Obstetrical Simulation: An Educational Strategy Suitable for Both the Classroom and the Bedside

Postpartum hemorrhage is a common and potentially life-threatening obstetric emergency that occurs in 4% to 6% of all births making it the number one cause of maternal death worldwide (Lagrew, 2014). Obstetrical nurses are faced with the immense task of developing and maintaining their clinical competencies in order to identify and care for a patient clinically deteriorating from postpartum hemorrhage. Despite completing lengthy educational programs as well as intense clinical training, nurses, especially new or novice nurses, may not be adequately prepared to perform such vital tasks in a timely manner (Gordon & Buckley, 2009; Levett-Jones et al., 2010). This is especially challenging for nurses who work in smaller rural hospitals because of the lower volume of deliveries.

Nurses are ultimately responsible for the safety of their patients. Hospitalized patients are especially vulnerable in relation to their increasing acuity levels as well as the care they receive by the health care team (Cooper, Kinsman, Buykx, McConnell-Henry, Endacott, & Scholes, 2010; Purling & King, 2012). A nurse is often accountable for recognizing subtle changes and intervening appropriately if a patient’s condition worsens or they clinically deteriorate. Furthermore, research supports the concept that nurses who have higher self-efficacy are more likely to recognize and respond appropriately to the high-risk patient with the appropriate skill or behavior (Guimond & Simonelli, 2012).

Several international campaigns have concentrated their efforts on establishing practice protocols for the treatment of postpartum hemorrhage in order to improve perinatal outcomes.        The World Health Organization (WHO) developed a comprehensive guideline to address the management of postpartum hemorrhage (2012).  This guideline was developed by numerous international stakeholders following specific procedures to systematically review relevant clinical questions, assess and synthesize the latest research-based evidence, formulate recommendations, and finally disseminate the updated guidelines for implementation worldwide.  Nationally, the California Maternal Quality Care Collaborative (CMQCC) created an obstetrical expert task force in order to develop a comprehensive toolkit as a resource for healthcare providers to improve readiness, recognition, response, and reporting of hemorrhage (2010, 2015). Additionally, Merck for Mothers is a 10-year, $500 million initiative focused on creating a world where no woman dies during pregnancy. This campaign is supporting the latest national research initiative by the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN). The postpartum hemorrhage project is designed to reduce clinician errors associated with obstetric hemorrhage mortality and morbidity by improving clinician’s recognition of, readiness for, and response to a postpartum hemorrhage event. The use of simulation in order to improve the treatment of postpartum hemorrhage is one of the specific recommendations made by all three of these organizations designed to support research and evidence-based practice initiatives.

The NCSBN recently published results from a longitudinal, randomized, controlled study that addressed the outcomes of utilizing simulation in nursing education. Students were shown to have similar education outcomes with 25 to 50% simulation versus traditional clinical hours. Six months post-graduation, new nurses were given comparable readiness for clinical practice evaluations by their supervisor (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014)

In an effort to improve maternal outcomes, an obstetrical simulation quality improvement and research project were implemented to address self-efficacy and knowledge in nursing students and obstetrical nurses caring for the patient experiencing postpartum hemorrhage. A quality improvement project for nursing students was implemented, following IRB and participant consent, from a cohort of 35 undergraduate junior Baccalaureate of Science in Nursing majors from a rural southern state university. The students were randomly assigned into traditional and simulation-enhanced clinical groups. Both clinical groups attended the same co-requisite theoretical course. Following pretesting, the traditional group proceeded with a three week inpatient obstetrical clinical, on a rotating schedule, throughout the semester. The simulation-enhanced group proceeded with three weeks of inpatient obstetrical clinical with approximately 10% substitution of low to high fidelity simulation, on a rotating schedule.  Initially, the simulation-enhanced group participated in well newborn and postpartum assessment simulations prior to the inpatient clinical. Near or at the completion of the inpatient rotations, the simulation-enhanced group participated in low to high fidelity scenarios including shoulder dystocia, cord prolapse, and postpartum hemorrhage. The California Maternal Quality Care Collaborative OB Hemorrhage Toolkit hemorrhage protocol and simulation was one of the main scenarios utilized in teams of three to five students (CMQCC, 2010). After simulation, team debriefing occurred on skill and protocol performance. Upon simulation and clinical rotation completion, all students completed the ONSE scale and a postpartum hemorrhage knowledge quiz (Darnell, 2014).

