Self-perceived long-term transfer of learning after postpartum hemorrhage simulation training

Virtual simulation training for postpartum hemorrhage in low-to-moderate-volume hospitals in the US

Background

Maternal mortality in the United States is rising and many deaths are preventable. Emergencies, such as postpartum hemorrhage, occur less frequently in non-teaching, rural, and urban low-birth volume hospitals. There is an urgent need for accessible, evidence-based, and sustainable inter-professional education that creates the opportunity for clinical teams to practice their response to rare, but potentially devastating events.

Objective

To assess the feasibility of virtual simulation training for the management of postpartum hemorrhage in low-to-moderate-volume delivery hospitals.

Study design

The study occurred between December 2021 and March 2022 within 8 non-academic hospitals in the United States with low-to-moderate-delivery volumes, randomized to one of two models: direct simulation training and train-the-trainer. In the direct simulation training model, simulation faculty conducted a virtual simulation training program with participants. In the train-the-trainer model, simulation faculty conducted virtual lessons with new simulation instructors on how to prepare and conduct a simulation course. Following this training, the instructors led their own simulation training program at their respective hospitals. The direct simulation training participants and students trained by new instructors from the train-the-trainer program were evaluated with a multiple-choice questionnaire on postpartum hemorrhage knowledge and a confidence and attitude survey at 3 timepoints: prior to, immediately after, and at 3 months post-training. Paired t-tests were performed to assess for changes in knowledge and confidence within teaching models across time points. ANOVA was performed to test cross-sectionally for differences in knowledge and confidence between teaching models at each time point.

Results

Direct simulation training participants (n=22) and students of the train-the-trainer instructors (n=18) included nurses, certified nurse midwives and attending physicians in obstetrics, family practice or anesthesiology. Mean pre-course knowledge and confidence scores were not statistically different between direct simulation participants and the students of the instructors from the train-the-trainer course (79%+/-13 versus 75%+/-14, respectively, P-value=.45). Within the direct simulation group, knowledge and confidence scores significantly improved from pre- to immediately post-training (knowledge score mean difference 9.81 [95% CI 3.23-16.40], P-value<.01; confidence score mean difference 13.64 [95% CI 6.79-20.48], P-value<.01), which were maintained 3-months post-training. Within the train-the-trainer group, knowledge and confidence scores immediate post-intervention were not significantly different compared with pre-course or 3-month post-course scores. Mean knowledge scores were significantly greater for the direct simulation group compared to the train-the-trainer group immediately post-training (89%+/-7 versus 74%+/-8, P-value<.01) and at 3-months (88%+/-7 versus 76%+/-12, P-value<.01). Comparisons between groups showed no difference in confidence and attitude scores at these timepoints. Both direct simulation participants and train-the-trainer instructors preferred virtual education, or a hybrid structure, over in-person education.

Conclusion

Virtual education for obstetric simulation training is feasible, acceptable, and effective. Utilizing a direct simulation model for postpartum hemorrhage management resulted in enhanced knowledge acquisition and retention compared to a train-the-trainer model.

Perceptions and experiences of the prevention, detection, and management of postpartum haemorrhage: a qualitative evidence synthesis

BACKGROUND

Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent complications of PPH with timely and appropriate detection and management. However, implementing the best methods of PPH prevention, detection and management can be challenging, particularly in low- and middle-income countries.

OBJECTIVES

Our overall objective was to explore the perceptions and experiences of women, community members, lay health workers, and skilled healthcare providers who have experience with PPH or with preventing, detecting, and managing PPH, in community or health facility settings.

SEARCH METHODS

We searched MEDLINE, CINAHL, Scopus, and grey literature on 13 November 2022 with no language restrictions. We then performed reference checking and forward citation searching of the included studies.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored perceptions and experiences of PPH prevention, detection, and management among women, community members, traditional birth attendants, healthcare providers, and managers.

DATA COLLECTION AND ANALYSIS

We used three-stage maximum variation sampling to ensure diversity in terms of relevance of the study to the review objectives, richness of data, and coverage of critical contextual elements: setting (region, country income level), perspective (type of participant), and topic (prevention, detection, management). We extracted data using a data extraction form designed for this review. We used thematic synthesis to analyse and synthesise the evidence, and we used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. To identify factors that may influence intervention implementation, we mapped each review finding to the Theoretical Domains Framework (TDF) and the Capability, Motivation, and Opportunity model of Behaviour change (COM-B). We used the Behaviour Change Wheel to explore implications for practice.

