Residents Working With Médecins Sans Frontières: Training and Pilot Evaluation

Residents Working With Médecins Sans Frontières: Training and Pilot Evaluation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Original research Residents Working With Médecins Sans Frontières: Training and Pilot Evaluation Alba Ripoll-Gallardo, Luca Ragazzoni, Ettore Mazzanti, Grazia Meneghetti, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-31885/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Aug, 2020 Read the published version in Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine → Version 1 posted 8 You are reading this latest preprint version Abstract Background Well-prepared humanitarian workers are now more necessary than ever. Essential to the preparation process are:clearly defined learning objectives, curricula tailored to the nuances of humanitarian settings, simulation-based training, and evaluation.This paper describes a training program designed to prepare medical residents for their first field deployment with Médecins Sans Frontières and presents the results of a pilot assessment of its effectiveness. Methods The training was jointly developed by the Research Center in Emergency and Disaster Medicine-CRIMEDIM of the Università del Piemonte Orientale, Novara, Italy, and the humanitarian aid organization Médecins Sans Frontières- Italy (MSF-Italy); the following topics were covered: disaster medicine, public health, safety and security, infectious diseases, psychological support, communication, humanitarian law, leadership, and job-specific skills. It used a blended-learning approach consisting of a 3-month distance learning module; 1-week instructor-led coaching; and a field placement with MSF. We assessed its effectiveness using the first three levels of Kirkpatrick’s training evaluation model. Results Eight residents took part in the evaluation. Four were residents in emergency medicine, 3 in anesthesia, and 1 in pediatrics; 3 of them were female and the median age was 31 years. Two residents were deployed in Pakistan, 1 in Afghanistan, 1 in the Democratic Republic of Congo, 1 in Iraq, 2 in Haiti and 1 on board of the MSF Mediterranean search & rescue ship. Mean deployment time was 3 months. The average median score for the overall course was 5 (excellent). There was a significant improvement in post-test multiple choice scores (p = 0.001) and in residents’ overall performance scores (P = 0.000001). Conclusion Residents were highly satisfied with the training program and their knowledge and skills improved as a result of participation. Trial registration: This study was approved by the Institutional Ethics Committee (date 24-02-2016, study code UPO.2015.4.10) Critical Care & Emergency Medicine Humanitarian Aid Education Residents Evaluation Low-resource environments Simulation Training E-learning Figures Figure 1 Figure 2 Figure 3 Introduction Widespread global health inequalities and the resulting shortage of humanitarian health workers have led to an increased presence of young doctors in disaster and humanitarian crises(1).However, although well-prepared humanitarian workers are more necessary than ever(2),traditional medical education struggles to meet the demands posed by globalization and the dramatic escalation of violence(3). Training objectives for physicians working with Médecins Sans Frontières (MSF) differ from the set of skills acquired in medical schools and residency programs.These professionals are in fact confronted with unique challenges and ethical dilemmas(3)including, but not limited to,different spectra of diseases, limited resources, cultural diversity, and social disruption. For these reasons, training objectives should be set far beyond individual job-specific skills and incorporate a set of core medical and non-medical competencies that all humanitarian workers must possess(4).Essential to the preparation process before first deployment are therefore clearly defined learning objectives, curricula tailored to the nuances of humanitarian settings, state-of-the-art teaching tools, including high fidelity simulation, and assessment to determine competency(5). Despite the need for curricula built on a testable package of knowledge and skills, evaluating the effectiveness of training programs is generallynot an essential component of preparedness for humanitarian health workers(6),orat best is limited to measuring satisfaction or knowledge. Assessing whether students improve their ability to handle complex situations is of paramount importance to guarantee the best outcomes for vulnerable populations; for this reason, this paper describes a training program designed to prepare medical residents for their first deployment with Médecins Sans Frontières and presents the results of a pilot assessment of its effectiveness. Materials And Methods Program Development Target Population Survey In 2012, we conducted a nationwide survey to investigate the interest of young doctors in humanitarian assistance(7). The survey included all residents in anesthesia and intensive care in Italy. Out of 924 respondents (RR 67.8%), 74.7% would have liked to make a major contribution to international humanitarian health care during their residencies and 97% would welcome specific training prior to deployment. Building on these results, we assumed that our training program would be of interest to doctors training in this discipline. Institutions involved In 2013, the Research Center in Emergency and Disaster Medicine-CRIMEDIM of the Università del Piemonte Orientale (Novara, Italy)in collaboration with Médecins Sans Frontières Italy (MSF-Italy) developed Humanitarian Medic(8),a competency-based training program delivered annually to senior residents in anesthesia andcritical care before their first deployment to MSF field missions. In 2015, the course was expanded to residents in emergency medicine and pediatrics. Candidate selection The number of participants cannot not exceed 10 per iteration; the course includes national and international senior residents (IV-V year) in anesthesia &critical care, emergency medicine, and pediatrics. Selection criteria coincide with the minimum MSF standard requirements for humanitarian workers, namely: At least B1 level proficiency in French and English (the languages of healthcare in the United Nations) according to the European Language Framework; Willingness to participate in international humanitarian field projects, including in armed conflict areas or following natural or man-made disasters; Flexibility and a positive attitude to working in multicultural contexts. Prior participation in international cooperation projects or humanitarian emergency response programs is considered an asset but is not mandatory for application. Candidate selection is carried out in a biphasic fashion by a recruitment commission composed of two CRIMEDIM investigators and two recruiters from MSF-Italy human resources department. Participants are first screened based on their curriculum vitae, self-assessed theoretical and practical skills and the results obtained in an on-line French and English language test. Subsequently, the best candidates are selected for interview. C urriculum Educational needs were established on the basis of an expert opinion survey(9),round tables with CRIMEDIM and MSF field experts, and a literature review of published competency sets for humanitarian workers(10).Since our training program targeted health workers but was meant to be extendable in the future to other sectors operating under the umbrella of humanitarian aid, four papers were selected on the basis of their cross-sectorial approach(6) and definition of discipline-specific competencies relevant to our audience(11–13).These competency sets served as a foundational basis for the course curriculum and were translated into 10 cross-sectorial and 1 profession-specific competency domain for each specialty [Table 1]. Learning objectives were phrased according to Bloom's Taxonomy. For each objective, a series of measurable performance goals was further developed. Curricula, learning and performance objectives were reviewed and validated by consensus between CRIMEDIM and MSF-Italy working groups. Table 1 Competency domains, general learning objectivesand some performance objectives at the basis of the training curriculum Competency domain General learning objectives Examples of performance objectives 1. Disaster medicine · Understand the definition and different phases of disasters. · Define the nature of injury or illness in relation to different types of disasters. · Describe objectives and features of disaster medicine. · Understand the international disaster response mechanism with involved bodies and organizations. · List the four phases of disaster management · Name the office of the United Nations responsible for the international coordination in case of disaster or humanitarian emergency 2. Incident Management System (IMS) · Describe the general principles and different phases of the IMS. · Demonstrate ability to work within an IMS. · Describe the concept and different methods of Mass Casualty Triage. · Define the concept of surge capacity and its role in unforeseen emergencies and disasters. · Correctly carry out the initial reporting from a simulated disaster site(METHANE) · Assign simulated victims with the correct priority code according to the START triage 3. Communication · Recognize a disaster in progress, assess and report the situation. · Define and apply the principles of successful communication with local and expatriate staff, within and among organizations and with the media during emergencies. · Describe the radio communication procedures and protocols. · Recognize the importance of postevent reports. · Implement the basic principles of communication in a public release statement with the media regarding the attack of a health facility by one belligerent party. · Write and present a post-event report after a simulated mass casualty event summarizing the facts occured and the actions taken. · Successfully collaborate with a member of local staff with very limited english speaking skills during the clinical management of a simulated critically -ll patient. 4. Resource management · Manage supplies, drugs and equipment and other resourcesfor an effective response. · Manage, supervise, and appropriately use local staff and expatriate aid workers during emergencies. · Consider early blood compatibility testing for relatives of patients in an hemorrhagic shock scenariowhen whole blood is scarce or not available. · Demonstrate competence in the use of outdated equipment (e.g ventilators) to provide safe anaesthesia in a low-resource-setting. 5. Public health · Recognise the top priorities for public health interventions during complex emergencies. · Describe indicators used to assess and monitor public health during complex emergencies. · Understand key epidemiological principles and terminology. · Define the minimum levels to be attained in humanitarian interventions regarding the provision of water, sanitation and hygiene. · Define the minimum levels to be attained in humanitarian interventions regarding the provision of food and nutrition. · Identify which infectious diseases can constitute a major threat following a disaster according to the geographical location and the type of emergency occurring. · Describe the information to be gathered during a Initial Rapid Assessment and ellaborate an intervention plan according to the identified public health needs. · Name the minimum quantityof safe drinking water (liters/person/day) to be provided in an humanitarian intervention. · List the main anthropometric indices used to assess malnutrition. · Demonstrate knowledge about the age groups to be covered by a measles vaccination campaign 6. Safety and security · Understand the need for a safe and secure approach in humanitarian environments. · Analyze the security environment on the basis of the seven pillars of security. · Apply the preventive measures and/or individual or collective responsibilities adapted to each form of stress. · Identify sources of risk, describe risk scenarios and identify risk mitigation measures. · Demonstrate successful negotiation skills when approaching a simulated check point. · Demonstrate ability to prevent incidents during road travels (e.g carrying ID card, being able to clearly explane the mission of his/her organization etc). · Identify landmine markings during outdoors exercises 7. Ethics and international humanitarian law · Apply basic principles of medical ethics to disaster situations. · Recognize and react accordingly to the difficulties entailed by humanitarian scenarios where different cultural backgrounds are represented. · Define the concept and understand the origins of International Humanitarian Law · List the main International Human Rights · Describe the role of International Humanitarian Law in in protecting the dignity and rights of the most vulnerable populations during armed conflicts · Demonstrate tollerancewhen dealing with local staff and patientswith different cultural background (e.g covered with burqa). · Describe the origin of the Geneva Convention 8. Situational awareness · Respond appropriately to an ever-changing environment and stress-induced situations. · Adapt to pressure and change to operate effectively within humanitarian contexts. · Demonstrate avoiding fixation errors during the management of critically-ll patients in simulated low-resource scenarios. · Demonstrate ability to anticipate likely events in crisis situations (e.g a huge number of victims to come after a single patient presents with acute organophosphorus pesticide poisoning in a war context). 