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Simulation training of caregivers at hospital discharge of patients with chronic diseases: an integrative review

Simulación de entrenamiento de cuidadores en el alta hospitalaria de pacientes con enfermedades crónicas: una revisión integradora

ABSTRACT

Objective:

to identify evidence about the use and effects of clinical simulation for preparing caregivers for discharging patients with chronic conditions.

Methods:

an integrative peer review in the Scopus, PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, ScienceDirect and Virtual Health Library databases, from July to September 2022.

Results:

3,218 studies were identified, with a final sample consisting of four national and two international articles. Using simulation as an educational technology contributed to caregiver preparation in home care. In most studies, using clinical simulation included using other strategies to complement training: expository dialogued class, conversation circle and audiovisual resources.

Final considerations:

simulation proved to be efficient for training caregivers, with the active participation of family members and nurses in health education actions.

Descriptors:
Simulation Training; Caregivers; Patient Discharge; Chronic Disease; Nursing

RESUMEN

Objetivo:

identificar evidencia sobre el uso y efectos de la simulación clínica para la preparación de cuidadores en la deshospitalización de pacientes con enfermedades crónicas.

Métodos:

revisión integradora por pares en Scopus, PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, ScienceDirect y Virtual Health Library, de julio a septiembre de 2022.

Resultados:

se identificaron 3.218 estudios, con una muestra final compuesta por cuatro artículos nacionales y dos internacionales. El uso de la simulación como tecnología educativa contribuyó a la preparación de los cuidadores en el cuidado domiciliario. En la mayoría de los estudios, el uso de la simulación clínica incluyó el uso de otras estrategias para complementar la formación: clase expositiva dialogada, círculo de conversación y recursos audiovisuales.

Consideraciones finales:

la simulación demostró ser eficiente para la formación de cuidadores, con la participación activa de familiares y enfermeros en acciones de educación en salud.

Descriptores:
Entrenamiento Simulado; Cuidadores; Alta del Paciente; Enfermedad Crónica; Enfermería

RESUMO

Objetivo:

identificar evidências acerca do uso e dos efeitos da simulação clínica para o preparo de cuidadores na desospitalização de pacientes em condições crônicas.

Métodos:

revisão integrativa, realizada por pares, nas bases Scopus, PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, ScienceDirect e Biblioteca Virtual de Saúde, no período de julho a setembro de 2022.

Resultados:

foram identificados 3.218 estudos, com amostra final composta por quatro artigos nacionais e dois internacionais. O uso da simulação como tecnologia educacional contribuiu para o preparo de cuidadores nos cuidados domiciliares. Na maioria dos estudos, o uso da simulação clínica contou com a utilização de outras estratégias para complemento da formação: aula expositiva dialogada, roda de conversa e recursos audiovisuais.

Considerações finais:

a simulação se mostrou eficiente para o treinamento dos cuidadores, com participação ativa de familiares e enfermeiros nas ações de educação em saúde.

Descritores:
Treinamento por Simulação; Cuidadores; Alta do paciente; Doenças Crônicas; Enfermagem

INTRODUCTION

Chronic non-communicable diseases affect populations all over the world, but their prevalence is higher in underdeveloped or developing countries, becoming the main cause of morbidity and mortality in all age groups. Challenges faced by patients with chronic illnesses include the need to achieve: relief and management of signs and symptoms; psychological adjustment; physical accommodation and resulting disability; prevention and management of crises and complications; management of family functionality; establishment of support networks and resources that can increase quality of life, among others(11 Malta DC, Gomes CS, Barros MBA, Lima MG, Almeida WS, Sá ACMGN, et al. Noncommunicable diseases and changes in lifestyles during the COVID-19 pandemic in Brazil. Rev Bras Epidemiol. 2021;24:e220009. https://doi.org/10.1590/1980-549720210009
https://doi.org/10.1590/1980-54972021000...
-22 Ferreira AMD, Oliveira JLC, Camillo NRS, Reis GAX, Évora YDM, Matsuda LM. Perceptions of nursing professionals about the use of patient safety computerization. Rev Gaúcha Enferm. 2019;40(spe.):e20180140. https://doi.org/10.1590/1983-1447.2019.20180140
https://doi.org/10.1590/1983-1447.2019.2...
).

Faced with these challenges, continuous search for health services to achieve safe care requires those involved in the process, i.e., professionals, patients, family members and their caregivers, to have a comprehensive and collaborative look in the planning and execution of this care. The Global Patient Safety Action Plan (2021-2030), in its guiding principles, emphasizes the importance of involving the health team in patient care, especially in the transition from care in hospital institutions to home care during discharge(33 World Health Organization (WHO). Global patient safety action plan 2021-2030: towards eliminating avoidable harm in health care [Internet]. Geneva: WHO; 2021 [cited 2022 Jan 5]. Available from: https://www.who.int/publications/i/item/9789240032705
https://www.who.int/publications/i/item/...
).

