Training with High Fidelity Simulation in the Care of Patients with Coronavirus—A Learning Experience in Native Health Care Multi-Professional Teams

The training of emergency and intensive care teams in technical and non-technical skills is fundamental. The general aim of this study was to evaluate the training of various professional teams with simulations based on the care of COVID-19 patients using Zone 3 simulations (native emergency medical services and intensive care units-ICU teams) in the Region of Murcia (Spain). A mixed pilot study was designed (qualitative/quantitative) comprised of three phases: Phase 1: detection of needs (focus groups), Phase 2: design of simulation scenarios, and Phase 3: training with high-fidelity simulation and evaluation of competences. The results were used to determine the real training needs of these health professionals, which were used to design four simulation scenarios in line with these needs. The team competences were evaluated before and after the training session, with increases observed after the training sessions, especially in non-technical skills such as communication. Training with zone 3 simulation, with multi-professional native emergency and intensive care teams who provided care to patients with coronavirus was shown to be an effective method, especially for training in non-technical skills. We should consider the training needs of the professionals before the start of any training program to stay one-step ahead of crisis situations.


Introduction
During the current world pandemic situation provoked by the COVID-19 virus [1,2], one of the most controversial aspects was the safety of the health professionals who provided care to sick patients [3]. When discussing safety, we are not only referring to physical safety, but also to psychological safety, which also became compromised, with important repercussions in the mental health of health workers [4,5]. In this sense, the frontline health workers have had to face a great challenge which has had unprecedented consequences, given the duration and persistence of this pandemic [6,7].
Health professionals were at a high risk of becoming infected during the initial phase of the coronavirus SARS Cov2 pandemic, especially before its transmission dynamics had been completely deciphered. The health personnel infection rate was high worldwide at the beginning of the pandemic, and in Spain, this was very worrisome [8,9]. The infection figures were around 120,000 infections and 63 deaths due to COVID-19, with the greatest number found during the "First Wave".
In addition, at present, experiences with clinical simulation have become a strategy for the training of professionals who have to care for COVID patients, given the success they have shown [31][32][33][34].
In this sense, organizations such as the European Society of Paediatric and Neonatal Intensive Care urges the use of training strategies based on clinical simulation, to efficiently increase the professionals' competences associated to COVID [35]. In the context of the pandemic, some health institutions have wagered on training based on simulation with their clinical staff, both veteran and new members [36].
The general aim of this study was to evaluate the training of various professional teams with simulations based on the care of COVID patients using zone 3 simulations (native Emergency Medical Services (EMS) and hospital Intensive Care Unit (ICU) teams in the Region of Murcia (Spain). The specific objectives were: To determine the training needs of multi-professional health care teams with respect to technical and non-technical skills associated to the care of COVID-19 patients; to design simulation scenarios adjusted to the needs of the participants; to put into practice high-fidelity clinical simulation scenarios with native workers (zone 3); and to analyze the acquisition of technical and non-technical competences during the simulated experiences.

Design
A mixed pilot study (qualitative/quantitative) was designed, comprised of three phases ( Figure 1). In the first phase, two focus groups of professionals were convened to discuss aspects related with the preparation of professionals for facing the health crisis due to the pandemic and the specific training needs. The results from the analysis of the focus groups helped the research team to decide on the competences to work on and to design a series of clinical simulation scenarios based on the different environments in which the COVID-positive patients would be treated. In addition, an evaluation tool was created for each scenario, which was adapted to the competences that were to be acquired with the training. This was the second phase of the study. In the third phase, a pre-post intragroup (without a control group) quasi-experimental study was conducted, in which health care professional teams were trained in the clinical simulation installations at the Catholic University of Murcia (Spain). The competences acquired by the health professionals were evaluated before and after the training with simulation. The contents of the debriefing sessions from each scenario were also analyzed qualitatively.

Participants
Two emergency medical services (EMS) teams were selected, as well as two public health intensive care unit (ICU) professional teams from the Region of Murcia (Spain). Non-random, snowball intentional sampling was utilized. The volunteers had to be willing to take part in the simulation experiences without prior knowledge of the scenarios, they had to be real teams with a long-term history (more than 2 years of experience), and must have exerted their caregiving labor during the pandemic. For the simulation experiences, the participating teams selected are shown in Table 1. For the focus groups, the selection was broadened to 12 participants in the case of the intensive care unit group, whose characteristics are detailed in the procedure section.

