A Cost-Effective Approach to Simulation-Based Team Training in Obstetrics

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2 A Cost-Effective Approach to Simulation-Based Team Training in Obstetrics Melanie Chichester - Nicole J. Hall Terri L. Wyatt - Rosemarie Pomilla Andrighetti, Knestrick, Marowitz, Martin, and Engstrom (2012) tout the benefits of simulation, explaining that participants are able to experience the management of a complication that they may never encounter during their student clinical experiences (p. 55). Recently, students attending a hospital-based diploma nursing program in our area were given the opportunity to participate in a postpartum hemorrhage simulation. Implementation was a collaborative effort between the school s nurse educators and an experienced obstetric nurse who practices in a high-volume, high-acuity institution. Students evaluations of the program were positive, with favorable comments conveying excitement that this kind of learning would now be integrated into their curriculum. When word traveled, as it so easily does in a small facility, to the labor and delivery (L&D) unit of the affiliated hospital, both the staff nurses and nurse manager expressed their interest in a similar learning scenario. The nurses desire for an emergency drill prompted the development of a simulation to allow for a realistic and pertinent learning experience. Abstract: Many larger facilities regularly stage obstetric drills in modern simulation departments equipped with expensive simulators. Despite lacking these resources, we wanted to provide effective simulation training at our rural hospital. A team of clinicians and educators developed a cost-effective and time-efficient simulation drill for nurses, which included both a didactic review and a simulation day. The drill included obstetric providers and incorporated scenarios for shoulder dystocia, neonatal resuscitation and postpartum hemorrhage. This was a successful multidisciplinary learning experience that was high in creativity and teamwork, but low in cost. DOI: / X Keywords: low-fidelity simulation obstetric simulation shared learning team training

3 Benefits of Simulation-Based Learning Galloway (2009) affirms that health care professionals who participate in simulation are able to hone clinical skills needed to provide excellent nursing care with the assurance that no harm will be done. According to Huwe and Jensen (2011), it s estimated that 30 percent to 50 percent of maternal deaths that occur during an acute event may be preventable. Oyelese and Ananth (2010) found that postpartum hemorrhage occurred more frequently in rural settings, highlighting the need to challenge knowledge and practice skills that require both critical thinking and rapid intervention by medical professionals. Furthermore, the Joint Commission recommends that perinatal departments conduct team training, clinical drills, and debriefings as a maternal and neonatal death prevention strategy (Huwe & Jensen, 2011, p. S56). Planning While simulation has become more common as a method to train teams and prepare for emergencies, not all facilities have the funding for sophisticated simulators and labs. For smaller facilities, it s still possible to carry out simulation training by using low-tech means with less expense (Ruth-Sahd, Schneider, & Strouse, 2011). The staff nurses at our level-one hospital, with approximately 900 annual deliveries, had never been provided an opportunity to learn safely with the goal of improving health outcomes. A brainstorming session led to an ambitious plan for a department simulation drill, involving coordinated obstetric emergencies for nursing staff and health care providers. A multidisciplinary team approach was quickly realized, including educators, management, nurses and obstetric providers, all with varying roles in planning or participating in the drill. With all the positive support and enthusiasm of the planning committee, it was easy to engage other members of the health care team. Plans were made to hold both a didactic review and a simulation day similar to what the students had experienced. The didactic portion, led by the L&D nurse, was an interactive, evidence-based lecture with case presentations integrated throughout. With the knowledge that a prescenario learner activity is a critical component of scenario development, the Melanie Chichester, BSN, RNC-OB, CPLC, is a staff nurse, level III, in Labor & Delivery at Christiana Care Health System in Newark, DE. Nicole J. Hall, MSN, MBA, RN, CNE, is a nursing instructor at Margaret H. Rollins School of Nursing, Beebe Healthcare in Lewes, DE. Terri L. Wyatt, MSN, RNC-LRN, GC-C, CPLC, CNE, is a nursing instructor at Margaret H. Rollins School of Nursing, Beebe Healthcare in Lewes, DE. Rosemarie Pomilla, BA, BSN, CRNP, is a neonatal nurse practitioner at the Women s Health Pavilion at Beebe Healthcare in Lewes, DE. