Lessons learnt from an obstetric and neonatal emergency simulation program in India

https://doi.org/10.1016/j.jnn.2020.07.004Get rights and content

Abstract

Background

Combined obstetric and neonatal emergency simulation based training is gaining popularity in healthcare settings. Methods: In this qualitative study, through semi-structured one to one interviews, we evaluated participant attitudes, perceptions of retention of learning, and application to clinical practice one year after a simulation workshop. Audio recordings of interviews were transcribed, collated and subjected to thematic analysis. Results: Five major themes were identified through the thematic analysis: comparing simulation to clinical practice; learning and working in teams; thinking retention and sustainability; relating relevance of simulation based education to roles; and managing leadership. Conclusions: Participants’ acknowledgement of training being relevant to their routine practice, and keenness to learn management of complicated births highlighted the sustained impact of obstetric and neonatal emergency simulation training.

Introduction

Simulation of obstetric and neonatal emergencies is increasingly being used to train healthcare professionals involved in birth and care of the newborn. Whether these programs are delivered in a birth unit or a simulation space, the eventual goal is to mimic the real settings where such emergencies may occur. The learning environment provided through Simulation Based Education (SBE) needs to support the learning needs of the team. Teams may consist of doctors, midwives, nurses, and students. These interprofessional learning opportunities facilitated through SBE, allow healthcare providers to interact, learn with, from and about each other (Barr, 2000).

Whilst simulation has become the mainstay of education and credentialing healthcare professionals in high-income countries, it is rarely used for routine training in low-middle income countries (LMICs) (Scott et al., 2016). In LMICs like India, simulation programs exist, especially in the context of adult and neonatal resuscitation programs (Kamath-Rayne et al., 2018), these mostly focus on improving the performance of the individual learner rather than team training. Obstetric simulation emergency training has only recently been introduced in LMICs (Evans et al., 2014; Nelissen et al., 2017; Walker et al., 2015, 2016) and one of the few known programs in India is the Obstetric and Neonatal Emergency Simulation (ONE-Sim) program (Kumar et al., 2019). The ONE-Sim learners include obstetric and neonatal healthcare staff (obstetricians, pediatricians, midwives, nurses and other healthcare providers) who attend the combined program on managing birth, newborn care, and any related emergencies.

Literature on interprofessional SBE frequently reports healthcare participants’ satisfaction surveys with perception of improved confidence after a simulation session. It occasionally identifies how gaps in learning were filled by this education. What is less often reported is how that learning is used in clinical practice or how that learning develops and evolves further after a delayed period of many months to years after attending the program. This is a well-acknowledged gap and it has been recommended that studies look to identify long-term gains for individuals, teams and institutions. However, very few studies report on these relatively non-tangible and difficult-to-measure outcomes. This may arise from participants getting lost to follow-up, complexity in creating valid tools to identify retention of skills and knowledge, and difficulties in identifying changes in participant behavior and the impact on day-to-day clinical practice.

In this study, we attempted to study the long-term impact of the ONE-Sim program on healthcare professionals’ attitudes and clinical practice. The main research question was “What did the healthcare staff participating in the ONE-Sim program think about it in relation to their clinical practice a year after workshop attendance?” and “How was the learning achieved through the ONE-Sim program applied (or not) to their work over the year since attendance?”

The ONE-Sim program is a mobile simulation program using simulation equipment that can easily be packed up in a suitcase and can be rolled out to teach obstetric and neonatal team members together as an experiential, hands-on interprofessional learning package (Kumar et al., 2019). The equipment needed for the ONE-Sim program is a childbirth simulator (Prompt-Flex, Limbs and Things, Bristol, UK) and a neonatal resuscitation baby (Laerdal Medical, Stavanger, Norway) simulator, or equivalent devices. The remaining equipment consists of standard ward supplies (depending on the local institution) including intravenous cannulae, infusion sets, fluids, syringes, mock blood, medications, plastic aprons, eye protection, gloves, towels and linen used in a birth setting.

The program was designed using blended simulation (Bodie et al., 2006), where the role of the birthing woman was played by an expert (obstetrician, midwife or trained simulated woman) with experience in teaching and debrief. The instructional design facilitated participant response to a simulated birthing woman, who responded to the verbal prompts and could have her clinical observations taken (pulse rate, blood pressure and temperature, etc.), while all intimate examinations were performed using the simulator (Chiniara et al., 2013; Kneebone et al., 2005). The workshop program consisted of initial pre-reading material and training videos shared with the participants a few days before the hands on simulation session. The participants were taught in small groups to mimic a real team on the birth unit and the newborn nursery. Initially, participants were given an opportunity to get familiar with the team, especially if they did not know each other, and familiar with the environment (simulation area). The second step was to give participants time to familiarize themselves with the simulators and birth equipment.

Participants were presented with a clinical scenario, where the mother's or baby's (or both) condition rapidly deteriorated intrapartum. The participants had to manage this deterioration as a team in a time-efficient manner, using only resources available similar to a real-life clinical setting. They were also presented with a neonatal emergency requiring them to function effectively as a team. Timed prompts, provided in real-time when possible, were based on the participants' responses to the evolving scenario. The simulation ended if the participants had either responded adequately or if the clinical situation deteriorated significantly. At the end of each simulated scenario, participants were debriefed as a team.

