Outcomes of the MAMA Training: A Simulation and Experiential Learning Intervention for Labor and Delivery Providers to Improve Respectful Maternity Care for Women Living with HIV in Tanzania.

Respectful maternity care (RMC) for women living with HIV (WLHIV) improves birth outcomes and may influence women's long-term commitment to HIV care. In this study, we evaluated the MAMA training, a team-based simulation training for labor and delivery (L&D) providers to improve RMC and reduce stigma in caring for WLHIV. The study was conducted in six clinical sites in the Kilimanjaro Region of Tanzania. 60 L&D providers participated in the MAMA training, which included a two-and-a-half-day workshop followed by a half-day on-site refresher. We assessed the impact of the MAMA training using a pre-post quasi-experimental design. To assess provider impacts, participants completed assessments at baseline and post-intervention periods, measuring RMC practices, HIV stigma, and self-efficacy to provide care. To evaluate patient impacts, we enrolled birthing women at the study facilities in the pre- (n = 229) and post- (n = 214) intervention periods and assessed self-reported RMC and perceptions of provider HIV stigma. We also collected facility-level data on the proportion of patients who gave birth by cesarean section, disaggregated by HIV status. The intervention had a positive impact on all provider outcomes; providers reported using more RMC practices, lower levels of HIV stigma, and greater self-efficacy to provide care for WLHIV. We did not observe differences in self-reported patient outcomes. In facility-level data, we observed a trend in reduction in cesarean section rates for WLHIV (33.0% vs. 24.1%, p = 0.14). The findings suggest that the MAMA training may improve providers' attitudes and practices in caring for WLHIV giving birth and should be considered for scale-up.

HIV-related Shame among Women Giving Birth in Tanzania: A Mixed Methods Study.

Women living with HIV (WLHIV) commonly experience HIV-related shame which can interfere with HIV care-seeking behavior and lead to poor clinical outcomes. HIV-related shame may be particularly heightened during the pregnancy and postpartum periods. This study aimed to describe HIV-related shame among WLHIV giving birth, identify associated factors, and qualitatively examine the impacts of HIV-related shame on the childbirth experience. Postpartum WLHIV (n = 103) were enrolled in the study between March and July 2022 at six clinics in the Kilimanjaro Region, Tanzania. Participants completed a survey within 48 h after birth, prior to being discharged. The survey included a 13-item measure of HIV-related shame, which assessed levels of HIV-related shame (Range: 0-52). Univariable and multivariable regression models examined factors associated with HIV-related shame. Qualitative in-depth interviews were conducted with pregnant WLHIV (n = 12) and postpartum WLHIV (n = 12). Thematic analysis, including memo writing, coding, and synthesis, was employed to analyze the qualitative data. The survey sample had a mean age of 29.1 (SD = 5.7), and 52% were diagnosed with HIV during the current pregnancy. Nearly all participants (98%) endorsed at least one item reflecting HIV-related shame, with an average endorsement of 9 items (IQR = 6). In the final multivariable model, HIV-related shame was significantly associated with being Muslim vs. Christian (ß = 6.80; 95%CI: 1.51, 12.09), attending less than four antenatal care appointments (ß = 5.30; 95%CI: 0.04, 10.55), and reporting experiences of HIV stigma in the health system (ß = 0.69; 95%CI: 0.27, 1.12). Qualitative discussions revealed three key themes regarding the impact of HIV-related shame on the childbirth experience: reluctance to disclose HIV status, suboptimal adherence to care, and the influence on social support networks. WLHIV giving birth experience high rates of HIV-related shame, and social determinants may contribute to feelings of shame. HIV-related shame impacts the childbirth experience for WLHIV, making the labor and delivery setting an important site for intervention and support.The study is funded by the National Institutes of Health (R21 TW012001) and is registered on clinicaltrials.gov (NCT05271903).

A simulation and experiential learning intervention for labor and delivery providers to address HIV stigma during childbirth in Tanzania: study protocol for the evaluation of the MAMA intervention.

