Background/rationale

The first case of coronavirus disease 2019 (COVID-19) in Pakistan was reported in Karachi, on February 26, 2020 [1]. At Combined Military Hospital (CMH) Landi Kotal Cantt in Pakistan, we arranged a special course for COVID-19. We formulated a training course that also included the non-medical staff of the hospital, including those working in the laundry service, security, and sanitation departments. The people in these professions are also at risk of being exposed to droplet-borne infections such as COVID-19. We also included simulation-based exercises in the training course. These exercises included carrying out clinical procedures such as endotracheal intubation, collection of blood samples, and collection of nasopharyngeal and oropharyngeal samples for polymerase chain reaction (PCR) testing for the severe acute respiratory syndrome coronavirus 2 on a manikin. We used mock patients to practice safe transport from one department of the hospital to another by the security staff. We simulated spillages of blood and vomitus on floor and linen for the sanitation and laundry staff to practice dealing with highly infectious materials and surfaces.

Objectives

This study aimed to determine whether health workers’ perceived levels of preparedness, safety, and willingness to care for COVID-19 patients changed after attending the simulation-based course. We hypothesized that this simulation-based training would impart confidence and a sense of preparedness to care for COVID-19 patients.

Ethics statement

We obtained permission from the Hospital Ethical Board to conduct our study (02/2020). Informed consent was obtained from the participants.

Study design

This was a survey-based descriptive study.

Participants

The participants in the study included nurses, doctors, nursing assistants, sanitation workers, ambulance drivers, and laundry service providers who attended the COVID-19 training course. Hospital staff who would not have any contact with patients or infectious materials (e.g., those on administrative duties) were excluded. Personnel with pre-existing medical conditions such as pulmonary diseases, ischemic heart disease, diabetes mellitus, or who were immunocompromised were also excluded from participation, as they are prone to have complications if they contract COVID-19 [2].

Setting

The study was conducted at CMH Landi Kotal Cantt, Khyber District from March 1 to April 30, 2020. This hospital is 1 of the 2 hospitals in Landi Kotal that have been designated to care for COVID-19 patients.

The hospital education department formulated the multi-professional training course to put the hospital action plan for COVID-19 into practice. The biosafety and infectious disease protocols of the hospital had already been revised and updated for COVID-19 as per the guidelines of the National Institute of Health in Islamabad. The training course was formulated in consultation with a medical and infectious disease specialist to cover the following aspects of the management of suspected and confirmed COVID-19 patients: (1) personal protective equipment (PPE) use; (2) the hospital’s biosafety protocols; (3) procedures such as oropharyngeal and nasopharyngeal sampling for PCR tests, intravenous blood sampling, patients’ bodily hygiene, and cleaning performed by the clinical staff on the patient; and, (4) procedures such as disinfection of surfaces and cleaning of infectious fluids (e.g., blood and vomitus) by sanitation staff, transport of patients and subsequent disinfection of the ambulance by the ambulance staff, clearing the corridors while maintaining patient isolation by the security staff, and collection and treatment of contaminated linen by laundry managers.

There were interactive classroom sessions and practical sessions in which every participant was required to don and doff PPE including gloves, gowns, goggles, N95 (National Institute for Occupational Safety and Health-approved) and surgical masks, face shields, splash-resistant aprons, and whole-body anti-viral suits. Clinical procedures were practiced using simulation techniques with the help of mock patients and manikins. Multiple scenarios were simulated and practiced as per the hospital protocols.

Measurement

All the participants of the training course were invited to participate in our study. We obtained permission to use and modify the questionnaire used by Carvalho et al. [3]. The questionnaire consisted of 2 parts. The first part contained questions about participants’ characteristics such as age, sex, their field of work/department, years of experience, any experience of participating in simulation-based training, and experience of caring for patients with infectious diseases. The second part contained 8 questions regarding their perceptions of risk and their preparedness to work with patients with COVID-19 or other infections requiring strict isolation (biosafety level III/ IV) (Supplement 1). The participants responded on a 10-point Likert scale. They were asked to complete the questionnaire before starting the training course and after finishing it.

