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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 1  |  Issue : 2  |  Page : 99-108

Comparing the pre–post knowledge score of health-care professionals on a simulation course for COVID-19 PCR sampling


1 Department of Clinical Sciences, Faculty of Medicine, University of Sharjah, Sharjah, United Arab Emirates; Faculty of Medicine, Balamand Medical Simulation Center, University of Balamand, Al Koura, Lebanon
2 Department of Education, University of Balamand, Al Koura, Lebanon
3 Office of Data and Institutional Research, University of Balamand, Al Koura, Lebanon

Date of Submission16-Sep-2021
Date of Decision03-Jan-2022
Date of Acceptance06-Jan-2022
Date of Web Publication25-Feb-2022

Correspondence Address:
Mode Al Ojaimi
Department of Clinical Sciences, Faculty of Medicine, University of Sharjah, P.O. Box 27272, Sharjah.
Lebanon
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/abhs.abhs_7_21

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  Abstract 

Background: This study describes the effectiveness of a simulation course for polymerase chain reaction (PCR) sampling for coronavirus disease of 2019 (COVID-19) on a heterogeneous cohort of 37 health-care professionals (HCPs) in North Lebanon. Materials and Methods: A pre–post repeated measure on a simulation course PCR sampling for COVID-19 was designed and conducted on a sample of 37 HCPs involved in COVID-19 PCR sampling in Lebanon. Attendees anonymously completed pre–post course questionnaires following the simulation training session. Data collected were analyzed on SPSS using the Wilcoxon signed-rank test and McNemar’s test to compare the knowledge score (Kscore) of participants and their perceptions measures related to the training. Results: Kscore increased and was significantly different pre (µ = 2.22,) and post-session (µ = 5.54). A Wilcoxon signed-rank test showed that post-session, only two remained the same, whereas all the rest (35) had higher post score. The proportion of correctly answered questions varied significantly pre–post session for all six questions. Years of experience and gender did not have an effect on Kscore pre–post session. The Kscore also varied for participants with previous COVID-19 PCR swab training or with current role related to COVID-19 with higher pre-Kscore and surprisingly lower post-Kscore. Conclusion: Our study shows that a simulation course regarding COVID-19 testing should be a requirement, regardless of years of experience or previous training, before allowing HCPs to perform sampling techniques on a patient having or suspected to have COVID-19 in order to ensure international standards.

Keywords: Face-to face-learning, health-care professionals’ training, medical simulation, pre–post training assessment, skills development


How to cite this article:
Al Ojaimi M, Khairallah M, Al Najjar R. Comparing the pre–post knowledge score of health-care professionals on a simulation course for COVID-19 PCR sampling. Adv Biomed Health Sci 2022;1:99-108

How to cite this URL:
Al Ojaimi M, Khairallah M, Al Najjar R. Comparing the pre–post knowledge score of health-care professionals on a simulation course for COVID-19 PCR sampling. Adv Biomed Health Sci [serial online] 2022 [cited 2022 Jun 30];1:99-108. Available from: https://www.abhsjournal.net/text.asp?2022/1/2/99/338537




  Background Top


The World Health Organization (WHO) declared coronavirus disease of 2019 (COVID-19) a pandemic on March 11, 2020 reaching over 210 countries and claiming over 200,000 lives [1]. International efforts aim to develop better diagnostic testing and increasing public health preparedness and response. For preventive measures to be most effective, extensive testing must be implemented.

Polymerase chain reaction (PCR) sampling is the primary method used in detecting COVID-19. Priority should be given to train health-care practitioners (HCPs) to effectively and safely administer PCR sampling accurately, safely, and according to stringent international guidelines. According to the United States Centers for Disease Control (CDC), the most important step for an accurate laboratory diagnosis of an infectious disease is proper specimen collection. Wrongly collected specimens may lead to false negatives [2]. Accordingly, there is a need to train all HCPs on the precautions, indications, and correct techniques for administering the test, sampling, and handling samples.

Lebanon detected its first case of COVID-19 on February 21, 2020, locked down on March 15 and has remained vigilant in the fight to stop the spread. By April 8, the Lebanese Ministry of Health increased the number of PCR testing centers from 1 to 16, which enabled Lebanon to increase its PCR testing capacity by April 1 to 500 tests per day [3].

