A Simulation Scenario Focused on Resuscitation of a Young Infant (Neonate) for Nurses and Midwives in Malawi, a Limited Resource Country

Despite the improvement in neonatal and infant mortality rates in Malawi, statistics still identify 27 neonatal mortalities per 1,000 live births and 42 infant mortalities per 1,000 live births. These figures are still unacceptably high. The common causes of neonatal death are prematurity (37%), intrapartum-related complications (28%), and severe infection (24%). These causes create an opportunity to further improve the mortality rates in both populations with a focus on improving the clinical skills of nursing and midwifery students in Malawi. Training to recognize when an infant requires resuscitation, as well as how to perform resuscitative and post-resuscitative care, may help to reduce Malawi’s infant mortality rate in the future.


Introduction
Mzuzu University is one of the public universities in Malawi that offers a Bachelor of Science in Nursing and Midwifery degree, which includes a formal course in neonatology. In the neonatology course, students are expected to acquire skills in infant resuscitation before proceeding to clinical placements in health facilities. However, the number of students in the program far exceeds the clinical placements at teaching hospitals. This results in limited exposure in a real practice setting. This is further compromised by the limited clinical and educational resources within most of these teaching facilities. Considering these issues, simulation represents a highly useful teaching method to provide nursing and midwifery students at Mzuzu University with opportunities for gaining clinical skills that might otherwise be difficult to obtain.
Simulation is defined as the replication of a task or a clinical event to create an opportunity for students to practice application of their knowledge and skill [1]. Simulation-based medical education (SBME) offers many benefits. It strives to enhance trainees' cognitive, technical, and behavioral skills, as well as self-confidence, with an ultimate benefit for the patient and family being managed. SBME is theoretically supported by the principles of patient safety. It is underpinned by learning theory: the assumption that practicing application of knowledge and skill with feedback will enhance decision making and skill sets which will lead to improved patient outcomes [2]. Per Weller et al. [3], health workers who engage in SBME report greater personal satisfaction, increased knowledge, and improved performance.
To appreciate the goal of engaging SBME in a neonatal and infant care context, it is important to define the population of interest. In Malawi, a young infant is defined as those aged three days up to two months [4][5]. The young infant resuscitation simulation detailed below aims to help learners (who are the in-service health care professionals) to identify when a young infant requires resuscitation, and to give learners the opportunity to practice performing resuscitative and post-resuscitative care in a safe and reproducible setting. In Malawi, most health facilities, including the teaching hospitals, are not equipped with the advanced equipment used to perform resuscitation as it is often done in developed countries. This resuscitation, therefore, aims to prepare learners for real-world practice by employing the same level of basic equipment they will encounter during their time in a Malawi health facility but using locally available simulation technology.

Technical Report
The scenario described in this technical report is designed to support one main and three specific learning objectives. The objectives will be articulated to the learners first, following which the facilitators will use a number of elements to guide the learning: pre-brief, resources and the environment, a scenario stem, the scenario, and the feedback session. After the feedback period, the learners will be given a second opportunity to manage the same scenario again to provide them with the opportunity to implement the feedback. This will help ensure learners will utilize their learning in a real practice setting [3].

Main objective
To create an opportunity for senior university nursing and midwifery learners in limited resource facilities to practice the resuscitation of a young infant with emergency signs.

Specific objectives
· Identify emergency signs using air-breathing circulation (ABC) approach · Manage emergency sign before proceeding with rest of systematic assessment. · Use team members to help conduct complete assessment and provide timely management. · Conduct the resuscitation using bag mask valve (BMV). · Conduct the cardiopulmonary resuscitation (CPR). · Reassessed ABC. · Provide follow-up care after resuscitation (definitive care).

Setting and resources
This simulation session has been designed for Mzuzu University and will be facilitated in the nursing and midwifery skills laboratory.
Resusci® Baby First Aid (model 160-01250) (Laerdal Medical, Stavanger, Norway) is the infant simulator that will be used for these scenarios. The infant simulator cannot breathe or show central cyanosis but can be ventilated with a self-inflating bag. Furthermore, it does not have a pulse and all clinical assessment parameters will be provided to learners by the facilitators in order to increase the realism when using a simulator that is not highly technologically advanced. Therefore, learners will be asked to talk aloud during the assessment and the management of the simulated infant patient so that the facilitators can provide relevant and timely information and prompts. Other equipment that will be needed and is found at the skills laboratory includes an Ambu® bag (Ambu A/S, Ballerup, Denmark), face mask, oxygen concentrator, nasal prongs, nasal catheters, suction catheters, penguin suction devices, and a suction machine.