9. Psychological support · Describe the main psychological needs in emergency contexts. · Describe the essential criteria to organize actions in psychological support. · Apply the principles of psychological first aid in emergency situations · Identify and list the basic principles of Disaster Mental Health. Demonstrate ability to provide the principles of Psychological First Aid · Demonstrate ability to develop good practices to manage personal stress in order to mitigate potential adverse effects of stress · 10. Leadership · Understand the definition of leadership and recognize the importance in an emergency context. · Describe the different management styles. · Understand conflict management and modify one’s own management style. · Apply the principles of Non-Violent communication. · Demonstrate ability to implement a Non-Violent communication when giving a member of the local staff a negative feedback regarding his performance during a recent emergency. · Demonstrate ability to make firm decisions during a critical event: e.g priority of transport for severely injured patients in an hostile environment. 11. Clinical considerations in the specific field of Anaesthesia, Pediatrics and Emergency Medicine in Low Resource Settings · Understand and apply the principles of safe anaesthesia, emergency medicine or pediatrics in low-resource settings acording to the needs and resource available. · · Demonstrate good knowledge in the use of Halothane, ketamine, suxamethonium and pancuronium · Demonstrate ability to perform a newborn resuscitation in a resource-constrained environment · Promptly recognize and treat signs and symptoms of malaria in high risk areas Delivery method The course intends to expose participants to a blended-learning experience consisting of three months of distance, self-directed learning and one week of residential instructor-led teaching. E-learning takes place through the Modular Object-Oriented Dynamic Learning Environment (MOODLE) educational software hosted on CRIMEDIM’s servers. The platform works as a content-driven learning model, hosting 11 e-modules and video lectures and offering a suite of tools and online-multiplayer-virtual exercises. The residential phase takes place at the SIMNOVA simulation center in Novara, Italy, and includes class-room sessions, table-top exercises, and group discussions withemphasis on high fidelity and outdoor real-size simulation exercises. Scenarios are designed based on the equipment, drugs and diagnostic tools available in MSF field projects and residents are exposed to the challenges most commonly encountered in daily activities. In clinical management scenarios, actors comply with the dress code of the country where the scenario is based and are also trained to act as typical members of the local staff. E-learning materials and best performances for simulation exercises are jointly developed based on current international guidelines and the typical resources available in real-life MSF missions. Upon successful completion of both phases, students receive a certificate of completion and are deployed to MSF field projects as local staff supervisors to work as part of the hospital duty roster. Evaluation Participants The first two editions in 2013 and 2014 were not included in the evaluation but were offered on a pilot basis to test the feasibility of the project from an organizational standpoint and refine the course contents according to the feedback provided by students and MSF field supervisors.; only participants to the 2015 course iteration (n=8) were included in the evaluation. All were Italian, four were residents in emergency medicine, 3 in anesthesia, and 1 in pediatrics; 3 of them were female and median age was 31 years old. Two residents were deployed in Pakistan, 1 in Afghanistan, 1 in the Democratic Republic of Congo, 1 in Iraq, 2 in Haiti and 1 on board of the MSF Mediterranean search & rescue ship. Mean deployment time was 3 months. Method The Kirkpatrick’s evaluation model has recently been used to evaluate training programs for health providers and focuses on the sequential assessment of the following levels(14): Level 1- Reaction: measures students’ satisfaction with the program; Level 2- Learning: measures improvement in knowledge, attitudes and skills; Level 3- Behavior : measures the transfer of learning to the workplace; Level 4- Results: measures the objective changes occurred as a result of participation in the training program. To determine the effectiveness of our course, we tested levels 1 to 3 using a prospective, observational, single-cohort study. Evaluation plan and evaluation tools. We designed the evaluation plan according to the recommendations of Kirkpatrick et al(15)[Figure1]: We assessedReactionusing a 5-point Likert scale questionnaire with a separate space for commentaries and personal opinions. We evaluated the three dimensions of Learningseparately in a pre- and post-test [Figure 1] as follows: Knowledge with a 30-question-multiple-choice test. Attitude with a 12-question-5-point Likert scale questionnaire. In this study, the term “attitude”was defined as the students’ positive or negative predisposition toward the competency domains at the basis of the course. Skills with simulation-based performance tests, in which each student acted as lead physician in the management of a critically-ill patient in a low-resource emergency room. To decrease the potential impact that reiterative exposure to simulation exercises during the residential phase might have had on post-test performance, students attended standardized simulation tutorials and managed a number of simulated cases before entering the pre-test scenario. Pre- and post-test scenarios progressed on a predefined fashion according to the cue system described by Kim et al.(16) We videotaped resident’s performance and passed the material on to an external independent evaluator, who rated all students according to the validated Italian translation (TIGR)(17)of the Ottawa Global Rating Scale (Ottawa GRS)(16).This scale uses a 7-point semi-anchored design to evaluate residents’ overall performance and their leadership, problem solving, situational awareness, resource utilization, and communication skills. Pre- and post-test were different tests with the same level of difficulty. Every resident was followed during the missionby his immediate MSF field supervisor who qualitatively assessed improvements inbehavior using the MSF standard evaluation formfor first missioners (form available upon request). MSF field supervisors were blinded to the students’ completion of the training program before deployment. This was necessary to prevent students’ participation from influencing the judgement of supervisorsand ensure that evaluations were carried out as usual for any MSF first missioner. All the evaluation tests/forms and case scenarios used to conduct the evaluation are available upon request. Statistical tests and data analysis The statistical analysis of Level 2 (Learning) was conducted by taking the difference in pre- and post-test scores as measured with a multiple-choice test as the primary objective. The difference in pre-and post-overall performance was defined as the secondary objective. We defined null hypotheses as no difference between the before and after multiple-choice test scores and no difference between the before and after overall performance. Alternative hypotheses were that both multiple choice test scores and overall performance scores would change significantly after completion of the course. We tested the null hypothesis of the primary objective of no difference between pre- and post-test scores against the two-sided alternative hypothesis of significant difference. The null hypothesis of the secondary objective of no difference between pre- and post-training overall performance scores was tested against the two-sided alternative of significant difference. Statistical analysis was performed using “R: A language and environment for statistical computing.” (R Development Core Team, Vienna, Austria). Null and alternative hypotheses and the statistical methods were completely specified before data collection. Differences between groups for the primary and secondary objectives were assessed using paired t -tests. P-values of less than .05 were considered significant for all tests. Two-sided alternative hypotheses were used in all cases. Ethical clearance To ensure anonymity and confidentiality during the entire evaluation process, we assigned a tracking number to each participant. This number was then reported on answer sheets, evaluation forms and videotape labels. All students signed the informed consent. This study was approved by the institutional Ethics Committee (date 24-02-2016, study code UPO.2015.4.10). Results Reaction All residents rated the course as “excellent” and strongly agreed with the statement “I would recommend the course to other doctors in training”. All participants emphasized their satisfaction with both course contents and mode of delivery. In particular, high-fidelity simulation exercises were highly appreciated. Two students expressed the view that the course schedule was too tight and one suggested adding more training in negotiations techniques. Learning There was a significant improvement in post-test multiple-choice scores when compared to pre-test scores (p = .001) (mean effect: 10.4/30; 95% CI: 5.7 to 15.0) [Figure 2] and also a significant improvement in residents’ overall performance scores (P = .000001) (mean effect: 3; 95% CI: 2.4 to 3.6) [Figure 3]. The median score for all other fields also improved after the training course (median differences: Leadership 3.3; Problem solving 2.6; Situational Awareness 3; Resource Utilization 3.5; Communication 2.7). No differences were detected in attitudes scores before and after the course. Behavior For most participants, MFPs highlighted the following strengths: compliance with MSF standards and principles, flexibility, good team working skills and cross-cultural sensitivity. All residents were recommended for future MSF missions [Table 2]. Table 2 Summary of evaluations from fieldsupervisors for each candidate Student Strong competences Competences to develop 1 Goodanalyticalthinking, well-organized, high workingcapacity, good training skills, compliance with MSF standards and principles, flexibility, empathy, good mass casualty management skills, goodtechnicalskills, hard work, good team workingskills, goodreource management skills. Human resource management Tropical medicine 2 Well-organized, goodtechnicalskills, good training skills, hard work, good team workingskills,goodreource management skills,cross-cultural sensitivity, compliance with MSF standards and principles, goodnegotiationskills, goodcomunicationskills. Human resource management 3 Cross-cultural sensitivity, good team workingskills, good training skills, goodpeople management skills, good leadership skills, well-organized, goodanalyticalthinking, goodproblemsolvingskills, goodreource management skills, gooddecisionmakingskills, responsibility, flexibility, good stress management skills, compliance with MSF standards and principles, implementgoodstrategies to ensure security and safetyskills in daily work, goodcomunicationskills, hard worker, workedas a personwith more experience in MSF. Participation in monthy reports 4 Cross-cultural sensitivity, good team workingskills, good training skills, compliance with MSF standards and principles, goodatmotivatinglocal staff, goodreource management skills, flexibility, multitasking, deepcommitment, hard work. Self-health care 5 Good mass casualty management skills, compliance with MSF standards and principles, good leadership skills, goodcommunicationskills, goodteam workingskills, responsibility, good training skills. Language skills 6 Goodanalyticalthinking, compliance with MSF standards and principles, good team workingskills, goodatsettingpriorities, goodclinicalskills, good team workingskills, goodcomunicationskills, flexibility, multitasking, will to improveorganizationwithin the project. Too ambitious with local staff settingsometimesunrealisticgoals 7 Maximum committment to MSF, compliance with MSF standards and principles, cross-cultural sensitivity, verygoodattitudetowards MSF staff, awareness of the project from a global perspective and notonly in own area of competence,committment to promotecapacity building, good team workingskills, goodatmotivatinglocal staff, flexibility, implemented an operationalresearchprojectapproved by MSF medicalcoordinationunit. Self-protectionduring life savingmaneuvers 8 Highly adaptable, goodskills to work with limitedresources, flexibility, responsibility,goodatcoaching and support oflocal staff, goodreource management skills. Discussion Expatriate health providers have been observed to be ill-prepared during recent humanitarian emergencies due to lack of experience in international relief and inadequate understanding of the local context(4,18). For this reason, the international humanitarian community has been drawing attention to the compelling need for competency-based training curricula based on astandard set of cross-cutting and profession-specific competencies(4,19).Since young doctors, born in a new era of highly-specialized medicine, have been increasing their presence in international aid projects, good preparation and performance oversight are paramount to guarantee best practice also in resource-strained settings(9). To our knowledge, this is the first study that describes the implementation and evaluation of a course based on published cross-sectorial and profession-specific competencies, jointly developed by an academic center and a robust humanitarian organization. Interestingly, while 61% of training programs for humanitarian workers in Europe(19)are defined as “competency-based”, none of them incorporates previously published competency sets. Evaluating the effectiveness of training programs is necessary to ensure credibility and decide whether they should be continued or not. In this regard, the assessment of a course for humanitarian workers using the first three