Study protocol training for life: a stepped wedge cluster randomized trial about emergency obstetric simulation-based training in a low-income country

BACKGROUND Simulation-based training is a common strategy for improving the quality of facility-based maternity services and is often evaluated using Kirkpatrick’s theoretical model. The results on the Kirkpatrick’s levels are closely related to the quality of the instructional design of a training program. The instructional design is generally considered as the ‘set of prescriptions for teaching methods to improve the quality of instruction with a goal of optimizing learning outcomes’. OBJECTIVE The aim of this study is to evaluate the instructional design of a technology-enhanced simulation-based training in obstetrics, the reaction of participants, and the effect on knowledge, teamwork, and skills in a low-income country. METHODS A stepped-wedge cluster randomized trial was performed in a University Hospital in Kampala, Uganda, with an annual delivery rate of over 31,000. In November 2014 a medical simulation center was installed with a full body birthing simulator (Noelle® S550, Gaumard, Miami), an interactive neonate (new-born Simon® S102, Gaumard, Miami) and an audio- and video recording system. Twelve local obstetricians were trained and certified as medical simulation trainer. From 2014 to 2016 training was provided to 57 residents in groups of six to nine students. Descriptive statistics were calculated for ten instructional design features of the training course measured by the 42-item ID-SIM. Wilcoxon signed rank test was conducted to investigate the difference in scores on knowledge, the clinical teamwork scale, and medical technical skills. RESULTS The mean scores on the ten instructional design features differed between 54.9 (95%CI 48.5 – 61.3) and 84.3 (95%CI 80.9-87.6) out of 100. The highest mean score was given on the feature feedback and the lowest scores on repetitive practice and controlled environment. The overall score for the training day was rated 92.8 out of 100 (95%CI 89.5 – 96.1). Knowledge improved significantly with a test score of 63.4 (95%CI 60.7 – 66.1) percent before and 78.9 (95%CI 76.8 – 81.1) percent after the training (P<.001). The overall score of the clinical teamwork scale, scored on a 10-point scale, was 6.0 (95%CI 4.4 – 7.6) before, and 5.9 (95%CI 4.5 – 7.2) after the training (P=.78). Medical technical skills were scored 55.5% (95%CI 47.2 – 63.8) before and 65.6% (95%CI 56.5 – 74.7) after training (P=.08). CONCLUSIONS Most instructional design features of a technology-enhanced simulation-based training in obstetrics in a low-income country were scored high, although intervals were large. The overall score for the training day was high, knowledge did improve after the training program, but no changes in teamwork and (most) medical technical skills were found. The lowest scored instructional design features may be improved to achieve further learning aims. CLINICALTRIAL ISRCTN98617255, retrospectively registered

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