Communal awareness is essential to prevent the mitigation of COVID-19 because pandemics require community efforts to harness expertise. Trained medical professionals and university training programs can join a communal response by providing training to less informed HCPs [4]. Simulation-based training has been increasingly recognized as one of the main tools for skills training and quality improvement in healthcare [5]. It relies on using manikins, trained stunt patients or software to create realistic scenarios.[6] Simulation-based medical education is growing worldwide [7,8] due to the increasing limitations to patients “exposure, intensified concerns about patients” safety and a radical shift towards competency-based medical training [9]. Simulation has been proven to have a beneficial role in medicine ranging from better grasping of basic sciences [10] to acquisition of complex and difficult skills such as surgery [11]. Systematic reviews have confirmed that training on a manikin transfers well to a human model [12] and that the acquired technical skills are retained over time [9,13]. It is effective in improving both the competence and the confidence of the learners [14] resulting in improving the performance of the simulated skill [15]. Compared with the traditional didactic learning, it offers a systematic approach to the acquirement and evaluation of the technical skills with no risk to patients and infinite practice opportunities [16]. The learning curve takes place in the simulation lab rather than on the patient. The ultimate result is reduction of medical error [17].

Accordingly, Balamand Medical Simulation Center (BMSC)––an internationally accredited American Heart Association (AHA) training center that delivers life support courses––developed and organized a simulation course to train volunteering HCPs in their respective municipalities in North Lebanon to administer COVID-19 PCR tests. This was done in collaboration with the Lebanese Order of Physicians North Chapter in order to address a communal and national need hoping to prevent the spread of COVID-19.

This research aims to study the effectiveness of a simulation course for PCR sampling for COVID-19 on a cohort of community HCPs in order to assess their knowledge base, attitudes and practical skills (KAP) prior to and after the course, by comparing the mean difference of the knowledge score (Kscore) ­ pre- and post-course delivery looking at the participants’ current role, years of experience, gender, and former involvement or training in the care of COVID-19 patients. This study highlights practical recommendations regarding the need of a training course as a prerequisite for equipping HCPs to perform sampling on COVID-19 patients for PCR testing.

Our study aimed to answer the following questions:

  1. Is there a difference in the Kscore pre–post session?


  2. Is there a mean difference between pre–post Kscore based on gender, years of experience, profession, or previous COVID-19 training?


  3. How did the attendees perceive this training course as a pre-requisite for COVID-19 sampling?


  4. Further to this session, what were the perceived training preferences of the attendees?



  Materials and methods Top


Study design

A pre–post repeated-measure study was conducted to evaluate changes in the cohort of HCP’s knowledge, practical skills, and attitude towards administering PCR Sampling for COVID-19 before and after attending a simulation-training course [Figure 1].
Figure 1: Description and outcomes of the PCR test course

Click here to view


After obtaining Institutional Review Board (IRB) approval for the study, the simulation course was delivered.

Attendees completed a “pre-session “questionnaire prior to onset of the simulation session. A “post-session “questionnaire was completed by each attendee after successfully completing his/her simulation practice [Figure 2].
Figure 2: Conceptual framework pre–post simulation course

Click here to view


The pre-session questionnaire consisted of four parts: demographic data, self-perception of readiness for COVID-19, COVID-19 Kscore, and training’s expectations along with suggestions for future trainings.

Demographics

Demographic data included age, gender, current hospital where the participant is working, profession, specialty, role, years of experience, having received previous COVID-19 education with its source, having performed a COVID-19 PCR swab before and being familiar with simulation-based medical training and the use of manikins.

Self-perception of readiness for COVID-19

The attendee was asked to rate his knowledge and skills related to COVID-19 specifying whether he feels fully competent and prepared, somewhat competent, unprepared or if he is not involved in COVID-19 response yet.

COVID-19 knowledge score

The level of related knowledge regarding COVID-19 was assessed using six questions. One question was about the best technique based on CDC to collect a sample for COVID-19 PCR testing, one question regarding nature of the swab used, one question related to handling of the collected swab, one question about oropharyngeal swab (OP), one question about sputum specimen, and one question about personal protective equipment (PPE) donning. A correct answer was assigned 1 point and an incorrect answer or “I don’t know” were assigned 0 points. A full score is 6.

Training expectations

These were assessed by three items: two items asked about the perception of the attendee regarding the necessity of this course and simulation session prior to performing COVID-19 sampling on patients and one item related to the expectation that this course will allow the participant to properly perform a nasopharyngeal (NP) or OP swab on a patient.

The post–questionnaire consisted of four parts: COVID-19 Kscore, self-reported readiness for performing an OP or NP swab after the simulation session, attendee’s perception about the importance and added value of this simulation course, and his preferred form and topics for future trainings in order to prepare him for better performance of his role.