Participants
Two emergency medical services (EMS) teams were selected, as well as two public health intensive care unit (ICU) professional teams from the Region of Murcia (Spain). Non-random, snowball intentional sampling was utilized. The volunteers had to be willing to take part in the simulation experiences without prior knowledge of the scenarios, they had to be real teams with a long-term history (more than 2 years of experience), and must have exerted their caregiving labor during the pandemic. For the simulation experiences, the participating teams selected are shown in Table 1. For the focus groups, the selection was broadened to 12 participants in the case of the intensive care unit group, whose characteristics are detailed in the procedure section.

Procedure
The study was conducted between the months of September and December 2020, at the UCAM installations (area of simulation). The procedure for each phase is explained below: Phase 1: This phase took place on the first week of September 2020. Two different focus groups were organized: a group of six EMS professionals and another group of 12 ICU professionals. The focus groups were moderated by an expert in qualitative methodology and were designed having in mind that the focus of discussion would be centered on the following subjects: Pandemic/Subjective impression/Self-evaluation of actions during the pandemic/Aspects to be improved in caregiving/Training needs. The two focus groups sessions took place at different times (Table 2). Both groups had the same structure: opening of the session with a welcome and presentation of the research project; presentation of the participants themselves; clarifications about the dynamics of the discussion; establishment of a spoken contract with the group, highlighting the ethical aspects of the research and the interaction processes; guidance of the debate centered on the subjects to be discussed; synthesis of the previous phases; closure of the session, and acknowledgement of the participants. Due to the risk of infection, all the safety measures were used (distancing, use of mask, ventilation of the room, and use of disinfecting gel before and after the meeting). Phase 2: It was carried out between the second week of September 2020 and the first week of October 2020. With the information obtained in the focus groups, four simulation scenarios were created (two for each group/one per team). The recommendations from the associated literature were considered for the design of the scenarios [37][38][39]. To evaluate each scenario, a tool was designed to evaluate the dimensions (due to their length). Each checklist organized the skills with a Likert-type scale with five response options: 1 = "never performed" and 5 = "always performed".
For the EMS group, two scenarios at the patient's home were designed. In the first scenario, the team is coming back to base from a call at the city center and are inside the ambulance. At that moment, they receive a call from the Emergency Coordination Center with a new emergency from a nearby town (20 min away). The data provided are the following: 45-year-old male with chest pain, who was infected with COVID with slight symptoms. The learning objectives for this case were: Heart attack code in a COVID context; Intubation in COVID context and Problem resolution and decision making in a complex context. The non-technical skills that were worked on were: Transfer of complex information (SBAR method); Problem resolution technique from D Zurilla and Goldfried [40].
In the second scenario, the team is having lunch. It is 1:35 pm, and they have just sat down to eat when they get the call: Woman, 67 years old, with dyspnea and fever. She lives alone and talks daily with her daughter Alicia, who is on her 36th week of pregnancy. Today, during a video call with her daughter (1 pm), the daughter saw her mother worse and went gone to see her, calling 112 afterwards. The 112 ambulance driver (who will be an actor) will hinder the work of the participants and will have a disruptive behavior throughout the scenario. The learning objectives in this case were: Assertiveness techniques; Level of severity in respiratory failure; Indication of transfer to hospital. The non-technical skills were: Assertiveness and assertiveness techniques, differentiating depersonalization behavior due to burn-out (driver) from a reaction due to fear (daughter), and personal self-control.
For the ICU group, two intensive care units scenarios were designed. In the first case, a scenario was planned about the administration of a common IV medicine to a patient who was in the prone position with full-blown hypoxia and critically sick. When the nurse is present, the patient suffers severe hemodynamic deterioration with sustained hypotension and cardiorespiratory arrest.
This scenario counted with the participation from the nurse who was with the patient and the ICU doctor, along with nursing assistant support. The learning objectives for this case were to perform advance life support on a patient in the prone position (according to the ERC guide), prioritizing safety, and effective communication within the team.
