Simulation-based training (SBT) can be used to provide health care professionals with situations similar to real-life emergencies. Proficiency in medical as well as nontechnical skills within a crisis resource management (CRM) framework—including leadership and followership, communication, teamwork, resource use, and situational awareness—is required to successfully recognize and resuscitate critically ill or injured patients.1 Simulation-based educational methodologies can provide a safe environment to effectively acquire and maintain medical and nontechnical skills and may be associated with large effects on knowledge, technical skills, and behavior as well as moderate effects on patient-related outcomes.2 Thus, there is an exponential increase in the use of simulation in medical education and educational research.3–5 It has been suggested that there will likely be a further growth of medical simulation programs between 10%–20% and 55% in 2015–2020.6
The simulated practice of both technical and nontechnical competencies has been well established in many high-income countries.3,5 However, according to our widespread knowledge of the “simulation landscape,” SBT is still in the fledging stages in German-speaking countries and regions. One international survey on the status of simulation in health care included only five centers (Greece, Israel, Spain, Sweden, UK) in Europe;6 as this study refers to a different region, we are unsure whether it actually underrepresents the number of simulation institutions in European countries or not. A study among medical schools in Central Europe showed that only 13 (32.5%) of 40 institutions were using SBT for physicians and health care professionals.7
The history of professional (pediatric) simulation in Central Europe dates back only several years. The first officially registered simulation association—Deutsche Gesellschaft zur Förderung der Simulation in der Medizin e.V. (DGSiM e.V.)8—was founded on July 29, 2014, in Reutlingen, Germany. Netzwerk Kindersimulation e.V. (Pediatric Simulation Network),9 a collaboration dedicated to the promotion of pediatric and neonatal simulation, was established shortly thereafter on October 17, 2015, in Tuebingen, Germany. The Swiss Association for Simulation in Healthcare was formed on July 4, 2012, in Lausanne, Switzerland. As for Austria and South Tyrol, there were no existing official simulation associations at the time of our survey. Despite the recent formation of the previously mentioned societies, we see an overall lack of awareness among simulation educators regarding the work of colleagues in neighboring countries. Simulation-based training, whether delivered in simulation centers or in situ, is currently being conducted without any officially established national or international quality criteria, accreditation processes, or guidelines.
Neonatal and pediatric emergencies including critical airway, resuscitation, and trauma are uncommon clinical conditions, thus lending themselves well to SBT.10,11 Specific pediatric training contents include perinatal emergencies, management of patients with congenital malformations, recognition of deteriorating children, invasive procedures including airway management and vascular access, extracorporeal membrane oxygenation, and communication with patients and parents or caregivers. However, international data regarding use of pediatric SBT in Central Europe have not yet been published.
Aim of the Study
This study aimed at identifying to what extent and how pediatric and neonatal SBT was being carried out in the Central European region. Our motivation is to build collaborations between individuals and individual institutions with the long-term goal of improving use and overall quality of SBT.
MATERIAL AND METHODS
We performed an exploratory descriptive study on simulation practices using a survey methodology. We surveyed pediatric and neonatal health care institutions in four regions (Germany [D], Austria [A], Switzerland [CH], and South Tyrol/Italy [S] [DACHS]) regarding current simulation activities.
For this purpose, we composed a comprehensive online questionnaire in German, based on expert opinion, including 26 questions covering organization, training contents, staffing, target groups, resources, education, and research activities (see document, Supplemental Digital Content 1, survey; https://links.lww.com/SIH/A355) (see document, Supplemental Digital Content 2, survey translated into English by the authors for publication purposes; https://links.lww.com/SIH/A356). To review language, grammar, content, completeness, and relevance of the questions, we sent out the first draft questionnaire, authored and revised by the primary investigators, to 37 health care professionals engaged in the field of pediatrics/pediatric simulation from the different countries/regions (D = 6, A = 8, CH = 13, S = 10) for their input. Comments from this pretest analysis included improved phrasing, the request for additional instructions, and adaptation of optional answers. All comments were recorded online. The questionnaire was revised accordingly by the primary investigators. The online survey was password protected.
We chose to survey all pediatric and neonatal health care institutions in Switzerland as German-speaking health care workers practice in all parts of Switzerland. In Italy, however, we focused on South Tyrol because this is the area where most German-speaking health care professionals practice.
The questionnaire was provided via the online tool SurveyMonkey (SurveyMonkey Europe UC, Dublin, Ireland; http://www.surveymonkey.de) between September 2015 and July 2016, with the link being sent to the respective head of the institution/representative of pediatric or neonatal hospital in DACHS by e-mail. The head was asked to distribute the questionnaire to the responsible person in charge of SBT. One written electronic reminder was sent, if there was no response after one month.
Data of all returned questionnaires were exported from SurveyMonkey and collected in a Microsoft Excel (Microsoft Corporation, Redmond, WA) database. For this descriptive analysis, data were presented as absolute numbers and percentages. Depending on data distribution, we calculated mean (SD) or median (range).