An experimental study was conducted to evaluate the effect of high-fidelity patient simulation in addition to traditional lecture on obstetrical nurses’ knowledge and self-efficacy in caring for a postpartum hemorrhage patient in a rural southern state in comparison to traditional lecture only. This study was conducted using an longitudinal pretest-posttest design with randomization of practicing nurses (N =50) to one of two groups, an experimental group and a control group. The study tested the effect of an educational intervention on the knowledge and self-efficacy of obstetrical nurses caring for the postpartum hemorrhage patient.  Data were collected at three time points:  pre-intervention, immediately post-intervention, and 3 months post-intervention. Each participant completed pre and post-tests at three time intervals to measure their knowledge and self-efficacy (dependent variables). The educational lecture sessions and the simulation sessions (independent variable) were implemented based upon the CMQCC Postpartum Hemorrhage Toolkit described earlier in this chapter. Changes in cognitive knowledge and self-efficacy between the control group (education only) and the experimental group (education plus simulation) were analyzed using repeated analysis of variance (ANOVA) comparing pre- and post-test scores for both a self-efficacy survey and a knowledge quiz.

Instrumentation for both projects consisted of measures for self-efficacy and postpartum hemorrhage knowledge. The postpartum hemorrhage knowledge quiz consisted of ten multiple choice questions developed by a content expert. The exam utilized content from CMQCC and items from Perinatal Nursing, 4^th edition with permission (Simpson and Creehan, 2014). The quiz had a content validity score of .94. Nursing students took the knowledge exam at the end of the semester, while the obstetrical nurses the quiz pre, immediately and three months post education. Mean scores on the postpartum hemorrhage knowledge quiz were compared between the traditional and simulation-enhanced groups.  An 18-item instrument, Obstetric Nursing Self-Efficacy (ONSE) Scale, was designed by Guimond and Simonelli (2012), using Bandura’s social-cognitive theory. The ONSE Scale was developed to measure student nurses perceptions of self-efficacy to assess, intervene and communicate changes when they are caring for the obstetric patient. During the pilot study conducted a range of split-half reliability scores was calculated at .85 to .96 from the preliminary reliability testing. The average content validity index of the scale was established as .91 (Guimond & Simonelli, 2012).

Overall, the nurses who participated in the high-fidelity simulation learning session in addition to the traditional lecture examining the care of the postpartum hemorrhage patient had statistically significant higher self-efficacy scores at the immediate post-test  (p = .007) and the three-month post-test periods (p = .002) compared to the control group.  Nurses who have higher self-efficacy are more likely to recognize and respond appropriately to the high-risk patient with the chosen skill or behavior (Guimond & Simonelli, 2012).  In nursing students, there was not a significant difference for self-efficacy between the traditional and simulation cohort (F (1, 28) = 2.92, p=.099).

Additionally, practicing nurses participating in either the traditional lecture or simulation activity did not have significant improvement in their knowledge test scores (p=.503 ), however, the three-month post-test period did reveal statistically significant higher knowledge quiz scores from the experimental group completing the simulation session ( p=.043). This finding implies that practicing nurses who participated in simulation may retain knowledge longer in comparison to traditional lecture. The nursing student simulation-enhanced cohort had a postpartum hemorrhage knowledge score (M=7.13, SD=.89)) greater than the traditional group (6.59, SD 1.28) although not statistically significant (p=.173). The students did show improved knowledge of certain nursing interventions.

Implications for practice include the use of high fidelity simulation in the rural obstetrical practice setting to improve future nurses and registered nurses knowledge and self-efficacy.  By embedding evidence-based practice, quality, safety, and recommended competencies into the nursing curriculum and continuing education for nurses, through simulation, the future graduate may enter the workforce with an increased knowledge, understanding, experience with obstetrical skills, and emergencies. Sharing of experiences and resources, such as the CMQCC, can help provide a pathway to enhancing specialty specific simulation practice.

Using high-fidelity simulation as an educational method also has many implications for nursing science. Nursing theory and practice are often taught separately in today’s educational paradigm, but simulation allows for both to be applied at the bedside in a safe environment. The findings from this study suggest high-fidelity simulation provides a realistic setting that promotes a different approach to transferring knowledge into practice. This approach improved the self-efficacy of nurses already working in the clinical setting and may prove the most beneficial for preparing nurses to respond competently in high-risk, low-incident emergency patient situations.