six physicians and 30 non-physician medical staff, and performs nearly 500 surgeries annually.

Table 1.

Characteristics of hospitals conducting simulations

Characteristics	Tribal Health Initiative	Gudalur Adivasi Hospital
Year founded	1993	1990
Location	Sittilingi, Tamil Nadu, India	Gudalur, Tamil Nadu, India
Time for transfer to higher level of care	2+ hours	2–8 hours
Number of staff
Doctors	6	7
Nurses	30	30
Number of outpatients seen (annually)	42 000	36 000
Size of hospital (in-patient beds)	30	50
Number of surgeries (annually)	800–900	400–500
Hospital features	Three wards. Labour room. Isolation rooms. Neonatal unit. Two operating theatres. High-dependency unit.	Three wards. High-dependency unit. Isolation rooms Maternity unit. Labour room. Antenatal + postnatal. Neonatal unit. Two operating theatres. Blood bank. Casualty department.
Educational initiatives	Education and outreach clinics in villages.	Nursing school. Community outreach clinics.

*This takes into consideration the level of resources/care needed to transfer, and the variable wait time for those resources.

Although the initial goal was for the primary facilitators to be the only ones leading simulations, we found that new facilitators were tasked with leading the simulations. Over 1 year, these primary facilitators transferred their newly acquired knowledge and simulation training to ‘secondary facilitators’—staff at local hospitals that were not present at the BCH SIMPeds training who, over time, also became tasked with facilitating simulations. This transfer of knowledge and responsibilities was unexpected—it was spontaneous and without any central coordination. The transfer of knowledge was not standardised but occurred by having secondary facilitators observe primary facilitators. Some secondary facilitators observed one 2-hour session run by the primary facilitator, while others were able to observe more sessions and have observed feedback on their own simulations by the primary facilitator.

Study design

One year after the initial BCH SIMPeds training (figure 1), qualitative in-depth interviews with current simulation facilitators (all secondary facilitators) at two hospitals were conducted (IW). Interviews were limited to the secondary facilitators in order to more honestly capture the experiences of just those responsible for currently leading the simulation programme. In addition, various primary facilitators were unavailable for interview. We conducted a series of semistructured interviews (appendix I) assessing the experiences of simulation facilitators of newly planted simulation programmes in rural Indian hospitals nearly 1 year after their founding. This method was chosen because it presumed the subjective experiences of our participants were likely shaped by their social environments. The interview subjects were not the facilitators initially trained at BCH (figure 2); instead, the interview participants (secondary facilitators) all received simulation facilitator training from the two primary facilitators. Study participants were identified by the head of each hospital as being responsible for facilitating ongoing simulations. The interviewer previously knew all interviewees, and all those approached agreed to participate.

Figure 1.

Timeline of training of primary and secondary simulation facilitators and subsequent interviews.

Figure 2.

Pictorial depiction of primary and secondary simulation facilitators. BCH, Boston Children’s Hospital.

Data collection

One semistructured interview in a single session for each of the two hospitals was conducted to elicit reflections on their simulation programmes—at one hospital, two participants were interviewed in person as a group in the hospital; at the other hospital, a single individual was interviewed via telephone. Each interview was conducted in English, lasted 1 hour, and was audio-recorded. These interviews represented all the secondary facilitators conducting simulations. Although small in absolute number, these three individuals represent the entire population-of-interest (ie, secondary facilitators), rather than a sampling of a larger population.

Analysis

The same researcher (IW) transcribed the audio recordings verbatim. The authors applied an interpretivist stance using the methodological approach of an inductive, latent thematic analysis. ¹⁰ An inductive, latent thematic approach was adopted due to the novelty of the topic: the seeding of simulation curricula in rural Indian hospitals and the desire to have the interviews shape the themes. Two researchers (VSh and IW) read the transcripts in their entirety for familiarisation, and then reread them for thematic content. Together, the researchers (VSh and IW) discussed the interviews and collaboratively identified themes. Initial themes identified were (1.) barriers, (2.) successes and (3.) improvements. After identifying themes that were shared between the two authors, the transcripts were reanalysed for any additional evidence and context to support the themes.

The authors identified several subthemes: knowledge, scheduling, roles, competency, teamwork, knowledge transmission, content creation and participation. The authors then looked for concordance and discordance in the evidence, finally forming a working structure that captured the experiences of interviewees and interviewers. Throughout the analysis, VSh and IW discussed any discrepancies in interpretations. Each author was involved in the simulation programme prior, during and after the study and they used that knowledge to inform their analysis.