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: Mchichester@Christianacare.org. health care professionals who participate in simulation are able to hone clinical skills needed to provide excellent nursing care with the assurance that no harm will be done lecture portion was offered during a monthly staff meeting to facilitate staff attendance (Waxman, 2010). The nurse manager chose to make the simulation drills mandatory/paid time, and a sign-up sheet was posted with slots for four to five nurses per 45-minute time slot. To increase interprofessional collaboration, the nurse manager invited obstetric providers to participate in the drill. Clark Fisher, Arafeh, and Druzin (2010) identified that when training includes multidisciplinary teams, it is more representative of clinical care and has more potential to improve team performance and competency (p. 269). As the scenario evolved, the unit s neonatal nurse practitioner offered to include a neonatal resuscitation drill. To maximize the time available, we decided to incorporate all three scenarios stacked into one simulation, beginning with shoulder dystocia, leading to a neonatal resuscitation and concluding with postpartum hemorrhage. This design allowed for the combination of multiple learning scenarios that more closely resembled realistic circumstances. These particular scenarios were chosen as the most common obstetric emergencies warranting regular drills to prepare obstetric nurses and providers (Alderman, 2012). The literature indicates simulation training for these emergencies is associated with improved health outcomes after training (Merien, van de Ven, Mol, Houterman, & Oei, 2010). And so what began as a simple postpartum hemorrhage drill designed for diploma nursing students became a stacked simulation exercise for L&D nursing staff at a rural hospital. Implementation Once we generated our proposal, it was time to focus on how to make it happen. Bastable (2014) explains that to create an optimal learning opportunity, a scenario should challenge a learner s All opening photos istock collection / thinkstockphotos.com 502 Nursing for Women s Health Volume 18 Issue 6

4 Photo ocean digital / thinkstockphotos.com decision-making skills, contain realistic levels of tension, include time restraints and be conducted in an environment that mirrors real life. We used this knowledge to guide us in adjusting the simulation to be effective for the experienced leaner. A short postpartum hemorrhage scenario would now be three scenarios in one. Waxman (2010) relates the importance of immersion in a case scenario that resembles reality to enhance learning. The L&D nurse drew on her years of experience to build the scenario for the school of nursing with actual case details. The planning team verified interventions with literature, and worked to modify the drill for nursing staff with input from one of the obstetricians. Questions quickly arose: How would the scene play out? (see Box 1). Who would play the woman? What additional supplies would we need? Where would the drill take place? What would be the objectives for each component, and who would debrief each group? Who would clean up and reset the stage between groups? The educator from the school of nursing who had voiced the woman for the student drills would again assume this role. She would be strategically positioned behind a curtain at the head of the bed where her questions, comments and, at times, hysterics could afford a higher level of realism to the low-fidelity simulator. The neonatal nurse practitioner would provide equipment necessary for the resuscitation simulation, including an infant warmer and resuscitation baby. The warmer would be left off with resuscitation equipment in disarray by design. The nurse manager took responsibility for ensuring there would be a foot stool in the room, as well as a designated area for obtaining medications and supplies during the drill. The planners agreed to share the task of mixing enough simulated blood for the hemorrhage scene, where an enema bag would be filled with varying amounts for each group. The enema bag tubing would be placed beneath the simulator to hemorrhage on command when the flow clamp was released. Much thought was given to finding a location that would optimize realism and influence the learners ability to suspend disbelief. Given the unpredictability of the L&D s unit census, we planned to hold the simulation in a triage room that s equipped to serve as an overflow labor room. The standard monitors and equipment it routinely houses made it a realistic alternative setting. An adult female simulator, Mrs. Chase, a curriculum staple for decades, would be brought from the school of nursing along with miscellaneous supplies. The team developed objectives targeted at staff nurses learning needs that could be met either during the scenario or the debriefing session. The expert nurse would serve as facilitator by providing guidance during the simulation via narration and leading the debriefing session. Facilitators play a critical role, as they must have complete understanding of the scenario and be observant for learner responses or lack thereof (Waxman, 2010). December 2014 January 2015 Nursing for Women s Health 503