levels of the Kirkpatrick’s evaluation model and including high fidelity simulation represents a real novelty. Overall, students’ satisfaction (Level 1) with the program was high. In particular, the delivery method and the residential phase were highly appreciated. It is worth noting that, aside from course curriculum and students’ previous academic background, the structure of the program and the educational environment also play a central role in learning(20).Over the last years, medical education has shifted toward different delivery modes in an attempt to achieve better educational outcomes. The combination of face-to-face lectures and online teaching, defined as blended learning, strengthens the interaction between course participants, lecturers and resources(21) and represents a flexible pedagogical system(22). Our study showed that students’ competency in simulated humanitarian scenarios increased after course completion (Level 2). The term “competency” is defined as the set of knowledge, attitudes and skills required to accomplish a task. A competency-based training must ensure the acquisition of a theoretical understanding of relevant concepts in the field of humanitarian assistance (e.g., learning the START triage algorithm), promote a positive predisposition toward the working methods and actions to be adopted in low-resource settings (e.g., recognizing the importance of applying the START triage), and develop students’ practical skills (e.g., conducting good quality triage in case of a mass casualty event). Yoon et al(23)used the Kirkpatrick model to evaluate a continuing professional development training for physicians and physician assistants. In their study, a single 5-point Likert scale form filled by trainers and trainees was used to assess learning. However, it is important to highlight that the inclusion of separate tests for knowledge (e.g., multiple choice), attitudes (e.g.,Likert scale questionnaire), and skills (e.g., performance test) should be preferred whenever possible(14). Our results reflect a clear improvement in participants’ knowledge and overall performance in a high-fidelity scenario, while no change in attitude was evident. A plausible explanation may lie in the selection process itself. Since all students were highly motivated and had decided to take part in the course on a voluntary basis, a positive attitude was to be expected. In a recent study, Schwartz et al highlighted the prominent role that simulations, and particularly high-fidelity simulations, may play in enhancing residents’ skills in the management of complex cases(24).Simulated environments are an invaluable setting to teach crisis resource management (CRM) skills(25),which are extremely important in humanitarian contexts. Some challenges commonly encountered in the field (e.g., communication barriers and shortage of resources) can be easily reproduced through simulation, giving students the chance to become acquainted with similar situations, receive feedback and improve their performance with no risks to patients. At the same time, simulated scenarios allow for the evaluation of performance objectives, reflecting how students would use in the field the competencies acquired through training(11).In their review entitled “Transfer of learning and patient outcome in simulated crisis resource management”, Boet et al found that CRM simulations improve not only learners behavior in the workplace but also, and more importantly, patient outcomes(26). According to Kirkpatrick et al,(14)a positive reaction and evidence of improvement in learning do not necessarily lead to desired changes in behavior. The transfer of learning to the workplace is heavily conditioned by the so-called ‘work climates’, and these are clearly established by a supervisor’s reaction to students’ practical application of the competencies acquired. To promote an encouraging work environment, heads of department and supervisors should be informed about the students’ participation in the training program, and preferably be involved in its development(14).In our case, keeping MSF field evaluators blinded was mandatory to prevent biases; however, all participants received very good feedbacks. The reason for this may be the fact that educational needs were decided and endorsed by a panel of experts that included MSF training staff. This ensured that the practical concepts, organizational principles and techniques taught complied with the organization’s best practice standards. The collaboration between an academic center and a robust humanitarian organization allowed us to demonstrate the effectiveness of a pre-deployment training course in improving participants’ learning. This may have several promising implications: If properly trained, medical residents with no previous experience in the field could be deployed without compromising the quality of care delivered. Incountrieswhere residents are authorized by contract to practice abroad for a certain period of time while maintaining their financial remuneration,non-governmental organizations (NGOs) could fill field gaps more rapidly by deploying well-prepared but inexpensive personnel. From an organizational standpoint, agreements between NGOs and training centers would allow humanitarian staff to benefit from simulation-based training, which is presently the best approximation to real work in emergency and disaster contexts(27). It is our hope that this collaborative initiative will serve worldwide as a model to bridge the gap between academia and field operations and contribute to the growth and professionalization of the humanitarian health sector. Limitations Despite our efforts to conduct this study thoroughly, a number of limitations should be considered. The competency sets and skills at the basis of our training curriculum, albeit published and peer-reviewed, were never validated. However, the authors believe that basing the learning objectives of the course on the needs emerged from discussions with different groups of experts would go some way toward remedying this deficiency.Incorporating the input of trainers working for the NGO partner would also be a fair compromise in the absence of a globally recognized competency set for humanitarian workers. The sample size used to test the effectiveness of this course was limited to 8 participants. Since our target population was composed of doctors still at an early stage of their careers, the tight enrollment criteria severely limited the number of eligible applicants for each iteration. Also, the evaluation process was logistically challenging and very resource consuming. All participants had to travel to Novara on purpose for the pre-test and their travel and living expenses had to be covered for two days both pre- and post-test. This prevented the evaluation to be repeated in the following editions, which would have positively impacted the sample size. Even though both primary and secondary outcomes improved significantly after the course, a larger study would be useful to confirm the significance of the specific changes found in each field of the TIGR evaluation scale. This study only assessed the first three levels of the Kirkpatrick model; additionally, for level 3 (Behavior) no pre-test was conducted. Since the course was designed to prepare residents to their first deployment with MSF, exposition to the real workplace environment was only possible upon completion. All participants obtained very good assessments from field supervisors, which may suggest that the training program played a role in the quality of their respective performances in the field. Level 4 (Results) measures the effect of students’ actions, which considering our target population should have translated into measurement of patients’ outcomes (e.g., decreased mortality). Taking into account the high turnover of doctors in humanitarian contexts and the diversity in the pattern of disease and affluence of patients depending on country, season, and ongoing environmental conditions (armed conflict, natural disaster, etc.), the influence on patients’ outcomes would have been very hard to ascertain. Finally, this study did not include a control group. According to MSF policy, deploying untrained doctors in the field at this early stage of their careers would have gone against basic principles of best practice. Conclusions Over the last decade, the humanitarian community has stressed the need to improve the quality of response through further investments in training for aid workers. Residents were highly satisfied with our training program and their knowledge and skills in simulated humanitarian environments improved as a result of participation. The implementation of this project shows how academia can successfully partner with humanitarian aid organizations to promote the professionalization of future humanitarian health workers. Further studies should be conducted to assess whether training programs effectively increase the competence of humanitarian workers in the field and if this translates into improvement of patients’ outcomes or further advantages for deploying organizations. List Of Abbreviations MSF: Médecins Sans Frontières; CRIMEDIM: Research Center in Emergency and Disaster Medicine of the Università del Piemonte Orientale, Novara, Italy; MOODLE: Modular Object-Oriented Dynamic Learning Environment; TIGR: Translated Italian Global Rating Scale; Ottawa GRS: Ottawa Global Rating Scale; CRM: crisis resource management; NGOs: non-governmental organizations. Declarations Ethics approval and consent to participate: All students signed the informed consent. This study was approved by the institutional Ethics Committee (date 24-02-2016, study code UPO.2015.4.10). Consent for publication: all authors read the manuscript and agreed to its submission and publicationin the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. Availability of data and materials: complete data and evaluation forms/tests used are available upon request. Competing interests: the authors declare that they have no competing interests Funding: none Authors' contributions: ARG is anesthesia consultant at Maggiore Hospital, School of Medicine, in Novara and postdoctoral fellow at CRIMEDIM, Novara, Italy. She was first investigator and training program developer and contributed to the curriculum design, implementation of the evaluation and data collection and interpretation. She drafted the manuscript and gave final approval for the final version to be published; she is accountable for the accuracy and integrity of every part of the study.LR is postdoctoral fellow at CRIMEDIM, Novara, Italy. He contributed as training program developer and to curriculum design and training implementation. EM is pool manager at Médecins Sans Frontières-Italy, Rome, Italy.He contributed as training program developer and to curriculum design. He was also accountable for the matching of residents to their missions in the field. GM is anesthesia consultant at Maggiore Hospital, School of Medicine, Novara, Italy. She acted as main assistant and organizer for the SIMNOVA simulation exercises.JMF is clinical professor of Emergency Medicine at the University of Alberta, Edmonton, AB, Canada, and visiting professor of Disaster Medicine at the Università del Piemonte Orientale, Novara, Italy. He contributed to study design and data analysis. AC is an Anesthesia and Intensive Care Resident in and CRIMEDIM research assistant, Università del Piemonte Orientale, Novara, Italy. He contributed to the organization of the training program and its evaluation. FDC is full professor at the department of Anesthesia and Intensive Care, Maggiore Hospital, School of Medicine and director of CRIMEDIM, Novara, Italy. He contributed to the organization of the training program and its evaluation. Acknowledgements: the authors thank all lecturers, assistants and actors involved in the training and simulations. They thank Pier Luigi Ingrassia, director of the simulation center SIMNOVA of the Università del Piemonte Orientale, for lending the simulation facilities and Katia Ansalone for her professional writing services. References Fouad FM, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts AP, et al. Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet–American University of Beirut Commission on Syria. Vol. 390, The Lancet. Lancet Publishing Group; 2017. p. 2516–26. Redmond AD, Mardel S, Taithe B, Calvot T, Gosney J, Duttine A, et al. A qualitative and quantitative study of the surgical and rehabilitation response to the earthquake in Haiti, January 2010. Prehosp Disaster Med.2011;26:449–56. Wass V, Southgate L. Doctors Without Borders. Acad Med. 2017;92:441–3. Burkle FM, Walls AE, Heck JP, Sorensen BS, Cranmer HH, Johnson K, et al. Academic affiliated training centers in humanitarian health, Part I: program characteristics and professionalization preferences of centers in North America. Prehosp Disaster Med 2013;28:155–62. Cranmer H, Chan JL, Kayden S, Musani A, Gasquet PE, Walker P, et al. Development of an evaluation framework suitable for assessing humanitarian workforce competencies during crisis simulation exercises. Prehosp Disaster Med. 2014;29:69–74. Burkle FM Jr James JJ. Cross-disciplinary competency and professionalization in disaster medicine and public health. In: Gursky E, Hreckovski B, eds. Handbook for Pandemic and Mass-Casualty Planning and Response 2012. Amsterdam: IOS Press; 2012:72-83. LJM. Ripoll Gallardo A, Ingrassia PL, Ragazzoni L, Djalali A, Carenzo L, Burkle FM, et al. Professionalization of anesthesiologists and critical care specialists in humanitarian action: a nationwide poll among italian residents. Prehosp Disaster Med. 2015;30:16–21. Course HM. Available at https://crimedim.uniupo.it/humanitarian-medic/. Last accessed January 2020. Djalali A, Ingrassia PL, Della Corte F, Foletti M, Gallardo AR, Ragazzoni L, et al. Identifying Deficiencies in National and Foreign Medical Team Responses Through Expert Opinion Surveys: Implications for Education and Training--ERRATUM. Prehosp Disaster Med. 2015;30:224. Ripoll Gallardo A, Djalali A, Foletti M, Ragazzoni L, Della Corte F, Lupescu O, et al. Core Competencies in Disaster Management and Humanitarian Assistance: A Systematic Review. Disaster Med Public Heal Prep. 2015;9:430–9. Schultz CH, Koenig KL, Whiteside M, Murray R. National Standardized All-Hazard Disaster Core Competencies Task F. Development of national standardized all-hazard disaster core competencies for acute care physicians, nurses, and EMS professionals. Ann Emerg Med. 2012;59:196-208 e1. Suchdev PS, Shah A, Derby KS, Hall L, Schubert C, Pak-Gorstein S, et al. A proposed model curriculum in global child health for pediatric residents. Acad Pediatr. 