Clinical decision-making: midwifery students' recognition of, and response to, postpartum haemorrhage in the simulation environment
- Authors: Scholes, Julie , Endacott, Ruth , Biro, Mary Anne , Bulle, Bree , Cooper, Simon J. , Miles, Maureen , Gilmour, Carole , Buykx, Penny , Kinsman, Leigh , Boland, Rosemarie , Jones, Janet , Zaidi, Fawzia
- Date: 2012
- Type: Text , Journal article
- Relation: BMC Pregnancy and Childbirth Vol. 12, no. 19 (2012), p. 1-12
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- Description: Background This paper reports the findings of a study of how midwifery students responded to a simulated post partum haemorrhage (PPH). Internationally, 25% of maternal deaths are attributed to severe haemorrhage. Although this figure is far higher in developing countries, the risk to maternal wellbeing and child health problem means that all midwives need to remain vigilant and respond appropriately to early signs of maternal deterioration. Methods Simulation using a patient actress enabled the research team to investigate the way in which 35 midwifery students made decisions in a dynamic high fidelity PPH scenario. The actress wore a birthing suit that simulated blood loss and a flaccid uterus on palpation. The scenario provided low levels of uncertainty and high levels of relevant information. The student's response to the scenario was videoed. Immediately after, they were invited to review the video, reflect on their performance and give a commentary as to what affected their decisions. The data were analysed using Dimensional Analysis. Results The students' clinical management of the situation varied considerably. Students struggled to prioritise their actions where more than one response was required to a clinical cue and did not necessarily use mnemonics as heuristic devices to guide their actions. Driven by a response to single cues they also showed a reluctance to formulate a diagnosis based on inductive and deductive reasoning cycles. This meant they did not necessarily introduce new hypothetical ideas against which they might refute or confirm a diagnosis and thereby eliminate fixation error. Conclusions The students response demonstrated that a number of clinical skills require updating on a regular basis including: fundal massage technique, the use of emergency standing order drugs, communication and delegation of tasks to others in an emergency and working independently until help arrives. Heuristic devices helped the students to evaluate their interventions to illuminate what else could be done whilst they awaited the emergency team. They did not necessarily serve to prompt the students' or help them plan care prospectively. The limitations of the study are critically explored along with the pedagogic implications for initial training and continuing professional development.
Managing women with acute physiological deterioration: student midwives performance in a simulated setting
- Authors: Cooper, Simon J. , Bulle, Bree , Biro, Mary Anne , Jones, Janet , Miles, Maureen , Gilmour, Carole , Buykx, Penny , Boland, Rosemarie , Kinsman, Leigh , Scholes, Julie , Endacott, Ruth
- Date: 2012
- Type: Text , Journal article
- Relation: Women and Birth Vol. 25, no. 3 (2012), p. e27-e36
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- Description: Abstract Objective Midwives’ ability to manage maternal deterioration and ‘failure to rescue’ are of concern with questions over knowledge, clinical skills and the implications for maternal morbidity and, mortality rates. In a simulated setting our objective was to assess student midwives’ ability to assess, and manage maternal deterioration using measures of knowledge, situation awareness and skill, performance. Methods An exploratory quantitative analysis of student performance based upon performance, ratings derived from knowledge tests and observational ratings. During 2010 thirty-five student, midwives attended a simulation laboratory completing a knowledge questionnaire and two video, recorded simulated scenarios. Patient actresses wearing a ‘birthing suit’ simulated deteriorating, women with post-partum and ante-partum haemorrhage (PPH and APH). Situation awareness was, measured at the end of each scenario. Applicable descriptive and inferential statistical tests were, applied to the data. Findings The mean total knowledge score was 75% (range 46–91%) with low skill performance, means for both scenarios 54% (range 39–70%). There was no difference in performance between the scenarios, however performance of key observations decreased as the women deteriorated; with significant reductions in key vital signs such as blood pressure and blood loss measurements. Situation, awareness scores were also low (54%) with awareness decreasing significantly (t(32) = 2.247, p = 0.032), in the second and more difficult APH scenario. Conclusion Whilst knowledge levels were generally good, skills were generally poor and decreased as the women deteriorated. Such failures to apply knowledge in emergency stressful situations may be resolved by repetitive high stakes and high fidelity simulation.