BACKGROUND: The experience of HIV stigma during intrapartum care can impact women's trust in the health care system and undermine their long-term commitment to HIV care engagement. Delivery of respectful maternity care (RMC) to women living with HIV (WLHIV) can improve quality of life and clinical outcomes. The goal of this study is to conduct an evaluation of MAMA (Mradi wa Afya ya Mama Mzazi, Project to Support the Health of Women Giving Birth), a simulation team-training curriculum for labor and delivery providers that addresses providers' instrumental and attitudinal stigma toward WLHIV and promotes the delivery of evidence-based RMC for WLHIV. METHODS: The MAMA intervention will be evaluated among healthcare providers across six clinics in the Kilimanjaro Region of Tanzania. To evaluate the impact of MAMA, we will enroll WLHIV who give birth in the facilities before (n = 103 WLHIV) and after (n = 103 WLHIV) the intervention. We will examine differences in the primary outcome (perceptions of RMC) and secondary outcomes (postpartum HIV care engagement; perceptions of HIV stigma in the facility; internal HIV stigma; clinical outcomes and evidence-based practices) between women enrolled in the two time periods. Will also assess participating providers (n = 60) at baseline, immediate post, 1-month post training, and 2-month post training. We will examine longitudinal changes in the primary outcome (practices of RMC) and secondary outcomes (stigma toward WLHIV; self-efficacy in delivery intrapartum care). Quality assurance data will be collected to assess intervention feasibility and acceptability. DISCUSSION: The implementation findings will be used to finalize the intervention for a train-the-trainer model that is scalable, and the outcomes data will be used to power a multi-site study to detect significant differences in HIV care engagement. TRIAL REGISTRATION: The trial is registered at clinicaltrials.gov, NCT05271903.

Factors associated with respectful maternity care and influence of HIV status among women giving birth in Kilimanjaro, Tanzania.

BACKGROUND: Respectful maternity care (RMC) is a rights-based approach to childbirth that centers the dignity, autonomy, and well-being of birthing women. This study aimed to examine factors associated with RMC among women giving birth in Tanzania and to examine whether HIV status was associated with self-reported RMC. METHODS: We enrolled 229 postpartum women in six clinics in the Kilimanjaro Region; of them, 103 were living with HIV. Participants completed a survey within 48 h after birth before being discharged. RMC was measured using a 30-item scale with three subscales (dignity and respect; supportive care; communication and autonomy), each standardized from 0 to 100. Univariable and multivariable regression models examined factors associated with RMC. RESULTS: The median score of the full RMC score was 74, differing slightly by subscale: 83 for dignity and respect, 76 for supportive care, and 67 for communication and autonomy. RMC did not differ by HIV status (median 67.0 vs. 67.0, p = 0.89). In multivariable linear regression, women who would not recommend the birth facility to their friends and who did not receive breastfeeding education had significantly lower RMC scores on the full RMC scale. In the dignity and respect subscale, variables associated with significantly lower RMC scores were not being able to read and write, delivering in a public facility, and delivering vaginally. CONCLUSIONS: Although self-reported RMC was generally high, we identified areas for improvement. Practitioners need ongoing training on RMC principles and the delivery of equitable care.

Facility-based simulation as a programmatic tool for implementing a statewide contraceptive initiative.

BACKGROUND: Assessing implementation fidelity is highly recommended, but successful approaches can be challenging. Family Planning Elevated (FPE) is a statewide contraceptive initiative which partnered with 28 health clinics across Utah. To assess implementation fidelity, we developed in-situ high-fidelity simulation training to both determine clinic adherence to FPE and offer education to implementing teams. This study aimed to develop, pilot, and assess the use of simulation as a tool for measuring implementation fidelity. METHODS: We developed two simulation scenarios to determine implementation fidelity: one scenario wherein a client is seeking a new method of contraception and another in which the same client has returned to discontinue the method. Both simulations contained multiple aspects of program implementation (e.g., determining program eligibility). We then offered simulations to all FPE partner organizations. To assess simulation training as a tool for determining implementation fidelity, we developed strategies aligned with each aspect of an adapted RE-AIM framework, including pre-post surveys, acceptability and self-efficacy testing, a checklist for programmatic adherence, field notes, action planning and analysis of monitoring data. RESULTS: Fifteen clinical sites and 71 team members participated in the in-situ simulations. Assessment of the checklist showed that 90% of the clinics successfully demonstrated key program components, including person-centered counseling techniques such as sitting at the patient's level (95.8%); asking open-ended questions (100%); and explaining how to use the contraceptive method selected (91.7%). More than half of clinics fell short in programmatic areas including: confirmation that the FPE program covered same-day intrauterine device insertion (54.2%), and education on health risks associated with the selected contraceptive method (58.3%). After simulation, participants reported improved knowledge of how FPE works (p = < 0.001), increased ability to identify FPE-eligible clients (p = 0.02) and heightened self-efficacy in helping clients select a method (p = 0.03). Participants were satisfied with the simulations, with most (84.1%) reporting that the simulation exceeded their expectations. CONCLUSIONS: Highly-realistic in-situ family planning simulations are acceptable to participants, positively change knowledge and clinical team confidence, and can identify systems gaps in clinical care and program implementation. Simulation offers a reciprocal way of monitoring implementation fidelity of a family planning access initiative. TRIAL REGISTRATION: This project was determined to be exempt by the IRB of the University of Utah, the larger Family Planning Elevated program under which this pilot study was nested is registered at ClinicalTrials.gov Identifier: NCT03877757 .