2012;12:229–37. Rossler B, Marhofer P, Hupfl M, Peterhans B, Schebesta K. Preparedness of anesthesiologists working in humanitarian disasters. Disaster Med Public Heal Prep. 2013;7(4):408–12. Kirkpatrick DL San Francisco, CA: Berret-Koehler Publishers; 2006 and KJDETPTFL 3rd ed. Kirkpatrick DL and Kirkpatrick JD. Implementing the Four Levels: A Practical Guide for Effective Evaluation of Training Programs. San Francisco CB-KP 2007. Kim J, Cardinal P, Chiu M, Clinch J. ND. A pilot study using high-fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Critical Care Medicine, High-Fidelity Simulation, and Crisis Resource Management I Study. Crit Care Med. 2006;34:2167–74. Franc JM, Verde M, Gallardo AR, Carenzo L, Ingrassia PL. An Italian version of the Ottawa Crisis Resource Management Global Rating Scale: a reliable and valid tool for assessment of simulation performance. Intern Emerg Med. 2017;12:651–6. Van Hoving DJ, Wallis LA, Docrat F, De Vries S. Haiti disaster tourism--a medical shame. Prehosp Disaster Med [Internet]. 2010;25(3):201–2. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20586008 Ingrassia PL, Foletti M, Djalali A, Scarone P, Ragazzoni L, Corte FD, et al. Education and training initiatives for crisis management in the European Union: a web-based analysis of available programs. Prehosp Disaster Med. 2014;29:115–26. Hutchinson L. Educational environment. BMJ. 2003;326:810–2. Garrison DR KH 2004. Blended learning: Uncovering its transformative potential in higher education. IHE 7(2):95–105. Lewin LO, Singh M, Bateman BL, Glover PB. Improving education in primary care: development of an online curriculum using the blended learning model. BMC Med Educ. 2009;9:33. Yoon HB, Shin JS, Bouphavanh K, Kang YM. Evaluation of a continuing professional development training program for physicians and physician assistants in hospitals in Laos based on the Kirkpatrick model. J Educ Eval Heal Prof. 2016;13:21. Schwartz KR, Prentiss KA. Simulation in Pre-departure Training for Residents Planning Clinical Work in a Low-Income Country. West J Emerg Med. 2015;16:1166–72. Gaba DM, Howard SK, Fish KJ, Smith BE, Sowb YA : Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. Simulation Gaming 2001, 32:175-193. Boet S, Bould MD, Fung L, Qosa H, Perrier L, Tavares W, et al. Transfer of learning and patient outcome in simulated crisis resource management: a systematic review. Can J Anaesth. 2014;6:571–82. Amat Camacho N, Hughes A, Burkle Jr. FM, Ingrassia PL, Ragazzoni L, Redmond A, et al. Education and Training of Emergency Medical Teams: Recommendations for a Global Operational Learning Framework. PLoS Curr.2016;8. Cite Share Download PDF Status: Published Journal Publication published 25 Aug, 2020 Read the published version in Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine → Version 1 posted Reviewer # 2 agreed at journal 07 Jul, 2020 Reviewers invited by journal 15 Jun, 2020 Reviewer # 1 agreed at journal 15 Jun, 2020 Review # 1 received at journal 15 Jun, 2020 Editor assigned by journal 28 May, 2020 Submission checks completed at journal 27 May, 2020 Editor invited by journal 27 May, 2020 First submitted to journal 26 May, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-31885","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Original research","associatedPublications":[],"authors":[{"id":624959,"identity":"0600ce36-2a77-4d55-bb80-71f9ad3024f3","order_by":0,"name":"Alba Ripoll-Gallardo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYDACdh4QKQFkMDc+YGBgBnIYG0BCPDi1MMO0MDM2G6BowamHGSbDzNgmAdECBbi08DfzHvzAuMcijx+opepGhTWDwe3mNumCCgYZexxaJA7zJUswPJMolmxmbLudcyadweDOwTbpGWfwOOwwj4EEwwGJxA2HgVpy2w4zGNxIbJPmbcOtRf4wj/EPmJbi3H9EaDE4zGMGt4U5t4EILYaH+dIsEg6A/dIsnXMsnUfyRmKz9YwzEjw8B7BrkTvee/jGhwN1efzszQc/59RYy/HdSH94u6DCxp69AZf/gSABjCAA7BxmcOQSAAkoPGbsikbBKBgFo2CEAgAQ10+dEABkLAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-4719-7333","institution":"CRIMEDIM","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Alba","middleName":"","lastName":"Ripoll-Gallardo","suffix":""},{"id":624960,"identity":"c27bb925-d884-43af-b62e-2483b7a3742f","order_by":1,"name":"Luca Ragazzoni","email":"","orcid":"","institution":"CRIMEDIM","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Luca","middleName":"","lastName":"Ragazzoni","suffix":""},{"id":624961,"identity":"291287dd-17fc-417d-9092-6e2d2e7f148e","order_by":2,"name":"Ettore Mazzanti","email":"","orcid":"","institution":"Medecins sans Frontieres","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ettore","middleName":"","lastName":"Mazzanti","suffix":""},{"id":624962,"identity":"8b719c80-e03b-410b-a586-6c9a907803f8","order_by":3,"name":"Grazia Meneghetti","email":"","orcid":"","institution":"CRIMEDIM","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Grazia","middleName":"","lastName":"Meneghetti","suffix":""},{"id":624963,"identity":"5622e2c9-5070-4104-8b8e-3d7d429e86ee","order_by":4,"name":"Jeffrey Michael Franc","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jeffrey","middleName":"Michael","lastName":"Franc","suffix":""},{"id":624964,"identity":"3ae4b247-ad9e-4435-8c72-58fd90ab5ad1","order_by":5,"name":"Alessandro Costa","email":"","orcid":"","institution":"CRIMEDIM","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alessandro","middleName":"","lastName":"Costa","suffix":""},{"id":624965,"identity":"a4c47fdc-7b2c-4103-84a8-2d1915df7560","order_by":6,"name":"Francesco Della Corte","email":"","orcid":"","institution":"CRIMEDIM","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Francesco","middleName":"Della","lastName":"Corte","suffix":""}],"badges":[],"createdAt":"2020-05-28 05:02:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-31885/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-31885/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13049-020-00778-x","type":"published","date":"2020-08-25T12:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":1240270,"identity":"b39b09f5-f1d4-4a85-85cd-1afbf7abce97","added_by":"auto","created_at":"2020-06-03 16:56:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50469,"visible":true,"origin":"","legend":"Graphic depiction of the evaluation process. Overall, residents participated in a face- to-face course opening session where Level 2-pre-test was administered. Level 1 and Level 2 (post-test) were assessed at the end of the residential course. Behavior was evaluated at the end of students’ field missions.","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-31885/v1/Figure1.jpg"},{"id":1240271,"identity":"4ca5d927-c5bf-4b89-9af7-d48c97efa01b","added_by":"auto","created_at":"2020-06-03 16:56:04","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":20221,"visible":true,"origin":"","legend":"Boxplot representing multiple choice test scores before and after the course.","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-31885/v1/Figure2.jpg"},{"id":1240272,"identity":"2db09dc3-cfa9-40f9-b384-df7887e532d1","added_by":"auto","created_at":"2020-06-03 16:56:04","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":20875,"visible":true,"origin":"","legend":"Boxplot representing (TIGR) overall performance test scores before and after the course","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-31885/v1/Figure3.jpg"},{"id":13535412,"identity":"2a7f6a82-5705-42be-9428-bca45f06c898","added_by":"auto","created_at":"2021-09-17 01:28:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":549669,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-31885/v1/d34ee76a-0ae5-4575-8f63-05fafefdf09a.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eResidents Working With Médecins Sans Frontières: Training and Pilot Evaluation\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWidespread global health inequalities and the resulting shortage of humanitarian health workers have led to an increased presence of young doctors in disaster and humanitarian crises(1).However, although well-prepared humanitarian workers are more necessary than ever(2),traditional medical education struggles to meet the demands posed by globalization and the dramatic escalation of violence(3).\u003c/p\u003e\n\u003cp\u003eTraining objectives for physicians working with M\u0026eacute;decins Sans Fronti\u0026egrave;res (MSF) differ from the set of skills acquired in medical schools and residency programs.These professionals are in fact confronted with unique challenges and ethical dilemmas(3)including, but not limited to,different spectra of diseases, limited resources, cultural diversity, and social disruption. For these reasons, training objectives should be set far beyond individual job-specific skills and incorporate a set of core medical and non-medical competencies that all humanitarian workers must possess(4).Essential to the preparation process before first deployment are therefore clearly defined learning objectives, curricula tailored to the nuances of humanitarian settings, state-of-the-art teaching tools, including high fidelity simulation, and assessment to determine competency(5).\u003c/p\u003e\n\u003cp\u003eDespite the need for curricula built on a testable package of knowledge and skills, evaluating the effectiveness of training programs is generallynot an essential component of preparedness for humanitarian health workers(6),orat best is limited to measuring satisfaction or knowledge. Assessing whether students improve their ability to handle complex situations is of paramount importance to guarantee the best outcomes for vulnerable populations; for this reason, this paper describes a training program designed to prepare medical residents for their first deployment with M\u0026eacute;decins Sans Fronti\u0026egrave;res and presents the results of a pilot assessment of its effectiveness.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003ch2\u003eProgram Development\u003c/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003e\u003cu\u003eTarget Population Survey\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eIn 2012, we conducted a nationwide survey to investigate the interest of young doctors in humanitarian assistance(7). The survey included all residents in anesthesia and intensive care in Italy. Out of 924 respondents (RR 67.8%), 74.7% would have liked to make a major contribution to international humanitarian health care during their residencies and 97% would welcome specific training prior to deployment. Building on these results, we assumed that our training program would be of interest to doctors training in this discipline.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003e\u003cu\u003eInstitutions involved \u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eIn 2013, the Research Center in Emergency and Disaster Medicine-CRIMEDIM of the\u0026nbsp; Universit\u0026agrave; del Piemonte Orientale (Novara, Italy)in collaboration with M\u0026eacute;decins Sans Fronti\u0026egrave;res Italy (MSF-Italy) developed Humanitarian Medic(8),a competency-based training program delivered annually to senior residents in anesthesia andcritical care before their first deployment to MSF field missions. In 2015, the course was expanded to residents in emergency medicine and pediatrics.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003e\u003cu\u003eCandidate selection\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe number of participants cannot not exceed 10 per iteration; the course includes national and international senior residents (IV-V year) in anesthesia \u0026amp;critical care, emergency medicine, and pediatrics. Selection criteria coincide with the minimum MSF standard requirements for humanitarian workers, namely:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eAt least B1 level proficiency in French and English (the languages of healthcare in the United Nations) according to the European Language Framework;\u003c/li\u003e\n\u003cli\u003eWillingness to participate in international humanitarian field projects, including in armed conflict areas or following natural or man-made disasters;\u003c/li\u003e\n\u003cli\u003eFlexibility and a positive attitude to working in multicultural contexts.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003ePrior participation in international cooperation projects or humanitarian emergency response programs is considered an asset but is not mandatory for application.\u003c/p\u003e\n\u003cp\u003eCandidate selection is carried out in a biphasic fashion by a recruitment commission composed of two CRIMEDIM investigators and two recruiters from MSF-Italy human resources department. Participants are first screened based on their curriculum vitae, self-assessed theoretical and practical skills and the results obtained in an on-line French and English language test. Subsequently, the best candidates are selected for interview.