In the second scenario, the multidisciplinary team, composed by an ICU doctor, nurse and nursing assistant, had to be responsible for an admission of a COVID+ patient in a situation of full-blown hypoxia, conscious, agitated, with spontaneous breathing, with a pattern of altered breathing. The health care team at the emergency entrance door (doctor and nurse) transfers the patient.
The learning objectives for this case were: the transfer of a COVID+ patient between the Emergency department and ICU, the initial management of a COVID+ patient, management of an agitated patient who rejects treatment, and the use of non-invasive mechanical ventilation (NIMV) on a COVID+ patient.
Along with the design of the scenarios, an ad hoc evaluation tool was created by the research team, which served to evaluate the behavior of the participants during the simulation session. To provide content validity, the dimensions and selected items were submitted to the judgment and discussion of a panel of experts. For each type of scenario, a different panel of experts was used; one for EMS scenarios; another for ICU scenarios. Each panel was comprised of three experts, at the teaching, care and scientific levels. The inclusion criteria as an expert were the following: to be an active professional in the study area for a period of no less than 5 years; have training experience in the area studied; be a university professor/clinical simulation instructor. Regarding the evaluated aspects, in each selected dimension, the following characteristics were evaluated with respect to the items issued: sufficiency (is the number of items sufficient/insufficient? Is there redundancy? Would any item be added?); clarity (is the item hard to understand? Do you require clarification?); coherence (does the item have a logical relationship with the action?); and relevance (can the item be eliminated without affecting the measurement of the dimension?). As conclusions of the two panels of experts, the registration scales were issued for each of the four designed scenarios.
The evaluation tools had good content validities (CVI = 1), were created through consensus after various meetings, and included dimensions with a variable number of items according to scenario, to be posteriorly evaluated by independent observers. Phase 3: Simulation sessions were planned for each group. The groups A (EMS) and B (ICU) were both subjected to two different simulation scenarios, which were repeated twice. It was carried out on different dates for each of the groups studied. EMS scenarios were performed on the first week of November 2020; the scenarios with the ICU team were carried out on the last week of November 2020. For the group A simulation, a teaching ambulance was utilized, which was equipped exactly as the one used by Emergency services in the Region of Murcia, and a simulation room, which re-created the patient's home. For the development of both scenarios, a high-fidelity simulation manikin (CAE ARES Emergency Care Manikin ® ) and a trained actress, who played the role of a family member, were utilized. In the case of group B (ICU), the scenarios took place in the simulation room, which re-created an environment of intensive care at a hospital with a high-fidelity simulator (Laerdal ® SimMan Essential).
In each group studied, six participants were selected according to intentional criteria of volunteerism and opportunity and minimum experience of 5 years in the department of 5 years, having recently experienced situations with COVID patients in the real world. In the composition of the teams, the work structure of the units themselves was maintained. Thus, the EMS team was composed of six members (two doctors, two nurses and two health emergency technicians). The intensive care team was composed of 6 other members (two doctors and four nurses).
On the day of the simulations, the participants became familiarized with the material, the room, the ambulance, and the surroundings. Afterwards, a psychologically safe environment was created so that the participants felt comfortable, by resolving the doubts that could arise after the explanation of what they were about to experience. Ice-breaking activities took place before the start of the simulations.
After this, we established two work teams (Team 1 and Team 2 for group A-EMS; Team 3 and Team 4 for group B-ICU) to perform in a simulated scenario. This team remained stable in the Pre and Post situation.
Afterwards, the initial guidelines were provided, and each team received brief instructions about the case (Briefing) in SBAR (Situation, Background, Assessment, and Recommendation) format. Next, the simulation scenario took place. The actions of the teams were recorded using two video cameras (one in front of the patient, and another set-up at an angle). After the simulation, a structured debriefing session took place (using the Gather/Analyze/Summarize format) [41]. After the debriefing session, each team repeated the same scenario a second time; in this manner, we obtained the Pre and Post debriefing action. The characteristics and duration of the scenarios are shown in Table 3.