Discharge occurs when patients, still hospitalized, have a satisfactory clinical stability of their health status, but will need to complement treatment at home, which may include professional follow-up, use of life-supporting equipment and attention of a caregiver(44 Silva DL, Souza JLB, Lima IS. Desospitalização: esse é o caminho? pesquisa realizada no pronto-socorro Clóvis Sarinho. Rev Cient Multi Núcleo do Conhecimento [Internet]. 2017 [cited 2022 Jan 15];1(2):474-500. Available from: https://www.nucleodoconhecimento.com.br/ciencias-sociais/desospitalizacao.
https://www.nucleodoconhecimento.com.br/...
). In this regard, it is considered important that informal caregivers are prepared even in a hospital environment so that they feel safer, more confident and capable of providing home care. Evidence produced in a quasi-experimental study denote that caregiver preparation in the hospital, through guidance and training, combined with post-discharge follow-up, increases the skills of this caregiver and reduces the chances of inappropriate actions at home(55 Rodrigues TFCS, Cardoso LCB, Rêgo AS, Silva ES, Elias MFAL, Radovanovic CAT. Educational intervention to increase the skill of informal caregivers: a quasi-experimental pilot study. Texto Contexto Enferm. 2021;30:e20200152. https://doi.org/10.1590/1980-265X-TCE-2020-0152
https://doi.org/10.1590/1980-265X-TCE-20...
). In order to comply with the Patient Safety Policy in the discharge process, a teaching and learning strategy called “clinical simulation in health” has been highlighted. It is defined as an educational strategy that exposes participants to hypothetical scenarios that mimic the reality of clinical practice(66 Kaneko RMU, Lopes MHBM. Realistic health care simulation scenario: what is relevant for its design? Rev Esc Enferm USP. 2019;53:e03453. https://doi.org/10.1590/S1980-220X2018015703453
https://doi.org/10.1590/S1980-220X201801...
). Clinical simulation practice is common for students, during academic training, and also for health professionals, in learning and improving health care, being a technology that has been improved in recent times for teaching and learning in several areas(77 Teles MG, Mendes-Castillo A, Oliveira-Kumakura AS, Silva, JLG. Clinical simulation in teaching Pediatric Nursing: students’ perception. Rev Bras Enferm. 2020;73(2):e20180720. https://doi.org/10.1590/0034-7167-2018-0720
https://doi.org/10.1590/0034-7167-2018-0...
). However, it is still an uncommon practice in interventions to prepare caregivers for discharge.

For this strategy to work, its phases, called preparation, participation and debriefing, must be conceptualized and understood. The preparation phase is divided into two stages: a pre-simulation, which covers participant preparation for the topics presented in clinical simulation, through the delivery of educational materials and skills training; and a pre-briefing/briefing, set up by interaction between facilitator and participant, immediately in the field, with clear scenarios, objectives and learning roles(88 Nascimento JSG, Nascimento KG, Regino DSG, Alves MG, Oliveira JLG, Dalri MCB. Clinical simulation: construction and validation of a script for Basic Life Support in adults. Rev Enferm UFSM. 2021;11:e44. https://doi.org/10.5902/2179769254578
https://doi.org/10.5902/2179769254578...
).

The participation phase involves carrying out the proposed scenario, while debriefing presents a discussion/reflection process that takes place during or after the scenario, enabling the improvement of skills and abilities. Clinical simulation planned and executed in three stages enables the teaching and learning process of complex subjects(88 Nascimento JSG, Nascimento KG, Regino DSG, Alves MG, Oliveira JLG, Dalri MCB. Clinical simulation: construction and validation of a script for Basic Life Support in adults. Rev Enferm UFSM. 2021;11:e44. https://doi.org/10.5902/2179769254578
https://doi.org/10.5902/2179769254578...
).

Patientand family-centered clinical simulation presents many challenges for academic and professional education. The financial, structural and organizational challenges in the clinical simulation proposal aimed at home care education include, in addition to caregivers’ literacy level, their feelings, emotional and affective states, which influence learning(99 Graham RJ, Amar-Dolan LR, Roussin CJ, Weinstock PH. Bridging the stressful gap between icu and home: medical simulation for pediatric patients and their families. Pediatr Crit Care Med. 2019;20(4):e221-e224. https://doi.org/10.1097/PCC.0000000000001869
https://doi.org/10.1097/PCC.000000000000...
).

This study was developed because it is understood that clinical simulation can also be developed with caregivers, with a view to producing safe home care, and because it was verified that the aforementioned teaching and learning methodology appears little among the interventions developed with caregivers in the discharge process.

OBJECTIVE

To identify evidence about the use and effects of clinical simulation to prepare caregivers for discharging patients with chronic conditions.

METHODS

Ethical aspects

According to Resolution 466/2012 of the Brazilian National Health Council of the Ministry of Health, as it is a review study, appraisal by an Ethics Committee is waived.

Study design

This is an integrative literature review, which included the following steps: guiding question elaboration; establishment of inclusion and exclusion criteria; search or sampling in the literature; data collect; categorization of studies; critical analysis of included studies; discussion of results; and integrative review presentation(1010 Souza MT, Silva MD, Carvalho R. Integrative review: what is it? how to do it? Einstein. 2010;8(1):102-6. https://doi.org/10.1590/S1679-45082010RW1134
https://doi.org/10.1590/S1679-45082010RW...
-1111 Teixeira E, Medeiros HP, Nascimento MHM, Silva BAC, Rodrigues C. Integrative literature review step-by-step & convergences with other methods of review. Rev Enferm UFPI. 2013;2(5):3-7. https://doi.org/10.26694/reufpi.v2i5.1457
https://doi.org/10.26694/reufpi.v2i5.145...
).