COVID-19 knowledge score

The same six items in the pre-session questionnaire are repeated here. Each participant was given the same code for his pre and post-session questionnaires in order to be able to compare them.

Self-reported readiness to perform an OP/NP swab after the simulation session

This was assessed via one item related to self-confidence in performing above tasks after the simulation session.

Attendee’s perception about the importance and added value of this simulation course

This was assessed via five items: two items about the importance of this training and course prior to performing COVID-19 PCR sampling on patients, one item related to recommending this course to other colleagues, and two items related to the details provided and the misconceptions about COVID-19 that were addressed.

Preferred form for future trainings and topics:

Two items addressed this: one related to the best form of training that the participant thinks would better prepare him to perform his role and one related to two specific areas for future trainings.

Participants

The sampling was predetermined to a maximum of 14 participants per session. The session sample size choice of 14 was to ensure optimal simulation session delivery and to respect the social distancing precautions as recommended by the CDC. Three sessions took place with a total sample of 37 HCPs who volunteered to do COVID-19 PCR sampling with the approval of their respective municipalities or medical institutions.

Procedure

With the advent of the COVID-19 pandemic, there has been a need to train all HCPs on the precautions, indications, and correct techniques for administering the test, sampling, and handling samples. The course was designed respecting and applying all infection control measures and covered the knowledge, application, and practice elements of the training. The course consisted of four parts:

  1. 15-min didactic instructions regarding COVID-19, PPE donning and doffing, CDC recommendations for COVID-19 PCR sampling with the indications and contraindications for each sampling site, the “Do and Don’t” when administering the test and how the sample should be labeled, stored, and dispatched.


  2. 3:54-min video about the detailed steps and instructions for NP and OP PCR sampling for COVID-19 by Amboss [18].


  3. 30-min hands-on OP and NP PCR sampling under direct observation of the instructor using a low fidelity task trainer.


  4. 15-min debriefing session.


Questions were answered on the go in order to encourage participation and make sure that all concerns are addressed.

The main learning outcomes of the session were as detailed below:

  • Sampling precautions


  • PPE donning and doffing


  • Appropriate swabs for taking a sample for COVID-19 testing


  • Labeling, shipping and storage of sample


  • Different sampling techniques, the indications and specifications for each


  • Hands on NP sampling


  • Hands on OP sampling


  • Data collection

    All HCPs attended the course voluntarily; all consented to be part of the study and were informed that their anonymity would be respected. The pre–post questionnaires were distributed to all on the registration site and each attendee was assigned a marker code matching both questionnaires [Figure 2]. Prior to their filling the questionnaires, the instructor explained all criteria/questions in both English and Arabic and provided any requested clarifications.

    Statistical analysis

    All data collected were entered into SPSS, and the Kscore calculation was automatically obtained based on the correct answers. To test significant variation in the data, normality was tested using Shapiro–Wilk and was found not normal for the Kscore and the six questions. Hence, the nonparametric tests were used including Wilcoxon sign rank test (instead of paired t test) for Kscore and exact McNemar’s for binary outcome.


      Results Top


    The sample consisted of 37 HCPs, mostly females 64.9% (n = 24) compared to males 35.1% (n = 13). They belonged to nine different health institutions and had five main professions (two medical laboratory staff, three midwives, six nurses, one infectious disease physician, and one senior health coordinator). Approximately 40.5% (n = 14) of participants had more than 10 years of experience in their respective fields and 19% (n = 7) between 5 and 10 years (20.8%, n = 4), compared to 14 attendees (38%) with less than 10 years of experience [Figure 3].
    Figure 3: Health-care professionals’ profile

    Click here to view


    Only 5 attendees (13.5%) had performed sampling on COVID-19 patients before, whereas 14 (38%) currently work with COVID-19 patients. The remaining attendees did not have any experience with COVID-19 patients yet. Regarding self-perception of current knowledge and skills for handling COVID-19 patients, 10 attendees (27%) felt fully competent and prepared, 18 (48.6%) felt somewhat competent, 8 (21.6%) felt unprepared and 1 reported not being involved in COVID-19 response.