Super Divya to the rescue! Exploring Nurse Mentor Supervisor perceptions on a digital tool to support learning and engagement for simulation educators in Bihar, India.

BACKGROUND: Since 2014, the Government of Bihar and CARE India have implemented a nurse mentoring program that utilizes PRONTO International's simulation and team trainings to improve obstetric and neonatal care. Together they trained simulation educators known as Nurse Mentor Supervisors to conduct simulation trainings in rural health facilities across the state. Sustaining the knowledge and engagement of these simulation educators at a large-scale has proven difficult and resource intensive. To address this, the University of Utah with PRONTO International and with input from the University of California San Francisco, created an interactive, virtual education module based on a comic superhero named Super Divya to reinforce simulation educator concepts. This study examined the perceptions of Nurse Mentor Supervisors on Super Divya's accessibility, usefulness, and potential after implementation of Super Divya: Origin Story. METHODS: We conducted qualitative interviews with 17 Nurse Mentor Supervisors in Bihar, India. In light of the COVID-19 pandemic, interviews were conducted virtually via Zoom™ using a semi-structured interview guide in Hindi and English. Participants were identified with strict inclusion criteria and convenience sampling methods. Interviews were analyzed using a framework analysis. RESULTS: Nurse Mentor Supervisors found Super Divya to be engaging, innovative, relatable, and useful in teaching tips and tricks for simulation training. Supervisors thought the platform was largely accessible with some concerns around internet connectivity and devices. The majority reacted positively to the idea of distributing Super Divya to other simulation educators in the nurse mentoring program and had suggestions for additional clinical and simulation educator training topics. CONCLUSIONS: This study demonstrates the potential of Super Divya to engage simulation educators in continuous education. At a time when virtual education is increasingly important and in-person training was halted by the COVID-19 pandemic, Super Divya engaged Supervisors in the nurse mentoring program. We have incorporated suggestions for improvement of Super Divya into future modules. Further research can help understand how knowledge from Super Divya can improve simulation facilitation skills and behaviors, and explore potential for reinforcing clinical skills via this platform. ETHICAL APPROVAL: This study was approved by the institutional review board at the University of California San Francisco (IRB # 20-29902).

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

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

Training and evaluating simulation debriefers in low-resource settings: lessons learned from Bihar, India.