Data Analysis
The data from the focus groups and discourses generated in the case debriefing sessions were collected as videos and transcribed verbatim. Afterwards, they were subjected to content analysis and categorization/codification to obtain qualitative data. Two independent researchers who utilized consensus to define the subjects, categories, and sub-categories that served as the basis for the design of the scenarios (Phases 1 and 2) performed the analysis. The conversations generated in each debriefing session served for contextualizing the learning and the quantitative data. The content of the debriefings in each case was transcribed, codified, and analyzed.
As for the quantitative results associated to the acquisition of competences after the simulation experience, an observational method of analysis was used, in which 10 independent expert observers (five different experts to evaluate each group, and who were not part of the research team) evaluated each scenario blindly (without knowing if the video they were evaluating corresponded to the initial simulated case or the repetition after the debriefing session). The experts were chosen for having 5 years of experience in an intensive care unit (ICU), and emergency medical system (EMS), respectively).
To ensure an objective evaluation, random numbers were assigned to the videos. The experts were chosen for having experience in the teaching of patient care through clinical simulation at the university, and for having broad experience in the area of care from the scenarios, (the experts who evaluated the scenarios from group A were not the same as for group B, as the areas of knowledge were different). These experts evaluated the acquisition of skills by the teams. To ensure that the evaluations were consistent, the experts were instructed on how to use the evaluation tool.
The expert's evaluations were entered into a Microsoft Excel ® sheet, which was used to build a database with the SPSS © v21 program (Statistical Package for the Social Sciences, IBM Corp. Release 2012) to process the data.
The main outcome of the research was the post-test scores obtained for the dimensions assessed such as protection, coping, and communication, among others. To analyze the data, different statistical tests were utilized: descriptive statistics (mean and standard deviation) for the quantitative variables, and frequencies and percentages for the categorical ones.
As most of the measurements of the results did not have a normal distribution, the data before and after the interventions were subjected to a bootstrap analysis [42] and were presented as mean and CI 95%. The differences between the variables were analyzed with Student's t-test with a Bonferroni correction for multiple comparisons. The data were considered statistically significant at p < 0.05.
To assess the internal consistency of the items amongst themselves, Cronbach's Alpha coefficient was calculated; a minimum value above 0.7 was considered as an acceptable Cronbach's Alpha value.
In addition, the effect size was calculated with Cohen's D to evaluate the magnitude of the effect of the intervention, utilizing the values proposed by Ferguson [43], where 0.41 indicates a small effect, 1.15 a medium effect, and 2.70 a large effect. To estimate the reliability of the evaluation forms, the inter-observer agreement test was applied by calculating the intraclass correlation coefficient (ICC) [44,45]; its value was interpreted as a percentage of the variability of the score which was solely dependent on the variability between the subjects evaluated.

Ethical Considerations
During the study, all the applicable institutional and governmental regulations on the ethical use of human subjects were followed. This research complied with the requisites from the Declaration of Helsinki and was approved by the Ethics Committee from the Catholic University of Murcia (code: CE072002). All the participants were informed about their participation and signed a form indicating their informed consent and authorizing the recording of their actions in the simulation to video, and the dissemination of these recording for scientific aims.

Results
For its better understanding, the results of this study are presented organized by phases.

Phase 1 3.1.1. Emergency Medical Services Team Focus Groups
After the analysis of the focus group, four main categories and 12 sub-categories were obtained (Table 4) associated to the dimension training/entertainment. The data related to other dimensions (such as the criticism about the management of the pandemic, or organization matters and negative experiences at the local level), which were also discussed, are not presented in the present work, as they were not part of the research objective.

Increase in Theoretical Knowledge
Need for clear protocols at the start of the pandemic "( . . . ) for me, to tell you the truth, the thing that caught my attention was the improvisation, the changes from one on-call to another, for us as a unit, as well as the hospitals as the patient reception units" "( . . . ) lots of fear on the street, fear in people with pathologies, but also a lot of misinformation. The problem is that trivial pathologies were being confused with coronavirus." Information about the clinical-epidemiological characteristics and transmission of COVID-19 Management of disposable residues contaminated with COVID-19 "( . . . ) we have to have set and very clear procedures about who has to check how they are removed, where they are located, where they are thrown away, and this training has to be given, especially because the more protocols there are, and the more training received, the easier it will be to avoid mistakes, everyone knows this" Management in the cleaning and disinfection of the ambulance "there has been a great lack of knowledge ( . . . ) each one did what he or she knew, because as there was no protocol ( . . . ), there have been days in which the cleaning of surfaces exclusively with diluted sodium hypochlorite with immediate activation of the unit was ordered and another day the application of an aerosol in the room and the seal of the ambulance was ordered for three hours." Triage/Resources in the context of the COVID-19 pandemic "If it is an ordinary situation, triage is important, in the situation we are in, in which we had 3000 calls, triage became a very important element. The problem is, as I've said, that there is a great amount of triage, because right now I'm looking at the screen, and 80% of the care provided is coronavirus. The assigning of resources is very, very complicated"