5 Across the hall was another triage room, which was used as a quiet space to conduct debriefing sessions, while the educators cleaned and prepared the simulation setting for the next group of participants. To reinforce material from the didactic, a 25-question quiz was available to be done individually or as a group, with the final exam being a table with three pads full of simulated blood (made with a mixture of Jell-O and Kool-Aid). The challenge would be given to see who could most accurately estimate the volume in each pad, with a prize awarded for the closest estimate. Rajan and Wing (2010) states that inaccuracies in determining blood loss have been confirmed by several authors and that using standard measures can improve accuracy (p. 165). The planned exercise was thus geared toward improving skill and confidence in correctly estimating blood loss. Simulations in Action With everything in place, we were ready to start. The didactic session, presented during a staff meeting, was well-attended. Two days later, our team was in place at 6:30 a.m., ready to begin the stacked simulations. Each group was given a brief explanation of how the students had enjoyed a simulation drill, the request for the nurses to also have a turn and the experimental nature of doing not one but three scenarios back-to-back with emphasis on a safe learning environment for all. The simulations ran fairly smoothly, with the exception of one drill when the simulated blood clotted in the tubing and wouldn t hemorrhage on command. Most groups completed the drills and debriefing in less than the 45-minute allotted time. Although the simulations were initially planned with a single physician serving in the health care provider role for the entire morning, this physician found the learning drill so beneficial that he encouraged other providers to participate. All the participants completed the drill by noon, including the staff nurses, nurse manager, lactation consultant and unit educator. Feedback was obtained and learning assessed through a posttest, written evaluations and a debriefing session. box 1 Summary of Simulation Scenario After uneventful labor, multigravida ready to deliver. L&D nurse calls obstetric provider. Provider recognizes and communicates shoulder dystocia. L&D staff respond appropriately to assist delivery (scenario 1). Provider calls for McRoberts maneuver, then fundal pressure. Nurses are expected to bring a stool and offer suprapubic pressure. Neonatal nurse practitioner called to stand by. Newborn is born limp, pale, not breathing (scenario 2). Neonatal nurse practitioner and neonatal nurses work to resuscitate newborn according to Neonatal Resuscitation Program guidelines. L&D staff continue to provide postpartum care. Woman is stable at this time. Obstetric provider leaves. Newborn scenario unfolds according to implementation of resuscitation efforts. Newborn is successfully resuscitated. After newborn is stable, mother experiences uterine atony and bleeds profusely. L&D staff call for obstetric provider, initiate postpartum hemorrhage protocols (scenario 3). Woman reports not feeling well/dizziness; expectation is nurse will check bleeding/fundus. Copious amount of bleeding noted; expectation is the nurse will call for charge nurse/more help. Provider examines woman, asks for carboprost (Hemabate). Woman states allergic to Hemabate; expectation is nurse will ask what reaction was. Woman will state she had diarrhea, provider requests carboprost to be given as ordered. Nurse to explain allergy versus side effects, also inquire if woman had postpartum hemorrhage with previous birth. Charge/assisting nurse expected to ask/offer complete blood count, type, possibly second intravenous access. As bleeding slows, nurse expected to reassess vital signs, fundus, bleeding. Nurse also expected to consider full bladder, offer to put infant to breast and offer pain medication. 504 Nursing for Women s Health Volume 18 Issue 6

6 to create an optimal learning opportunity, a scenario should challenge a learner's decision-making skills, contain realistic levels of tension, include time restraints and be conducted in an environment that mirrors real life Photo monkey business images / thinkstockphotos.com Evaluations The educational activities were deemed a success, with evaluations and feedback indicating an overwhelmingly positive response for both the didactic review and simulation. The instructors were pleased that the staff actively participated and were engaged throughout the drill. During the debriefing sessions, nurse participants recognized their peers for prompt reactions and interventions and attending to the scenario woman s need for comfort and education. Many nurses selfidentified areas of strength and areas for