BACKGROUND: To develop effective and sustainable simulation training programs in low-resource settings, it is critical that facilitators are thoroughly trained in debriefing, a critical component of simulation learning. However, large knowledge gaps exist regarding the best way to train and evaluate debrief facilitators in low-resource settings. METHODS: Using a mixed methods approach, this study explored the feasibility of evaluating the debriefing skills of nurse mentors in Bihar, India. Videos of obstetric and neonatal post-simulation debriefs were assessed using two known tools: the Center for Advanced Pediatric and Perinatal Education (CAPE) tool and Debriefing Assessment for Simulation in Healthcare (DASH). Video data was used to evaluate interrater reliability and changes in debriefing performance over time. Additionally, twenty semi-structured interviews with nurse mentors explored perceived barriers and enablers of debriefing in Bihar. RESULTS: A total of 73 debriefing videos, averaging 18 min each, were analyzed by two raters. The CAPE tool demonstrated higher interrater reliability than the DASH; 13 of 16 CAPE indicators and two of six DASH indicators were judged reliable (ICC > 0.6 or kappa > 0.40). All indicators remained stable or improved over time. The number of 'instructors questions,' the amount of 'trainee responses,' and the ability to 'organize the debrief' improved significantly over time (p < 0.01, p < 0.01, p = 0.04). Barriers included fear of making mistakes, time constraints, and technical challenges. Enablers included creating a safe learning environment, using contextually appropriate debriefing strategies, and team building. Overall, nurse mentors believed that debriefing was a vital aspect of simulation-based training. CONCLUSION: Simulation debriefing and evaluation was feasible among nurse mentors in Bihar. Results demonstrated that the CAPE demonstrated higher interrater reliability than the DASH and that nurse mentors were able to maintain or improve their debriefing skills overtime. Further, debriefing was considered to be critical to the success of the simulation training. However, fear of making mistakes and logistical challenges must be addressed to maximize learning. Teamwork, adaptability, and building a safe learning environment enhanced the quality enhanced the quality of simulation-based training, which could ultimately help to improve maternal and neonatal health outcomes in Bihar.

Can an integrated obstetric emergency simulation training improve respectful maternity care? Results from a pilot study in Ghana.

BACKGROUND: Few evidence-based interventions exist on how to improve respectful maternity care (RMC) in low-resource settings. We sought to evaluate the effect of an integrated simulation-based training on provision of RMC. METHODS: The pilot project was in East Mamprusi District in northern Ghana. We integrated specific components of RMC, emphasizing dignity and respect, communication and autonomy, and supportive care, into a simulation training to improve identification and management of obstetric and neonatal emergencies. Forty-three providers were trained. For evaluation, we conducted surveys at baseline (N = 215) and endline (N = 318) 6 months later, with recently delivered women to assess their experiences of care using the person-centered maternity care scale. Higher scores on the scale represent more respectful care. RESULTS: Compared to the baseline, women in the endline reported more respectful care. The average person-centered maternity care score increased from 50 at baseline to 72 at endline, a relative increase of 43%. Scores on the subscales also increased between baseline and endline: 15% increase for dignity and respect, 87% increase for communication and autonomy, and 55% increase for supportive care. These differences remained significant in multivariate analysis controlling for several potential confounders. CONCLUSIONS: The findings suggest that integrated provider trainings that give providers the opportunity to learn, practice, and reflect on their provision of RMC in the context of stressful emergency obstetric simulations have the potential to improve women's childbirth experiences in low-resource settings. Incorporating such trainings into preservice and in-service training of providers will help advance global efforts to promote RMC.

Logistical, cultural, and structural barriers to immediate neonatal care and neonatal resuscitation in Bihar, India.

BACKGROUND: In India, the neonatal mortality rate is nearly double the Sustainable Development Goal target with more than half of neonatal deaths occurring in only four states, one of which is Bihar. Evaluations of immediate neonatal care and neonatal resuscitation skills in Bihar have demonstrated a need for significant improvement. However, barriers to evidence based practices in clinical care remain incompletely characterized. METHODS: To better understand such barriers, semi-structured interviews were conducted with 18 nurses who participated as mentors in the AMANAT maternal and child health quality improvement project, implemented by CARE India and the Government of Bihar. Nurse-mentors worked in primary health centers throughout Bihar facilitating PRONTO International emergency obstetric and neonatal simulations for nurse-mentees in addition to providing direct supervision of clinical care. Interviews focused on mentors' perceptions of barriers to evidence based practices in immediate neonatal care and neonatal resuscitation faced by mentees employed at Bihar's rural primary health centers. Data was analyzed using the thematic content approach. RESULTS: Mentors identified numerous interacting logistical, cultural, and structural barriers to care. Logistical barriers included poor facility layout, supply issues, human resource shortages, and problems with the local referral system. Cultural barriers included norms such as male infant preference, traditional clinical practices, hierarchy in the labor room, and interpersonal relations amongst staff as well as with patients' relatives. Poverty was described as an overarching structural barrier. CONCLUSION: Interacting logistical, cultural and structural barriers affect all aspects of immediate neonatal care and resuscitation in Bihar. These barriers must be addressed in any intervention focused on improving providers' clinical skills. Strategic local partnerships are vital to addressing such barriers and to contextualizing skills-based trainings developed in Western contexts to achieve the desired impact of reducing neonatal mortality.

