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Healthcare Simulation in Resource-Limited Regions and Global Health Applications

2017; Lippincott Williams & Wilkins; Volume: 12; Issue: 3 Linguagem: Inglês

10.1097/sih.0000000000000220

1559-713X

Pamela Andreatta,

Innovations in Medical Education

The benefits of healthcare simulation in resource-limited regions and for global health applications parallel to those that have been demonstrated in resource abundant, technologically advanced locales. These include safety advantages realized by the opportunities that simulation provides to clinicians to prepare, learn, practice, rehearse, and improve clinical performance without adversely impacting patient care. Benefits also include opportunities to improve healthcare quality by facilitating the development and testing of novel devices, techniques, procedures, equipment, and process efficiencies without adversely impacting patient care. Healthcare simulation provides alternatives to remedy ethical considerations associated with accomplishing these objectives by using animals or during the provision of actual patient care. It also provides a foundation for enhanced, lower cost, and more effective training of clinicians in every clinical specialty by facilitating the development of mastery-based instruction and standards-based practices. The needs for these advantages are in many ways more pronounced in resource-limited regions and global health applications because the gaps between the means of service providers to deliver safe, high-quality healthcare and the abilities of patients to access that care are wider and more difficult to bridge than in more developed regions of the world. In addition to the benefits simulation brings to affluent, technology-centered societies, simulation adds value for resource-limited rural and remote regions of the world in the following three areas: (1) rapidly preparing entry-level providers and facilitating career development opportunities through academic institutions; (2) developing the abilities of community-based providers (traditional healers, teachers, village and tribal leaders) to work in partnership with professional providers; and (3) bridging the gaps of understanding between professional health services providers and local populations who mistrust modern medicine. PREPARATION OF ENTRY-LEVEL PROVIDERS AND CAREER DEVELOPMENT IN RURAL/REMOTE REGIONS Longer life spans and growing populations in all parts of the world have led to clinician shortages, but in rural and remote areas these shortages are much more evident. Global health researchers have documented many reasons for this, including the limitations rural and remote locations impose on the feasibility for service providers to collaboratively engage with their peers, continue to advance their abilities through specialized training, secure a comfortable home and provide high-quality education for their children, and maintain an active and comfortable lifestyle.1–3 In many rural and remote parts of the world, university-educated service providers may be the only clinicians with formal academic training in a community of many thousands of people. Not only does this limit the achievement of the aforementioned socioeconomic and professional advancement objectives, it places an enormous personal and professional burden on service providers to manage a steady stream of patients who have limited ability to pay for services, who require clinical care across multiple medical and surgical contexts, and to do so every day with minimal or no backup from other academically trained clinicians.4–6 The result is a dearth of university-educated, credentialed clinicians in many parts of the world, further reducing the desirability for service providers to work in these areas and contemporaneously limiting access to high-quality care for much of the world's population. These challenges could be significantly mitigated through the application of simulation-supported instruction and practice contexts, which extends the value of simulation-based methodologies beyond those typically identified for affluent regions with access to advanced technologies and supporting infrastructures. In most resource-limited regions of the world, academically trained clinical providers follow a similar path as other parts of the world toward developing professional competencies and successfully meeting licensing requirements, by matriculating through accredited programs in nursing, midwifery, medicine, or one of the other health professions (eg, pharmacy, dentistry, etc). However, because of the extreme shortages of professional clinicians in these areas, there are often additional tiers of service providers to supply as much coverage as possible, even if the extent of training for those providers is reduced. For example, entry-level nurses may enter into professional service with a reduced scope of practice through a 2-year credential in many regions, rather than a 4-year degree. Although many of these entry-level providers continue to acquire more advanced credentials, some maintain service in a reduced capacity working collaboratively with those who have acquired more training. Entry-level providers may be community based or at least situated within a catchment area of a district or regional medical center that is staffed by licensed service providers. These licensed providers have similar credentials to physicians, surgeons, nurses, and other health professionals in other parts of the world. Working collaboratively, these professional clinicians provide services to hundreds of thousands of widely distributed people throughout rural and remote regions, many situated several hours or days away from the nearest medical center. In addition to these professional service providers, nonprofessional traditional healers frequently serve communities through time-honored practices that are acquired outside academic environments. Healthcare simulation has value for both professional and traditional service providers. Healthcare simulation can facilitate effectual training of licensed clinical service providers through two mechanisms. The