    Based on the pre–post session questionnaire

    Only 13 attendees (35.1%) knew that NP swab is the best-recommended sampling technique for COVID-19 by the CDC and 11 (29.7%) were not aware that a sputum specimen can be used for COVID-19 PCR testing. Only 4 of the attendees could arrange the steps for donning PPE in the correct order. 13 attendees (35.1%) answered that the PCR collection sample should be kept at room temperature, whereas 2 (5.4%) chose to keep it at –70°C. Only 22 attendees (59.5%) knew that it should be stored at 2°C–8°C. Regarding the swabs that can be used for COVID-19 PCR sampling, the answers were distributed as follows: 1 (2.7%) calcium alginate, 19 (51.4%) wood sticks, 10 (27%) synthetic fiber, and 8 (21.6%) did not know the answer. Only 10 attendees (27%) knew that they should not rub the swab on the tonsils while performing an OP swab, 19 (51.4%) thought that they should and 8 (21.6%) did not know whether the answer is yes or no.

    It is worth mentioning that 24 of the attendees (65%) were familiar with using a simulation manikin as a form of training for skills acquisition, whereas 20 did not take attend any course, the rest already attended courses about COVID-19 by the CDC (2), WHO (3), the Lebanese Ministry of Health (3) or respective hospitals (9). All respondents agreed or strongly agreed that the training is a must before taking COVID-19 PCR swabs and that “practicing the sampling techniques on a manikin” is a must before applying it on patients. Approximately 84% (n = 32) of the participants expected that this training would enable them to properly perform a NP or OP swab on a patient.

    After the simulation session, 100% of the attendees answered that the best technique to collect a sample for COVID-19 PCR testing based on CDC is the NP swab and that it should be kept at 2°C–8°C. 100% of the attendees answered that sputum specimen can be used for COVID-19 testing. A total of 33 attendees (89.2%) indicated that synthetic fiber swabs should be used for viral sampling vs. wooden or calcium alginate swabs. In total, 31 attendees (83.2%) answered that the swab should not be rubbed on the tonsils when performing an OP swab. 100% of the attendees agreed or more that after this training they felt more confident in taking an NP or OP swab on a patient, that this training explained many details practical for COVID-19 testing and that it cleared many misconceptions about COVID-19 PCR testing. 100% agreed or more that this training along with practicing on a manikin is a must before performing COVID-19 swab on a patient and they would recommend this training to their colleagues.

    KRQ1: Is there a difference in the knowledge score pre–post session?

    The Kscore was derived based on six questions and ranged between 0 and 6. 83.8% (n = 31) of the attendees had scores of 3 or below prior to simulation sessions with 10.8% (n = 4) had no correct answers at all, and one answered all questions right. This was not the case after the simulation as 94.6% of the attendees (n = 35) had ratings above 3 with only one scoring 3 [Figure 4]. This means that the majority of attendees were able to completely understand the process after the simulation session.
    Figure 4: Knowledge score pre vs. post COVID-19 sampling simulation course

    Click here to view


    To test significant variation in this data, normality was tested using the Shapiro–Wilk test. The null hypothesis of normality was rejected (P = 0) and the nonparametric Wilcoxon sign rank test was used instead of the paired test. The Wilcoxon signed-rank test shows that the observed difference between both measurements is significant (P = 0).

    In fact, none (negative ranks = 0) had a post score less than the pre score. Two had the same score, and all the rest (positive ranks = 35) had positive ranks with post score higher that pre score. This is in line with the mean value for each category, where the mean of Kscore (µ) was 2.22 pre-test compared to 5.54 post-test. These results suggest that the significant increase in the K score after the simulation course is equivalent to a better knowledge of the subject.

    Moreover, each of the scores of the six questions was separately tested using McNemar test as the outcome variable is binary (dichotomous) a “Correct” or “Incorrect” answer (0 or 1). This test was also a repeated measure similar to the previously used Wilcoxon sign rank test but for binary outcome. An exact McNemar’s test determined that there was a statistically significant difference in the proportion of correctly answered questions pre- and post-session for all six questions (P < 0.05) [Table 1].
    Table 1: McNemar results for questions k1 to k6

    Click here to view


    KRQ2: Is there a mean difference between pre–post knowledge score based on gender, years of experience, profession, or previous trainings?

    The post-knowledge mean score was more than 5 for all participants irrespective of the years of experience. However, results revealed that irrespective of the years of experience, all participants in the pre-test have a lower mean score and it is lower than 3 (2.33 for those with more than 10 years of experience, 1.86 for those who have 5 to 10 years of experience, and 2.14 for those with less than 5 years of experience).

    Male participants had a slightly lower post mean Kscore compared to females with a higher pre score for males.