The theme “clinical simulation in preparation for discharge” was established. From there, the object of the study was defined, specifying the interest in preparing caregivers of people with chronic conditions and, consequently, elaborating the guiding question: how is clinical simulation used and what are its effects on preparation of caregivers of patients with chronic conditions in the discharge process? The acronym PVO was used, from which the following attributions were performed: P (population): caregivers of patients with chronic diseases; V (variable): clinical simulation; and O (outcome): discharge.

Study period and place

The search for articles in the databases took place in July 2022. Two independent researchers searched for the studies, in pairs. It is noteworthy that search strategies were defined after mapping the terms and synonyms searched in the Medical Subject Headings (MeSH) and Descriptors of Health Sciences (DeCS). The terms, in Portuguese and English, were combined in different ways, using the Boolean operators “OR” and “AND”. For testing with the broader strategy, a search was also carried out for the most used words in titles and descriptors/keywords of research already published on the subject. To search the bases, the indexed descriptors and their respective synonyms in MeSH were used (Chart 1).

Chart 1
Indexed descriptors and their respective synonyms in Medical Subject Headings, 2022

It is noteworthy that synonyms were used in order to identify the largest possible number of publications related to the object under study. Database crossings occurred with the use of the AND operator, namely: crossing 1: “Caregivers AND Chronic disease AND Simulation Training AND Transitional Care”; crossing 2: “Caregivers AND Simulation Training AND Transitional Care”; crossing 3: “Simulation Training AND Transitional Care”. The awareness strategies used are shown in Chart 1. Due to specificities and for the feasibility of the review, different strategies were used for each base.

This review was carried out in the following indexed databases: Scopus; National Library of Medicine (PubMed); Web of Science; ScienceDirect; Cumulative Index to Nursing and Allied Health Literature (CINAHL); and Virtual Health Library (VHL) portal. The analysis of collected material was carried out in September 2022.

Population and sample

A total of 3,218 studies were found in the selected data sources. After removal of paid materials and exclusion based on initial reading of titles, abstracts and removal of duplicates, six studies were selected to compose the results.

Inclusion and exclusion criteria

Inclusion and exclusion criteria were defined, including complete articles available in full, online and free of charge that answered the guiding question, in addition to studies in any language and without time frame. Editorials, letters to the editor, abstracts, expert opinion, other reviews, correspondence, reviews, book chapters, monographs, theses and dissertations as well as duplicate productions were excluded.

Study protocol

All databases were accessed via the Federated Academic Community (CAFe - Comunidade Acadêmica Federada), in the Coordination for the Improvement of Higher Education Personnel (CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) Journal Portal. After searching for studies in the databases, the articles were exported to the Zotero 5.0 reference manager, where duplicates were excluded. Study selection and analysis were carried out by two researchers, master’s students of the graduate course in nursing at the Integrated Health Institute of the Universidade Federal do Mato Grosso do Sul, members of research groups linked to the aforementioned program. When there were disagreements, a third reviewer, professor and leader of the research group, was contacted, minimizing biases regarding selection and interpretation errors.

Analysis of results

After defining and extracting information from the articles, a chart was prepared in Microsoft Excel 2013, containing study identification, reference, objective, methodological approach, type of simulation and simulators used, impact factor of the journal in which the article was published, levels of evidence and main results.

For the critical assessment of the studies included in the review, which included hierarchical classification regarding the level of evidence, the primary study’s research question was considered. For this assessment, three types of questions and the levels of evidence corresponding to them were proposed, namely: 1: treatment or intervention (seven levels of evidence); 2: prognosis or etiology (five levels of evidence); and 3: meaning or experience (five levels of evidence)(1212 Fineout-Overholt E, Stillwell SB. Asking compelling, clinical questions. In: Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare: a guide to best practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011, p. 25-39.).

In the corpus of this review, the classification of evidence from studies with the clinical question directed to treatment or intervention in the health area was used, according to the following hierarchy: N1: systematic review or meta-analysis of randomized controlled clinical trials; N2: randomized controlled clinical trials; N3: clinical trials without randomization; N4: cohort and case-control; N5: systematic review of descriptive and qualitative studies; N6: descriptive or qualitative study; N7: expert opinion(1212 Fineout-Overholt E, Stillwell SB. Asking compelling, clinical questions. In: Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare: a guide to best practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011, p. 25-39.).

It should be added that the information analyzed in the primary research included in this study was presented unchanged, as per the original production. They were only translated into Portuguese when the article was in Spanish or English.

RESULTS

The sample of this review study comprises six articles. Figure 1 shows the article selection route flowchart.

Figure 1
Flowchart of identification, selection and inclusion of studies, prepared from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendation, 2022

Thereafter, the characterization of selected studies will be described. When analyzing the period of publications, according to triennial distribution, from 2012 to 2014, an article was published; from 2018 to 2020, four articles; and in 2022, an article. Regarding study origin, four were produced in Brazil and two in the United States. With regard to the methodological approach, two studies with a qualitative approach and four studies with a quantitative approach were found. With regard to the studies’ level of evidence, two were level VI and four were level IV.