Statistical analysis

The data were analyzed using IBM SPSS Statistics ver. 23.0 (IBM Corp., Armonk, NY, USA). The frequency and percentages of categorical variables were calculated. For continuous variables, the median and interquartile range (25th–75th percentiles) were calculated. The Mann-Whitney U-test was used to test the significance of differences between independent samples.

Participant characteristics

The demographic characteristics of the 44 participants are shown in Table 1.

Descriptive data

After the course, all the questionnaire results showed significant changes (P<0.05) (Dataset 1). The participants felt better prepared to take care of patients with infections requiring strict isolation such as COVID-19. They considered other participants of the course to be ready for it too. Moreover, their perceptions regarding the preparedness of those colleagues who had not attended the course were significantly lower. They felt safer and were significantly more willing to participate in the management of COVID-19 patients. Finally, their fear of working with a patient requiring high isolation was also reduced after attending the course. The responses provided by the participants before and after the course are shown in Fig. 1 using box plots.

Interpretation

Our results showed that at the start of the course, the participants perceived themselves to be neither prepared nor motivated to take care of COVID-19 patients. They also did not feel safe in dealing with such patients. However, at the end of the course, there were significant improvements in perceptions of preparedness, willingness to work, and the feeling of being safe when working with patients with COVID-19. Varying results have been reported in other studies regarding perceptions of preparedness after simulation-based training. Prescott and Garside [4] reported that all the participants of their study felt better prepared for the assigned tasks after a simulation-based training. However, it has also been reported that fewer participants felt prepared for the tasks for which they had received simulation-based training [5]. Our study showed a significant improvement in perceptions of preparedness among the participants after the training.

The participants in our training course believed from the beginning that their colleagues who were not attending the course were not prepared to handle COVID-19 patients. At the end of the course, this perception was strengthened. This implies that they perceived that the course had prepared them for the challenge of caring for COVID-19 patients as compared to their colleagues who had not trained with them. We interpreted this result as validating the effectiveness of our new multi-disciplinary training course.

We saw that the feeling of fear regarding caring for infectious patients requiring strict isolation was reduced after the participants had completed the course. Fear is an irrational feeling that can hamper performance. Fear can also hamper learning. It is important that health personnel feel safe while learning, and simulation-based training provides a safe environment to learn to deal with a broad range of potentially dangerous situations [6]. Thus, simulation-based learning effectively imparts confidence, competence, and knowledge to the learner. If they feel safe, we can assume that they would be able to deliver better care to the patients.

At the end of simulation-based training, there is usually a debriefing session, which is considered to be a crucial part of the learning exercise. We also found debriefing to be invaluable in our course. It was used to reinforce good practices and to reflect upon, discuss, and improve aspects that had not been performed up to the mark. It gave the participants insights and helped them develop a better understanding of the rationale behind the procedures.

It has been reported that repeated team-based simulation training increased the frequency of task completion [7]. The reason may be either familiarity with the role that each member of the team plays in a given situation or reduction in anxiety with practice. Thus, we recommend that essential skills and procedures should be practiced through regular simulation-based training programs organized at hospitals.

Limitations

The sample size was small and the study was conducted at only 1 hospital. Therefore, the results cannot be generalized. It is recommended that we follow up this study with a larger sample size and conduct it at multiple institutions. Furthermore, simulations should be compared with other training methods to clarify their effect on perceptions of safety and preparedness to care for patients with infections requiring strict isolation. This will help in formulating appropriate training programs for health care workers from different departments and will yield maximum benefits.

Conclusion

Multi-professional simulation-based training imparted confidence and a sense of preparedness among health workers to care for patients with infections that require strict isolation, such as COVID-19. The feelings of insecurity and fear regarding caring for such patients were reduced through such training programs.

Acknowledgments

Supplementary materials

Fig. 1.

Answers to the questions regarding perceptions of preparedness, risk, and willingness to care for patients with COVID-19 or other infections requiring high isolation before and after the simulation-based training course. (A) Q1: I feel ready to participate in the management of patients infected with COVID-19. (B) Q2: I feel ready to participate in the management of patients with infections that require high isolation. (C) Q3: I think that my colleagues who are participating in the course are ready to manage patients with COVID-19 or other infections that require high isolation. (D) Q4: I think that my colleagues who are not participating in the course are ready to manage patients with COVID-19 or other infections that require high isolation. (E) Q5: I feel safe if I had to participate in the management of a patient infected with COVID-19. (F) Q6: If today I have to take care of a patient infected with COVID-19, I would do it. (G) Q7: If today I have to take care of a patient with an infection requiring high isolation measures, I would do it. (H) Q8: I am afraid to participate in the management of a patient infected with COVID-19 or other agents requiring high isolation. COVID-19, coronavirus disease 2019.

