Background/Purpose: Simulation has been consistently used across nursing curricula to provide experiential opportunities for practice in safe environments. Students have been found to view simulations as a positive experience (Kameg, Engler, Howard, & Perozzi, 2013). Students are encouraged to practice over and over again until they feel comfortable performing the particular skill being addressed. While most schools of nursing provide equipment or mannequins, fewer have the resources to employ standardized patients. Students voice that the most difficult simulations are those involving live patients in a particular scenario. Assigning roles which lead to deep involvement in scenarios increases self-efficacy and improves critical thinking (Weiler, Gibson, & Saleem, 2018).
Methods: The postpartum assessment is not a particularly difficult one to learn. Many of the tasks such as auscultation of heart, lungs, bowel sounds, examination of peripheral edema or pulses, will have already been reviewed and practiced in other courses. However, examination of breasts and female genitalia is more problematic for the novice student. Student discomfort may be exhibited by giggling, making jokes or by asking if hands on examination is really necessary. While most students feel discomfort in performing the exam, male students, and Muslims may be the most reluctant to actively engage in postpartum assessment. It is left up to faculty to structure the postpartum simulation experience in a way that provides adequate opportunity to practice the skill but also to process related student anxiety.
The Texan experience: Faculty in central Texas at a large university prepare students for practice of postpartum assessment by first requiring that students view the postpartum assessment video on their own. During orientation to the clinical course, students also receive a brief overview of the postpartum exam and are afforded an opportunity to practice on a mannequin. The faculty member models the postpartum exam. Locating the level of the fundus, palpating uterine consistency, viewing a variety of perineal lacerations, examining nipple models and estimating lochia amount, are then practiced by each student with the help of a faculty member.
The following week students meet in a large classroom to discuss the postpartum scenario they are about to encounter. Students are divided into small groups with a primary and secondary nurse, an observer, and a family member as needed. Standardized patients (SP) wearing Mama Natalie then engage the students in a scenario. Students are required to assess the postpartum patient while attending to any questions or educational needs that arise. Questions or concerns raised by the SP include: issues with breastfeeding, perineal or uterine pain, and self-care. The primary and secondary nurses concur with each other throughout. The scenario is followed by debriefing. During debriefing faculty raise issues around student discomfort with the scenario and critical thinking around actions taken by the nurses. The professional role of the nurse is highlighted throughout the simulation and scenario days.
The Lebanese experience: (N.B. faculty from the Texas university taught at the Lebanese university for 6 years.) Faculty at a major university in Beirut prepare students for the postpartum exam despite having fewer resources. In the absence of a postpartum video, powerpoint slides of the postpartum assessment are shown to students prior to arrival in the simulation lab. In the lab students are divided into small groups. Each group is instructed to visit the postpartum station. There, each student must locate the level of the fundus and palpate uterine consistency on a mannequin, view a variety of perineal lacerations, examine nipple models and estimate lochia amounts. A faculty member is available to direct the activity. Some students question what is to be done if a patient refuses a student or a male student nurse. Students are encouraged to view this activity as they would any other aspect of the professional nurse’s role and present it thusly to the patient. Muslim students may wear gloves at all times (even when taking the blood pressure) so that they do not have to touch the female body. This is especially important for male Muslim students. However, not all Muslim males follow this practice and not all female patients, even Muslims, refuse care from a male student. So, as in all encounters in the hospital setting, the motto is, “ask the patient.”
Following this activity students who are to rotate through the postpartum unit must meet in the simulation lab the week before the rotation. The faculty asks for a volunteer and then models how a postpartum exam is to be conducted. Each student then must perform an assessment using the faculty member as a SP. Students are initially uncomfortable with this idea but are quickly drawn into the scenarios. Each student is required to perform an assessment and respond to the patient’s need. The group functions as a support group and offers suggestions and ideas as issues arise.
Results: Four scenarios are enacted, each student being presented with a different scenario. Students must introduce themselves and proceed to examine the SP not knowing what the scenario will be. Scenario #1 is a primigravida excited about her delivery and on the phone recounting details of the event. She does not stop talking when the nurse enters the room. Scenario #2 is a multigravida who relates that as she started to go to the bathroom there was a gush of blood running down her legs. Scenario #3 is a primary c-section patient experiencing unrelieved incisional pain. Scenario #4 is a primigravida breastfeeding mother experiencing pain while breastfeeding. She begins to cry. Debriefing by the faculty member is conducted after each scenario as for the Texan students.
Conclusion: Students at both institutions reported that the simulation experiences helped them to prepare for live encounters with patients. They stated that they felt they had acquired the knowledge to perform a postpartum assessment and were less anxious about doing so. They also stated they were prepared to incorporate other activities such as education and patient questions that might occur during the assessment activity.