The power of practice: simulation training improving the quality of neonatal resuscitation skills in Bihar, India.

BACKGROUND: Globally, neonatal mortality accounts for nearly half of under-five mortality, and intrapartum related events are a leading cause. Despite the rise in neonatal resuscitation (NR) training programs in low- and middle-income countries, their impact on the quality of NR skills amongst providers with limited formal medical education, particularly those working in rural primary health centers (PHCs), remains incompletely understood. METHODS: This study evaluates the impact of PRONTO International simulation training on the quality of NR skills in simulated resuscitations and live deliveries in rural PHCs throughout Bihar, India. Further, it explores barriers to performance of key NR skills. PRONTO training was conducted within CARE India's AMANAT intervention, a maternal and child health quality improvement project. Performance in simulations was evaluated using video-recorded assessment simulations at weeks 4 and 8 of training. Performance in live deliveries was evaluated in real time using a mobile-phone application. Barriers were explored through semi-structured interviews with simulation facilitators. RESULTS: In total, 1342 nurses participated in PRONTO training and 226 NR assessment simulations were matched by PHC and evaluated. From week 4 to 8 of training, proper neck extension, positive pressure ventilation (PPV) with chest rise, and assessment of heart rate increased by 14%, 19%, and 12% respectively (all p ≤ 0.01). No difference was noted in stimulation, suction, proper PPV rate, or time to completion of key steps. In 252 live deliveries, identification of non-vigorous neonates, use of suction, and use of PPV increased by 21%, 25%, and 23% respectively (all p < 0.01) between weeks 1-3 and 4-8. Eighteen interviews revealed individual, logistical, and cultural barriers to key NR skills. CONCLUSION: PRONTO simulation training had a positive impact on the quality of key skills in simulated and live resuscitations throughout Bihar. Nevertheless, there is need for ongoing improvement that will likely require both further clinical training and addressing barriers that go beyond the scope of such training. In settings where clinical outcome data is unreliable, data triangulation, the process of synthesizing multiple data sources to generate a better-informed evaluation, offers a powerful tool for guiding this process.

Measuring movement towards improved emergency obstetric care in rural Kenya with implementation of the PRONTO simulation and team training program.

As the proportion of facility-based births increases, so does the need to ensure that mothers and their newborns receive quality care. Developing facility-oriented obstetric and neonatal training programs grounded in principles of teamwork utilizing simulation-based training for emergency response is an important strategy for improving the quality care. This study uses 3 dimensions of the Kirkpatrick Model to measure the impact of PRONTO International (PRONTO) simulation-based training as part of the Linda Afya ya Mama na Mtoto (LAMMP, Protect the Health of mother and child) in Kenya. Changes in knowledge of obstetric and neonatal emergency response, self-efficacy, and teamwork were analyzed using longitudinal, fixed-effects, linear regression models. Participants from 26 facilities participated in the training between 2013 and 2014. The results demonstrate improvements in knowledge, self-efficacy, and teamwork self-assessment. When comparing pre-Module I scores with post-training scores, improvements range from 9 to 24 percentage points (p values < .0001 to .026). Compared to baseline, post-Module I and post-Module II (3 months later) scores in these domains were similar. The intervention not only improved participant teamwork skills, obstetric and neonatal knowledge, and self-efficacy but also fostered sustained changes at 3 months. The proportion of facilities achieving self-defined strategic goals was high: 95.8% of the 192 strategic goals. Participants rated the PRONTO intervention as extremely useful, with an overall score of 1.4 out of 5 (1, extremely useful; 5, not at all useful). Evaluation of how these improvements affect maternal and perinatal clinical outcomes is forthcoming.

Care of the mother-infant dyad: a novel approach to conducting and evaluating neonatal resuscitation simulation training in Bihar, India.