Training in Technical Skills
Wearing and placement of PPEs "the subject of putting on and taking off the PPE has not been explained either. It was explained back then with the Ebola scare, I don't remember. I've put it on and taken it off was well as I could, trying to do it in the best possible manner, but self-learned"

Removal of PPEs
Reanimation of COVID+ patients "And then the management of the Covid+ patient in a CPR, with a respiratory problem, which we have not done either, just like you say, in a self-learned manner, and whatever you have read, and what you know from other experiences, and I've made this mistake, and I know that next time it shouldn't happen." Training on Non-TechnicaL Skills and/or Attitudes

ICU Teams Focus Groups
In this group, three categories and six sub-categories associated with training were obtained, as shown in Table 5. These categories were remarkably similar to those obtained in the EMS group. The data showed the need to train on technical (related with teams and procedures) as well as non-technical (related with the management of emotions or communication, especially bad news) skills. . and the answer was that . . . .because it's protocol . . . " "I remember that case and seeing the woman on the floor, . . . and I started to cry . . . but it was the mental collapse of everyone at the moment" "( . . . ) She was in very bad shape, very distressed . . . she was seeing that the patient was not doing well . . . and she had a small child . . . and for me, that moment . . . puff . . . " "( . . . ) I remember hearing people say that they didn't want to come to work" "It's more about the emotional stress, the fear you have about becoming infected, and your family . . . especially at the start" Management of emotions

Phase 2
As for aspects to be discussed in the debriefing session for the first EMS scenario, these were contraindications of the thrombolytic drugs and CPR maneuvers in a COVID context. The dimensions were: Protection (personal and environmental), with six items that could be evaluated; Clinical management of the scenario, with nine items that could be evaluated, and Effective communication with seven items.
To evaluate the second EMS scenario, each checklist organized the learning skills according to the different interventions, and evaluated the skills with a Likert-type scale. The dimensions were: protection (personal and environmental)/comfort with nine items to be evaluated; clinical management of the scenario, with five items to be evaluated; and management/control of a disruptive profile, with four items that could be evaluated.
To evaluate the ICU first scenario, each checklist organized the learning skills according to the different interventions, and evaluated the skills with a Likert-type scale with 5 response options: 1 = "never performed", and 5 "always performed". The dimensions were: perform advanced life support on a COVID+ patient in the prone position; protection; (personal and environmental) effective communication, with a total of 24 items to be evaluated.

Phase 3
The results of the dimensions showed an increase in the mean score obtained when the simulation scenario was repeated. The results of the dimensions for each scenario (initial and repeated) are shown in Table 6.
For the ICU scenarios, the dimensions which were statistically significantly different were "protection" (Figure 1) in the scenario with the agitated patient and "communication" in the ALS in prone position scenario. Within the "protection" dimension, significant differences in the initial and final evaluations were observed in items 5 (t = 2.99, p = 0.04, CI 95% 0. 16-4.24) and 7 (t = 3.14, p = 0.04, CI 95% 0.18-3.02). In the dimension "communication", the following items showed significant differences between the initial and final scores: item 4 (t = 3.16, p = 0.034, CI 95% 0.12-1.88) and 6 (t = 3.09, p = 0.037, CI 95% 0.18-3.42). In the EMS scenarios, the dimensions in which differences were observed were those for the CPR scenario, the dimension "communication", with a small effect size. Within this dimension, items 3 "Clear communication is established in the team" (t = 3.87, p = 0.037, CI 95% 0.18-3.42) and 6 "Order and control of the situation is maintained" (t = 3.207, p = 0.033, CI 95% 0. 16-2.23).
The Cronbach's Alpha values for the EMS scenarios were α = 0.890 for the CPR scenario, and α = 0.923 for the agitated patient. As for the ICU scenarios, these following values were obtained: α = 0.953 and α = 0.95 for the CPR and agitated patient, respectively.
The Cronbach's Alpha values for the EMS scenarios were α = 0.890 for the CPR scenario, and α = 0.923 for the agitated patient. As for the ICU scenarios, these following values were obtained: α = 0.953 and α = 0.95 for the CPR and agitated patient, respectively.
The ICC obtained for the ICU scenarios were: agitated patient, ICC = 0.904 (very good), ALS scenario = 0.61 (substantial). The values for the EMS scenarios were: for the ALS case, ICC = 0.788 (substantial), and for the patient with respiratory difficulty case, ICC = 0.72. Figure 2a-d show the differences in the overall scores of the dimensions for each scenario in the initial and repeated evaluations.