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003e\u003cu\u003eC\u003c/u\u003e\u003ca href=\"http://thesecondprinciple.com/instructional-design/types-of-curriculum/\"\u003eurriculum\u003c/a\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eEducational needs were established on the basis of an expert opinion survey(9),round tables with CRIMEDIM and MSF field experts, and a literature review of published competency sets for humanitarian workers(10).Since our training program targeted health workers but was meant to be extendable in the future to other sectors operating under the umbrella of humanitarian aid, four papers were selected on the basis of their cross-sectorial approach(6) and definition of discipline-specific competencies relevant to our audience(11\u0026ndash;13).These competency sets served as a foundational basis for the course curriculum and were translated into 10 cross-sectorial and 1 profession-specific competency domain for each specialty [Table 1]. Learning objectives were phrased according to Bloom's Taxonomy. For each objective, a series of measurable performance goals was further developed. Curricula, learning and performance objectives were reviewed and validated by consensus between CRIMEDIM and MSF-Italy working groups.\u003c/p\u003e\n\n\u003ctable border=\"1\" width=\"1040\"\u003e\n \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCompetency domains, general learning objectivesand some performance objectives at the basis of the training curriculum\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"201\"\u003e\n\u003cp\u003e\u003cstrong\u003eCompetency domain\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"451\"\u003e\n\u003cp\u003e\u003cstrong\u003eGeneral learning objectives\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"387\"\u003e\n\u003cp\u003e\u003cstrong\u003eExamples of performance objectives\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"201\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Disaster medicine\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"451\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Understand the definition and different phases of disasters.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Define the nature of injury or illness in relation to different types of disasters.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Describe objectives and features of disaster medicine.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Understand the international disaster response mechanism with involved bodies and organizations.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"387\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; List the four phases of disaster management\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Name the office of the United Nations responsible for the international coordination in case of disaster or humanitarian emergency\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"201\"\u003e\n\u003cp\u003e\u003cstrong\u003e2. Incident Management System (IMS)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"451\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Describe the general principles and different phases of the IMS.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Demonstrate ability to work within an IMS.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Describe the concept and different methods of Mass Casualty Triage.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Define the concept of surge capacity and its role in unforeseen emergencies and disasters.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"387\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Correctly carry out the initial reporting from a simulated disaster site(METHANE)\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Assign simulated victims with the correct priority code according to the START triage\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"201\"\u003e\n\u003cp\u003e\u003cstrong\u003e3. Communication \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"451\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Recognize a disaster in progress, assess and report the situation.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Define and apply the principles of successful communication with local and expatriate staff, within and among organizations and with the media during emergencies.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Describe the radio communication procedures and protocols.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Recognize the importance of postevent reports.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"387\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Implement the basic principles of communication in a public\u0026nbsp; release statement with the media regarding the attack of a health facility by one belligerent party.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Write and present a post-event report after a simulated mass casualty event summarizing the facts occured and the actions taken.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Successfully collaborate with a member of local staff with very limited english speaking skills during the clinical management of a simulated critically -ll patient.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"201\"\u003e\n\u003cp\u003e\u003cstrong\u003e4. Resource management\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"451\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Manage supplies, drugs and equipment and other resourcesfor an effective response.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Manage, supervise, and appropriately use local staff and expatriate aid workers during emergencies.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"387\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Consider early blood compatibility testing for relatives of patients in an hemorrhagic shock scenariowhen whole blood is scarce or not available.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Demonstrate competence in the use of outdated equipment (e.g ventilators) to provide safe anaesthesia in a low-resource-setting.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"201\"\u003e\n\u003cp\u003e\u003cstrong\u003e5. Public health \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"451\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Recognise the top priorities for public health interventions during complex emergencies.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Describe indicators used to assess and monitor public health during complex emergencies.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Understand key epidemiological principles and terminology.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Define the minimum levels to be attained in humanitarian interventions regarding the provision of water, sanitation and hygiene.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Define the minimum levels to be attained in humanitarian interventions regarding the provision of food and nutrition.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Identify which infectious diseases can constitute a major threat following a disaster according to the geographical location and the type of emergency occurring.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"387\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Describe the information to be gathered during a Initial Rapid Assessment and ellaborate an intervention plan according to the identified public health needs.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Name the minimum quantityof safe drinking water\u0026nbsp; (liters/person/day) to be provided\u0026nbsp; in an humanitarian intervention.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; List the main anthropometric indices used to assess malnutrition.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Demonstrate knowledge about the age groups to be covered by a measles vaccination campaign\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"201\"\u003e\n\u003cp\u003e\u003cstrong\u003e6. Safety and security \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"451\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Understand the need for a safe and secure approach in humanitarian environments.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Analyze the security environment on the basis of the seven pillars of security.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Apply the preventive measures and/or individual or collective responsibilities adapted to each form of stress.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp; Identify sources of risk, describe risk scenarios and identify risk mitigation measures.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"387\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Demonstrate successful negotiation skills when approaching a simulated check point.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Demonstrate ability to prevent incidents during road travels (e.g carrying ID card, being able to clearly explane the mission of\u0026nbsp; his/her organization etc).\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Identify landmine markings during outdoors exercises\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"201\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e7. Ethics and international humanitarian law \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"451\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; Apply basic principles of medical ethics to disaster situations.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; Recognize and react accordingly to the difficulties entailed by humanitarian scenarios where different cultural backgrounds are represented.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; Define the concept and understand the origins of International Humanitarian Law\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; List the main International Human Rights\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; Describe the role of International Humanitarian Law in in protecting the dignity and rights of the most vulnerable populations during armed conflicts\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"387\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Demonstrate tollerancewhen dealing with local staff and patientswith different cultural background (e.g covered with burqa).\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Describe the origin of the Geneva Convention\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"201\"\u003e\n\u003cp\u003e\u003cstrong\u003e8. Situational awareness\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"451\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; Respond appropriately to an ever-changing environment and stress-induced situations.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; Adapt to pressure and change to operate effectively within humanitarian contexts.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"387\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Demonstrate avoiding fixation errors during the management of critically-ll patients in simulated low-resource scenarios.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Demonstrate ability to anticipate likely events in crisis situations (e.g a huge number of victims to come after a single patient presents with acute organophosphorus pesticide poisoning in a war context).\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"201\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"451\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"387\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"201\"\u003e\n\u003cp\u003e\u003cstrong\u003e9. Psychological support \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"451\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; Describe the main psychological needs in emergency contexts.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; Describe the essential criteria to organize actions in psychological support.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; Apply the principles of psychological first aid in emergency situations\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"387\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Identify and list the basic principles of Disaster Mental Health.\u003cbr /\u003e Demonstrate ability to provide the principles of Psychological First Aid\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Demonstrate ability to develop good practices to manage personal stress in order to\u0026nbsp;mitigate potential adverse effects of stress\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"201\"\u003e\n\u003cp\u003e\u003cstrong\u003e10. Leadership \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"451\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; Understand the definition of leadership and recognize the importance in an emergency context.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; Describe the different management styles.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; Understand conflict management and modify one\u0026rsquo;s own management style.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; Apply the principles of Non-Violent communication.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"387\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Demonstrate ability to implement a Non-Violent communication when giving a member of the local staff a negative feedback regarding his performance during a recent emergency.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Demonstrate ability to make firm decisions during a critical event: e.g priority of transport for severely injured patients in an hostile environment.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"201\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e11.\u003cstrong\u003eClinical considerations in the specific field of Anaesthesia, Pediatrics and Emergency Medicine in Low Resource Settings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"451\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; Understand and apply the principles of safe anaesthesia, emergency medicine or pediatrics in low-resource settings acording to the needs and resource available.