Chart 2 shows the numbering according to reference, authors, year of publication, author training, article title, journal name, study origin, impact factor and level of evidence.

Chart 2
Characterization of articles regarding authors, year of publication, author training, article title, journal name, country of publication, impact factor and level of evidence, 2022

As for the format, simulations were predominantly developed in a skills training format. A1 used low and medium fidelity training; A2, A3 and A5 used the low-fidelity one; eA4 used high-fidelity training to prepare family caregivers. Chart 3 presents the objectives, method, participants, types of simulation and simulators, main results and limitations of the studies.

Chart 3
Characterization of articles regarding objective, method, participants, type of simulation and simulator of the articles included in this review, 2022

As for study objectives, one was developed for clinical reasoning training, and five for skills training. The findings indicate positive effects regarding the use of simulation as a teaching strategy, in which it improves the performance of caregivers trained in a simulated environment, improvement of technical skills, in addition to development of skills required for patient care stand out.

With regard to the population, three studies addressed simulation in preparation for caring for children(1414 Silva APM, Pina JC, Rocha PK, Anders JC, Souza AIJD, Okido ACC. Training of caregivers of children with special healthcare needs: simulation contributions. Texto Contexto Enferm. 2020;29:e20180448. https://doi.org/10.1590/1980-265X-TCE-2018-0448
https://doi.org/10.1590/1980-265X-TCE-20...
,1616 Stanley TA, Battles M, Bezruczko N, Latty C. Efficacy of simulation for caregivers of children with a tracheostomy. Clin Simul Nurs. 2019;31:9-16. https://doi.org/10.1016/j.ecns.2019.03.005
https://doi.org/10.1016/j.ecns.2019.03.0...
-1717 Thrasher J, Baker J, Ventre KM, Martin SE, Dawson J, Cox R, et al. Hospital to home: a quality improvement initiative to implement high-fidelity simulation training for caregivers of children requiring long-term mechanical ventilation. J Pediatr Nurs. 2018;38:114-21. https://doi.org/10.1016/j.pedn.2017.08.028
https://doi.org/10.1016/j.pedn.2017.08.0...
), one with newborns(1515 Santos AST, Góes FGB, Ledo BC, Silva LF, Bastos MPC, Silva MA. Educational technology on home care with low-risk newborns. Rev Enferm UERJ. 2020;28:e44488. https://doi.org/10.12957/reuerj.2020.44488
https://doi.org/10.12957/reuerj.2020.444...
), one with mastectomized women(1818 Esteves MT, Domenico EBL, Petito EL, Gutiérrez MGRD. Educational intervention for self-management of continuous drainage in the postoperative period of mastectomy. Rev Gaúcha Enferm. 2013;34(4):75-83. https://doi.org/10.1590/s1983-14472013000400010
https://doi.org/10.1590/s1983-1447201300...
), and one with informal caregivers of dependent people(1313 Silva M, Charlo PB, Zulin A, Santos FGT, Jaques AE, Haddad MCFL, et al. Construction and validation of clinical scenarios for training informal caregivers of dependent persons. Rev Bras Enferm. 2022;75(5):e20220140. https://doi.org/10.1590/0034-7167-2022-0140
https://doi.org/10.1590/0034-7167-2022-0...
).

Simulation through skills training was mainly used for training and health education aimed at family caregivers of children with special needs using tracheostomy, using long-term mechanical ventilation, in the process of discharge from maternity hospital to home and, finally, in the self-monitoring of continuous drainage system. It was developed using audiovisual materials, a training course at the simulation center and a conversation circle, in addition to a dialogued expository class. The characterization of the articles included in this integrative review is represented in Charts 3 and 4.

Chart 4
Characterization of articles regarding main results and limitations of the articles included in this review, 2022

DISCUSSION

This review sought to identify evidence about the use and effects of simulated clinical practice with caregivers of patients with chronic health conditions as a training strategy in preparing patients for discharge. The evidence found reflects that use of simulation as a teaching and training strategy has been of international and national relevance(1919 Janicas RCSV, Narchi NZ. Evaluation of nursing students’ learning using realistic scenarios with and without debriefing. Rev Latino-Am Enfermagem. 2019;27:e3187. https://doi.org/10.1590/1518-8345.2936.3187
https://doi.org/10.1590/1518-8345.2936.3...
), allowing caregivers to have contact with real contexts simulated in home discharge care, which provides security for caregivers so that they are able to develop not only technical skills, but also clinical reasoning in emergency situations that may cause damage to the real patient in both hospital and home settings. Thus, simulation proved to be a significant learning tool(1414 Silva APM, Pina JC, Rocha PK, Anders JC, Souza AIJD, Okido ACC. Training of caregivers of children with special healthcare needs: simulation contributions. Texto Contexto Enferm. 2020;29:e20180448. https://doi.org/10.1590/1980-265X-TCE-2018-0448
https://doi.org/10.1590/1980-265X-TCE-20...
-1515 Santos AST, Góes FGB, Ledo BC, Silva LF, Bastos MPC, Silva MA. Educational technology on home care with low-risk newborns. Rev Enferm UERJ. 2020;28:e44488. https://doi.org/10.12957/reuerj.2020.44488
https://doi.org/10.12957/reuerj.2020.444...
) in preparing caregivers to act in critical conditions.