first is through traditional matriculation and graduation from academic programs affiliated with accredited institutions that lead to clinical licensing credentials. The second is through the nontraditional process of training community-based providers to perform specific clinical functions that extend the reach of the few licensed service providers in an underserved area. This is not an unusual concept and is exemplified by first aid training and cardiopulmonary resuscitation courses available to the general public in many affluent regions of the world. The difference in resource-limited rural and remote regions of the world is that the delays in securing licensed care for a patient are typically much longer, and as a result, the extent of care required for community service providers to perform is frequently more complex. Simulation provides a platform for developing expertise in both of these performance contexts, especially when integrated with mastery learning principles. Mastery learning programs in healthcare are designed to assure demonstrated achievement of specific performance objectives before advancing through sequentially more complex concepts, techniques, and integrated practice requirements.7,8 Simulation-supported training environments provide a strong foundation for implementing mastery learning principles because performance assessment is an essential component for mastery-based programs. Simulation provides a framework for performance feedback and assessment that are both sustainable and repeatable, regardless of the level of technology used in the training program.9–11 Programs built around mastery learning principles lead to more efficient acquisition of abilities that are tied to specific performance standards, which in turn facilitates self-regulated maintenance of abilities because the performance standards are clearly defined and known by all practitioners in the clinical domain. Mastery learning facilitates a strong foundation for clinical practice and has been demonstrated to lead to greater retention of abilities over time because the framework for all subsequent learning is cognitively anchored at the onset of professional development.9 As such, simulation-supported mastery learning frameworks are ideally aligned to support impactful training contexts that lead to the rapid acquisition of healthcare proficiencies, especially for entry-level and first-responder providers who are able to serve communities in rural and remote regions.12–18 It also provides a framework for expansion of practice and maintenance of skills for specialists who are situated in resource-limited rural and remote areas, including surgeons and emergency medicine physicians.19–23 Notably, a key component of the success of these types of programs is that they are designed to leverage local resources, which increases the likelihood of both sustainability and adaptation to meet the needs of the communities served.24 Facilitating simulation-supported training in these regions requires creativity, resourcefulness, and willingness to think outside of the more common methods of integrating technology-centered solutions. It is essential to consider the resources that are available in the region where training will take place to implement a successful training encounter, as well as to assure its repeatability.18,25 Resources such as electrical power and network connectivity are taken for granted in many parts of the world but are often scarcely and inconsistently available in resource-limited areas. To design an optimally effective simulation in any context requires well-defined learning objectives, and this is especially true in resource-limited areas. Defining the end-performance objective for what the trainees will be able to do after the simulated event will facilitate the development of what is essential and supportable based on availability, rather than what is desirable but not available. There are multiple corporations that support low-technology solutions for these purposes, several of whom also have foundations working to design and implement solutions for specific needs. Working in partnership with these organizations, as well as with nonprofit organizations, the World Health Organization, United States Agency for International Development, and other governmental groups will help those who wish to support simulation-based training and professional development efforts in resource-limited regions to be successful. EXPANDING ABILITIES OF TRADITIONAL PROVIDERS IN RURAL/REMOTE REGIONS In many parts of the world, traditional healers and nonacademically trained community-based providers are the predominate source of clinical care for the population. These providers are not typically trained through formal academic programs or credentialed through licensing organizations, but they are often highly skilled and knowledgeable in their specific practice areas. For example, I have worked with traditional birth attendants who each manage the care of more than 400 pregnant women per year, including labor and delivery and referral to licensed providers at regional medical centers when their examinations indicate the need for nontraditional intervention (pre-eclampsia, gestational diabetes, breech presentation, etc). Many professional service providers work closely with traditional community-based providers to connect with and improve the health and wellbeing of the population in their service area. For example, in rural and remote regions in Africa, there may be one physician, a few nurses, and a few community health workers in a district serving a quarter-million people or more; many of whom might need to travel more than a day by foot to access professional clinical care. As a result, by the time a sick or injured person reaches the nearest professional service providers or clinically staffed medical center, they are all too often past the point where morbidities or mortality can be averted. Astute professional service providers may engage traditional providers in their catchment areas and teach them how to recognize and manage specific clinical conditions so that patients may be stabilized during transport