Education for Health

: 2020  |  Volume : 33  |  Issue : 2  |  Page : 37--45

Train-the-trainer: Pilot trial for ebola virus disease simulation training

Catherine D Tobin1, Myrtede Alfred1, Dulaney A Wilson2, Lacey MenkinSmith3, Kathy L Lehman-Huskamp4, John J Schaefer1, Kenneth Catchpole1, Lydia Zeiler1, Brian Fletcher5, JG Reves6,  
1 Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
2 Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
3 Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC, USA
4 Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
5 Brian Fletcher and Associates, LLC, Medical University of South Carolina, Charleston, SC, USA
6 Department of Anesthesia and Perioperative Medicine; Dean Emeritus and Distinguished University Professor, College of Medicine, Medical University of South Carolina, Charleston, SC, USA

Correspondence Address:
Catherine D Tobin
Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 167 Ashley Avenue Suite 301, MSC 912, Charleston, SC 29425


Background: Highly infectious but rare diseases require rapid dissemination of safety critical skills to health-care workers (HCWs). Simulation is an effective method of education; however, it requires competent instructors. We evaluated the efficacy of an internet-delivered train-the-trainer course to prepare HCWs to care for patients with Ebola virus disease (EVD). Methods: Twenty-four individuals without prior EVD training were recruited and divided into two groups. Group A included nine trainees taught by three experienced trainers with previous EVD training. Group B included 15 trainees taught by five novice trainers without previous EVD training who completed the train-the-trainer course. We compared the efficacy of the train-the-trainer course by examining subject performance, measured by time to complete 13 tasks and the proportion of steps per task flagged for critical errors and risky and positive actions. Trainees’ confidence in their ability to safely care for EVD patients was compared with a self-reported survey after training. Results: Overall trainees’ confidence in ability to safely care for EVD patients did not differ by group. Participants trained by the novice trainers were statistically significantly faster at waste bagging (P = 0.002), lab specimen bagging (P = 0.004), spill clean-up (P = 0.01), and the body bagging (P = 0.008) scenarios compared to those trained by experienced trainers. There were no significant differences in the completion time in the remaining nine training tasks. Participants trained by novice and experienced trainers did not differ significantly with regard to the proportion of steps in a task flagged for critical errors, risky actions, or positive actions with the exception of the task “Man Down in Gown” (12.5% of steps graded by experienced trainers compared to 0 graded by novice trainers, P = 0.007). Discussion: The online train-the-trainer EVD course is effective at teaching novices to train HCWs in protective measures and can be accomplished swiftly.

How to cite this article:
Tobin CD, Alfred M, Wilson DA, MenkinSmith L, Lehman-Huskamp KL, Schaefer JJ, Catchpole K, Zeiler L, Fletcher B, Reves J G. Train-the-trainer: Pilot trial for ebola virus disease simulation training.Educ Health 2020;33:37-45

How to cite this URL:
Tobin CD, Alfred M, Wilson DA, MenkinSmith L, Lehman-Huskamp KL, Schaefer JJ, Catchpole K, Zeiler L, Fletcher B, Reves J G. Train-the-trainer: Pilot trial for ebola virus disease simulation training. Educ Health [serial online] 2020 [cited 2021 Jan 16 ];33:37-45
Available from:

Full Text


Outbreaks of high-risk infectious diseases or bioterrorism require methods for rapid knowledge dissemination that allow health-care workers (HCWs) to quickly diagnose and effectively care for contagious patients while protecting themselves. The exemplar is the Ebola virus disease (EVD), which is highly infectious and has high mortality among HCWs.[1] During the 2014–2016 EVD outbreak, the total case fatality rate (CFR) in West Africa exceeded 45%, while in the US and Europe, the estimated CFR was 18.5%.[1] Infection rates in West Africa were especially high among HCWs.[2] Factors contributing to high CFR include insufficient personal protective equipment (PPE), unrecognized infected patients or delayed diagnosis, and inadequate HCW training.[1] The 2018–2020 EVD outbreak in the Democratic Republic of Congo which just ended in June of 2020 resulted in 3481 cases and 2299 deaths with a CFR over 60%.[3,4]