Discussion
Considering the results found, the following discussion elements are now presented. The primary concern is the need to count with health professionals when creating a training plan according to their needs. Usually, the training plans in health centers and official training centers do not consider the real needs of the participants. As for the pandemic due to COVID-19, the training plans were at first scarce and improvised. The health professionals were almost self-learners in the acquisition of knowledge and the skills needed to face this challenge.
Facing a novel health crisis, such as a pandemic, is a challenge for scientists and organizations responsible for the health of the population. These viral outbreaks have historically provoked the need for the global communities to rapidly plan, prepare, and ensure health care. Nevertheless, this immediacy and novelty of the pandemic-epidemic did not give us enough time or foresight to consider the training needs. In the present pandemic (especially at the start), information and training were provided to health professionals in an improvised manner, with much of the information lacking in certainty.
In this sense, the practice of technical skills, as well as the application of procedures (maneuvers in the management of the airway, ventilation therapies, etc.), and the use of personal protection equipment were urgent matters, in detriment to the non-technical competences, such as communication skills or caring for colleagues [46].
The immediacy and the improvisation of the specific training programs in technical aspects, experienced during the period of COVID in different health centers, goes against the recommendations according to evidence [47], which indicate that the "foresight" through the programmed training of the personnel and teams contribute with minimizing the impact of these events on the quality of care. In this sense, training plans should be created that are adequate to "future" needs, based on prior events, or in deficiencies observed in the present, which can be projected into the future.
The needs detected in our study, at the technical and non-technical levels, could contribute with minimizing the negative impacts of these new epidemic "outbreaks" on health personnel. The possible improvements in the present and the future, in the training and the plans to improve the non-technical skills, are especially striking, with special emphasis on emotions themselves, together with the care and support of one's colleagues.
The use of simulation as a multidisciplinary training strategy in contexts of emergencies has been successfully described [48][49][50], and our study corroborates the need for its implementation and its general use to work on all types of competences in a small amount of time.
In this study, we have learned that an adequate training plan must be based on an appropriate plan, which considers the needs of the professionals who will receive this training. A good strategy for collecting this information is the use of qualitative research techniques based on the production of opinions through the explicit use of interaction. We believe that the points of view on this phenomenon (pandemic and training needs), aside from being individual, are highly enriched if we consider the points of view produced during the interaction of different individuals in a focus group, aside from those that are produced in isolation.
In our study, the training needs were focused on both technical and non-technical skills. Therefore, the scenarios were designed to include contents that referred to the types of skills mentioned by the participants in the prior focus groups.
The use of clinical simulation allowed for experiential and reflective learning that was immersive in nature, within the context of caring for coronavirus patients. This element allowed the professionals to re-create possible scenarios from their real-world practice and to evaluate their actions and behaviors. It also allowed them to discuss their weaknesses and aspects to be improved in a safe environment. It is important to highlight that the safety offered by simulation training is beyond doubt. In a simulated environment, complex situations can be re-created which the participants can address by using their professional competences with complete safety (simulations are safe tools, for both the patients and the participants). This aspect is key when interpreting the results.
In agreement with the results from this study, the non-technical skills were the most impacted by the training with clinical simulation, as skills such as communication obtained statistically significant differences in most of the scenarios (EMS CPR p = 0.04; EMS breathing difficulty p = 0.015; ICU-ALS p = 0.05). In the results we can see how most of the dimensions showed higher scores after simulation training. In addition, the non-technical dimensions showed significant differences after training, with moderate effect sizes. Among the dimensions with the largest effect sizes after simulation were "Communication" and "Management Control of disruption". We believe that the impact on the technical skills was lower, as the professionals had clinical experience in their respective areas, and perhaps the most novel learning results were associated with aspects such as communication or controlling a disruptive situation. For example, with respect to specific technical skills, statistically significant differences were not found in the scores of EMS-CPR protection (p = 0.67), and the posterior score was even lower than the previous score (although this was not statistically significant and the effect size was small and very close to 0.41, which is the minimum effect size that represents a "practically" significant effect.). This could be interpreted by considering that the technical competence of the health professionals was already high, and small changes during the repeated scenario could have affected the score of the evaluation.
The development of non-technical skills in the context of COVID was one of the strategies recommended for minimizing the impact of the experiences of the health personnel with this disease. Thus, this could contribute with the improvement of inter-professional relations, the recognition of roles, the situational awareness, the care of the members of a healthcare team, and the management of situations that are potentially harmful for the interests of the patient [51].
The optimization of the team's actions through improved non-technical skills can lead to better decision-making, a greater efficiency, and greater adherence to safety standards, a greater resilience, and better results. The non-technical skills are cognitive and social skills that characterize high-performance individuals and teams. In this sense, the strategy utilized is useful [52] and pertinent, as it respects the realism and the psychological and social fidelity of the scenes.
It should be underlined that in our study, the training in non-technical skills was demanded, such as the transfer of patients between health care teams, communication, teamwork, and the management of a crisis, aspects which were not defined as important at the start of the pandemic by those responsible of training in the area of health.
In the literature [53,54], specific theoretical-practical frameworks exist for the management of non-technical skills by health care teams. The more popular models which stress the importance of teamwork and non-technical skills in emergencies and critical care are the Crisis Resource Management (CRM) [55,56] or TeamSTEPPS [57,58]. These skills are broadly defined as situational awareness, making of decisions, team communication, and leadership. In this sense, the strategies described by TeamSTEPPS have shown their usefulness in the management of these types of situations in intensive care contexts.
As for the clinical application/transfer of the results of the present research to a real health care environment, many aspects need to be discussed. In first place, we find the ethical dimension: a simulated learning environment is safer for the participants (especially during a pandemic). On the other hand, it is also better for the patients for the health professionals to train with manikins or actors, on skills or protocols so that they are safely utilized or applied in the future. We can also attest that more competent professionals can be obtained if they are trained on situations that they do not sufficiently control in the real world. The importance of non-technical skills has become evident in the present work, given that training on these skills is usually not provided or is shadowed by the technical skills. Thus, our results support the need to create multidimensional learning programs that take into account technical aspects (clinical skills and procedures), as well as non-technical skills (teamwork, assertiveness, leadership, etc.).
A reflection about the future perspectives of this research was provided by the recognition given by the health professionals to the suitability of this type of training, especially their desire to keep to training on non-technical competences within the functional work team. This proposal was kept in mind for a future line of work that will be directed towards the identification of a baseline of non-technical competences within a functional work team and the planning and implementation of training based on clinical simulation that covers the specific objectives defined for each group.