MAIN RESULTS

We included 67 studies and sampled 43 studies for our analysis. Most were from low- or middle-income countries (33 studies), and most included the perspectives of women and health workers. We downgraded our confidence in several findings from high confidence to moderate, low, or very-low confidence, mainly due to concerns about how the studies were conducted (methodological limitations) or concerns about missing important perspectives from some types of participants or in some settings (relevance). In many communities, bleeding during and after childbirth is considered "normal" and necessary to expel "impurities" and restore and cleanse the woman's body after pregnancy and birth (moderate confidence). In some communities, people have misconceptions about causes of PPH or believe that PPH is caused by supernatural powers or evil spirits that punish women for ignoring or disobeying social rules or for past mistakes (high confidence). For women who give birth at home or in the community, female family members or traditional birth attendants are the first to recognise excess bleeding after birth (high confidence). Family members typically take the decision of whether and when to seek care if PPH is suspected, and these family members are often influenced by trusted traditional birth attendants or community midwives (high confidence). If PPH is identified for women birthing at home or in the community, decision-making about the subsequent referral and care pathway can be multifaceted and complex (high confidence). First responders to PPH are not always skilled or trained healthcare providers (high confidence). In health facilities, midwives may consider it easy to implement visual estimation of blood loss with a kidney dish or under-pad, but difficult to accurately interpret the amount of blood loss (very low confidence). Quantifying (rather than estimating) blood loss may be a complex and contentious change of practice for health workers (low confidence). Women who gave birth in health facilities and experienced PPH described it as painful, embarrassing, and traumatic. Partners or other family members also found the experience stressful. While some women were dissatisfied with their level of involvement in decision-making for PPH management, others felt health workers were best placed to make decisions (moderate confidence). Inconsistent availability of resources (drugs, medical supplies, blood) causes delays in the timely management of PPH (high confidence). There is limited availability of misoprostol in the community owing to stockouts, poor supply systems, and the difficulty of navigating misoprostol procurement for community health workers (moderate confidence). Health workers described working on the maternity ward as stressful and intense due to short staffing, long shifts, and the unpredictability of emergencies. Exhausted and overwhelmed staff may be unable to appropriately monitor all women, particularly when multiple women are giving birth simultaneously or on the floor of the health facility; this could lead to delays in detecting PPH (moderate confidence). Inadequate staffing, high turnover of skilled health workers, and appointment of lower-level cadres of health workers are key challenges to the provision of quality PPH care (high confidence). Through team-based simulation training, health workers of different cadres (doctors, midwives, lay health workers) can develop a shared mental model to help them work quickly, efficiently, and amicably as a team when managing women with PPH (moderate confidence).

AUTHORS' CONCLUSIONS

Our findings highlight how improving PPH prevention, detection, and management is underpinned by a complex system of interacting roles and behaviours (community, women, health workers of different types and with different experiences). Multiple individual, sociocultural, and environmental factors influence the decisions and behaviours of women, families, communities, health workers, and managers. It is crucial to consider the broader health and social systems when designing and implementing PPH interventions to change or influence these behaviours. We have developed a set of prompts that may help programme managers, policymakers, researchers, and other key stakeholders to identify and address factors that affect implementation and scale-up of interventions to improve PPH prevention, detection, and management.

The limited use of instructional design guidelines in healthcare simulation scenarios: an expert appraisal

Background

Systematic reviews on simulation training effectiveness have pointed to the need to adhere to evidence-based instructional design (ID) guidelines. ID guidelines derive from sound cognitive theories and aim to optimize complex learning (integration of knowledge, skills, and attitudes) and learning transfer (application of acquired knowledge and skills in the workplace). The purpose of this study was to explore adherence to ID guidelines in simulation training programs for dealing with postpartum hemorrhage (PPH), a high-risk situation and the leading cause of maternal mortality worldwide.

Methods

A total of 40 raters analyzed simulation training programs as described in 32 articles. The articles were divided into four subsets of seven articles and one subset of four articles. Each subset was judged by seven to ten raters on adherence to ID guidelines. The 5-point Likert score rating scale was based on Merrill’s First Principles of Instruction and included items relating to key ID features categorized into five subscales: authenticity, activation of prior knowledge, demonstration, application, and integration/transfer. The authors searched for articles published in English between January 2007 and March 2017 in PubMed, Eric, and Google Scholar and calculated the mean Likert-scale score, per subscale, and interrater reliability (IRR).

Results

The mean Likert-scale scores calculated for all subscales were < 3.00. For the number of raters used to judge the papers in this study (varying between 7 and 10), the IRR was found to be excellent for the authenticity and integration/transfer subscales, good-to-excellent for the activation of prior knowledge and application subscales, and fair-to-good for the demonstration subscale.

Conclusion

The results demonstrate a paucity of the description of adherence to evidence-based ID guidelines in current simulation trainings for a high-risk situation such as PPH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41077-022-00228-x.