Ethical considerations

The study was submitted for Institutional Review Board (IRB) approval at the Harvard Medical School and was determined to not meet requirements for research or clinical investigation review (IRB18-2074). Verbal, informed consent was obtained from each study participant prior to the interview.

RESULTS

Three secondary facilitators, split between two hospitals, were identified. These facilitators were responsible for conducting ongoing simulations at the two hospitals and were a nurse administrator, medical officer and consultant physician. All were women, and none were trained at the initial BCH SIMPeds course; instead, all were secondary facilitators, having observed ongoing simulations at their institutions by primary facilitators. Over the subsequent year, each site conducted approximately 15–20 simulations (occurring roughly once every other week) on various anaesthetic emergencies, incorporating physicians, nurses, and technicians depending on the simulation context. The simulation scenarios were bradycardia, hypotension, hypopnea, anaphylaxis, respiratory arrest and cardiac arrest.

Successes, barriers and improvements to the implementation and sustainability of the simulation programmes were identified (table 2). For each subtheme, illustrative quotations from the interviewees are presented.

Table 2.

Thematic highlights from simulation programmes

Successes	Barriers	Improvements
(1) Promotion of interdisciplinary teamwork.	(1) Time required to run simulations.	(1) Increased formal training of simulation facilitators.
(2) Improved reported competency in managing emergencies.	(2) Difficulties arising from rigid and fixed roles.	(2) Demonstration of model simulation to participants.
	(3) Variable resource availability.	(3) Local creation and ownership of content.

Successes

Promotion of interdisciplinary teamwork

The first success identified resulted from having non-physician staff participate in the simulations and being directly involved in treating the emergent situation and patient. Interviewees noted an improved ability after simulations to work together in teams when handling emergencies on the hospital wards:

The other staff also give suggestions now; when a doctor misses the things in the hurry, another person … can suggest you do these things to help. It’s about building teamwork. Medical officer

If there are four of us in an emergency, we take four roles. In the past, we would only think of one thing, but now we think of different roles. Medical officer

Improved competency in managing emergencies

The second success identified was better planning for and management of emergencies. Simulations helped to organise the thinking of participants in approaching emergencies:

Simulations definitely helped me … [they] are a good way to handle emergencies in real life … we were able to plan, able to think; that really helped us. Medical officer

After a simulation when an emergency happened, we told the instructor that we were able to better manage the emergency after the simulation … we learned to do that systematically. Nurse administrator

Barriers

Time required to run simulations

The first barrier identified was setting aside time to conduct simulations. The simulation facilitators identified that the clinical duties of simulation participants prevented participants from attending simulations:

… mainly because of staff shortages. We may set a certain time, but they may have done a night shift, or be on leave. Consultant

The thought is not away from our mind; we want to do it … but the hospital is getting busy. Nurse administrator

Difficulties arising from rigid and fixed roles

The second barrier identified included (1) inability to suspend disbelief, (2) reluctance to engage in debriefs and (3) lack of disseminating lessons from simulations to peers. Interviewees identified an unwillingness to engage with and question simulation facilitators, making it difficult to have a productive debrief:

They don’t treat the mannequin as a patient, even though we tell them they should assume it’s a real patient … no matter however you try to make it real, they still feel it’s not real. They don’t have the seriousness … they tend to remain silent when doctors speak; they won’t argue. Whatever you said is right.

So whichever group you are planning to train, they’ll be absent. And the group that attended, won’t go train the others. We have tried to tell them, but they don’t discuss with other people. Consultant

Variable resource availability

The third barrier identified resulted from the difficulty in writing simulation scenarios to be used in settings that have different drugs and treatments:

For emergency situations, the resources are less here … so the drugs will be different [than at other, higher-resource locations]. Consultant

For example, if there is hypotension and doesn’t respond to fluids or epinephrine, we don’t have pressors [as an option]. Whatever is available in our setup I used in the simulations. I did that by myself. Consultant

Improvements

Increased formal training of simulation facilitators

The first improvement identified would be to have a formal ‘train-the-trainer’ course. Interviewees cited the benefits from formal training of simulation facilitators, expressing a desire to spread/transfer the training and skills that primary facilitators underwent to secondary facilitators, too.