BACKGROUND: As the global under-five mortality rate declines, an increasing percentage is attributable to early neonatal mortality. A quarter of early neonatal deaths are due to perinatal asphyxia. However, neonatal resuscitation (NR) simulation training in low-resource settings, where the majority of neonatal deaths occur, has achieved variable success. In Bihar, India, the poorest region in South Asia, there is tremendous need for a new approach to reducing neonatal morality. METHODS: This analysis aims to assess the impact of a novel in-situ simulation training program, developed by PRONTO International and implemented in collaboration with CARE India, on NR skills of nurses in Bihar. Skills were evaluated by clinical complexity of the simulated scenario, which ranged from level 1, requiring NR without a maternal complication, to level 3, requiring simultaneous management of neonatal and maternal complications. A total of 658 nurses at 80 facilities received training 1 week per month for 8 months. Simulations were video-recorded and coded for pre-defined clinical skills using Studiocode™. RESULTS: A total of 298 NR simulations were analyzed. As simulation complexity increased, the percentage of simulations in which nurses completed key steps of NR did not change, even with only 1-2 providers in the simulation. This suggests that with PRONTO training, nurses were able to maintain key skills despite higher clinical demands. As simulation complexity increased from level 1 to 3, time to completion of key NR steps decreased non-significantly. Median time to infant drying decreased by 7.5 s (p = 0.12), time to placing the infant on the warmer decreased by 21.7 s (p = 0.27), and time to the initiation of positive pressure ventilation decreased by 20.8 s (p = 0.12). Nevertheless, there remains a need for improvement in absolute time elapsed between delivery and completion of key NR tasks. CONCLUSIONS: PRONTO simulation training enabled nurses in Bihar to maintain core NR skills in simulation despite demands for higher-level triage and management. Although further evaluation of the PRONTO methodology is necessary to understand the full scope of its impact, this analysis highlights the importance of conducting and evaluating simulation training in low-resource settings based on simultaneous care of the mother-infant dyad.

A process evaluation of PRONTO simulation training for obstetric and neonatal emergency response teams in Guatemala.

BACKGROUND: Despite expanding access to institutional birth in Guatemala, maternal mortality remains largely unchanged over the last ten years. Enhancing the quality of emergency obstetric and neonatal care is one important strategy to decrease mortality. An innovative, low-tech, simulation-based team training program (PRONTO) aims to optimize care provided during obstetric and neonatal emergencies in low-resource settings. METHODS: We conducted PRONTO simulation training between July 2012 and December 2012 in 15 clinics in Alta Verapaz, Huehuetenango, San Marcos, and Quiche, Guatemala. These clinics received PRONTO as part of a larger pair-matched cluster randomized trial of a comprehensive intervention package. Training participants were obstetric and neonatal care providers that completed pre- and post- training assessments for the two PRONTO training modules, which evaluated knowledge of evidence-based practice and self-efficacy in obstetric and neonatal topics. Part of the training included a session for trained teams to establish strategic goals to improve clinical practice. We utilized a pre/post-test design to evaluate the impact of the course on both knowledge and self-efficacy with longitudinal fixed effects linear regression with robust standard errors. Pearson correlation coefficients were used to assess the correlation between knowledge and self-efficacy. Poisson regression was used to assess the association between the number of goals achieved and knowledge, self-efficacy, and identified facility-level factors. RESULTS: Knowledge and self-efficacy scores improved significantly in all areas of teaching. Scores were correlated for all topics overall at training completion. More than 60 % of goals set to improve clinic functioning and emergency care were achieved. No predictors of goal achievement were identified. CONCLUSIONS: PRONTO training is effective at improving provider knowledge and self-efficacy in training areas. Further research is needed to evaluate the impact of the training on provider use of evidence-based practices and on maternal and neonatal health outcomes. TRIAL REGISTRATION: NCT01653626.

Team training in obstetric and neonatal emergencies using highly realistic simulation in Mexico: impact on process indicators.

BACKGROUND: Ineffective management of obstetric emergencies contributes significantly to maternal and neonatal morbidity and mortality in Mexico. PRONTO (Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) is a highly-realistic, low-tech simulation-based obstetric and neonatal emergency training program. A pair-matched hospital-based controlled implementation trial was undertaken in three states in Mexico, with pre/post measurement of process indicators at intervention hospitals. This report assesses the impact of PRONTO simulation training on process indicators from the pre/post study design for process indicators. METHODS: Data was collected in twelve intervention facilities on process indicators, including pre/post changes in knowledge and self-efficacy of obstetric emergencies and neonatal resuscitation, achievement of strategic planning goals established during training and changes in teamwork scores. Authors performed a longitudinal fixed-effects linear regression model to estimate changes in knowledge and self-efficacy and logistic regression to assess goal achievement. RESULTS: A total of 450 professionals in interprofessional teams were trained. Significant increases in knowledge and self-efficacy were noted for both physicians and nurses (p <0.001- 0.009) in all domains. Teamwork scores improved and were maintained over a three month period. A mean of 58.8% strategic planning goals per team in each hospital were achieved. There was no association between high goal achievement and knowledge, self-efficacy, proportion of doctors or nurses in training, state, or teamwork score. CONCLUSIONS: These results suggest that PRONTO's highly realistic, locally appropriate simulation and team training in maternal and neonatal emergency care may be a promising avenue for optimizing emergency response and improving quality of facility-based obstetric and neonatal care in resource-limited settings. TRIAL REGISTRATION: NCT01477554.