During outbreaks of highly infectious diseases, HCWs need to be trained quickly and reliably to ensure they can care for patients safely. Simulation is an effective method of instruction in high-risk disease management,[5-12] allowing HCWs to learn and practice the skills needed to care for contagious patients. Simulation education requires competent instructors to teach the material, run the training scenarios, and grade the trainees’ performance. Thus, educating trainers is an essential element of simulation. However, technically trained experts and trainers are not always available to deliver training in times of disease outbreaks. Train-the-trainer courses are vital to the successful education of HCWs, specifically during disease outbreaks. The Centers for Disease Control and Prevention (CDC),[13] European Network for Infectious Diseases,[14] World Health Organization (WHO), Ministry of Health and Sanitation Sierra Leone,[15] International Organization of Migrants,[15] US Department of Health and Human Services,[16] and the US National Ebola Training and Education Center,[17] all have formal EVD training courses that rely on participants traveling to on-site training centers. These courses do not facilitate rapid training of a large number of HCWs in remote places where EVD may appear nor support rapid retraining in centers with prior EVD preparedness training.

In 2014 and 2015, a massive online course for EVD was developed by experts at Emory University and used with good success.[18] However, this course did not explicitly instruct HCWs on how to train other HCWs to deliver the course. Knowledgeable instructors must be available to teach the skills, facilitate the simulation, and assess the HCWs, who will be caring for infected patients. An internet-based course can support instructor education as it offers swift, widespread, flexible, and economical sharing of knowledge and interventions for highly contagious diseases during outbreaks. There have been simulation studies on doffing protocols for PPE in human factors in EVD; such research will increase the body of knowledge to improve the safety of HCWs when caring for patients with contagious diseases.[9]

We have previously reported our experience with an online EVD training system,[10-12] but there was no companion train-the-trainer internet course that permits relatively rapid creation of an effective trainer cadre where needed. In this study, we examined the efficacy of an internet-based train-the-trainer course for EVD by comparing the teaching of naïve individuals by novice trainers to the previously reported traditionally trained experienced trainers.[10,11] We compare the performance of trainees trained by experienced trainers to the performance of individuals taught by novice trainers created by the same online course with local practice with assessment of 13 EVD health-care tasks.



After receiving educational exemption by the institutional review board, 24 individuals with no prior EVD training were recruited to serve as trainees. All trainees completed a survey designed to capture demographic variables, educational levels, and prior training or work in infectious disease setting, took an online EVD knowledge course and then completed an internet-based Ebola Simulation Course. For the EVD simulation training, trainees were randomly divided into two groups taught by two different trainer groups. Group A trainees were taught by experienced trainers (previous EVD training and experience teaching) and Group B trainees were taught by novice trainers (no previous EVD education training) who had completed the online train-the-trainer course.

Online Ebola Virus Disease train-the-trainer course development

The trainer materials were provided as online modules. The modules were all based on the CDC[13] and WHO[19] protocols for performing basic patient care tasks while using PPE. The course includes high-reliability team principles and processes; use of detailed checklists; mutual responsibility for individual safety; and clear, closed loop communication practices and is previously described in MenkinSmith et al.[11] All course materials were housed online and available to the trainer via a secure site server and organized through a common learning platform. There were 11 facilitator train-the-trainer online modules: (1) applicable infectious disease background information; (2) review of protocols with train-the-trainer video demonstration of proper conduct; (3) training goals; (4) training room setup; (5) logistic training ratio; (6) safety considerations; (7) scoring performance and providing feedback; (8) learning to run simulation scenarios (that measure performance); (9) facilitating performance: debriefing; (10) schedule and logistics of training; and (11) facilitator curriculum (to use the day of the course as a support aid for facilitators running the course).


The Simulation Training and Reporting System (STARS) tools[12] were developed to support standardized patient assessments, objective structured clinical examinations, and skills performed on task trainers or with high-fidelity simulators. STARS runs on a portable device such as a laptop or tablet using a touchscreen interface. Trainers have the ability to record predetermined technical and nontechnical, as well as communication and behavioral errors for each individual during the simulation exercise at each step of the assessment. Trainers can also note any positive actions [Figure 1]. Recorded errors can be classified as either critical – those putting the provider or patient at risk for an adverse outcome, or noncritical, risky actions – that increase the chance of making a critical error, such as rushing. Grading criteria can be programmed into the assessment to support automatic scoring at the end of the simulation exercise. The summative report provides data on the time taken to complete the scenario and each individual step, the number of attempts, and all of the errors and positive actions reported.{Figure 1}


Group A trainers, who had previous EVD training and experience teaching, did not complete the train-the-trainer course.