In A1, simulated patients were used to train caregivers through educational videos. Moreover, most articles that addressed simulation as a training technique (A2, A3, A4 and A5) in caregiver preparation were published in the last 5 years, and only one article (A6) contemplated in the review was published longer than this period. This demonstrates the relevance of the discussion today.

The articles included in this integrative review highlighted the importance of carrying out educational actions during hospitalization as a strategy to train family and caregiver for the care to be performed at home after hospital discharge.

Therefore, simulation can be seen as a strategy that provides the opportunity to provide safe and controlled care in a practice similar to what will be done at home, thus promoting safe patient care(2020 Ferreira RPN, Guedes HM, Oliveira DWD, Miranda JL. Realistic simulation as a method of teaching in the learning of the health field students. Rev Enferm Cent O Min. 2018;8:e2508. https://doi.org/10.19175/recom.v8i0.2508
https://doi.org/10.19175/recom.v8i0.2508...
-2121 Costa RRO, Medeiros SM, Martins JCA, Coutinho VRD. Simulation in training nurses: reflections and justifications based on bioethics and human rights approaches. Acta Bioeth. 2018;24(1):31-8. https://doi.org/10.4067/S1726%2D569X2018000100031
https://doi.org/10.4067/S1726%2D569X2018...
). Thus, it is necessary for caregivers to be guided and trained, in a more reliable way, to provide adequate home care for users dependent on care(1313 Silva M, Charlo PB, Zulin A, Santos FGT, Jaques AE, Haddad MCFL, et al. Construction and validation of clinical scenarios for training informal caregivers of dependent persons. Rev Bras Enferm. 2022;75(5):e20220140. https://doi.org/10.1590/0034-7167-2022-0140
https://doi.org/10.1590/0034-7167-2022-0...
).

The use of simulated scenarios as an educational tool has shown promise, and there is positive evidence that it can be used to prevent adverse events arising from inadequate care(2222 Santos FGT, Harmuch C, Paiano M, Radovanovic CAT, Rêgo AS, Carreira L. Competence of aged informal caregivers of people in home care. Esc Anna Nery. 2022;26:e20210288. https://doi.org/10.1590/2177-9465-EAN-2021-0288
https://doi.org/10.1590/2177-9465-EAN-20...
-2323 Santos FGT, Zulin A, Cardoso LCB, Sanches RCN, Rêgo AS, Girardon-Perlini NMO et al. Factors associated with the skills of informal caregivers in home care. Rev Bras Enferm. 2022;75(4):e20210744. https://doi.org/10.1590/0034-7167-2021-0744
https://doi.org/10.1590/0034-7167-2021-0...
).

Moreover, in the case of caregivers who receive training to face the limitations of the health condition of users undergoing treatment, their skills and care practices become adequate, resolute and precise, which culminates in the reduction of stressful events related to care(2424 Smith TO, Pearson M, Pfeiffer K, Crotty M, Lamb SE. Caregiver interventions for adults discharged from the hospital: systematic review and meta-analysis. J Am Geriatr Soc. 2019;67(9):1960-9. https://doi.org/10.1111/jgs.16048
https://doi.org/10.1111/jgs.16048...
-2525 McDonald J, McKinlay E, Keeling S, Levack W. The ‘wayfinding’ experience of family carers who learn to manage technical health procedures at home: a grounded theory study. Scand J Caring Sci. 2017;31(4):850-8. https://doi.org/10.1111/scs.12406
https://doi.org/10.1111/scs.12406...
).

That said, A1 brings the relevance of implementing a methodology using information technology, building realistic clinical simulation scenarios through educational videos; this would be an important tool in caregivers’ educational process and training. These strategies can directly impact users’ quality of life and reduce the need for health care(2626 Rosaasen N, Mainra R, Kukha-Bryson A, Nhin V, Trivedi P, Shoker A, et al. Development of a patient-centered video series to improve education before kidney transplantation. Patient Educ Couns. 2018;101(9):1624-9. https://doi.org/10.1016/j.pec.2018.04.014
https://doi.org/10.1016/j.pec.2018.04.01...

27 Galindo-Neto NM, Alexandre ACS, Barros LM, Sá GGM, Carvalho KM, Caetano JA. Creation and validation of an educational video for deaf people about cardiopulmonary resuscitation. Rev Latino-Am Enfermagem. 2019;27(1):e3130. https://doi.org/10.1590/1518-8345.2765.3130
https://doi.org/10.1590/1518-8345.2765.3...
-2828 Sinha S, Dillon J, Dargar SK, Archambault A, Martin P, Frankel BA, et al. What to expect that you’re not expecting: a pilot video education intervention to improve patient self-efficacy surrounding discharge medication barriers. Health Informatics J. 2019;25(4):1595-605. https://doi.org/10.1177/1460458218796644
https://doi.org/10.1177/1460458218796644...
).

In A4, caregivers, parents of children with tracheostomy, expressed confidence and security after training with the use of a mannequin and simulated patient, and training was directed to the needs of each child and family. A decrease in the mortality rate was also observed in the homes of family members of caregivers who participated in simulations. Participants reported acquiring empowerment and greater preparation for care after hospital discharge, preventing home complications from complicating patients’ clinical condition(1616 Stanley TA, Battles M, Bezruczko N, Latty C. Efficacy of simulation for caregivers of children with a tracheostomy. Clin Simul Nurs. 2019;31:9-16. https://doi.org/10.1016/j.ecns.2019.03.005
https://doi.org/10.1016/j.ecns.2019.03.0...
).