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"387\"\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Demonstrate good knowledge in the use of Halothane, ketamine, suxamethonium and pancuronium\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Demonstrate ability to perform a newborn resuscitation in a resource-constrained environment\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Promptly recognize and treat signs and symptoms of malaria in high risk areas\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"1040\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003e\u003cu\u003eDelivery method\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe course intends to expose participants to a blended-learning experience consisting of three months of distance, self-directed learning and one week of residential instructor-led teaching. E-learning takes place through the Modular Object-Oriented Dynamic Learning Environment (MOODLE) educational software hosted on CRIMEDIM\u0026rsquo;s servers. The platform works as a content-driven learning model, hosting 11 e-modules and video lectures and offering a suite of tools and online-multiplayer-virtual exercises. The residential phase takes place at the SIMNOVA simulation center in Novara, Italy, and includes class-room sessions, table-top exercises, and group discussions withemphasis on high fidelity and outdoor real-size simulation exercises. Scenarios are designed based on the equipment, drugs and diagnostic tools available in MSF field projects and residents are exposed to the challenges most commonly encountered in daily activities. In clinical management scenarios, actors comply with the dress code of the country where the scenario is based and are also trained to act as typical members of the local staff.\u003c/p\u003e\n\u003cp\u003eE-learning materials and best performances for simulation exercises are jointly developed based on current international guidelines and the typical resources available in real-life MSF missions. Upon successful completion of both phases, students receive a certificate of completion and are deployed to MSF field projects as local staff supervisors to work as part of the hospital duty roster.\u003c/p\u003e\n\u003ch2\u003eEvaluation\u003c/h2\u003e\n\u003col\u003e\n\u003cli\u003e\u003cstrong\u003e\u003cu\u003eParticipants \u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe first two editions in 2013 and 2014 were not included in the evaluation but were offered on a pilot basis to test the feasibility of the project from an organizational standpoint and refine the course contents according to the feedback provided by students and MSF field supervisors.; only participants to the 2015 course iteration (n=8) were included in the evaluation. All were Italian, four were residents in emergency medicine, 3 in anesthesia, and 1 in pediatrics; 3 of them were female and median age was 31 years old. Two residents were deployed in Pakistan, 1 in Afghanistan, 1 in the Democratic Republic of Congo, 1 in Iraq, 2 in Haiti and 1 on board of the MSF Mediterranean search \u0026amp; rescue ship. Mean deployment time was 3 months.\u003c/p\u003e\n\u003col start=\"2\"\u003e\n\u003cli\u003e\u003cstrong\u003e\u003cu\u003eMethod\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe Kirkpatrick\u0026rsquo;s evaluation model has recently been used to evaluate training programs for health providers and focuses on the sequential assessment of the following levels(14):\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eLevel 1- \u003cem\u003eReaction: \u003c/em\u003emeasures students\u0026rsquo; satisfaction with the program;\u003c/li\u003e\n\u003cli\u003eLevel 2- \u003cem\u003eLearning: \u003c/em\u003emeasures improvement in knowledge, attitudes and skills;\u003c/li\u003e\n\u003cli\u003eLevel 3- \u003cem\u003eBehavior\u003c/em\u003e: measures the transfer of learning to the workplace;\u003c/li\u003e\n\u003cli\u003eLevel 4- \u003cem\u003eResults:\u003c/em\u003e measures the objective changes occurred as a result of participation in the training program.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eTo determine the effectiveness of our course, we tested levels 1 to 3 using a prospective, observational, single-cohort study.\u003c/p\u003e\n\u003col start=\"3\"\u003e\n\u003cli\u003e\u003cstrong\u003e\u003cu\u003eEvaluation plan and evaluation tools.\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eWe designed the evaluation plan according to the recommendations of Kirkpatrick et al(15)[Figure1]:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eWe assessedReactionusing a 5-point Likert scale questionnaire with a separate space for commentaries and personal opinions.\u003c/li\u003e\n\u003cli\u003eWe evaluated the three dimensions of Learningseparately in a pre- and post-test [Figure 1] as follows:\n\u003cul\u003e\n\u003cli\u003eKnowledge with a 30-question-multiple-choice test.\u003c/li\u003e\n\u003cli\u003eAttitude with a 12-question-5-point Likert scale questionnaire. In this study, the term \u0026ldquo;attitude\u0026rdquo;was defined as the students\u0026rsquo; positive or negative predisposition toward the competency domains at the basis of the course.\u003c/li\u003e\n\u003cli\u003eSkills with simulation-based performance tests, in which each student acted as lead physician in the management of a critically-ill patient in a low-resource emergency room. To decrease the potential impact that reiterative exposure to simulation exercises during the residential phase might have had on post-test performance, students attended standardized simulation tutorials and managed a number of simulated cases before entering the pre-test scenario. Pre- and post-test scenarios progressed on a predefined fashion according to the cue system described by Kim et al.(16) We videotaped resident\u0026rsquo;s performance and passed the material on to an external independent evaluator, who rated all students according to the validated Italian translation (TIGR)(17)of the Ottawa Global Rating Scale (Ottawa GRS)(16).This scale uses a 7-point semi-anchored design to evaluate residents\u0026rsquo; overall performance and their leadership, problem solving, situational awareness, resource utilization, and communication skills.\u003c/li\u003e\n\u003cli\u003ePre- and post-test were different tests with the same level of difficulty.\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003cli\u003eEvery resident was followed during the missionby his immediate MSF field supervisor who qualitatively assessed improvements inbehavior using the MSF standard evaluation formfor first missioners (form available upon request).\u003c/li\u003e\n\u003cli\u003eMSF field supervisors were blinded to the students\u0026rsquo; completion of the training program before deployment. This was necessary to prevent students\u0026rsquo; participation from influencing the judgement of supervisorsand ensure that evaluations were carried out as usual for any MSF first missioner.\u003c/li\u003e\n\u003cli\u003eAll the evaluation tests/forms and case scenarios used to conduct the evaluation are available upon request.\u003c/li\u003e\n\u003c/ul\u003e\n\u003col start=\"4\"\u003e\n\u003cli\u003e\u003cstrong\u003e\u003cu\u003eStatistical tests and data analysis\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe statistical analysis of Level 2 (Learning) was conducted by taking the difference in pre- and post-test scores as measured with a multiple-choice test as the primary objective. The difference in pre-and post-overall performance was defined as the secondary objective. We defined null hypotheses as no difference between the before and after multiple-choice test scores and no difference between the before and after overall performance. Alternative hypotheses were that both multiple choice test scores and overall performance scores would change significantly after completion of the course.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; We tested the null hypothesis of the primary objective of \u003cem\u003eno difference between pre- and post-test scores\u003c/em\u003e against the two-sided alternative hypothesis of significant difference. The null hypothesis of the secondary objective of \u003cem\u003eno difference between pre- and post-training overall performance scores\u003c/em\u003e was tested against the two-sided alternative of significant difference. Statistical analysis was performed using \u0026ldquo;R: A language and environment for statistical computing.\u0026rdquo; (R Development Core Team, Vienna, Austria). Null and alternative hypotheses and the statistical methods were completely specified before data collection. Differences between groups for the primary and secondary objectives were assessed using paired \u003cem\u003et\u003c/em\u003e-tests. P-values of less than .05 were considered significant for all tests. Two-sided alternative hypotheses were used in all cases.\u003c/p\u003e\n\u003col start=\"5\"\u003e\n\u003cli\u003e\u003cstrong\u003e\u003cu\u003eEthical clearance\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTo ensure anonymity and confidentiality during the entire evaluation process, we assigned a tracking number to each participant. This number was then reported on answer sheets, evaluation forms and videotape labels. All students signed the informed consent. This study was approved by the institutional Ethics Committee (date 24-02-2016, study code UPO.2015.4.10).\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eReaction\u003c/h2\u003e\n\u003cp\u003eAll residents rated the course as \u0026ldquo;excellent\u0026rdquo; and strongly agreed with the statement \u0026ldquo;I would recommend the course to other doctors in training\u0026rdquo;. All participants emphasized their satisfaction with both course contents and mode of delivery. In particular, high-fidelity simulation exercises were highly appreciated. Two students expressed the view that the course schedule was too tight and one suggested adding more training in negotiations techniques.\u003c/p\u003e\n\u003ch2\u003eLearning\u003c/h2\u003e\n\u003cp\u003eThere was a significant improvement in post-test multiple-choice scores when compared to pre-test scores (p = .001) (mean effect: 10.4/30; 95% CI: 5.7 to 15.0) [Figure 2] and also a significant improvement in residents\u0026rsquo; overall performance scores (P = .000001) (mean effect: 3; 95% CI: 2.4 to 3.6) [Figure 3]. The median score for all other fields also improved after the training course (median differences: Leadership 3.3; Problem solving 2.6; Situational Awareness 3; Resource Utilization 3.5; Communication 2.7). No differences were detected in attitudes scores before and after the course.\u003c/p\u003e\n\u003ch2\u003eBehavior\u003c/h2\u003e\n\u003cp\u003eFor most participants, MFPs highlighted the following strengths: compliance with MSF standards and principles, flexibility, good team working skills and cross-cultural sensitivity. All residents were recommended for future MSF missions [Table 2].\u003c/p\u003e\n\u003ctable border=\"1\" width=\"669\"\u003e\n \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of evaluations from fieldsupervisors for each candidate\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e\u003cstrong\u003eStudent\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"425\"\u003e\n\u003cp\u003e\u003cstrong\u003eStrong competences\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e\u003cstrong\u003eCompetences to develop\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"425\"\u003e\n\u003cp\u003eGoodanalyticalthinking, well-organized, high workingcapacity, good training skills, compliance with MSF standards and principles, flexibility, empathy, good mass casualty management skills, goodtechnicalskills, hard work, good team workingskills, goodreource management skills.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eHuman resource management\u003c/p\u003e\n\u003cp\u003eTropical medicine\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"425\"\u003e\n\u003cp\u003eWell-organized, goodtechnicalskills, good training skills, hard work, good team workingskills,goodreource management skills,cross-cultural sensitivity, compliance with MSF standards and principles, goodnegotiationskills, goodcomunicationskills.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eHuman resource management\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"425\"\u003e\n\u003cp\u003eCross-cultural sensitivity, good team workingskills, good training skills, goodpeople management skills, good leadership skills, well-organized, goodanalyticalthinking, goodproblemsolvingskills, goodreource management skills, gooddecisionmakingskills, responsibility, flexibility, good stress management skills, compliance with MSF standards and principles, implementgoodstrategies to ensure security and safetyskills in daily work, goodcomunicationskills, hard worker, workedas a personwith more experience in MSF.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eParticipation in monthy reports\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"425\"\u003e\n\u003cp\u003eCross-cultural sensitivity, good team workingskills, good training skills, compliance with MSF standards and principles, goodatmotivatinglocal staff, goodreource management skills, flexibility, multitasking, deepcommitment, hard work.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eSelf-health care\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"425\"\u003e\n\u003cp\u003eGood mass casualty management skills, compliance with MSF standards and principles, good leadership skills, goodcommunicationskills, goodteam workingskills, responsibility, good training skills.