Training nurse simulation educators at scale to improve maternal and newborn health: a case study from Bihar, India

Background: Simulation has been shown to improve clinical and behavioral skills of birth attendants in low-resource settings at a low scale. Populous, low-resource settings such as Bihar, India, require large cadres of simulation educators to improve maternal and newborn health. It’s unknown if simulation facilitation skills can be adopted through a train of trainers’ cascade. To fill this gap, we designed a study to evaluate the simulation and debrief knowledge and skills of a cadre of 701 simulation educators in Bihar, India. In addition, we assessed the physical infrastructure where simulation takes place in primary healthcare facilities in Bihar, India. Methods: We performed a 1 year before–after intervention study to assess the simulation facilitation strengths and weaknesses of a cadre of 700 nurses in Bihar, India. The data included 700 pre-post knowledge and self-efficacy tests; videos of simulations and associated debriefs conducted by 700 providers at 40 primary healthcare centers Results: We observed a statistically significant difference in knowledge and self-efficacy scores before and after the 4-day PRONTO simulation educator training. The average number of participants in a simulation video was 5 participants (range 3-8). The average length of simulation videos was 10:21 minutes. The simulation educators under study, covered behavioral in 90% of debriefs and cognitive objectives were discussed in all debriefs. Conclusion: This is the first study assessing the simulation and debrief facilitation knowledge and skills of a cadre of 700 nurses in a low-resource setting. Simulation was implemented by local nurses at 353 primary healthcare centers in Bihar, India. Primary healthcare centers have the physical infrastructure to conduct simulation training. Some simulation skills such as communication via whiteboard were widely adopted. Advanced skills such as eliciting constructive feedback without judgement require practice.