Confidence and care competence increased with participation in simulation training, with caregivers becoming, over time, more sensitive to their children’s suffering and more likely to use the emergency service when deemed necessary by parents who participated in the research. The predominant expectation in the research was that skills and confidence converged as caregivers gained experience(1616 Stanley TA, Battles M, Bezruczko N, Latty C. Efficacy of simulation for caregivers of children with a tracheostomy. Clin Simul Nurs. 2019;31:9-16. https://doi.org/10.1016/j.ecns.2019.03.005
https://doi.org/10.1016/j.ecns.2019.03.0...
).

The results, therefore, revealed that simulation practice has been shown to be more effective for teaching and learning than traditional teaching. Simulation is a strategy that allows a greater practical experience according to reality, collaborating for a more risk-free assistance(2929 Silva T, Ramos AR, Quadros A. Use of realistic simulation as a teaching strategy for undergraduate nursing courses. Conjecturas. 2021;21(6):221-42. https://doi.org/10.53660/CONJ-338-612
https://doi.org/10.53660/CONJ-338-612...
). A2, A3, A4, A5 and A6 caregivers considered that training contributed to safety in carrying out care and procedures provided to patients, thus providing support in continuity of treatment at home and in facing the challenges of home care, avoiding readmissions.

Through in-depth reading of the articles that make up the corpus of this review, it is clear that simulation is an educational and innovative tool in training caregivers in the face of complex care. It is a practice capable of improving caregivers’ and family members’ skills and knowledge in the exchange of clinical experience, contributing to qualifying home care as well as encouraging empowerment and self-confidence(1414 Silva APM, Pina JC, Rocha PK, Anders JC, Souza AIJD, Okido ACC. Training of caregivers of children with special healthcare needs: simulation contributions. Texto Contexto Enferm. 2020;29:e20180448. https://doi.org/10.1590/1980-265X-TCE-2018-0448
https://doi.org/10.1590/1980-265X-TCE-20...
-1515 Santos AST, Góes FGB, Ledo BC, Silva LF, Bastos MPC, Silva MA. Educational technology on home care with low-risk newborns. Rev Enferm UERJ. 2020;28:e44488. https://doi.org/10.12957/reuerj.2020.44488
https://doi.org/10.12957/reuerj.2020.444...
).

The studies found had the participation of different professionals who make up the multidisciplinary health team, such as nurses, physicians, physiotherapists and psychologists, demonstrating that professionals are committed to improving their performance and the relationship with the team(3030 Almeida MN, Duarte TTP, Magro MCS. In situ simulation: the gain of self-confidence by nursing professionals during cardiopulmonary arrests. Rev Rene. 2019;20:e41535. https://doi.org/10.15253/2175-6783.20192041535
https://doi.org/10.15253/2175-6783.20192...
). It is noteworthy that most of professionals in the studies were nurses.

A2, whose objective was to know the simulation strategies for training caregivers of children with special health needs in preparation for hospital discharge, showed that professional nurses played the social role of educator, equipping families with home care. This professional represented an important element in preparing these patients for hospital discharge. Knowledge was transmitted through demonstration, in which skills were improved for the execution of techniques. As caregivers need to be prepared to deal with possible complications at home, there is a need for strategies that favor the role of caregivers in the process of caring for patients(1414 Silva APM, Pina JC, Rocha PK, Anders JC, Souza AIJD, Okido ACC. Training of caregivers of children with special healthcare needs: simulation contributions. Texto Contexto Enferm. 2020;29:e20180448. https://doi.org/10.1590/1980-265X-TCE-2018-0448
https://doi.org/10.1590/1980-265X-TCE-20...
,3131 Góes FGB, Cabral IE. Discourses on discharge care for children with special healthcare needs. Rev Bras Enferm. 2017;70(1):154-61. https://doi.org/10.1590/0034-7167-2016-0248
https://doi.org/10.1590/0034-7167-2016-0...
).

Regarding the types of simulations and simulators found in the articles, a strategy addressed by the researchers was conversation circle with low-fidelity simulation as an educational technology, focusing on participants’ doubts and the use of a static vinyl mannequin with dimensions of a newborn body. This strategy proved to be effective in meeting the family’s learning needs in the transition from motherhood to home. After its completion, the educational action received positive feedback from caregivers: everyone considered it efficient and valid in understanding baby care(1414 Silva APM, Pina JC, Rocha PK, Anders JC, Souza AIJD, Okido ACC. Training of caregivers of children with special healthcare needs: simulation contributions. Texto Contexto Enferm. 2020;29:e20180448. https://doi.org/10.1590/1980-265X-TCE-2018-0448
https://doi.org/10.1590/1980-265X-TCE-20...
).

It stands out as a valid strategy for training caregivers, as it seeks to explore the potential of simulation in a context different from the one in which it will be used, which is the training of family caregivers involved in home care. This is an innovative study, as it sought to qualify home care through the use of simulation. In this context, two categories of feelings emerged: Experience of simulation as a learning strategy; and Implications of training for home care(1414 Silva APM, Pina JC, Rocha PK, Anders JC, Souza AIJD, Okido ACC. Training of caregivers of children with special healthcare needs: simulation contributions. Texto Contexto Enferm. 2020;29:e20180448. https://doi.org/10.1590/1980-265X-TCE-2018-0448
https://doi.org/10.1590/1980-265X-TCE-20...
).