References

• 1. Government of Pakistan. Coronavirus in Pakistan [Internet]. Islamabad: Government of Pakistan; 2020 [cited 2020 May 1]. Available from: http://covid.gov.pk/
• 2. Hussain A, Bhowmik B, do Vale Moreira NC. COVID-19 and diabetes: knowledge in progress. Diabetes Res Clin Pract 2020;162:108142. https://doi.org/10.1016/j.diabres.2020.108142 ArticlePubMedPMC
• 3. Carvalho E, Castro P, Leon E, Del Rio A, Crespo F, Trigo L, Fernandez S, Trilla A, Varela P, Nicolas JM. Multi-professional simulation and risk perception of health care workers caring for Ebola-infected patients. Nurs Crit Care 2019;24:256-262. https://doi.org/10.1111/nicc.12396 ArticlePubMed
• 4. Prescott S, Garside J. An evaluation of simulated clinical practice for adult branch students. Nurs Stand 2009;23:35-40. https://doi.org/10.7748/ns2009.02.23.22.35.c6776 Article
• 5. Feingold CE, Calaluce M, Kallen MA. Computerized patient model and simulated clinical experiences: evaluation with baccalaureate nursing students. J Nurs Educ 2004;43:156-163. https://doi.org/10.3928/01484834-20040401-03 ArticlePubMed
• 6. Mohammadi G, Tourdeh M, Ebrahimian A. Effect of simulation-based training method on the psychological health promotion in operating room students during the educational internship. J Educ Health Promot 2019;8:172. https://doi.org/10.4103/jehp.jehp_106_19 ArticlePubMedPMC
• 7. Falcone RA Jr, Daugherty M, Schweer L, Patterson M, Brown RL, Garcia VF. Multidisciplinary pediatric trauma team training using high-fidelity trauma simulation. J Pediatr Surg 2008;43:1065-1071. https://doi.org/10.1016/j.jpedsurg.2008.02.033 ArticlePubMed