I would love to have some training. We should have a proper curriculum to be able to teach someone. Some instructor should certify them before they start teaching. Consultant

Demonstration of model simulation to participants

The second improvement identified would be to address the barrier of not taking the simulations seriously. A suggestion that appeared across all interviews was to have a trained group of simulation participants to demonstrate the proper way of participating in a simulation:

It will be useful if we train the [simulation participants] who are going to undergo the simulations. Medical officer

If we train four-five people properly and get the [simulation participants] to watch them, then [the new simulation participants] would definitely know how to act and do [the simulations]. Consultant

Local creation and ownership of content

The third improvement identified would be to address the barrier of variable resources available at each simulation site. Interviewees felt the scenarios must be based on the existing drugs and treatments for relevant conditions:

I feel like each individual center should do their own scenarios … probably [others] can suggest some things, but we should prepare our own things using our resources. Consultant

The people who experienced the [simulations in their own environment] should talk about it [and develop scenarios]. Medical officer

DISCUSSION

Modern anaesthesia training programmes in resource-rich countries commonly use simulation to augment clinical experience. ¹¹ However, the use of simulation programmes to either augment training in perioperative care or to provide continuing medical education remains a relatively novel endeavour in resource-poor settings. ^{7 12} Most models of simulation programmes in resource-poor settings involve bringing the equipment and training to the location of interest. Our report demonstrates the success, efficiency and immediate transfer of ownership of the simulation programme through the above-described methods. Although this project is in rural Southern India, it may represent a generalisable and replicable model that can be employed in a wide variety of resource-poor settings requiring only buy-in from local caregivers and minimal financial investment. The financial costs can be offset through partnerships with higher-income actors.

Simulation-based training to manage perioperative emergencies in rural Indian hospitals holds promise to train medical staff but requires increased investment in training simulation facilitators. Airway manikins and mock patient monitors to conduct simulations were useful to facilitators in conducting simulations, as noted by increased reported competency in managing emergencies. These successes were in line with previously reported benefits from medical simulation. ⁵ From the perspective of newly trained simulation facilitators, however, barriers to sustainable and effective simulation training programmes included time required to run simulations, difficulties arising from rigid and fixed roles, and variable resource (medication and equipment to manage these emergencies) availability. These findings were consistent with hurdles identified by previous studies. ^{13 14} In order to help overcome these hurdles, interviewees requested more formal training in leading simulations. This is the first study to assess the sustainability of planting simulation programmes in a resource-constrained environment.

The initial BCH SIMPeds training was intended to train two Indian consultant anaesthetists who could return to their home institutions and conduct and lead simulations. However, we found that these primary facilitators shared their simulation leadership roles with secondary facilitators. These secondary facilitators were staff at their respective home institutions who had not undergone the initial BCH-based training in Boston. Secondary facilitators received their knowledge and skills only through instruction by the primary facilitators and observation of the primary facilitators leading simulation exercises. Our results demonstrate that the study participants, all secondary facilitators, desired more robust and formal training to lead and facilitate simulations. In short, training primary facilitators to conduct simulations is not enough; instead, primary facilitators must be prepared to formally train other simulation facilitators (secondary facilitators), too. Although others have found that the sheer number of facilitators corresponds with robustness of simulation programmes, ¹⁵ our findings indicate that method of training also is important—with formal training preferable to shadowing other facilitators.

Although the two Indian consultant anaesthetists underwent a ‘train-the-trainer’ programme at the BCH SIMPeds, they were only explicitly taught skills to lead successful simulation programmes. In this sense, they were ‘trainers’ for the staff who would participate in their future simulation programmes. These anaesthetists, however, were not equipped to become higher-level trainers—in being able to develop and train other simulation facilitators. Our findings suggest that this higher-level skill—the ability to train other facilitators—is necessary in addition to the training to lead simulations oneself. Previous studies have developed a tiered approach to simulation faculty development that progresses through various domains of increasing complexity that includes observation, didactic and interactive learning experiences, practice, expert feedback and mentoring. ¹⁶ Although our primary facilitators received in-person training along this model, there is a role for an additional domain in transmitting their knowledge and skills to other potential facilitators.

In a survey assessing a multicenter cohort, Takahashi et al found that the odds of achieving a sustainable simulation programme—defined by the authors as annual simulation time of at least 10 hours—increased by 33% with each additional simulation facilitator. ¹⁵ We hypothesise that primary facilitators in our study had other duties, making it difficult to find uninterrupted time to conduct simulations and, thus, led to the need for secondary facilitators. For example, one of the primary facilitators was not employed full time at the location—visiting roughly once every other month when his clinical services were needed. This made it difficult to conduct simulations on a regular basis. As local champions for simulations are identified, the ability to pass along the simulation leadership (via structured training) becomes important to both increase the number of simulation facilitators available at any given location and improve the quality of simulation activities. Another method would be to explore the potential for remote simulation facilitators. Although previous groups have found success with tele-simulation,17 this expansion of facilitation relies on robust and high-quality internet connections, a potential limitation in the environment of many rural hospitals.