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eLanguage skills\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"425\"\u003e\n\u003cp\u003eGoodanalyticalthinking, compliance with MSF standards and principles, good team workingskills, goodatsettingpriorities, goodclinicalskills, good team workingskills, goodcomunicationskills, flexibility, multitasking, will to improveorganizationwithin the project.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eToo ambitious with local staff settingsometimesunrealisticgoals\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"425\"\u003e\n\u003cp\u003eMaximum committment to MSF, compliance with MSF standards and principles, cross-cultural sensitivity, verygoodattitudetowards MSF staff, awareness of the project from a global perspective and notonly in own area of competence,committment to promotecapacity building, good team workingskills, goodatmotivatinglocal staff, flexibility, implemented an operationalresearchprojectapproved by MSF medicalcoordinationunit.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eSelf-protectionduring life savingmaneuvers\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"425\"\u003e\n\u003cp\u003eHighly adaptable, goodskills to work with limitedresources, flexibility, responsibility,goodatcoaching and support oflocal staff, goodreource management skills.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eExpatriate health providers have been observed to be ill-prepared during recent humanitarian emergencies due to lack of experience in international relief and inadequate understanding of the local context(4,18). For this reason, the international humanitarian community has been drawing attention to the compelling need for competency-based training curricula based on astandard set of cross-cutting and profession-specific competencies(4,19).Since young doctors, born in a new era of highly-specialized medicine, have been increasing their presence in international aid projects, good preparation and performance oversight are paramount to guarantee best practice also in resource-strained settings(9).\u003c/p\u003e\n\u003cp\u003eTo our knowledge, this is the first study that describes the implementation and evaluation of a course based on published cross-sectorial and profession-specific competencies, jointly developed by an academic center and a robust humanitarian organization. Interestingly, while 61% of training programs for humanitarian workers in Europe(19)are defined as \u0026ldquo;competency-based\u0026rdquo;, none of them incorporates previously published competency sets. Evaluating the effectiveness of training programs is necessary to ensure credibility and decide whether they should be continued or not. In this regard, the assessment of a course for humanitarian workers using the first three levels of the Kirkpatrick\u0026rsquo;s evaluation model and including high fidelity simulation represents a real novelty.\u003c/p\u003e\n\u003cp\u003eOverall, students\u0026rsquo; satisfaction (Level 1) with the program was high. In particular, the delivery method and the residential phase were highly appreciated. It is worth noting that, aside from course curriculum and students\u0026rsquo; previous academic background, the structure of the program and the educational environment also play a central role in learning(20).Over the last years, medical education has shifted toward different delivery modes in an attempt to achieve better educational outcomes. The combination of face-to-face lectures and online teaching, defined as blended learning, strengthens the interaction between course participants, lecturers and resources(21) and represents a flexible pedagogical system(22).\u003c/p\u003e\n\u003cp\u003eOur study showed that students\u0026rsquo; competency in simulated humanitarian scenarios increased after course completion (Level 2). The term \u0026ldquo;competency\u0026rdquo; is defined as the set of knowledge, attitudes and skills required to accomplish a task. A competency-based training must ensure the acquisition of a theoretical understanding of relevant concepts in the field of humanitarian assistance (e.g., learning the START triage algorithm), promote a positive predisposition toward the working methods and actions to be adopted in low-resource settings (e.g., recognizing the importance of applying the START triage), and develop students\u0026rsquo; practical skills (e.g., conducting good quality triage in case of a mass casualty event). \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Yoon%20HB%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=27246494\"\u003eYoon\u003c/a\u003e et al(23)used the Kirkpatrick model to evaluate a continuing professional development training for physicians and physician assistants. In their study, a single 5-point Likert scale form filled by trainers and trainees was used to assess learning. However, it is important to highlight that the inclusion of separate tests for knowledge (e.g., multiple choice), attitudes (e.g.,Likert scale questionnaire), and skills (e.g., performance test) should be preferred whenever possible(14).\u003c/p\u003e\n\u003cp\u003eOur results reflect a clear improvement in participants\u0026rsquo; knowledge and overall performance in a high-fidelity scenario, while no change in attitude was evident. A plausible explanation may lie in the selection process itself. Since all students were highly motivated and had decided to take part in the course on a voluntary basis, a positive attitude was to be expected.\u003c/p\u003e\n\u003cp\u003eIn a recent study, Schwartz et al highlighted the prominent role that simulations, and particularly high-fidelity simulations, may play in enhancing residents\u0026rsquo; skills in the management of complex cases(24).Simulated environments are an invaluable setting to teach crisis resource management (CRM) skills(25),which are extremely important in humanitarian contexts. Some challenges commonly encountered in the field (e.g., communication barriers and shortage of resources) can be easily reproduced through simulation, giving students the chance to become acquainted with similar situations, receive feedback and improve their performance with no risks to patients. At the same time, simulated scenarios allow for the evaluation of performance objectives, reflecting how students would use in the field the competencies acquired through training(11).In their review entitled \u0026ldquo;Transfer of learning and patient outcome in simulated crisis resource management\u0026rdquo;, Boet et al found that CRM simulations improve not only learners behavior in the workplace but also, and more importantly, patient outcomes(26).\u003c/p\u003e\n\u003cp\u003eAccording to Kirkpatrick et al,(14)a positive reaction and evidence of improvement in learning do not necessarily lead to desired changes in behavior. The transfer of learning to the workplace is heavily conditioned by the so-called \u0026lsquo;work climates\u0026rsquo;, and these are clearly established by a supervisor\u0026rsquo;s reaction to students\u0026rsquo; practical application of the competencies acquired. To promote an encouraging work environment, heads of department and supervisors should be informed about the students\u0026rsquo; participation in the training program, and preferably be involved in its development(14).In our case, keeping MSF field evaluators blinded was mandatory to prevent biases; however, all participants received very good feedbacks. The reason for this may be the fact that educational needs were decided and endorsed by a panel of experts that included MSF training staff. This ensured that the practical concepts, organizational principles and techniques taught complied with the organization\u0026rsquo;s best practice standards.\u003c/p\u003e\n\u003cp\u003eThe collaboration between an academic center and a robust humanitarian organization allowed us to demonstrate the effectiveness of a pre-deployment training course in improving participants\u0026rsquo; learning. This may have several promising implications:\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003eIf properly trained, medical residents with no previous experience in the field could be deployed without compromising the quality of care delivered.\u003c/li\u003e\n\u003cli\u003eIncountrieswhere residents are authorized by contract to practice abroad for a certain period of time while maintaining their financial remuneration,non-governmental organizations (NGOs) could fill field gaps more rapidly by deploying well-prepared but inexpensive personnel.\u003c/li\u003e\n\u003cli\u003eFrom an organizational standpoint, agreements between NGOs and training centers would allow humanitarian staff to benefit from simulation-based training, which is presently the best approximation to real work in emergency and disaster contexts(27).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eIt is our hope that this collaborative initiative will serve worldwide as a model to bridge the gap between academia and field operations and contribute to the growth and professionalization of the humanitarian health sector.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eDespite our efforts to conduct this study thoroughly, a number of limitations should be considered.\u003c/p\u003e\n\u003cp\u003eThe competency sets and skills at the basis of our training curriculum, albeit published and peer-reviewed, were never validated. However, the authors believe that basing the learning objectives of the course on the needs emerged from discussions with different groups of experts would go some way toward remedying this deficiency.Incorporating the input of trainers working for the NGO partner would also be a fair compromise in the absence of a globally recognized competency set for humanitarian workers.\u003c/p\u003e\n\u003cp\u003eThe sample size used to test the effectiveness of this course was limited to 8 participants. Since our target population was composed of doctors still at an early stage of their careers, the tight enrollment criteria severely limited the number of eligible applicants for each iteration. Also, the evaluation process was logistically challenging and very resource consuming. All participants had to travel to Novara on purpose for the pre-test and their travel and living expenses had to be covered for two days both pre- and post-test. This prevented the evaluation to be repeated in the following editions, which would have positively impacted the sample size. Even though both primary and secondary outcomes improved significantly after the course, a larger study would be useful to confirm the significance of the specific changes found in each field of the TIGR evaluation scale.\u003c/p\u003e\n\u003cp\u003eThis study only assessed the first three levels of the Kirkpatrick model; additionally, for level 3 (Behavior) no pre-test was conducted. Since the course was designed to prepare residents to their first deployment with MSF, exposition to the real workplace environment was only possible upon completion. All participants obtained very good assessments from field supervisors, which may suggest that the training program played a role in the quality of their respective performances in the field.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLevel 4 (Results) measures the effect of students\u0026rsquo; actions, which considering our target population should have translated into measurement of patients\u0026rsquo; outcomes (e.g., decreased mortality). Taking into account the high turnover of doctors in humanitarian contexts and the diversity in the pattern of disease and affluence of patients depending on country, season, and ongoing environmental conditions (armed conflict, natural disaster, etc.), the influence on patients\u0026rsquo; outcomes would have been very hard to ascertain.\u003c/p\u003e\n\u003cp\u003eFinally, this study did not include a control group. According to MSF policy, deploying untrained doctors in the field at this early stage of their careers would have gone against basic principles of best practice.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOver the last decade, the humanitarian community has stressed the need to improve the quality of response through further investments in training for aid workers. Residents were highly satisfied with our training program and their knowledge and skills in simulated humanitarian environments improved as a result of participation. The implementation of this project shows how academia can successfully partner with humanitarian aid organizations to promote the professionalization of future humanitarian health workers. Further studies should be conducted to assess whether training programs effectively increase the competence of humanitarian workers in the field and if this translates into improvement of patients\u0026rsquo; outcomes or further advantages for deploying organizations.\u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003cul\u003e\n\u003cli\u003eMSF: M\u0026eacute;decins Sans Fronti\u0026egrave;res;\u003c/li\u003e\n\u003cli\u003eCRIMEDIM: Research Center in Emergency and Disaster Medicine of the Universit\u0026agrave; del Piemonte Orientale, Novara, Italy;\u003c/li\u003e\n\u003cli\u003eMOODLE: Modular Object-Oriented Dynamic Learning Environment;\u003c/li\u003e\n\u003cli\u003eTIGR: Translated Italian Global Rating Scale;\u003c/li\u003e\n\u003cli\u003eOttawa GRS: Ottawa Global Rating Scale;\u003c/li\u003e\n\u003cli\u003eCRM: crisis resource management;\u003c/li\u003e\n\u003cli\u003eNGOs: non-governmental organizations.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate:\u003c/h2\u003e\n\u003cp\u003eAll students signed the informed consent. This study was approved by the institutional Ethics Committee (date 24-02-2016, study code UPO.2015.4.10).