Process
The entire learning process will occur in two distinct phases. In the first phase, the learners will be familiarized with the technical skills necessary to participate in the simulation scenario. In the second phase, they will be able to practice the scenario using the same simulator, but the focus will be on the development of non-technical skills.
More specifically, in the first phase, the learners have practiced the ABC assessment and management, including oxygen delivery and effective use of a bag and mask to ventilate an infant using a single-handed, two-point top hold technique (referred to as C-E technique because of the "C" shape formation between the thumb and the index finger, and the "E" formation between the remaining three fingers during the hold) [6]. The learners will then be given a brief outline stating the objectives of the simulation scenario prior to the start. The facilitators will demonstrate the technical skills involved in the scenario on the simulator. After the initial demonstrations, the learners will be allowed to practice these skills with guidance until competence is observed by the facilitators.
Next, in the second phase, the learners will be introduced to the entire simulation scenario. The introduction to the scenario will start with a pre-brief, which will take between five and 10 minutes. This is important as it helps create a safe learning environment, familiarizing the learners with expectations and the simulated clinical context [7]. The learners will be oriented to the setting and equipment that will be used in the scenario. They will also be asked to speak out loud and clear so that the facilitator can hear them. They will be encouraged to ask for any information when they feel that the simulated infant cannot provide. Furthermore, the learners will be reminded to maintain a standard of professionalism similar to that of the clinical setting for enhanced learning. Lastly, to create a safe learning environment, the learners will be told that they are expected to make mistakes and it is okay as that is where learning will happen. All learners will be asked to hold the basic assumption that everyone is intelligent, motivated, and cares about doing their best. Table 1 depicts the simulation scenario. The following scenario stem can be used to introduce the learners to the scenario: "Nana, a 7-week-old girl is being admitted to the nursery ward from the "under five outpatient department". The nurse escorting Nana to the ward says he or she is concerned that Nana looks unwell and has started having noisy breathing. Please assess and manage Nana.

Objective Expected learner action Facilitator prompts
Looks for chest rise Listens and feels for When the learner says they are looking at the

Feedback
Feedback on learners' performance is the most important feature of simulation education as it creates an opportunity for guided personal reflection about their performance and insight into performance gaps that may not be obvious to them [8]. The goal of providing feedback is to close the gaps to improve management and simulated patient outcomes. In SBME, learners may get emotional because of something they did or wish they did in front of their peers, or a perception that they would have done things differently in a real situation as the information and clinical findings in real patients would have provided more accurate guidance. Giving learners an opportunity to express their emotions is helpful as it allows them to focus on discussion and learning. If learners respond defensively, the facilitator should address their concerns in a non-confrontational way. The learners' responses and details about what frustrated them often provide the facilitator with important insight into the needs of the learners, inclusive of how the SBME might be improved to support more realism. Once emotion is expressed, the facilitator can focus on feedback.
Three methods of giving feedback can be used for the scenario, and the choice of the method will depend on the learners' and facilitators' experiences with simulation [7]. These include: 1. Direct feedback: A facilitator-centered feedback method that focuses on closing any performance gaps by telling the learner what they have done wrong and how to do it appropriately next time.
2. Plus/delta: A learner-centered feedback method that focuses on the learners identifying what they did well, what potential performance gaps challenged management (what would they do differently next time), and elaborate on how to close these gaps. In this method, the facilitators may use frames such as "What worked well? What would you do again?" to identify the positive aspects of performance (i.e. the plus). This is typically followed by phrases such as "What would you do differently?" to identify the perceived gaps in performance that need to be changed (i.e., the delta). Finally, the facilitators can check if the performance gaps have been closed by introducing a phrase to stimulate reflection such as "How would you summarize your experience? What did you learn?".
3. Observation, point of view, and inquiry: A learner-centered feedback method that is used to check the learners' assumptions and to ensure that the feedback is based not only on learners' perceptions of what happened but also why actions were taken (i.e., the assumptions). In this method, the facilitator identifies what they saw or did not see and heard or did not hear. After that, they express their concern about these points and then direct it back to the learners to get their perspectives. This approach focuses on identifying thoughts or experiences that led to learner actions so they can be discussed further and performance gaps can be closed.

Discussion
The technical report described here is a direct outcome of a larger initiative looking at the development of simulation expertise in developing countries described in our earlier paper [7]. The long-term aim of our initiative is to decrease morbidity and mortality through the introduction of a context-specific faculty development program focused on pedagogy and the administration of SBL programs. In this regard, we have successfully developed and implemented several train-the-trainer courses described earlier [7]. We hypothesized that the knowledge developed through these courses will cascade in a few directions -from new courses being offered across Malawi in health institutions to individual educators taking initiative and writing technical reports describing locally relevant simulation scenarios [9].

Conclusions
The simulation scenario described in this technical report was designed to improve the ability of senior nursing and midwifery university students in Malawi to recognize when an infant requires resuscitation, perform effective resuscitation, and provide post-resuscitative care to help reduce Malawi's infant mortality rate in the future.
It is our intention that by sharing this scenario, it may be used in other such settings with nursing and midwifery students to build their capacity with neonatal emergency management. From our experience, the inclusion of SBME creates opportunities for learning in circumstances when learning cannot be achieved in the real practice setting. It also decreases potential risk to real patients as midwives and nurses responding to these challenging events are confident and competent because they have practiced the management. Ultimately, SBME creates an opportunity to improve how we care for this vulnerable population, which should positively impact these high mortality rates over time.
In the future, the simulation scenario described in this technical report will be embedded into the training schedule at the university and affiliated teaching hospitals in order to assess its effectiveness in achieving the learning objectives.

Additional Information Disclosures
Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.