Transfer of learning from simulated setting to the clinical setting: identifying instructional design features

Background: Transfer of learning (ToL) is the endpoint of simulation-based training (SBT). It is affected by numerous factors, which can be classified into 3 categories: learner characteristics, work environment, and training design. The first 2 have been identified to some extent in previous research. In this study, the aim was to identify the instructional design (ID) features affecting the ToL in SBT. Methods: This qualitative study was conducted in 2 phases. Phase 1 covers thematic analysis of comparative studies in the field of SBT. A systematic search was performed on 6 databases of Ovid MEDLINE, EMBASE, PsycINFO, CENTRAL, Scopus, and Web of Science, and the references of related systematic reviews were also checked. In phase 2, semi-structured interviews were conducted with key informants (instructors and learners) and analyzed using directed content analysis. The results of the 2 phases were combined, and finally ID features of SBT were identified and categorized. Results: In the first phase, 121 comparative studies were reviewed and in the second phase, 17 key informants were interviewed. After combining the results of the phases, the ID features affecting the ToL in SBT were classified into 3 broad categories and 15 subcategories as follows: (1) presimulation: preparation, briefing, and teaching cognitive base; (2) underlying theories: deliberate practice, mastery learning, and proficiency-based training; (3) and methods and techniques: distributed practice, variability, increasing complexity, opportunity for practice, repetitive practice, active learning, feedback/debriefing, simulator type, and simulator fidelity. Conclusion: Although learning is transferred from the simulated setting to the clinical setting, this process is not automatic and straightforward. Numerous factors affect this transfer. The results of this research can be used in designing and evaluating the SBT programs.

Changing the landscape of obstetric resident education in low- and middle-income countries using simulation-based training

OBJECTIVE

To evaluate simulation-based training (SBT) in low- and-middle-income countries (LMIC) and the long-term retention of knowledge and self-efficacy.

METHODS

We conducted an SBT course on the management of postpartum hemorrhage (PPH), shoulder dystocia (SD), and maternal cardiac arrest (MCA) in three government teaching hospitals in Guatemala. We evaluated changes in knowledge and self-efficacy using a multiple-choice questionnaire for 46 obstetrics/gynecology residents. A paired Student's t test was used to analyze changes at 1 week and 6 months after the SBT.

RESULTS

There was an increase in scores in clinical knowledge of MCA (p < 0. 001, 95% confidence interval [CI] 0.81-1.49) and SD (p < 0.001, 95% CI 0.41-1.02) 1 week after SBT, and a statistically insignificant increase in PPH scores (p = 0.617, 95% CI -0.96 to 0.60). This increase in scores was maintained after 6 months for MCA (p < 0.001, 95% CI 0.69-1.53), SD (p = 0.02 95% CI 0.07-0.85), and PPH (p = 0.04, 95% CI 0.01-1.26). For MCA and SD, the levels of self-efficacy were increased 1 week following training (p < 0.001, 95% CI 0.83-2.30 and p = 0.008, 95% CI 0.60-3.92, respectively), and at 6 months (p < 0.001, 95% CI 0.79-2.42 and p = 0.006, 95% CI 0.66-3.81, respectively). There was a slight increase in PPH self-efficacy scores 1 week after SBT (p = 0.73, 95% CI -6.05 to 4.41), maintained after 6 months (p = 0.38, 95% CI -6.85 to 2.85).

CONCLUSION

SBT was found to be an effective and feasible method to increase short- and long-term clinical knowledge and self-efficacy of obstetric emergencies in LMIC.

Planning, construction and use of handmade simulators to enhance the teaching and learning in Obstetrics*

to describe the development process and present the results of a pilot study on the use of low-cost handmade simulators for teaching and learning Obstetrics.

Effects of an in situ instructional design based postpartum hemorrhage simulation training on patient outcomes: an uncontrolled before-and-after study