    Participants who had previously taken COVID-19 PCR swab training had higher pre-score mean of 2.4 with a lower post score of 4.6 compared to a lower pre-score mean of 2.19 and a higher post-score mean of 5.7 for those who did not previously take PCR training. This highlights the resistance of some HCPs to adopt international guidelines that are incompatible with their current practices.

    By segmenting the roles assigned based on COVID-19 practices, the participant who were currently involved in COVID-19 have higher mean of K score pre-session (2.9) with a lower score post-session (5.22) compared to those not working with COVID-19 (pre µ = 1.96, post µ = 5.64). It is worth noting here that the proportion of correct answers increased in both cases but for those involved in COVID-19 the proportion increased less than those not working with COVID-19.

    KRQ 3: How did the attendees perceive this training course as a pre-requisite for COVID-19 sampling?

    All attendees agreed that this hybrid didactic and simulation course should be undertaken before doing NP or OP swabs on patients. A valuable advantage was that after the hands on simulation, all of the attendees agreed or more that they felt more confident in taking a NP or OP swab on a patient.

    KRQ 4: Further to this session, what were the perceived training preferences of the attendees?

    This question was answered in the last part of the post-survey where each participant stated two specific areas needed for future training including mainly infection control (4), management of cardiopulmonary emergencies (5) which is a requirement for complicated acute cases of COVID-19, hospital management (1), isolation facilities (1), ventilation for COVID-19 patients (1), and activities during confinement phase (1). As for the anticipated training method, 89.2% of the attendees selected face-to-face learning as the best tool to help them perform their role compared to other forms of online and virtual learning. In fact, face-to-face came first (89.2%, n = 33), followed by online slides/videos (18.9%, n = 7), mobile learning applications (8.1%, 3), and only one stated written text and webinars.


      Discussion Top


    Correct sampling technique is the first step towards valid diagnosis of infectious diseases [19]. Therefore, it is essential to assess the knowledge of the HCPs who are performing or expected to perform sampling for COVID-19 PCR about PPE, sampling techniques, indications about the different sampling modalities, the details related to sampling swabs types and handling of the sample as well [20]. In our study, the K score showed a significant difference pre-course (62.2% of the HCPs scored <3) versus post-course delivery (100% of HCPs scored >= 3). The significant difference in the K score pre-course suggests that after this course the knowledge mean score not only significantly varied but also increased. This overall increase implies better knowledge of the subject. These results were reconfirmed by the exact McNemar’s test which confirmed the statistically significant difference in the proportion of correctly answered pre- and post-session for all six questions (P < 0.05).

    Some of the participants were already performing OP swabbing by sampling the tonsils and getting positive results. This is why it was difficult to convince them not to do so as some of these health institutions do not follow CDC recommendations strictly. This illuminates the need to reinforce this specific learning outcome by providing more objective data to convince these HCPs with established practices about the presented information

    Donning and doffing PPE are crucial for ensuring patient and HCP safety and for limiting the spread of the infection [21]. Our study shows a major weakness of the participants in donning which is alarming considering that some had already received courses about COVID-19 before. This is a red flag to reassess the awareness sessions given by third parties regarding donning and doffing PPE and the need for continuous assessment and monitoring of COVID-19 precautions. As per our results, 27% of the participants answered this question wrong post-course. Simulating donning and doffing while supervised by an instructor should be undertaken in order to ensure retention of this skill. This was not done during this course to preserve these resources for patient care. Our findings confirm results of earlier studies where PPE training was suboptimal when demonstration of proficiency was not required and that official training in donning and doffing PPE is unusual [22].

    Running a live course with simulation session during COVID-19 pandemic may cause concern because of social distancing measures adopted nationally to limit the asymptomatic spread of the virus. Many academic programs have moved to alternative virtual learning tools such as webinars and video conferencing. We aimed to have a live session while minimizing the contamination risk for COVID-19 spread by strictly applying the needed precautions of the CDC. This is in line with the results of our survey where the majority of the attendees (89.2%) selected face-to-face as their preferred method of learning. Previous studies have shown that students prefer face-to-face learning when application of skills is required [23].

