The “Empty Chairs” Approach to Learning: Coast-to-Coast Canadians Run a Simulation-Based Train the Trainer Program in Mzuzu, Malawi.

By Adam Dubrowski

 

Introduction

Together, with a group of my Canadian colleagues from Calgary, Alberta (some via Doha) and London, Ontario I was privileged to represent MUN’s Faculty of Medicine during the first Train the Trainer in Simulation-Based Learning (TTT-SBL) program in Mzuzu Central Hospital and Mzuzu University in Malawi.  Our team, led by Elaine Sigalet (Doha) and consisting of Ian Wishart (Calgary) and Faizal Haji (London), was invited to Malawi by Norman Lufesi, to conduct a 2-day TTT-SBL course for facilitators who teach an Emergency Triaging, Assessment of Trauma (ETAT) course.

The TTT-SIM facilitator team (from left to right): Adam Dubrowski, Elaine Sigalet, Norman Lufesi, Ian Wishart, and Faizal Haji.

Why?

This course was developed in response to an evolving partnership between the International Pediatric Simulation Society (IPSS), the World Federation of Pediatric Intensive Care Societies (WFPICCS), and the Ministry of Health. The long-term objective of this partnership is to decrease pediatric morbidity and mortality through the introduction of context specific faculty development programs focused on pedagogy and administration of simulation programs. It is anticipated that such programs will lead to the improvement of on-going health care educational efforts and the development of effective future programs, subsequently improving health service delivery for patients in Malawi. 

What?

This was our third visit to Malawi.  The first, in 2012, was primarily an environmental scan for us to understand the health care system as a whole and to listen to the relevant stakeholders about their needs for simulation.  Together with the Malawians, we identified that their on-going ETAT course would provide the right context for implementing simulation-based learning (SBL).  The second visit in 2014, consisted of observations of ETAT courses and mapping the TTT-SBL course.  Our most recent visit’s purpose was to implement the TTT-SBL course and to observe how the newly trained facilitators performed.

Norman Lufesi, who works for the Malawi Ministry of Health and is responsible for delivery of the ETAT courses in Malawi, had a vision for revising the current format of the ETAT to include more simulation.  Although elements of simulation are already used during the ETAT, he articulated that there are a number of shortcomings.  First, the local ETAT facilitators are not trained in how to use simulation effectively.  Secondly, the simulation that is used focuses on the development of technical skills by an individual health care professional. Finally, the course now is mainly 4.5 day long filled with didactic lectures.  Norman strongly believes that ETAT should also focus on the development of team-based learning, specifically elements of leadership, team communication, and resource management.  In his opinion, improving the teaching skills of the facilitators, and adding team training as part of the ETAT course offerings will make the course more effective and shorter (aiming at 2.5 days).  He adds that at this moment ETAT is a multi-professional course, where nurses, doctors, and clinical officers work in collaboration with each other.  By including team-based training, Norman hopes that the course will become an inter-professional course where all these health professions will learn with and about each other.  Furthermore, in his vision Norman hopes that this shift towards inter-professional education will cascade into inter-professional practice, ultimately leading to improved clinical outcomes.

Over the past 2 years, our group focused on the development of a 2-day TTT-SBL course.  The scope of this course includes providing the fundamental knowledge and skills necessary to prepare learners for SBL, for designing and running simulations, and for providing proper debriefing and feedback.  During the course the learners were provided with ample opportunities to actively implement the newly gained skills and knowledge.  The inaugural TTT-SBL course, conducted in September 2016, was strategically timed just prior to an ETAT course, where the newly trained facilitators were able to test their simulation teaching skills with 30 ETAT learners.  In the spirit of experiential learning and deliberate practice, the Canadian team hung out until the end of the course to provide these new ETAT facilitators with feedback.    

The TTT-SIM facilitators, ETAT facilitators, and the cohort of the Mzuzu ETAT students.

But our work is not done yet!  Together with Norman, the Canadian team has committed to a long-term mentor-ship plan that includes four initiatives.  First, the Canadian mentor team has re-written one of the modules of the current ETAT course to minimize the amount of didactic lectures, and when appropriate, to provide more simulation experiences, especially in the areas of critical thinking, leadership and team work.  Next, as a follow-up exercise, the newly trained ETAT facilitators have been tasked with re-writing the other modules of the ETAT course.  Third, the facilitators were asked to produce a TTT-SBL manual and supporting materials that can be used as a local resource for future TTT-SBL courses.  Finally, the facilitators were asked to establish a group of dedicated individuals to formulate a process for organizing TTT-SBL courses in other parts of Malawi and conduct a review of the existing materials.

Two way street

Working on and delivering the TTT-SBL made me realize the parallels between Malawi and rural and remote Newfoundland.  Our problems are very similar.  Rural and remote areas do not have access to high fidelity, high technology simulation.  Even with low tech substitutes, the health care professionals may lack the educational skills to make it most effective, and finally these health care professionals are often the only ones available to the local patient population and taking them away from their patients can be hard.  Is there a role for a version of this 2-day TTT-SBL course in rural an d remote Newfoundland? 

I left Malawi with mixed feelings of being home sick and longing for more - the excitement and energy during both the TTT-SBL and the ETAT courses were very stimulating and rewarding. But, I know this will not be my last trip to Malawi.

Acknowledgments: I would like to thank the Tuckamore Simulation Research Collaborative, and the Dean’s office for supporting this work. I would also like to thank the other members of our team for making this happen!