Objective: To compare postpartum hemorrhage (PPH) patient outcomes before and after an in situ instructional design based PPH simulation attended by obstetrics and gynecology (OBGYN) residents.Methods: This uncontrolled before-and-after study was conducted in Recife, Brazil including all 1388 women delivering from June to August 2012 and all 1357 delivering from June to August 2013. The 36 OBGYN residents were divided into13 teams of two or three participants and were trained through ID based PPH simulation training with the following eight steps: (1) prior knowledge activation, (2) video demonstration, (3) dual-coding PPH protocol discussion-an image association during the training, (4) training scenario # 1, (5) debriefing, (6) training scenario # 2 with immediate feedback, (7) training scenario # 3, and (8) debriefing with self-assessment. The training scenarios had an increasing level of complexity. The main goal of the training was the adequate management of PPH and situational awareness improvement-the ability to anticipate, recognize, and intercept unfolding error chains. The primary patient outcomes rates used for the before and after comparison were therapeutic uterotonics use within 24 h of birth and blood transfusion. Secondary outcomes were therapeutic oxytocin mean dosage IU within 24 h of birth, postpartum Hb < 6 g/dL, among others. Chi-square test was used for categorical variables comparison and independent t-test for continuous variables.Results: PPH rates were 100 (7.2% of 2012 deliveries) and 80 cases (5.9% of 2013 deliveries), respectively. Comparison of primary post- and pre-simulation outcomes revealed no significant differences. However, in the comparison for therapeutic oxytocin mean dosage IU within 24 h of birth, there was an increase found after the simulation (15.98 ± 7.4 versus 25.1 ± 12.3; p < .001). For all other outcome measures, there were no statistical differences.Conclusions: In situ ID based PPH simulation leads to an increase in the mean dosage of oxytocin after training, in selected cases. This may indicate better situational awareness when managing women with PPH.

Obstetric emergency simulation training course: experience of a private-public partnership in Brazil

Background

Lack of skills on how to diagnose and manage obstetric emergencies contribute to substandard institutional care and preventable maternal deaths in Brazil. Simulation-based obstetric emergency team training can reduce adverse maternal outcomes. However, this type of training is expensive and not widely available, especially in low resource settings. We present the experience of a private-public partnership that offered a two-day obstetric emergency simulation-training course to hundreds of Brazilian professionals working in the public sector. We also present participants´ short-term learning outcomes (Kirkpatrick’s level 2) and satisfaction (Kirkpatrick’s level 1).

Methods

This was a non-experimental before-and-after study. The free 16-h course was held over a 14 months period in a large private hospital’s simulation center using multidisciplinary scenario and model-based training. The training sessions consisted of four (4-h) modules on pre-eclampsia/eclampsia, hemorrhage, sepsis and resuscitation. An anonymous questionnaire collected participants´ satisfaction at the end of each module. Learning outcomes were assessed by comparing differences in participants´ pre- versus immediate post-course test scores. Wilcoxon, Kruskal-Wallis and Friedman tests were used for statistical analyses. P < 0.05 was considered significant.

Results

340 professionals (117 doctors, 179 registered nurses-RN and 44 licensed practical nurses-LPN) working in 33 public Brazilian hospitals were trained. There was a significant increase in post-course test scores in all four modules. On average, scores increased 55% in the hypertension and 65–69% in the hemorrhage, sepsis and resuscitation modules (p = 0.019). Knowledge acquisition of RN and LPN was similar in the hypertension, hemorrhage and sepsis modules and significantly higher than doctors´ (p < 0.05). On a 0 to 10 scale, mean overall satisfaction ranged from 9.6 (for the hypertension module) to 9.8 (for the resuscitation module).

Conclusions

This successful experience of a private-public partnership to offer obstetric emergency simulation training required strategic organization and a strong commitment from both sides. This promising private-public partnership model could be replicated in similar settings. The training course obtained high satisfaction scores and significantly improved the knowledge of public-sector health professionals on how to manage the main causes of maternal mortality.

A pilot study on the simulation-based training for Ethiopia skilled birth attendants

This simulation-based Ethiopia Midwife Train-the-Trainer program for skilled birth attendants is one part of the China-UK Global Health Support Program (GHSP) activities and an approach to improving the Ethiopia trainers' midwifery teaching skills. This pilot study aimed to evaluate the effectiveness of a simulation-based training for Ethiopia skilled birth attendants. This program was divided into three stages. In Stage 1, Fudan team trained 5 trainers from Ethiopia. In Stage 2, Fudan team supervised and evaluated the 1st stage Ethiopia trainers to train their peers becoming the trainers in Fudan University. In Stage 3, Fudan team evaluated the training program implementation in established Advanced Midwifery Practice Center in Tirunesh Beijing General Hospital. The participatory observational method was used for process evaluation and the Kirkpatrick model was used for effectiveness evaluation. The Ethiopia staff's teaching skills for simulation-based midwifery training were strengthened and their abilities to deal with various complicated obstetric situations were improved by group explanation, questions, rehearsal, and step-by-step interactive teaching (p < .01). The mean score of total mastery degree was 3.48 ± 0.16 by self-assessment and 3.63 ± 0.16 by peer-assessment in stage 2, and 3.27 ± 0.24 by self-assessment and 3.38 ± 0.34 by peer-assessment in stage 3.The GHSP-OP4-V01 Ethiopia Midwife Train-the-Trainer Program has received positive response in Ethiopia by in-depth interview and questionnaire survey. This study demonstrated that the simulation-based training is an effective approach for midwifery Train-the-Trainer program in Ethiopia.