Improving the Surgical Education Experience: 9-month Outcomes of an Education Time-Out Pilot Study.

OBJECTIVE: We aimed to: 1) create a Surgical Education Time-Out Tool (SET-OuT) checklist training module for faculty utilizing a highly-realistic simulation and 2) assess faculty and resident perioperative educational experiences pre- and post-SET-OuT intervention. DESIGN, SETTING, AND PARTICIPANTS: We recruited gynecologic surgical faculty and PGY1 to PGY3 obstetrics and gynecology (OBGYN) residents from the University of Utah. Each enrolled participant completed a baseline and 9-month survey about their educational experiences and SET-OuT satisfaction. Faculty enrollment required completion of highly-realistic SET-OuT simulation with a simulated resident actor. We compared individual measures and composite teacher self-efficacy scale and composite resident procedural self-confidence scale between time points using rank sum tests. We converted Likert-scale items to 5-point scales and used mixed linear models to investigate whether relationships persisted after accounting for individual surgeons' and residents' effects. RESULTS: Twenty-five of 62 (40%) faculty and 15/17 (88%) residents enrolled with 100% baseline survey completion. Twenty of 25 (80%) faculty and 12/15 (80%) residents completed the 9-month survey. Faculty scored a median 34/45 points on the self-efficacy scale at baseline and 41/45 points at 9 months (p < 0.01). Faculty demonstrated a 0.9-point improvement in teaching performance satisfaction (p < 0.01). Residents' procedural self-confidence was 16.5/30 at baseline and 22/30 at 9-months (p = 0.01) and felt their value and input in the surgical education experience improved. Residents reported improved satisfaction with feedback at 9-months compared to baseline (p = 0.01). Faculty and residents reported 85% and 100% satisfaction with the ETO as a teaching tool, respectively. CONCLUSIONS: Implementation of a perioperative SET-OuT improved faculty teaching self-efficacy and resident procedural confidence. Both groups highly rated the SET-OuT as an acceptable perioperative teaching tool.

Factors associated with a negative Patient Acceptable Symptom State (PASS) response with intrauterine device placement: A retrospective survey of HER Salt Lake participants.

OBJECTIVES: In an established cohort of HER Salt Lake Contraceptive Initiative participants with a prior intrauterine device (IUD) placement, we sought to (1) define the proportion of participants who reported a negative Patient Acceptable Symptom State (PASS) response, (2) explore factors associated with an unacceptable PASS response, and (3) identify pain management preferences for IUD placement. STUDY DESIGN: A retrospective survey was sent to 1440 HER Salt Lake IUD users. A PASS question queried IUD placement pain experience acceptability. We explored associations between an unacceptable PASS response and sociodemographic, reproductive and other individual characteristics using t-tests, chi-square tests, and multivariable logistic regression. RESULTS: Of those surveyed, 620 responded (43%), and 41.6% reported an unacceptable PASS response. Those with an unacceptable PASS response reported a significantly higher experienced pain level (79.2 mm vs 51.8 mm; p < 0.01) than those with an acceptable response, were more likely to have an anxiety diagnosis (47.7% vs 37.1%; p < 0.01), and have a trauma history (33.7% vs 25.1%; p = 0.02). Most patients were not offered pain control options, but 29.4% used ibuprofen and 25.3% had a support person. Regardless of PASS response, if offered, 59.0% desired numbing medication, 56.8% ibuprofen, 51% heating pad, 33.2% support person, and 31.8% anti-anxiety medication, among others. In our multivariable logistic regression model, higher pain was associated with unacceptable PASS response (OR 1.07, 95% CI 1.05-1.08; p < 0.01). CONCLUSIONS: The common finding of unacceptable pain experiences with IUD placement may cause negative perceptions of an otherwise desirable method. Incorporation of the PASS response into IUD pain management studies could expand our pain experience understanding. IMPLICATIONS: IUD placement resulted in unacceptable pain experiences for 41.6% of respondents. Screening for anxiety and trauma history could identify at-risk patients to individualize pain management strategies. Incorporation of the PASS into future IUD pain management studies could result in a more comprehensive, patient-centered measure of patient experiences.