After dispatching 440 questionnaires (D: n = 360, A: n = 42, CH: n = 31, I: n = 7), we achieved a response rate of 45.9% (202/440), with 38.6% (139/360) respondents from Germany, 83.3% (35/42) from Austria, 67.7% (21/31) from Switzerland, and 100% (7/7) from South Tyrol.
Delivery of SBT and Simulation Equipment
Among all respondents, 124 (61.4%) already implemented simulation-based pediatric and/or neonatal training in their institutions. Simulation-based training was declared as either algorithm training (eg, basic life support training), low-fidelity, or high-fidelity SBT. In this context, high-fidelity SBT referred to immersive CRM simulations with that attempt to replicate both the medical and teamwork aspects of a crisis situation. In 34.9% (37/106) of institutions, SBT was provided in a designated simulation center, whereas 59.4% (63/106) delivered in situ trainings at their own institution.
The most frequently trained professions were reported to be nurses with 75.3% (70/93) and physicians with 97.8% (91/93) (Fig. 1). In 88.9% (104/117) of institutions, SBT was conducted interprofessionally (defined as two or more health care professions), and in 60.7% (71/117) of institutions, SBT was conducted in a multidisciplinary setting (defined as two or more academic disciplines/medical specialties training together).
A total of 53.8% (57/106) of the institutions providing high-fidelity SBT used mobile audio-video recording systems, and 52.8% (56/106) had dedicated debriefing rooms. Most frequently available simulators were basic life support (61.4% [54/88]), advanced life support (61.4% [54/88]), preterm high-fidelity (51.9% [52/88]), and newborn high-fidelity (59.1% [52/88]) mannequins.
Type and Contents of SBT
A total of 87.4% (97/111) of institutions performed algorithm training, defined as basic/advanced life support training. This was followed by technical skills training with 62.2% (69/111), high-fidelity SBT with 56.8% (63/111), and dedicated human factor training with 46.8% (52/111) (Fig. 2). Contentwise, algorithm training was reported to most frequently cover pediatric basic life support in 78.1% (82/105), newborn life support in 74.3% (78/105), and pediatric advanced life support in 51.4% (54/105). Perinatal newborn resuscitation was the most commonly stated content of SBT with 85.6% (95/111) (Fig. 3).
Group Sizes and Training Frequency
Algorithm and high-fidelity training were most frequently provided for five to eight participants per course (44.9% [48/107] and 56.6% [43/76], respectively) and most often conducted by two to three instructors (56.1% [60/107] and 60.3% [47/78], respectively). In most cases, physicians and nurses (each 30.6% [34/111]) had the possibility to participate in algorithm training once per year; 25.2% (28/111) of physicians and nurses received training every three months. Of those institutions offering high-fidelity SBT, physicians with 21.6% (24/111) and nurses with 19.8% (22/111) were most often trained once per year.
In 29.5% (23/78) of responding institutions, instructors had completed specific simulation instructor courses. A total of 70.5% (55/78) of simulation teams employed instructors without any specific education or training. Dedicated additional instructor courses for simulation professionals were offered infrequently (Fig. 4).
Simulation instructors were physicians in 97.8% (91/93) and certified nurses in 75.3% (70/93). In the fewest cases, educators and psychologists (each 3.2% [3/93]) took over these roles. Technicians (26.1% [23/88]) and secretaries (30.1% [25/83]) were rather uncommon members of simulation teams.
A total of 15.3% (15/98) of institutions surveyed claimed to be actively engaged in simulation-related research, yet 69.4% (68/98) of institutions indicated interest in future research activities in the field of pediatric simulation. Most institutions with 84.7% (83/98) also expressed their interest to join the Netzwerk Kindersimulation e.V. (Pediatric Simulation Network).
Most frequently mentioned obstacles for implementing SBT in institutions currently not providing such programs were financial with 62.2% (46/74) and personnel with 54.1% (40/74) resource restrictions (Fig. 5).
Among the key findings of our comprehensive analysis is a previously undescribed, yet widely prevalent use of pediatric and neonatal simulation in Central Europe. This is exemplified by a large number of already existing SBT programs, with 61.4% of surveyed institutions having implemented SBT, which compares relatively favorably to 88% in Austria11 and 91% among US emergency medicine residency programs.3 Although pediatric advanced life support certification (which includes simulation-based elements) is required for all US-based pediatric residents, no such obligation exists in the regions surveyed. This may partially explain why more than a third of the institutions surveyed do not use SBT.
Furthermore, our results show that there is heterogeneity with regard to the provision of SBT, specifically concerning training sites (hospital-linked simulation centers, dedicated facilities inside the hospital in situ - in the real health care working environment), target groups, instructor-to-participant ratio, and frequency of training.