growth. Debriefing always had two standard questions: What do you think went well? And what do you think could have been done better? Further discussion and learning were spurred by asking additional review questions, such as what risk factors/indicators were noted for a shoulder dystocia or postpartum hemorrhage? An identified strength for the entire nursing staff was that in each group when the provider ordered fundal pressure, the nurse refused but was willing to administer suprapubic pressure instead. Another positive moment occurred when the woman claimed to be allergic to the uterotonic requested by the obstetric provider. In each scenario without fail, a team member asked what her previous reaction was, even recognizing that a previous history of postpartum hemorrhage had not been disclosed in the admission data. Debriefing also allowed the opportunity to discuss failure of all, but one group to question and assess for bladder distension during the postpartum hemorrhage scenario. Interestingly, this was also a piece of information most frequently missed by the nursing students when the drill was done in the school of nursing. And while upon review nursing staff knew that a foot stool would have been useful to administer suprapubic pressure, December 2014 January 2015 Nursing for Women s Health 505

7 With creative, thoughtful planning, we were able to provide team training for an entire department at minimal expense not all looked for one, utilizing the bed or relying on their height instead. The neonatal resuscitation segment of the stacked drill went fairly well with the majority of nurses correctly verbalizing and independently performing the correct steps in neonatal resuscitation. Most groups designated a specific individual to be the nursery nurse who prompted them to anticipate needs, such as checking equipment and readying the warmer for imminent delivery. In some cases, the neonatal nurse practitioner needed to provide this guidance with a few simple prompting questions. Each group identified the importance of clear communication among team members and utilization of ancillary staff to assist with resuscitation. All nurse participants commented on their evaluations that they found the stacked simulation exercise useful and some expressed the desire to do the drills more often; one individual requested more information on shoulder dystocia maneuvers. The physicians and midwives expressed positive appraisals as well. Implications for Nursing Practice With creative, thoughtful planning, we were able to provide team training for an entire department at minimal expense. A simulator doesn t have to be an expensive electronic model; our scenario worked well with a much older prototype and an actor as voice. Blood was created using inexpensive grocery store items with an enema bag serving as the reservoir. What was truly critical to our success was the teamwork and creativity of the planning team, the commitment of the nurse manager to educate her staff and the willingness of both nurses and providers to work together with a goal of optimizing health outcomes. This activity demonstrates that with a supportive environment, an effective team can rely on resources beyond financial ones to influence educational success. For others considering replicating a similar event, it s important to understand that the key component to success is meticulous planning. Preparing a detailed script with predetermined patient status changes will enable the facilitators to effectively execute the drill. Another critical component is to run through the entire simulation before the planned day to enable the planners to identify any number of unexpected findings. Determining the appropriate amount of time is also a priority so that learners don t feel rushed. We suggest scheduling extra time, even if it doesn t initially appear to be necessary. Follow- Up Our feedback on the learning activity was positive, but for it to be considered truly successful, outcome data should also include staff nurses feedback following a real-life emergency and how the simulation experience influenced team performance during an actual event. We gathered data 1 year later to do just Photo Oksana Kostyushko, illustration from istock collection / thinkstockphotos.com 506 Nursing for Women s Health Volume 18 Issue 6