    The need for highly competent and skilled HCPs is a must in the complex existing health-care system in order to secure patient safety [24] and minimize medical errors [25]. The COVID-19 pandemic highlighted the importance of patient safety and quality improvement of medical care worldwide. Many health-care services are rapidly converting their infrastructure and retraining or repurposing their HCPs for services in critical care [26]. Simulation is learning by doing and promoting understanding of a skill to its execution through experiential learning [27]. Although simulation is not new, its adoption in healthcare is variable and its emphasis in the medical literature has been on the rise nationally and internationally [28]. It is gaining popularity in the medical field because it allows the learning curve to happen in the lab instead of on the patient [29] which reduces the exposure of patients to medical errors and unnecessary risks [30]. In addition, simulation allows the HCPs to improve their confidence in practicing PCR testing prior to being exposed to real patients [31] and it is proven to be an effective tool to evaluate learners [16]. This is in line with the results of our study.

    According to our search, this is the first descriptive study published in this field involving HCPs undergoing sampling training for COVID-19 PCR. Our study revealed many gaps in related knowledge and needed precautions to address and monitor for before performing the sampling. It also highlighted the resistance among some HCPs to adopt international guidelines and change their current practices.

    The COVID-19 pandemic has necessitated rapid changes to health-care systems around the world. Health-care workers are being asked to learn new skills and Continuing Professional Development programs help develop skill-based training specifically relevant to the COVID-19 virus [32]. This pandemic has shown that traditional training practices need to be revamped to incorporate social distancing rules while functioning in a face-to-face environment [32]. Simulations allow HCPs to make connections between previous practices in newer scenarios/situations [33]. This study has shown that it takes flexibility and forward-thinking to adapt newer constraints onto current practices. According to Price and Campbell (2020), this pandemic has provided opportunities to develop skills’ based professional development opportunities and new competencies that help fill the gaps when dealing with this virus. The simulation approach to the PCR training in this study provided intrinsic cognitive load because it tapped into participants’ previous knowledge in addition to germane cognitive load as the topic was highly relevant to the urgent nature of the pandemic [32]. These results are commensurate with other studies that showed improvement in students’ knowledge, self-efficacy, satisfaction, and confidence after a simulation course using pre–posttest questionnaires [35-37].


      Conclusion Top


    To date, despite the widespread use of PCR sampling for COVID-19 and the serious complications that may arise from inappropriate sample collection, there is no previously described formal simulation course given to HCPs prior to COVID-19 PCR sampling on patients. According to our search, this is the first descriptive study published in this field among HCPs undergoing sampling for COVID-19 PCR. Our study revealed many gaps to address and monitor for before performing COVID-19 PCR sampling as far as related knowledge and needed precautions. It also highlighted the resistance among HCPs to adopt international guidelines and change their current practices.

    There is an immediate need for spreading awareness about the correct sampling practices regarding PCR sampling for COVID-19 along with supervising PPE donning and doffing of HCPs. A uniform protocol for sampling techniques with clear instructions based on international guidelines could immediately be adopted in all Lebanon in order to avoid confusion or mistakes in sampling.

    Based on our results, a simulation course for COVID-19 PCR testing should be a requirement before allowing HCPs to perform sampling techniques on patients. The marked improvement in the Kscore and self-confidence post-training reveal that this course was successful in delivering the learning outcomes to the attendees.

    Study limitations

    One limitation of the study is the small sample size, but this was a must in order to optimize course delivery and respect the CDC and WHO social distancing precautions. In addition, this study was conducted at the early onset of the COVID-19 pandemic (February, March, and April 2020) where HCPs were reluctant in performing PCRs due to concerns about their own safety and because there was barely enough available information about this virus. A larger national and international study should be conducted in order to better assess the effectiveness of simulation courses about COVID-19 sampling on the knowledge, skills, and confidence levels of the attendees. Simulation course was suboptimal: Simulation of donning and doffing of PPE was not performed in order to preserve resources for patients’ care namely that they were scarce worldwide during the period of the study.

    Acknowledgement

    We thank Dr. Ziad Nehme, DBA for helping us in data collection.

    Authors’ contributions

    MAO conceived the research idea, developed research design, and conducted the research. REN performed the statistical analysis. All authors contributed substantially to the write-up of the article. All authors reviewed and approved the final draft of the manuscript and all take responsibility of the content of the publication.

    Ethical statement

    This research study was approved by the Institutional Review Board (IRB)/Research Ethics Committee (REC) of the University of Balamand/Saint George Hospital University Medical Center on November 27, 2020. The research collected secured full consent from the participants and they remained anonymous.

    Financial disclosure

    The author declares that they have no relevant or material financial interests that relate to the research described in this article.

    Conflicts of interest

    There are no conflicts of interest.

    Data availability statement

    All collected data are available in this study. Raw data were generated at Balamand Medical Simulation center. Derived data supporting the findings of this study are available on request from the corresponding author.



     
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