Figure & Data

References

Citations

Citations to this article as recorded by  

• Investigating the barriers to sustainable higher education in the post pandemic environment
  Saleha Ansari, Abdul Waheed
  Education and Information Technologies.2024; 29(18): 24677.     CrossRef
• A Scoping Review of Pakistani Healthcare Simulation: Insights for Lower-Middle-Income Countries
  Maria Bajwa, Fizza Najeeb, Haneen Alnazzawi, Ayesha Ayub, Jessica G Bell, Fouzia Sadiq
  Cureus.2024;[Epub]     CrossRef
• Health Care Simulation as a Training Tool for Epidemic Management
  Marcia A. Corvetto, Fernando R. Altermatt, Francisca Belmar, Eliana Escudero
  Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare.2023; 18(6): 382.     CrossRef
• Factors Affecting the Preparedness to Care for Patients with Highly Infectious Diseases among Nursing Staff in Long-term Care Hospitals: A Cross-Sectional Descriptive Study
  Ye Seul Lee, Min Hye Lee
  Korean Journal of Adult Nursing.2023; 35(1): 35.     CrossRef
• Effectiveness of Simulation-Based Education for Caring Patients with COVID-19
  Min Hye Lee, Eun-Young Noh
  Journal of Korean Academy of Nursing.2023; 53(4): 397.     CrossRef
• Education and Training Adaptations for Health Workers during the COVID-19 Pandemic: A Scoping Review of Lessons Learned and Innovations
  Perla Boutros, Nour Kassem, Jessica Nieder, Catalina Jaramillo, Jakob von Petersdorff, Fiona J. Walsh, Till Bärnighausen, Sandra Barteit
  Healthcare.2023; 11(21): 2902.     CrossRef
• COVID-19 Pandemic Support Programs for Healthcare Workers and Implications for Occupational Mental Health: A Narrative Review
  Eden David, Jonathan M. DePierro, Deborah B. Marin, Vanshdeep Sharma, Dennis S. Charney, Craig L. Katz
  Psychiatric Quarterly.2022; 93(1): 227.     CrossRef
• How stressful was the COVID-19 pandemic for residents specializing in family practice?. A study of stressors and psychological well-being of physicians in further training specializing in family practice (GP trainees) within a pandemic context
  Anna-Maria von Oltersdorff-Kalettka, Janina Meinel, Karen Voigt, Thomas Mundt, Markus Bleckwenn, Antje Bergmann, Mandy Gottschall
  BMC Primary Care.2022;[Epub]     CrossRef
• An update on developments in medical education in response to the COVID-19 pandemic: A BEME scoping review: BEME Guide No. 64
  Michelle Daniel, Morris Gordon, Madalena Patricio, Ahmad Hider, Cameron Pawlik, Rhea Bhagdev, Shoaib Ahmad, Sebastian Alston, Sophie Park, Teresa Pawlikowska, Eliot Rees, Andrea Jane Doyle, Mohan Pammi, Satid Thammasitboon, Mary Haas, William Peterson, Ma
  Medical Teacher.2021; 43(3): 253.     CrossRef
• Training in healthcare during and after COVID-19: proposal for simulation training
  Carolina Felipe Soares Brandão, Ellen Cristina Bergamasco, Gabriela Furst Vaccarezza, Maria Luiza Ferreira de Barba, Enrico Ferreira Martins de Andrade, Dario Cecilio-Fernandes
  Revista da Associação Médica Brasileira.2021; 67(suppl 1): 12.     CrossRef
• COVID-19 Critical Care Simulations: An International Cross-Sectional Survey
  Mohamad-Hani Temsah, Abdulkarim Alrabiaah, Ayman Al-Eyadhy, Fahad Al-Sohime, Abdullah Al Huzaimi, Nurah Alamro, Khalid Alhasan, Vaibhavi Upadhye, Amr Jamal, Fadi Aljamaan, Ali Alhaboob, Yaseen M. Arabi, Marc Lazarovici, Ali M. Somily, Abdulaziz M. Boker
  Frontiers in Public Health.2021;[Epub]     CrossRef
• Interprofessional work in health in the context of the COVID-19 pandemic: a scoping review
  Sâmara Fontes Fernandes, Jaira Gonçalves Trigueiro, Márcio Adriano Fernandes Barreto, Rhanna Emanuela Fontenele Lima de Carvalho, Maria Rocineide Ferreira da Silva, Thereza Maria Magalhães Moreira, Marcelo Viana da Costa, Rodrigo Jácob Moreira de Freitas
  Revista da Escola de Enfermagem da USP.2021;[Epub]     CrossRef
• Effect of Simulation-Based Education on the Preparedness of Healthcare Professionals for the COVID-19 Pandemic: a systematic review and meta-analysis
  Marc-André Maheu-Cadotte, Alexandra Lapierre, Guillaume Fontaine, Tanya Mailhot, Patrick Lavoie
  Science of Nursing and Health Practices.2021; 4(1): 1.     CrossRef
• Being Prepared During the Evolving COVID-19 Pandemic: A Neonatal Experience in Training and Simulation
  Juin Yee Kong, Srabani Samanta Bharadwaj, Amutha Chinnadurai, Selina Kah Ying Ho
  Frontiers in Pediatrics.2021;[Epub]     CrossRef
• The role of educating health-care personnel in prevention, diagnosis, or treatment of COVID-19
  Parinaz Tabari, Mitra Amini, Neil Arya, Mohsen Moghadami, Kaveh Khoshnood, Mansoureh Shokripour, Navid Omidifar
  Journal of Education and Health Promotion.2021; 10(1): 476.     CrossRef
• Reflections as 2020 comes to an end: the editing and educational environment during the COVID-19 pandemic, the power of Scopus and Web of Science in scholarly publishing, journal statistics, and appreciation to reviewers and volunteers
  Sun Huh
  Journal of Educational Evaluation for Health Professions.2020; 17: 44.     CrossRef