The rural locations of our study hospitals present unique challenges in planting simulation programmes because of the shortage of staff, part-time availability of specialists, and the overstretched demands on the staff to perform multiple roles simultaneously. These demands lead to both a need for simulations—to help expand the clinical expertise of the staff—as well as the difficulty in sustaining simulation programmes. We found that the turnover and itinerant nature of some of the staff in rural locations led to the need for primary facilitators to transmit their simulation skills to others. These environmental barriers add to previously described hurdles—time, motivation or culture, organisational responsibility and lack of robust competency measures—in founding simulation programmes in the USA, the UK, Canada, France and Japan. ^{17 18}

An additional hurdle encountered by those interviewed arose from occasionally fixed and rigid roles and hierarchies in the clinical realm that bled into the simulations. All interviewees identified difficulty in creating a setting in which simulation participants took the scenario seriously. Shaw-Battista et al identified the importance of achieving an ‘immersive environment’ to facilitate both a productive simulation and debrief. ^{18 19} The difficulty suspending disbelief in the scenarios led to less effective debriefs.

Debriefs have been shown to be an integral part of achieving the goals of simulations. ^{19 20 21} We found that simulation participants, however, were often reluctant to fully engage in debriefs—instead of engaging in a dialogue with the facilitators and fellow participants, debriefs often became one-sided, didactic transmission of information from facilitator to simulation participants. This was perhaps due to the novelty of a discussion that demanded participation across different seniority levels. Moreover, the potential impact of gender roles, the experiences between formally and non-formally trained medical providers, as well as the language of instruction may have further contributed to difficulty in debriefs. Despite the importance of leadership, interest, motivation and behaviour of the participants were also integral to achieving a successful simulation and debrief. It is possible that a formally trained facilitator leading a debrief may not be enough to achieve a successful debrief; helping to train simulation participants on best practices for engaging in the debrief may also be necessary.

A primary goal of the BCH SIMPeds collaboration was to introduce and plant simulation programmes in rural hospitals, and this study offers an initial assessment of the experiences of secondary simulation facilitators in those settings. However, our study is limited in that it evaluates only two sites and three individual study subjects in planting simulation programmes. As more simulation programmes are planted in new settings, further monitoring and evaluation is needed to develop best practices in achieving sustainable, situation-appropriate simulation programmes. Additionally, our study does not capture the experiences of the primary facilitators, which would be an important step toward better understanding the transmission of knowledge and experience within simulation programmes. Having identified the transmission of knowledge from primary to secondary facilitators as an important theme in this study, future work can now dive deeper into how this transmission occurs.

In summary, in-person training of simulation facilitators is necessary to initially plant and sustain simulation programmes in rural Indian hospitals. Based on the results of our study, we recommend that those seeking to plant simulation programmes in rural India and similar contexts consider the following:

• Train initial primary facilitators to formally train local, secondary facilitators;

• Develop examples of well-run simulations (either video or in-person) to demonstrate best practices to simulation participants;

• Identify valid competency checks and feedback for participants ^{21 22} (ie, presurveys and postsurveys to look at differences in the success of crisis management presimulation and postsimulation training).

Additional evaluations of the experiences of primary facilitators and their perspectives on knowledge transmission to secondary facilitators would provide further insight on how to best scale simulation programmes in rural, low-resource settings. Additionally, observation and comparison of simulations led by BCH SIMPeds trainers, primary facilitators and secondary facilitators may yield useful information on what specific gaps, if any, exist in the leading of simulations by various facilitators. Future studies might also assess how to best select training sites, as well as the primary and secondary facilitators who could most effectively plant new simulation programmes.

What is already known on this subject.

• The scarcity of trained surgical and anaesthesia personnel in rural Indian hospitals often results in non-speciality trained physicians and non-physician providers managing clinical cases, in particular emergencies, for which they may not have received formal training.

• Simulation-based teaching has been shown to be effective in teaching and refining new skills and knowledge, and can facilitate training of medical staff.

• The most effective way to plant simulation training programmes in rural settings, however, remains undescribed.

What this study adds.

• In-person training of simulation facilitators is necessary to initially plant and sustain simulation programmes in rural Indian hospitals.

• Although a simulation programme was sustained for over a year, additional attention in the future should be given to training initial primary simulation facilitators to formally train local, secondary facilitators.