8 that. The survey asked nurses if they had encountered any of the three emergencies in practice, and if the team simulation had improved their ability to act. While only 25 percent of the nurses subsequently had an emergency situation in the year following the team drill, of those who had, 100 percent reported feeling better prepared for it as a result of the simulation. All requested more team drills, with several specifically asking for additional neonatal resuscitation practice. The goal now is to consider integrating this as an annual, or more frequent, educational opportunity. We, as the planning team, are very satisfied with how it came together and believe that staff at any small facility, whether rural, free-standing or affiliated with a nursing school or not, can benefit from this experience. Conclusion Parents, school teachers and coaches are known for stressing that practice makes perfect. This old adage is now being translated into the health care arena in the form of drills and simulations to improve clinical skills, content knowledge, inter-professional communication, teamwork, physical assessment, nursing therapeutics and critical thinking (Lapkin & Levett-Jones, 2011, p. 3544). Cant and Cooper (2011) found that adults learn best with active engagement, problem-centered learning and when they can apply new knowledge to their lives. Simulation training is the ultimate embodiment of this type of learning and lends itself perfectly to adult professional students. Within the obstetric field, where most maternal deaths occur during an acute crisis, simulations are of particular benefit by providing an optimal environment for practicing emergency scenarios without the risk of compromising safety (Huwe & Jensen, 2011). Unfortunately, the knowledge that there s benefit from this type of learning doesn t mean that a new process is easy to implement. While large health care institutions acquire simulators and develop settings for simulation learning at a remarkable pace, this sort of investment may not be a realistic option for smaller facilities or in countries with fewer resources (Lapkin & Levett- Jones, 2011). In our instance, we were able to overcome over this shortcoming and initiate a new learning experience, foster multidisciplinary collaboration and realize a successful, costeffective obstetric simulation. We hope our experience inspires others to do the same. NWH Acknowledgments The authors thank Denice Powell, RNC-LRN, nurse manager of the Women s Health Pavilion at Beebe Healthcare, for her assistance and support organizing the simulations described in this article, and Paula Dominique, BSN, RN, CCRN, Karen Antell, MD, MPH, and Adeyinka Reid, BA, BSN, RNC-OB, for their editorial suggestions on this manuscript. This article is based on a presentation made by the authors at the 2013 Sigma Theta Tau International Biennium in Indianapolis, IN. References Alderman, J. T. (2012). Using simulation to teach nursing students and licensed clinicians obstetric emergencies. MCN, American Journal of Maternal Child Nursing, 37(6), doi: / NMC.0b013e318264bbe7 Andrighetti, T., Knestrick, J., Marowitz, A., Martin, C., & Engstrom, J. (2012). Shoulder dystocia and postpartum hemorrhage simulations: Student confidence in managing these complications. Journal of Midwifery & Women s Health, 57(1), doi: /j x Bastable, S. B. (2014). Nurse as educator: Principles of teaching and learning for nursing practice (4th ed.). Burlington, MA: Jones and Bartlett. Cant, R., & Cooper, S. (2011). The benefits of debriefing as formative feedback in nurse education. Australian Journal of Advanced Nursing, 29(1), Clark, E., Fisher, J., Arafeh, J., & Druzin, M. (2010). Team training/ simulation. Clinical Obstetrics and Gynecology, 53(1), Galloway, S. (2009). Simulation techniques to bridge the gap between novice and competent healthcare professionals. Online Journal of Issues in Nursing, 14(2), Manuscript 3. doi: / OJIN.Vol14No02Man03 Galloway, S. (2009). Simulation techniques to bridge the gap between novice and competent healthcare professionals. Online Journal of Issues in Nursing, 14(2), Manuscript 3. doi: / OJIN.Vol14No02Man03 Huwe. V., & Jensen, C. (2011). A new direction in simulation education: Regionalizing low fidelity obstetric emergency simulation classes so all hospitals can participate. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 40(Suppl. 1), S56 S57. doi: /j _78.x Lapkin, S., & Levett-Jones, T. (2011). A cost-utility analysis of medium vs. high-fidelity human patient simulation manikins in nursing education. Journal of Clinical Nursing, 20, doi: /j x Merien, A. E., van de Ven, J., Mol, B. W., Houterman, S., & Oei, S. G. (2010). Multidisciplinary team training in a simulation setting for acute obstetric emergencies: A systematic review. Obstetrics & Gynecology, 115(5), Oyelese, Y., & Ananth, C. (2010). Postpartum hemorrhage: Epidemiology, risk factors, and causes. Clinical Obstetrics and Gynecology, 53(1), Rajan, P., & Wing, D. (2010). Postpartum hemorrhage: Evidencebased medical interventions for prevention and treatment. Clinical Obstetrics and Gynecology, 53(1), Ruth-Sahd, L., Schneider, M. A., & Strouse, A. (2011). Fostering cultural and interdisciplinary awareness with low-tech simulation in a fundamentals nursing course to prepare student nurses for critical care clinical rotations. Dimensions of Critical Care Nursing, 30(5), doi: /dcc.0b013e e Waxman, K. T. (2010). The development of evidence-based clinical simulation scenarios: Guidelines for nurse educators. Journal of Nursing Education, 49(1), doi: / December 2014 January 2015 Nursing for Women s Health 507