Research carried out in a simulation center of a public university in southern Brazil developed a training program based on simulations to prepare caregivers of technology-dependent children for hospital discharge. As a health education strategy associated with low-fidelity simulation, a conversation circle was held in order to demonstrate procedural techniques, such as the use of a dummy with technological devices. The findings showed positive results, as long as simulation is performed procedurally during hospitalization, as it favored the exchange of knowledge and experiences among participants, in addition to promoting safety in care(3232 Viana IS, Silva LF, Cursino EG, Conceição DS, Goes FGB, Moraes, JRMM. Educational encounter of nursing and the relatives of children with special health care needs. Texto Contexto Enferm. 2018;27(3):e5720016. https://doi.org/10.1590/0104-070720180005720016
https://doi.org/10.1590/0104-07072018000...
).

A2 used simulation strategies associated with low, medium and high-fidelity simulators, in a systematic way, in preparing caregivers to face possible complications at home(1414 Silva APM, Pina JC, Rocha PK, Anders JC, Souza AIJD, Okido ACC. Training of caregivers of children with special healthcare needs: simulation contributions. Texto Contexto Enferm. 2020;29:e20180448. https://doi.org/10.1590/1980-265X-TCE-2018-0448
https://doi.org/10.1590/1980-265X-TCE-20...
). Adequate preparation of caregivers for hospital discharge is especially important, as it reduces the risk of readmissions due to domestic complications that impact the worsening of children’s health status(3333 Okido ACC, Pina JC, Lima RAG. Factors associated with involuntary hospital admissions in technology-dependent children. Rev Esc Enferm USP. 2016;50(1):29-35. https://doi.org/10.1590/S0080-623420160000100004
https://doi.org/10.1590/S0080-6234201600...
).

According to the North American literature, the period of adaptation of parents to the therapeutic regime can be influenced by the type of procedure to be performed. Procedures that require greater frequency, such as tracheostomy care, were learned more easily, and helped to reduce the chances of readmissions to hospital services. As family members experienced daily child care and developed the necessary skills to care for this device, readmissions became less frequent(3434 Brittan MS, Sills MR, Fox D, Campagna EJ, Shmueli D, Feinstein JA, et al. Outpatient follow-up visits and readmission in medically complex children enrolled in Medicaid. J Pediatr. 2015;166(4):998-1005.e1. https://doi.org/10.1016/j.jpeds.2014.12.022
https://doi.org/10.1016/j.jpeds.2014.12....
).

Similarly, a North American study (A5), whose objective was to create a multimodal discharge preparation curriculum, incorporating high-fidelity simulation training, to prepare family caregivers of children with complex medical problems in conditions that require mechanical ventilation over the long term, resulted in a trend of reduced readmissions within seven days of discharge since the implementation of the revised curriculum. Simulation training can be incorporated into discharge training for families of children requiring prolonged mechanical ventilation. Trial of emergency management in a simulated clinical setting increased caregiver confidence to take care of their ventilator-dependent child(1717 Thrasher J, Baker J, Ventre KM, Martin SE, Dawson J, Cox R, et al. Hospital to home: a quality improvement initiative to implement high-fidelity simulation training for caregivers of children requiring long-term mechanical ventilation. J Pediatr Nurs. 2018;38:114-21. https://doi.org/10.1016/j.pedn.2017.08.028
https://doi.org/10.1016/j.pedn.2017.08.0...
).

In a survey whose objective was to analyze the association between outpatient follow-up of children with medical complexities and readmissions in the first 30 days, it was identified that, after hospital discharge, as family members gained experience in daily care necessary for children, their skills were developed through the proper care of this device. Readmissions were also less frequent(3434 Brittan MS, Sills MR, Fox D, Campagna EJ, Shmueli D, Feinstein JA, et al. Outpatient follow-up visits and readmission in medically complex children enrolled in Medicaid. J Pediatr. 2015;166(4):998-1005.e1. https://doi.org/10.1016/j.jpeds.2014.12.022
https://doi.org/10.1016/j.jpeds.2014.12....
).

Caregiver training, therefore, can have an impact on reducing the deterioration of patients’ clinical condition, avoiding new hospitalizations that, sometimes, can accompany the emergence of new needs(1414 Silva APM, Pina JC, Rocha PK, Anders JC, Souza AIJD, Okido ACC. Training of caregivers of children with special healthcare needs: simulation contributions. Texto Contexto Enferm. 2020;29:e20180448. https://doi.org/10.1590/1980-265X-TCE-2018-0448
https://doi.org/10.1590/1980-265X-TCE-20...
).

A study that investigated professionals’ knowledge through simulated scenarios revealed that the level of knowledge was low before simulations and that, after implementing training with this strategy, there was a perception of improvement in knowledge, suggesting that simulation should be widely implemented(3535 Shrestha R, Shrestha AP, Shrestha SK, Basnet S, Pradhan A. Interdisciplinary in situ simulation-based medical education in the emergency department of a teaching hospital in Nepal. Int J Emerg Med. 2019;12(1):19. https://doi.org/10.1186/s12245-019-0235-x
https://doi.org/10.1186/s12245-019-0235-...
).