or, if transport is not possible, until professional care can arrive to the remote location. Simulation is an ideal mechanism for this type of training, where specific skills require demonstration and practice to assure accuracy, and where language and literacy considerations might also be limiting considerations. For example, simulation-supported training for traditional birth attendants in Ghana significantly improved their abilities to recognize and manage emergent postpartum hemorrhage from uterine atony (a leading cause of maternal mortality in the region) and to coordinate with professional providers in the regions to assure follow-up care of the mother.26 BRIDGING GAPS OF UNDERSTANDING IN RURAL/REMOTE REGIONS The partnerships that develop between community-based providers and professional service providers in rural and remote regions also have the potential to educate the local populations about how modern medical practices can enhance their wellbeing, without abdicating their local or tribal customs. When trusted community-based providers convey information in partnership with professional providers who are located within the catchment area of the community, suspicion is reduced and understanding is increased because the values of both entities are respected and leveraged to effect positive health outcomes for the local population. Simulation methodologies have a unique role to serve in these types of exchanges, especially for translational and literacy considerations. Simulation-supported activities that are partnered with traditional methods of teaching, such as storytelling, songs, and dance, facilitate a mutual conversation that includes the rituals and customs of the local population with the techniques and practices of modern medicine. Through integrating clinical models, simulated patient methodologies, and other low-technology simulation proxies, it is possible to introduce techniques and processes that would otherwise be considered verboten within the boundaries of village or tribal culture, especially for gender-related considerations. For example, simulation lends itself well to teaching family planning practices and how to prevent or guard against sexually transmitted diseases. In this manner, simulation has the potential to build trust, respect, and understanding between the practices of traditional culture and professional practice in health services.27–31 PARALLEL BENEFITS FOR AFFLUENT TECHNOLOGICALLY ADVANCED REGIONS Simulation-supported practices in rural and remote regions can significantly benefit healthcare practices in affluent technologically advanced regions of the world as well. As modern medical practices continue to evolve and diseases become eradicated or rare, many clinicians are unfamiliar with diagnostic, treatment, processes, and procedural techniques that are essential for recognizing and managing potentially dangerous clinical situations. In the United States, it is not unusual for a physician to have never cared for a patient with mumps or polio, largely because of successful population education around immunization programs. Unfortunately, these preventable diseases are again on the rise, and simulations developed for training clinicians in resource-limited communities without ready access to immunizations can help prepare clinicians in areas where people choose to not immunize their children. The same benefits can be realized for diseases that are not typically located in geographic regions but can be transported through travel, such as yellow fever, malaria, and Ebola. Infected patients may require clinical care by service providers who are unfamiliar with the diagnostic, treatment, and protection protocols required to effectively manage both the patient and clinical environment itself. Therefore, simulation-supported instruction for clinicians in limited resource remote and rural areas, where these clinical conditions are prevalent, has relevance in affluent, technologically advanced areas as well. Lastly, simulation-supported training in rural and remote regions can provide a deeper understanding of clinical practice standards and remind service providers of the fundamentals of hands-on patient care when present day clinician preparation trends toward reliance on high-end technologies and expensive diagnostic tests (eg, echocardiogram vs. auscultation, ultrasound vs. fetal scope, minimally invasive surgery vs. open surgery). Retaining these conventional clinical abilities is an important component for developing diagnostic and procedural expertise, as well as for cost containment considerations. Simulation developed for resource-limited regions where these high technology solutions are not available can also provide a bridge back to the basics when a program of instruction emphasizes advanced technologies.32–36 SUMMARY The healthcare education and training needs of rural and remote regions of resource-limited countries are similar to those of affluent technologically advanced nations, but also include considerable challenges associated with clinician shortages, competing interests between professionally trained health services providers and traditional community-based providers, and significant knowledge gaps with attendant mistrust of modern medical practices in the general population. Carefully designed culturally sensitive simulation-supported encounters and mastery learning-centered instruction can help bridge these gaps and provide significant value to both professional service providers and community-based providers by aiding their abilities to care for and educate patients in their practice areas. Simulation designed and developed for resource-limited rural and remote regions of the world also have value for affluent technologically advanced regions by providing a foundation for acquiring conventional skills appropriated by technologies and familiarizing clinicians with rare diseases or disorders that are atypical to their geographic location. These benefits amplify the many other advantages simulation brings to clinical providers during their initial training and throughout their careers, regardless of their locale or economic status.