Article Text

Download PDFPDF
Simulation capacity building in rural Indian hospitals: a 1-year follow-up qualitative analysis
  1. Veena Sheshadri1,
  2. Isaac Wasserman2,3,
  3. Alexander W Peters3,4,
  4. Vatshalan Santhirapala3,5,
  5. Shivani Mitra6,
  6. Simone Sandler3,
  7. Emma Svensson3,7,
  8. David Ljungman3,8,
  9. Regi George9,
  10. Arundhathi Ambepu9,
  11. Jithendranath Krishnan1,
  12. Raman Kataria10,
  13. Salim Afshar3,6,11,
  14. John G Meara3,6,11,
  15. Jerome T Galea12,
  16. Peter Weinstock11,13,
  17. Christopher Roussin11,14,15,
  18. Matthew Taylor13,
  19. Nandakumar Menon1,
  20. Craig D McClain3,11,16
  1. 1 Gudalur Adivasi Hospital, Gudalur, Tamil Nadu, India
  2. 2 Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
  3. 3 Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
  4. 4 Department of Surgery, Weill Cornell Medical College, New York, New York, USA
  5. 5 Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK
  6. 6 Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
  7. 7 Lund University, Lund, Sweden
  8. 8 Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenborg, Sweden
  9. 9 Tribal Health Initiative, Sittilingi, Tamil Nadu, India
  10. 10 Jan Swasthya Sahyog, Bilaspur, Chhattisgarh, India
  11. 11 Harvard Medical School, Boston, Massachusetts United States of America
  12. 12 School of Social Work, University of South Florida, Tampa, Florida, USA
  13. 13 Simulator Program, Boston Children’s Hospital, Boston, Massachusetts, USA
  14. 14 Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
  15. 15 Center for Medical Simulation, Boston, Massachusetts, USA
  16. 16 Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
  1. Correspondence to Isaac Wasserman, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA, USA; wasserman.isaac{at}


Introduction The benefits of simulation-based medical training are well described. The most effective way to plant and scale simulation training in rural locations remains undescribed. We sought to plant simulation training programmes for anaesthesia emergencies in two rural Indian hospitals.

Methods Two Indian consultant anaesthetists without experience in medical simulation underwent a 3-day course at the Boston Children’s Hospital’s (BCH) Simulator Program. They returned to their institutions and launched simulation programmes with an airway manikin and mock patient monitor. The 1-year experience was evaluated using individual, in-depth interviews of simulation facilitators. Three staff members (responsible for facilitating medical simulations over the prior year) at two rural hospitals in India were interviewed. None attended the BCH training; instead, they received on-the-job training from the BCH-trained, consultant anaesthetist colleagues.

Results Successes included organisational adoption of simulation training with exercises 1 year after the initial BCH-training, increased interdisciplinary teamwork and improved clinical competency in managing emergencies. Barriers to effective, local implementation of simulation programmes fell into three categories: time required to run simulations, fixed and rigid roles, and variable resources. Thematic improvement requests were for standardised resources to help train simulation facilitators and demonstrate to participants a well-run simulation, in addition to context-sensitive scenarios.

Conclusion An in-person training of simulation facilitators to promote medical simulation programmes in rural hospitals produced ongoing simulation programmes 1 year later. In order to make these programmes sustainable, however, increased investment in developing simulation facilitators is required. In particular, simulation facilitators must be prepared to formally train other simulation facilitators, too.

  • Acute Care
  • Anesthesia
  • Assessment/Credentialling
  • Assessment Of Crisis Management Skills
  • Simulation-Based Training

Statistics from


  • VS and IW contributed equally

  • NM and CDM contributed equally

  • Twitter Alexander W Peters @HarvardPGSSC, Isaac Wasserman @WassermanIsaac, Emma Svensson @EmmaCarinaSve, John G Meara @JohnMeara, Craig D McClain @mcc_craig.

  • Contributors AWP, SS, ES, DL, RG, RK, JK, SA, JGM, CR, PW, MT, NM and CDM were involved in the design and implementation of the train-the-trainer programme. VSh, IW, AWP, VS, SM, RG, AA, RK, SA, JGM, JTG, NM and CDM were involved in the conception and design of the qualitative follow-up interviews. IW was responsible for gathering and transcribing all the data. IW and VSh were responsible for the initial analysis of the data. IW, VSh, AWP, VS, SM, SA, JGM, JTG and CDM were responsible for secondary analysis. All authors were involved in the writing or revision of the manuscript, and all provided their approval for publication.

  • Funding This work was funded by the Harvard Medical School Center for Global Health Delivery—Dubai (under a Cooperative Research Award to CDM and NM). Additionally, VS was supported by a Diamedica UK research grant. Finally, the Program in Global Surgery for Social Change receives grant funding from the GE foundation.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.