Novice trainers in Group B, who did not have previous history in EVD education, completed the online EVD knowledge course.[11] Next, they were trained to conduct the course. Trainers practiced a series of graduated drills using the STARS tool until they achieved accurate and timely grading [Figure 2]. The practice to accomplish this was approximately 30 min.{Figure 2}

An experienced instructor was present for the duration of the training to answer questions regarding the grading tool. The new trainers spent <20 h to become competent trainers, including practicing the simulation scenarios (12 h). The novice trainers then graded videos of trainees doing two EVD scenarios, bedside commode setup and lab specimen, to demonstrate their ability to evaluate trainers in real time.

Next, both the trainers from Group A and B led the trainees through the course over 2 days. The course was mastery-based learning in structure, and thus all teams of trainees repeated each scenario until the teams passed.[20,21] The trainers conducted the simulation using the STARS tool[12] and graded teams on positive and negative technical, communication, and behavioral actions [Figure 3]. The team roles for the trainees were varied with each scenario to ensure that each trainee had a different role (participant, buddy, and supervisor) with various protocols. Similarly, the trainers worked with different teams.{Figure 3}


Trainer effectiveness

Novice trainers trained and evaluated teams of novices in 13 EVD simulation scenarios as previously described by MenkinSmith et al.[11] over the course of 2 days. Performance was graded in terms of time to complete the task and number of steps flagged for critical error, risky actions, and positive actions. Team performance in participants trained by novice trainers was compared to those trained by experienced trainers.

Trainee confidence

After EVD simulation training, the trainees completed a self-evaluation of their confidence to care for EVD patients using a 10-question questionnaire. The survey used a Likert scale ranging from 1 to 5, with 5 being the most confident and 1 being the least confident for all questions except question 4 in which the responses ranged from 1 – strongly disagree to 5 – strongly agree. The scale was reversed for question 4 for ease of interpretation.[22]

Statistical analysis

All statistical analyses were conducted using STATA version 13,, StataCorp LP: College Station, TX, USA.[23] Demographic characteristics of the trainees trained by the two groups (experienced trainers and novice trainers) were compared using Chi-squared tests of homogeneity; P < 0.05 was considered statistically significantly different. The effectiveness of the training was evaluated using a one-way ANOVA which examined the differences in mean time to perform all mastery-based tasks and the proportion of steps flagged for critical technical errors, critical communication error, risky communication actions, risky behavioral actions, and positive actions – technical, communication actions, and behavioral. The confidence of the trainees was described using median and interquartile ranges for each question and a total composite confidence score.



The study included 24 trainees (eight triads); 9 of whom were trained by experienced trainers and 15 trained by novice trainers [Table 1]. The trainees were medical residents (9), medical students (3), and nursing specialty trained (12). There were an equal number of female and male trainees. Other demographic information of the trainees (gender, education, specialized education, employment, and scores on didactic tests) was also similar between the groups. The two groups did not differ by pre- or posttest scores from the EVD knowledge course.{Table 1}

There were three trainers for Group A who were “experienced.” Of those, two were female and one was male. One trainer was an MD who had completed a medical residency and was now in a fellowship. The other two trainers had specialized nursing training and had completed a Masters in Nursing. This demographic data are shown in [Table 2].{Table 2}

Trainer effectiveness

The time to complete each of the 13 simulation scenarios and tasks (lab specimen bagging, donning gown) is shown in [Table 3]. Trainees trained by the novice trainers completed several tasks significantly faster than those trained by experienced trainers: waste bagging (P = 0.002), lab specimen bagging (P = 0.004), spill clean-up (P = 0.01), and body bagging (P = 0.008). There were no significant differences in the completion time in the remaining nine training tasks.{Table 3}

