Evaluating the Instructional Design and Effect on Knowledge, Teamwork, and Skills of Technology-Enhanced Simulation-Based Training in Obstetrics in Uganda: Stepped-Wedge Cluster Randomized Trial
Authors: van Tetering Anne Antonia Cornelia , Segers Maartje Henrica Martine , Ntuyo Peter , Namagambe Imelda , van der Hout-van der Jagt M Beatrijs , Byamugisha Josaphat K , Oei S Guid 
Published: June 2020

Background
Simulation-based training is a common strategy for improving the quality of facility-based maternity services and is often evaluated using Kirkpatrick’s theoretical model. The results on the Kirkpatrick levels are closely related to the quality of the instructional design of a training program. The instructional design is generally defined as the “set of prescriptions for teaching methods to improve the quality of instruction with a goal of optimizing learning outcomes.”

Objective
The aim of this study is to evaluate the instructional design of a technology-enhanced simulation-based training in obstetrics, the reaction of participants, and the effect on knowledge, teamwork, and skills in a low-income country.

Methods
A stepped-wedge cluster randomized trial was performed in a university hospital in Kampala, Uganda, with an annual delivery volume of over 31,000. In November 2014, a medical simulation center was installed with a full-body birthing simulator (Noelle S550, Gaumard Scientific), an interactive neonate (Simon S102 Newborn CPR Simulator, Gaumard Scientific), and an audio and video recording system. Twelve local obstetricians were trained and certified as medical simulation trainers. From 2014 to 2016, training was provided to 57 residents in groups of 6 to 9 students. Descriptive statistics were calculated for ten instructional design features of the training course measured by the 42-item ID-SIM (Instructional Design of a Simulation Improved by Monitoring). The Wilcoxon signed rank test was conducted to investigate the differences in scores on knowledge, the Clinical Teamwork Scale, and medical technical skills.

Results
The mean scores on the ten instructional design features ranged from 54.9 (95% CI 48.5-61.3) to 84.3 (95% CI 80.9-87.6) out of 100. The highest mean score was given on the feature feedback and the lowest scores on repetitive practice and controlled environment. The overall score for the training day was 92.8 out of 100 (95% CI 89.5-96.1). Knowledge improved significantly, with a test score of 63.4% (95% CI 60.7-66.1) before and 78.9% (95% CI 76.8-81.1) after the training (P<.001). The overall score on the 10-point Clinical Teamwork Scale was 6.0 (95% CI 4.4-7.6) before and 5.9 (95% CI 4.5-7.2) after the training (P=.78). Medical technical skills were scored at 55.5% (95% CI 47.2-63.8) before and 65.6% (95% CI 56.5-74.7) after training (P=.08).

Conclusions
Most instructional design features of a technology-enhanced simulation-based training in obstetrics in a low-income country were scored high, although intervals were large. The overall score for the training day was high, and knowledge did improve after the training program, but no changes in teamwork and (most) medical technical skills were found. The lowest-scored instructional design features may be improved to achieve further learning aims.

Trial Registration
ISRCTN Registry ISRCTN98617255; http://www.isrctn.com/ISRCTN98617255

International Registered Report Identifier (IRRID)
RR2-10.1186/s12884-020-03050-3