Conclusions
In general, the skills that were worked on with simulation with native emergency multi-disciplinary and ICU teams were improved, especially all the non-technical aspects such as communication. The demands from the care teams included technical and nontechnical competences associated with the lack of training for dealing with the care of coronavirus patients. The scenarios designed according to the real training needs of the professionals allowed them to successfully work on these competences. Efficient training in a safe environment can be accomplished with the use of contextual high-fidelity simulation, through the insertion of personal elements and materials that grant realism to the re-created scene.

Limitations
Among the limitations, we find the low number of participants in the training planned, given the safety conditions defined by the risk of infection in meetings in which the students come in close contact with each other; more specifically, the need for social distancing during the study period. This made necessary the reduction in the number of participants in each space destined for the simulation. This also led to the establishment of measures such as a group composed of no more than six individuals, the use of adequate personal protection equipment in all the sessions (such as N95 masks), routine hand hygiene with the use of hydroalcoholic gel, and routine ventilation of the space every 15 min.
Another aspect to consider is about the measuring instrument. The use of an evaluation rubric format could be used as a way to avoid measurement distortion and decrease possible inter-observer variability. However, the internal consistency is adequate with the Likert-type format of the observation template. simulation technicians at UCAM, especially Vicente Martínez, Luis Suárez, and Pedro J. Escamez, for their collaboration in this project.