Promoting cultural humility during labor and birth: putting theory into action during PRONTO obstetric and neonatal emergency training.

Maternal and neonatal mortality in Northern Guatemala, a region with a high percentage of indigenous people, is disproportionately high. Initiatives to improve quality of care at local health facilities equipped for births, and increasing the number of births attended at these facilities will help address this problem. PRONTO (Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) is a low-tech, high-fidelity, simulation-based, provider-to-provider training in the management of obstetric and neonatal emergencies. This program has been successfully tested and implemented in Mexico. PRONTO will now be implemented in Guatemala as part of an initiative to decrease maternal and perinatal mortality. Guatemalan health authorities have requested that the training include training on cultural humility and humanized birth. This article describes the process of curricular adaptation to satisfy this request. The PRONTO team adapted the existing program through 4 steps: (a) analysis of the problem and context through a review of qualitative data and stakeholder interviews, (b) literature review and adoption of a theoretical framework regarding cultural humility and adult learning, (c) adaptation of the curriculum and design of new activities and simulations, and (d) implementation of adapted and expanded curriculum and further refinement in response to participant response.

Context Matters: Factors Affecting Implementation of Simulation Training in Nursing and Midwifery Schools in North America, Africa and Asia.

Background: Robust evidence supports the effectiveness of simulation training in nursing and midwifery education. Simulation allows trainees to apply newly-learned skills in a supportive environment. Method: This study was conducted using the Consolidated Framework for Implementation Research (CFIR). We conducted in-depth individual interviews with simulation experts around the world. Results: Findings from this study highlight best-practices in facilitating simulation implementation across resources settings. Universal accelerators included: (1) adaptability of simulation (2) "simulation champions" (3) involving key stakeholders and (4) culturally-informed, pre-implementation planning. Conclusions: Shared constructs reported in diverse settings provide lessons to implementing evidence-based, flexible simulation trainings in pre-service curriculum.

A comic based interactive digital intervention to enhance facilitation skills of nurse mentors in public facilities - results of a pilot intervention in Bihar, India.

BACKGROUND: Various trainings are designed to educate nurses to become simulation educators. However, there are no good strategies to sustain their learnings and keep them engaged. We developed a series of 10 interactive digital storytelling comic episodes 'The Adventures of Super Divya (SD)' to strengthen simulation educator's facilitation knowledge, skills, confidence, and engagement. This endline evaluation presents results on the change in knowledge after watching the episodes and retention of that knowledge over 10 months. OBJECTIVES: The objectives of this pilot study are to: 1) assess the change in knowledge between the baseline and post-episode surveys; and 2) understand the retention of knowledge between the post-episode and the endline survey. METHODS: A human-centred design was used to create the episodes grounded in the lived experience of nurse simulation educators. The heroine of the comic is Divya, a 'Super Facilitator' and her nemesis is Professor Agni who wants to derail simulation as an educational strategy inside obstetric facilities. Professor Agni's schemes represent real-life challenges; and SD uses effective facilitation and communication to overcome them. The episodes were shared with a group of nurse mentors (NM) and nurse mentor supervisors (NMS) who were trained to be champion simulation educators in their own facilities. To assess change in knowledge, we conducted a baseline, nine post-episode surveys and an endline survey between May 2021 and February 2022. RESULTS: A total 110 NM and 50 NMS watched all 10 episodes and completed all of the surveys. On average, knowledge scores increased by 7-9 percentage points after watching the episodes. Comparison of survey responses obtained between 1 and 10 months suggest that the gain in knowledge was largely retained over time. CONCLUSIONS: Findings suggest that this interactive comic series was successful in a resource limited setting at engaging simulation educators and helped to maintain their facilitation knowledge over time.