In this review, the use of simulation in the development of different skills prevailed, both technical (tracheostomy; oxygen therapy; gastrostomy; nasojejunal tube; cardiopulmonary resuscitation; mechanical ventilation; and drain) and non-technical (communication; control of anxiety, fear, insecurity and stress; decision-making; and management and confidence building), related to caregivers’ attitudes, values, and experiences. The literature argues that skills are fundamental and necessary to perform a given task(3636 Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226-35. https://doi.org/10.1001/jama.287.2.226
https://doi.org/10.1001/jama.287.2.226...
-3737 Pronovost PJ, Nolan T, Zeger S, Miller M, Rubin H. How can clinicians measure safety and quality in acute care? Lancet. 2004;363(9414):1061-7. https://doi.org/10.1016/S0140-6736(04)15843-1
https://doi.org/10.1016/S0140-6736(04)15...
), i.e., caregivers with greater technical skills represent a differential for success in home care.

The results of a quasi-experimental study that investigated the use of in situ simulation training to improve professionals’ skills in a scenario of postpartum hemorrhage showed that simulated training emphasizes mastery and experience, verbal persuasion and physiological state, improving collective skills(3838 Egenberg S, Øian P, Eggebø TM, Arsenovic MG, Bru LE. Changes in self-efficacy, collective efficacy and patient outcome following interprofessional simulation training on postpartum haemorrhage. J Clin Nur. 2017;26(19-20):3174-87. https://doi.org/10.1111/jocn.13666
https://doi.org/10.1111/jocn.13666...
).

A3 showed that clinical simulation, during skills training, is useful for the discharge process and for proposing an innovative educational technology in the context of home care for the main actors in this process: caregivers, the family, and patients who need care for their chronic conditions(1515 Santos AST, Góes FGB, Ledo BC, Silva LF, Bastos MPC, Silva MA. Educational technology on home care with low-risk newborns. Rev Enferm UERJ. 2020;28:e44488. https://doi.org/10.12957/reuerj.2020.44488
https://doi.org/10.12957/reuerj.2020.444...
).

Furthermore, simulation-based education plays, every day, an increasingly important role in health education around the world, as it enables the creation of conditions that optimize learning, in addition to protecting users from possible risks(3939 Andrade PON, Oliveira SC, Morais SCRV, Guedes TG, Melo GP, Linhares FMP. Validation of a clinical simulation setting in the management of postpartum haemorrhage. Rev Bras Enferm. 2019;72(3):624-31. https://doi.org/10.1590/0034-7167-2018-0065
https://doi.org/10.1590/0034-7167-2018-0...
).

Study limitations

A possible limitation is the unavailability of some studies in freely accessible databases. Also noteworthy is the number of studies found (only six), which demonstrates that the use of clinical simulation in caregiver training still represents a challenge. Most studies are focused on caregivers of child patients (children and newborns), which indicates a gap for studies involving caregivers of adult patients and patients with chronic health conditions.

Contributions to nursing, health, or public policies

This study provides possible strategies for training caregivers of chronic patients to be used in clinical nursing practice, helping to develop safer, evidence-based care. It can also help in a better caregiver qualification, through clinical simulation as an effective teaching-learning methodology, considering it a tool for qualifying caregivers in home care.

FINAL CONSIDERATIONS

The findings of this review indicate that caregivers trained through clinical simulation improved procedural skills and coping with possible complications at home, which led to positive changes in patients’ clinical outcomes, with a reduction in home complications and readmissions, due to the adequate management of patients.

This study made it possible to verify that the simulation strategies performed with caregivers for the discharge process were conducted, for the most part, by professional nurses.

In the synthesis of results, several strategies were found combined with the use of clinical simulation to guide and train caregivers. Among the identified strategies, researchers used conversation circle with a low-fidelity simulator to remove doubts from family members, which dealt with basic life needs, along with procedural skills training, high-fidelity simulation with simulated patients and computer-controlled mannequins, to prepare family caregivers of children with complex medical problems. These educational technologies applied to health constituted important resources to improve health care for patients discharged from hospital or under home care.

It is inferred the importance of considering the rigor for the use of clinical simulation as well as to assess its applicability in practice. Finally, a gap is identified with regard to clinical simulation studies aimed at training caregivers for adult patients.

The findings of this study indicate the importance of simulation as an educational technology for caregivers and family members of patients, especially for the acquisition of skills (knowledge, skills and attitudes) aimed at different health care themes and scenarios. The use of this technology facilitated demonstration of care and the understanding of how to carry it out, favoring the reflection of the situation to be experienced at home from visualization of a concrete environment of care.

  • EDITOR IN CHIEF: Antonio José de Almeida Filho
  • ASSOCIATE EDITOR: Jules Teixeira
  • FUNDING
    This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Funding Code 001 and the Federal University of Mato Grosso do Sul - UFMS/MEC - Brazil.

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Publication Dates

  • Publication in this collection
    04 Dec 2023
  • Date of issue
    2023

History

  • Received
    16 Feb 2023
  • Accepted
    11 Aug 2023
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