Type and Contents of SBT
Simulation was most often applied to the practical training of medical algorithms and technical skills, which is comparable to other study results.12 Simulation-based training for the conveyance of CRM principles or nontechnical skills was more uncommon among surveyed institutions, although teamwork and CRM may markedly improve patient outcome.13–16
One possible explanation for the fact that CRM training is still underrepresented to date may be attributed to the heterogeneity of instructor training in DACHS. Instructors may have been trained to teach on resuscitation algorithms and technical skills courses without having undergone specific CRM training, which differs substantially from sole algorithm training courses in various dimensions such as planning and delivery of training, teaching goals, learning outcomes, and debriefing tools. Lack of proof of standardized instructor trainings as a prerequisite to deliver SBT seems to be another quality gap in the surveyed region. There are, however, medical simulation fellowships in other countries such as the United States and Australia that can be looked at as examples of how such training could be accomplished.3 Therefore, we recommend that quality criteria be defined for the education of actual SBT instructors, which is different from algorithm and skills training instructor education, and be adopted across DACHS.
On the other hand, an encouraging finding of our work is that most institutions provide SBT in an interprofessional and/or multidisciplinary setting, thus taking advantage of one of the major strengths of SBT.17
Group Sizes and Training Frequency
The most widely reported training frequency among surveyed institutions offering algorithm and/or high-fidelity training was once per year, which may not be sufficient to effectively maintain essential knowledge and skills.18 In contrast, a survey among American emergency medicine residency programs found high-fidelity SBT to be most often conducted every 1 to 4 months at 42% of institutions.12 This clearly shows a deficit in training frequency in the surveyed region; thus, we suggest that institutions aim at increasing their training frequency within the realms of possibility to raise and maintain the effectiveness of SBT.
Based on our results, mainly physicians and nurses were engaged as simulation instructors, whereas other health care professions were significantly underrepresented in this role. This constitutes a further weak point in simulation instructor education, and we propose the recruitment of midwives, paramedics, and even medical and nursing students early on in their career to promote a true multiprofessional teaching approach. A recent study has shown the benefit of using medical students as SBT instructors, among other things resulting in a reduction of associated costs.19 As SBT should and does include several health care professions, interprofessional and multidisciplinary instructor teams may further increase learning by combining multifaceted views and experiences.
Learning outcomes may be further optimized if the simulation instructor corps regularly attend continuing education, such as “debrief the debriefer” workshops, lectures on different aspects of SBT, journal clubs, or simulation conferences. In addition, designated simulation fellowship programs in Central Europe could further help accomplishing this task. Our work, however, brings forth a lack of true multiprofessional faculty development and continuing education for simulation instructors across most parts of DACHS at this time.
Lack of financial funding and insufficient staffing were named as the most common obstacles to implementation of SBT by institutions without existing SBT programs, which is consistent with other published data.3,12 To approach this problem, leaders of acute care institutions should be made aware of the true direct benefits of SBT on their patients and teams.
Despite the financial burden of medical simulation training and research,20 SBT may ultimately lead to cost savings by reducing complications resulting from medical care.21 The funding for SBT, including instructor education, availability of facilities, and the purchase of simulation mannequins, requires thorough argumentation but can be solidly based on the continuously emerging evidence on the benefits of SBT in the published literature.
Strengths and Limitations
The major strengths of this questionnaire-based survey include the high-response rate among hospitals surveyed and the presence of representative data from four regions in Central Europe.
We acknowledge the following limitations of this study: We did not survey institutions in countries with smaller numbers of native German-speaking health care professionals (ie, Belgium, Luxembourg, etc). Secondly, more direct and effective communication paired with better interaction among colleagues in smaller countries such as Austria, Switzerland, and the region South Tyrol may explain the higher response rates in these regions compared with Germany: this discrepancy might have possibly influenced our results to some extent. Furthermore, data quality in this survey mainly depends on the respondents' answers—a small number of questionnaires were unfortunately returned incompletely, which in return may have limited generalization of some of our results. In addition to this, no questions about perceived expertise in simulation program operations were included on the survey. This raises the possibility that some centers may possess adequate equipment but use it ineffectively. The low percentage of educational program opportunities in the surveyed area further supports this concern. Lastly, we did not collect data to directly quantify the size of surveyed institutions, which would have allowed us to assess whether the detected heterogeneity was due to a broad spectrum of different training institutions or based on a more homogeneous sample of larger simulation centers offering a greater variety of courses.
Our findings provide an overview of existing pediatric and neonatal simulation activities in four Central European regions. Although there was significant heterogeneity in the provision of SBT, our study showed that almost two thirds of surveyed institutions already implemented some form of SBT. These findings were unexpected but will help us start collaborations with previously unknown simulation educators and institutions. This should promote pediatric and neonatal simulation, improve local networking along with educational opportunities, and make existing human and physical resources more widely available. Among our future goals are developing multicenter research projects and implementation of a simulation fellowship program. The establishment of dedicated quality criteria for the certification of simulation instructors and accreditation of simulation curricula and institutions in DACHS may contribute to the provision of high-quality SBT and ultimately increase patient safety. In addition, this study may serve as a driving force for an international survey aiming at assessing the global status of simulation.
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