The critical errors, risky actions, and positive actions noted by the trainers are shown in [Table 4]. Novice trainers flagged fewer teams for critical errors and more teams for risky actions and positive actions than experienced trainers. The percentage of steps with critical errors, risky actions, or positive actions did not differ by trainer status with the exception of the task “Man Down in Gown.” The trainees trained by experienced trainers had critical errors noted in 12.5% of the steps, while the trainees trained by novice trainers did not have any critical errors noted (P = 0.007).{Table 4}

Subject confidence

Confidence scores are shown in [Table 5]. Overall confidence scores did not differ by trainer status (P = 0.27). Participants trained by experienced trainers had a median score of 4.3 (IQR = 4.1–4.5), whereas participants trained by novice trainers had a median score of 4.4 (IQR 4.2–4.7). Nine of the ten questions did not show statistically significant differences between the two groups; only question 2, “The level of protective equipment used during care is adequate to prevent contamination,” was statistically significant between the two groups with those trained by experienced trainers reporting slightly lower confidence (P = 0.02).{Table 5}


In this pilot study testing a prototype online train-the-trainer system, the effectiveness of newly trained trainers was demonstrated by their ability to train 15 trainees without prior experience in EVD preparedness. Novice trainers successfully trained a diverse range of HCWs using the EVD simulation course which was consistent and effective using the STARS tool for hands-on simulation training. Trainers and participants represented a wide spectrum of educational backgrounds, indicating that the course can be used by a variety of clinicians.

Furthermore, trainees reported a high level of confidence in their ability to safely care for EVD patients in both groups. The overall confidence scores did not differ by trainer status. Trainees taught by experienced trainers had a median score of 4.3 out of 5 and trainees taught by novice trainers had a median score of 4.4 out of 5. Only one question regarding the adequacy of the level of protective equipment resulted in a statistically significant difference between the two groups, with those trained by experienced trainers, reporting slightly lower confidence in the adequacy of protective equipment (P = 0.02). It is possible that differences in demeanor or anecdotal experiences shared by experienced trainers resulted in slightly lower confidence among trainees in protective equipment adequacy. Confidence of HCWs to care for EVD, and other contagious diseases, is essential. HCWs may not volunteer or even attend work if they think they will not be safe or put their loved ones at risk. The fact that all trainees felt confident overall suggests that it is feasible to use an online train-the-trainer course to prepare EVD instructors to effectively train inexperienced HCWs.

Just-in-time training of trainers during disease outbreaks has to be time efficient. The internet-delivered train-the-trainer trial presented here has two major components that may be done relatively rapidly. First, the novice trainers reviewed course content and practiced the simulation scenarios as if they were students using the recently published online course.[11] Subsequently, novice trainers learned via the Internet how to teach the same course they just experienced. The 24 modules in the train-the-trainer covered all aspects of being a trainer. Thus, the new trainers were equipped to teach in 1–2 days, a very efficient use of their time. The novice trainers proved proficient with the grading tool. The complexity of the grading tool was challenging with the potential marking of critical errors, risky actions, and positive actions at each step in each scenario (number of steps per task ranged from 7 to 42) incorrectly.

The efficacy of the novice trainers was demonstrated by comparing the performance of the trainees instructed by the novice trainers. Trainees were trained in a consistent manner, and there were few significant differences when comparing the experienced trainers and the novice trainers. Only one task, “Man Down in Gown,” differed with respect to the percent of steps with critical errors. We interpret that as an indication that the novice trainers were as effective in simulation training as experienced, conventionally trained trainers. However, a higher failure rate experienced by some trainees taught by experienced instructors reflects that they may have tended to employ more stringent criteria in their performance assessment of trainees. This observation merits further investigation.

Simulation education requires competent trainers to teach the didactic material and run training scenarios as well as evaluate the performance of their trainees. Thus, educating trainers to ensure they are proficient in running scenarios, providing feedback, and debriefing is an essential element in any successful simulation course.[24-28] Conventionally, trainers are taught to teach by taking the course or creating the course and then practicing with oversight from an experienced subject trainer. In complex high-technology simulation centers, there are often technicians as well as experienced trainers who conduct the teaching.