\u003c/p\u003e\n\u003ch2\u003eConsent for publication:\u003c/h2\u003e\n\u003cp\u003eall authors read the manuscript and agreed to its submission and publicationin the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e\n\u003cp\u003ecomplete data and evaluation forms/tests used are available upon request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests:\u003c/h2\u003e\n\u003cp\u003ethe authors declare that they have no competing interests\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003enone\u003c/p\u003e\n\u003ch2\u003eAuthors' contributions:\u003c/h2\u003e\n\u003cp\u003eARG is anesthesia consultant at Maggiore Hospital, School of Medicine, in Novara and postdoctoral fellow at CRIMEDIM, Novara, Italy. She was first investigator and training program developer and contributed to the curriculum design, implementation of the evaluation and data collection and interpretation. She drafted the manuscript and gave final approval for the final version to be published; she is accountable for the accuracy and integrity of every part of the study.LR is postdoctoral fellow at CRIMEDIM, Novara, Italy. He contributed as training program developer and to curriculum design and training implementation. EM is pool manager at M\u0026eacute;decins Sans Fronti\u0026egrave;res-Italy, Rome, Italy.He contributed as training program developer and to curriculum design. He was also accountable for the matching of residents to their missions in the field. GM is anesthesia consultant at Maggiore Hospital, School of Medicine, Novara, Italy. She acted as main assistant and organizer for the SIMNOVA simulation exercises.JMF is clinical professor of Emergency Medicine at the University of Alberta, Edmonton, AB, Canada, and visiting professor of Disaster Medicine at the Universit\u0026agrave; del Piemonte Orientale, Novara, Italy. He contributed to study design and data analysis. AC is an Anesthesia and Intensive Care Resident in and CRIMEDIM research assistant, Universit\u0026agrave; del Piemonte Orientale, Novara, Italy. He contributed to the organization of the training program and its evaluation. FDC is full professor at the department of Anesthesia and Intensive Care, Maggiore Hospital, School of Medicine and director of CRIMEDIM, Novara, Italy. He contributed to the organization of the training program and its evaluation.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\n\u003cp\u003ethe authors thank all lecturers, assistants and actors involved in the training and simulations. They thank Pier Luigi Ingrassia, director of the simulation center SIMNOVA of the Università del Piemonte Orientale, for lending the simulation facilities and Katia Ansalone for her professional writing services.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFouad FM, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts AP, et al. Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet\u0026ndash;American University of Beirut Commission on Syria. Vol. 390, The Lancet. Lancet Publishing Group; 2017. p. 2516\u0026ndash;26.\u003c/li\u003e\n\u003cli\u003eRedmond AD, Mardel S, Taithe B, Calvot T, Gosney J, Duttine A, et al. A qualitative and quantitative study of the surgical and rehabilitation response to the earthquake in Haiti, January 2010. Prehosp Disaster Med.2011;26:449\u0026ndash;56.\u003c/li\u003e\n\u003cli\u003eWass V, Southgate L. Doctors Without Borders. Acad Med. 2017;92:441\u0026ndash;3.\u003c/li\u003e\n\u003cli\u003eBurkle FM, Walls AE, Heck JP, Sorensen BS, Cranmer HH, Johnson K, et al. Academic affiliated training centers in humanitarian health, Part I: program characteristics and professionalization preferences of centers in North America. Prehosp Disaster Med 2013;28:155\u0026ndash;62.\u003c/li\u003e\n\u003cli\u003eCranmer H, Chan JL, Kayden S, Musani A, Gasquet PE, Walker P, et al. Development of an evaluation framework suitable for assessing humanitarian workforce competencies during crisis simulation exercises. Prehosp Disaster Med. 2014;29:69\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003eBurkle FM Jr James JJ. Cross-disciplinary competency and professionalization in disaster medicine and public health. In: Gursky E, Hreckovski B, eds. Handbook for Pandemic and Mass-Casualty Planning and Response 2012. Amsterdam: IOS Press; 2012:72-83. LJM.\u003c/li\u003e\n\u003cli\u003eRipoll Gallardo A, Ingrassia PL, Ragazzoni L, Djalali A, Carenzo L, Burkle FM, et al. Professionalization of anesthesiologists and critical care specialists in humanitarian action: a nationwide poll among italian residents. Prehosp Disaster Med. 2015;30:16\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eCourse HM. Available at https://crimedim.uniupo.it/humanitarian-medic/. Last accessed January 2020.\u003c/li\u003e\n\u003cli\u003eDjalali A, Ingrassia PL, Della Corte F, Foletti M, Gallardo AR, Ragazzoni L, et al. Identifying Deficiencies in National and Foreign Medical Team Responses Through Expert Opinion Surveys: Implications for Education and Training--ERRATUM. Prehosp Disaster Med. 2015;30:224.\u003c/li\u003e\n\u003cli\u003eRipoll Gallardo A, Djalali A, Foletti M, Ragazzoni L, Della Corte F, Lupescu O, et al. Core Competencies in Disaster Management and Humanitarian Assistance: A Systematic Review. Disaster Med Public Heal Prep. 2015;9:430\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eSchultz CH, Koenig KL, Whiteside M, Murray R. National Standardized All-Hazard Disaster Core Competencies Task F. Development of national standardized all-hazard disaster core competencies for acute care physicians, nurses, and EMS professionals. Ann Emerg Med. 2012;59:196-208 e1.\u003c/li\u003e\n\u003cli\u003eSuchdev PS, Shah A, Derby KS, Hall L, Schubert C, Pak-Gorstein S, et al. A proposed model curriculum in global child health for pediatric residents. Acad Pediatr. 2012;12:229\u0026ndash;37.\u003c/li\u003e\n\u003cli\u003eRossler B, Marhofer P, Hupfl M, Peterhans B, Schebesta K. Preparedness of anesthesiologists working in humanitarian disasters. Disaster Med Public Heal Prep. 2013;7(4):408\u0026ndash;12.\u003c/li\u003e\n\u003cli\u003eKirkpatrick DL San Francisco, CA: Berret-Koehler Publishers; 2006\u0026nbsp; and KJDETPTFL 3rd ed.\u003c/li\u003e\n\u003cli\u003eKirkpatrick DL and Kirkpatrick JD. Implementing the Four Levels: A Practical Guide for Effective Evaluation of Training Programs. San Francisco CB-KP 2007.\u003c/li\u003e\n\u003cli\u003eKim J, Cardinal P, Chiu M, Clinch J. ND. A pilot study using high-fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Critical Care Medicine, High-Fidelity Simulation, and Crisis Resource Management I Study. Crit Care Med. 2006;34:2167\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003eFranc JM, Verde M, Gallardo AR, Carenzo L, Ingrassia PL. An Italian version of the Ottawa Crisis Resource Management Global Rating Scale: a reliable and valid tool for assessment of simulation performance. Intern Emerg Med. 2017;12:651\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eVan Hoving DJ, Wallis LA, Docrat F, De Vries S. Haiti disaster tourism--a medical shame. Prehosp Disaster Med [Internet]. 2010;25(3):201\u0026ndash;2. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20586008\u003c/li\u003e\n\u003cli\u003eIngrassia PL, Foletti M, Djalali A, Scarone P, Ragazzoni L, Corte FD, et al. Education and training initiatives for crisis management in the European Union: a web-based analysis of available programs. Prehosp Disaster Med. 2014;29:115\u0026ndash;26.\u003c/li\u003e\n\u003cli\u003eHutchinson L. Educational environment. BMJ. 2003;326:810\u0026ndash;2.\u003c/li\u003e\n\u003cli\u003eGarrison DR KH 2004. Blended learning: Uncovering its transformative potential in higher education. IHE 7(2):95\u0026ndash;105.\u003c/li\u003e\n\u003cli\u003eLewin LO, Singh M, Bateman BL, Glover PB. Improving education in primary care: development of an online curriculum using the blended learning model. BMC Med Educ. 2009;9:33.\u003c/li\u003e\n\u003cli\u003eYoon HB, Shin JS, Bouphavanh K, Kang YM. Evaluation of a continuing professional development training program for physicians and physician assistants in hospitals in Laos based on the Kirkpatrick model. J Educ Eval Heal Prof. 2016;13:21.\u003c/li\u003e\n\u003cli\u003eSchwartz KR, Prentiss KA. Simulation in Pre-departure Training for Residents Planning Clinical Work in a Low-Income Country. West J Emerg Med. 2015;16:1166\u0026ndash;72.\u003c/li\u003e\n\u003cli\u003eGaba DM, Howard\u0026nbsp; SK, Fish KJ,\u0026nbsp; Smith BE,\u0026nbsp; Sowb YA : Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. Simulation Gaming 2001, 32:175-193.\u0026nbsp;\u003c/li\u003e\n\u003cli\u003eBoet S, Bould MD, Fung L, Qosa H, Perrier L, Tavares W, et al. Transfer of learning and patient outcome in simulated crisis resource management: a systematic review. Can J Anaesth. 2014;6:571\u0026ndash;82.\u003c/li\u003e\n\u003cli\u003eAmat Camacho N, Hughes A, Burkle Jr. FM, Ingrassia PL, Ragazzoni L, Redmond A, et al. Education and Training of Emergency Medical Teams: Recommendations for a Global Operational Learning Framework. PLoS Curr.2016;8.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scandinavian-journal-of-trauma-resuscitation-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"stre","sideBox":"Learn more about [Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine](http://sjtrem.biomedcentral.com)","snPcode":"13049","submissionUrl":"https://submission.nature.com/new-submission/13049/3","title":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine","twitterHandle":"@SJTREM","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Humanitarian Aid, Education, Residents, Evaluation, Low-resource environments, Simulation, Training, E-learning","lastPublishedDoi":"10.21203/rs.3.rs-31885/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-31885/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eWell-prepared humanitarian workers are now more necessary than ever. Essential to the preparation process are:clearly defined learning objectives, curricula tailored to the nuances of humanitarian settings, simulation-based training, and evaluation.This paper describes a training program designed to prepare medical residents for their first field deployment with Médecins Sans Frontières and presents the results of a pilot assessment of its effectiveness.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe training was jointly developed by the Research Center in Emergency and Disaster Medicine-CRIMEDIM of the Università del Piemonte Orientale, Novara, Italy, and the humanitarian aid organization Médecins Sans Frontières- Italy (MSF-Italy); the following topics were covered: disaster medicine, public health, safety and security, infectious diseases, psychological support, communication, humanitarian law, leadership, and job-specific skills. It used a blended-learning approach consisting of a 3-month distance learning module; 1-week instructor-led coaching; and a field placement with MSF. We assessed its effectiveness using the first three levels of Kirkpatrick’s training evaluation model.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eEight residents took part in the evaluation. Four were residents in emergency medicine, 3 in anesthesia, and 1 in pediatrics; 3 of them were female and the median age was 31 years. Two residents were deployed in Pakistan, 1 in Afghanistan, 1 in the Democratic Republic of Congo, 1 in Iraq, 2 in Haiti and 1 on board of the MSF Mediterranean search \u0026amp; rescue ship. Mean deployment time was 3 months. The average median score for the overall course was 5 (excellent). There was a significant improvement in post-test multiple choice scores (p = 0.001) and in residents’ overall performance scores (P = 0.000001). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eResidents were highly satisfied with the training program and their knowledge and skills improved as a result of participation. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eThis study was approved by the Institutional Ethics Committee (date 24-02-2016, study code UPO.2015.4.10)\u003c/p\u003e","manuscriptTitle":"Residents Working With Médecins Sans Frontières: Training and Pilot Evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-06-03 16:56:03","doi":"10.21203/rs.3.rs-31885/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2020-07-07T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-06-15T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-06-15T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-06-15T12:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"editorAssigned","content":"","date":"2020-05-28T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-05-27T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-05-27T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-05-26T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scandinavian-journal-of-trauma-resuscitation-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"stre","sideBox":"Learn more about [Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine](http://sjtrem.biomedcentral.com)","snPcode":"13049","submissionUrl":"https://submission.nature.com/new-submission/13049/3","title":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine","twitterHandle":"@SJTREM","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2aacb355-4209-41aa-bd6c-d3de4bd5f56c","owner":[],"postedDate":"June 3rd, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":112319,"name":"Critical Care \u0026 Emergency Medicine"}],"tags":[],"updatedAt":"2020-09-03T15:59:02+00:00","versionOfRecord":{"articleIdentity":"rs-31885","link":"https://doi.org/10.1186/s13049-020-00778-x","journal":{"identity":"scandinavian-journal-of-trauma-resuscitation-and-emergency-medicine","isVorOnly":false,"title":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine"},"publishedOn":"2020-08-25 12:00:00","publishedOnDateReadable":"August 25th, 2020"},"versionCreatedAt":"2020-06-03 16:56:03","video":"","vorDoi":"10.1186/s13049-020-00778-x","vorDoiUrl":"https://doi.org/10.1186/s13049-020-00778-x","workflowStages":[]},"version":"v1","identity":"rs-31885","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-31885","identity":"rs-31885","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}