This study was conducted 12 months post-attendance of the ONE-Sim program, with an expected change in their new knowledge, attitudes, and behaviors.

The concept of this follow-up study is based on two related learning theories, explaining how new learning occurs over pre-existing knowledge; and how environment and clinical experiences contribute to the development of further learning. Cognitive development in children (from the initial sensorimotor stage of interacting with the environment in the first stage, to the fourth stage of understanding abstract theoretical concepts) was initially explained by Jean Piaget, (1977). This concept was later interpreted in the context of adult learning principles. Concepts evolve based on an interaction between an individual's pre-existing knowledge with clinical experiences (accommodation of prior learning and new experiences) leading to a process of assimilation, where the new clinical experiences add to the pre-existing knowledge. Piaget further explains the concept of equilibration, where there is tension between the knowledge and environmental stress (caused by the either an individual's own or others' behavior or any other environmental factors) that continuously challenges the existing equilibrium, and eventually leads to a newfound equilibrium. This may be particularly applicable in the case of intense clinical pressures in a high-stake environment where the cycles of equilibration may be more frequent. This concept is further explained through Kolb's Experiential Learning Theory (Kolb, 1984), where new knowledge is the product of clinical experiences superimposed over old knowledge. This leads to a process of continuous development where newly developed knowledge becomes old pre-existing knowledge as the cycle continues to evolve under the influence of added real-life experiences.

Section snippets

Study design

Qualitative study using thematic analysis of semi-structured interviews.

Setting

The initial simulation workshops and subsequent semi-structured interviews were conducted at the Hind Institute of Medical Sciences, Barabanki, Uttar Pradesh, India.

Participant recruitment

All doctors, midwives, nurses and healthcare workers who had attended the ONE- Sim program in 2017 (n = 48) were invited to participate in this follow-up study. There were no pre-specified exclusions, although participants who were no longer working in the

Results

A total of seven one to one interviews were conducted including the Nurse Unit Manager (NUM), a midwifery educator, two midwives, two Special Care (SCN) nurses, and a community-based healthcare worker. Clinical experience for participants ranged between 2 and 25 years. A total of five themes were identified from the interviews which were: comparing simulation to clinical practice; learning and working in teams; thinking retention and sustainability; relating relevance of SBE to roles; and

Thinking retention and sustainability

Staff members thought the ideal time for refreshing their knowledge of rare emergency skills was 6–12 months, as skills were thought to deteriorate over time. The “train the trainer” model of the ONE-Sim program was appreciated, not only in teaching, but in self-learning as well. Procedural skills were however, perceived to be retained better than behavioral skills.

Managing leadership

Leadership skills were reported to be enhanced by teaching others. Teaching was seen as a way of deeper learning and reinforcing one's own learning.

Conclusions

The main focus of this study was the value of learning acquired through simulation in obstetric and newborn emergencies, with the added perspective of reflection by participants that occurred over time in their clinical practice. Participants acknowledged that simulation training was relevant to their clinical practice and were keen to learn about the management of complicated births, despite many members not routinely practising on a birth unit. This highlights the engaging nature of SBE

Discussion

This study reports the effects of an interprofessional simulation workshop on healthcare practitioners' learning, one year after attending the ONE-Sim program in a LMIC setting. Over the year post-training, some participants had encountered related emergency situations in their clinical work, while others had considered the possibility of encountering emergency situations. This paper reports on key themes comparing simulation to practitioners’ clinical work. In this context, learning skills and

Declaration of competing interest

There are no disclosures or conflicts of interest to declare.

Acknowledgements

The work was supported by funding from Royal Australasian College of Physicians, Overseas Medical Graduate Association, and philanthropic donations by members of the medical fraternity in Melbourne, Australia.

We would also like to acknowledge the faculty and staff of Hind Institute of Medical Sciences for organizing and participating in these educational initiatives.

References (36)

  • H. Barr
  • G.D. Bodie et al.

    Chunking, priming and active learning: toward an innovative and blended approach to teaching communication- related skills

    Interact. Learn. Environ.

    (2006)
  • S. Bradley et al.

    Midwives' perspectives on (dis)respectful intrapartum care during facility-based delivery in sub-Saharan Africa: a qualitative systematic review and meta-synthesis

    Reprod. Health

    (2019)
  • V. Braun et al.

    Using thematic analysis in psychology

    Qual. Res. Psychol.

    (2006)
  • G. Chiniara et al.

    Simulation in healthcare: a taxonomy and a conceptual framework for instructional design and media selection

    Med. Teach.

    (2013)
  • J.F. Crofts et al.

    Management of shoulder dystocia: skill retention 6 and 12 months after training

    Obstet. Gynecol.

    (2007)
  • J. Dewey

    Democracy and Education (Public Domain, Numerous Editions)

  • S. Gorantla et al.

    Introduction of an undergraduate interprofessional simulation based skills training program in obstetrics and gynaecology in India

    Advances in simulation (London, England)

    (2019)
  • Cited by (4)

    View full text