One downside of this classic model of trainer education involves the necessity of sending an experienced trainer to the area of need which is both costly and time consuming. This can be especially challenging during humanitarian crises, such as was seen in the 2018–2020 EVD outbreak in the Democratic Republic of Congo.[29,30] Furthermore, education of this type is most needed during pandemics, when countries may close their borders, limiting travel and capacity for classic in-person training modalities.[31] The benefit to the methodology used in our study is that the novice trainers can be taught to lead simulations by reviewing the online course and simulation exercise materials and studying modules on how to be a trainer, run a course, and evaluate performance. This online approach to train-the-trainer is very distinct from traditional pedagogical methodology and allows for remote education in any location with internet access. Our study demonstrated that these trainers were able to master the material and the methods involved in running a simulation course and using the digital grading tool without the support of technicians and other assets. This approach to train-the-trainers could be of immense benefit to resource-limited regions of the world, such as parts of sub-Saharan Africa, where epidemic high-risk infectious diseases are of particular concern. It also requires fewer human resources and learning can be done at times convenient to the learners with no travel required, thus obviating the need for simulation centers. Online instruction also addresses the problem created by scarcity of simulation education experts. While this particular course was written in English, the same training model could be translated into any language. Future studies are needed to evaluate the efficacy of a similar train-the-trainer model in multiple languages and in these resource-limited settings.

The finding from our work is timely given a recent forecast postulated a moderately contagious and moderately lethal novel pathogen pandemic would kill 150 million people in the 1st year.[32] The ability to rapidly and widely practice simulation education to protect workers could help avoid the problems seen in Dallas, Texas, where nurses became infected with EVD despite having PPE but inadequate knowledge regarding its use.[33] Furthermore, we should have a single level of high-quality standard of care universally including HCWs with protection and training.[34] It is not acceptable to have separate standards of care for patients and HCWs based on geographic location. The standards for EVD should not be different for countries with little resources and those with many resources available.[35] Our train-the trainer course can help global health reach universal education and standards of care to protect HCWs and treat EVD patients.


Our approach suggests that further work exploring the functionality, usability, efficacy, and ideal users of online training and train-the-trainer platforms may be warranted. First, we used a digital grading tool with limited but uniform prescribed outcome for each scenario step in the performance assessment, and there are alternative manual grading methods that might alter the grading consistency. Traditional simulation assessment tools, such as checklists and global rating scales,[36-38] might be used to guide structured and semi-objective assessment of the clinical performance instead of STARS. We found some individual variability in grading, with one trainer grading more harshly than the other four, and with more variability in assigning positive actions than in finding mistakes or communication errors.

We also had an experienced trainer physically present available to the new trainers to answer questions for their 30 min of familiarization with the STARS grading tool. This could be considered a limitation though this could easily be offered online through online video consultation or a digital “help desk” instead of having a person physically present.

One major limitation was the small sample size, with only 24 trainees and 8 trainers. Future studies could evaluate use of the tool with a larger group of novice trainees. It is valuable to note that our trainers in the groups worked with different teams for different scenarios to avoid any confounding of familiarity or bias built up over previous scenarios. Our scenarios were preprogrammed based on existing specialized medical unit training scenarios; however, it would be important for a final online training program to have the flexibility and ability to reprogram scenarios to reflect the materials and resources in that particular setting where the trainees would function. Finally, the pilot was not used during an EVD breakout and whether these trainers taught over the internet can train HCWs in the field to use effective protective methods can only be tested in a real outbreak.


To our knowledge, our course is the first online train-the-trainer course for EVD. The train-the-trainer module we tested demonstrated that online curriculum can be deployed rapidly and widely to provide new trainers with the tools to help HCWs protect themselves and control EVD and other pandemic. This study demonstrates great promise for simulation educators to develop online train-the-trainer courses to facilitate the rapid and widespread simulation education required to meet emergency conditions.

Financial support and sponsorship

This work was funded by the CDC (Grant Number: 1R43CK000444-01A1).

Conflicts of interest

Dr. Reves is the Scientific Director of SimTunes LLC and receives >35% of his compensation from them. His participation in this project was as principal investigator of the CDC-funded project. Dr. Schaefer is the minority owner of SimTunes and receives <35% of his compensation from that source. His involvement was limited to editing the manuscript.


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