OBSTETRIC SIMULATION - Designing Simulation-Based Medical Education and the Role of Physical Fidelity
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OBSTETRIC SIMULATION - Designing simulation-based medical education and the role of physical fidelity Jette Led Sørensen The research reported here was carried out at In the School of Health Professions Education In the context of the research school (Interuniversity Center for Educational Research) © copyright Jette Led Sørensen, Maastricht 2016 Printing: Datawyse | Universitaire Pers Maastricht ISBN 978 94 6159 559 1 Obstetric simulation Designing simulation-based medical education and the role of physical fidelity DISSERTATION to obtain the degree of Doctor at Maastricht University, on the authority of the Rector Magnificus, Prof. Dr. L.L.G. Soete in accordance with the decision of the Board of Deans, to be defended in public on Wednesday the 1st of June 2016, at 16.00 hours Minderbroedersberg 4-6, Maastricht University by Jette Led Sørensen Supervisors Professor Cees van der Vleuten Professor Bent Ottesen, University of Copenhagen, Denmark Assessment Committee Professor Jan-Joost Rethans, chair Professor Berit Eika, University of Aarhus, Denmark Professor Ide Heyligers Professor Fedde Scheele, Vrije University, Amsterdam Professor Laurents Stassen “I have never tried that before, so I think I should definitely be able to do that” Pippi Longstocking Jette Led Sørensen created the idea for this collage. The original drawing is by Henry Thelander (1902-1986) and Eva Kristine Hedtoft did the graphic design. Abbreviations ANCOVA: analysis of covariance CA: Cognitive Appraisal CI: Confidence interval CS: Cesarean section CTG: Cardiotocography DK: Denmark Hb: Hemoglobin HELLP: Hemolysis, Elevated Liver enzymes, Low Platelets count ICC: Intraclass correlation coefficient IPE: Inter-professional education ICMJE: International Committee of Medical Journal Editors IMI: Intrinsic motivation inventory ISS: In situ simulation JMC: Juliane Marie Centre for Children, Women and Reproduction KOS-test: Knowledge of skills test MCQ: Multiple-choice question MPE: Multi-professional education PPB: Postpartum bleeding PPH: Postpartum haemorrhage OSS: Off site simulation RBC: Red blood cell RCT: Randomised controlled trial RH: Rigshospitalet SAQ: Safety Attitudes Questionnaire SMBE: Simulation-based medical education SD: Standard Deviation STAI: Stress-Trait Anxiety Inventory TEAM: Team Emergency Assessment Measure UK: United Kingdom TABLE OF CONTENTS CHAPTER 1 Introduction 9 CHAPTER 2 The implementation and evaluation of a mandatory multi- professional obstetric skills training program 29 Jette Led Sørensen, Ellen Løkkegaard, Marianne Johansen, Charlotte Ringsted, Svend Kreiner, Sean McAleer. Published in Acta Obstet Gynecol Scand 2009;88:1107-17. CHAPTER 3 Evaluation of multi-professional obstetric skills training for postpartum haemorrhage 49 Veronika Markova, Jette Led Sørensen, Charlotte Holm, Astrid Norgaard, Jens Langhoff-Roos. Published in Acta Obstet Gynecol Scand 2012; 91:346-52. CHAPTER 4 Unannounced in situ simulation of obstetric emergencies: staff perceptions and organisational impact 63 Jette Led Sørensen, Pernille Lottrup, Cees van der Vleuten, Kristine Sylvan Andersen, Mette Simonsen, Pernille Emmersen, Bent Ottesen. Published in Postgrad Med J 2014;90:622-9. CHAPTER 5 Development of knowledge tests for multi-disciplinary emergency training: a review and an example 89 Jette Led Sørensen, Line Thellensen, Jeanett Strandbygaard, Kira D. Svendsen, Karl Bang Christensen, Marianne Johansen, Pernille Langhoff-Roos, Kim Ekelund, Bent Ottesen, Cees van der Vleuten. Published in Acta Anaesthesiol Scand 2015;59:123-33. CHAPTER 6 Part I ‘In situ simulation’ versus ‘off site simulation’ in obstetric emergencies and their effect on knowledge, safety attitudes, team performance, stress, and motivation: study protocol for a randomized controlled trial 109 Jette Led Sørensen, Cees van der Vleuten, Jane Lindschou, Christian Gluud, Doris Østergaard, Vicki Leblanc, Marianne Johansen, Kim Ekelund, Charlotte Krebs Albrechtsen, Berit Woetmann Pedersen, Hanne Kjærgaard, Pia Weikop and Bent Ottesen. Published in Trials 2013;14:220. CHAPTER 6 Part II Simulation based multi-professional obstetric anaesthesia training conducted in situ versus off site leads to similar individual and team outcomes — a randomised educational trial 127 Jette Led Sørensen, Cees van der Vleuten, Susanne Rosthoj, Doris Østergaard, Vicki Leblanc, Marianne Johansen, Kim Ekelund, Liis Starkopf, Jane Lindschou, Christian Gluud, Bent Ottesen. Published in BMJ Open 2015;5:e008344. CHAPTER 7 Clarifying the learning experiences of healthcare professionals with in situ and off site simulation-based medical education: a qualitative study 159 Jette Led Sørensen, Laura Emdal Navne, Helle Max Martin, Bent Ottesen, Charlotte Krebs Albrechtsen, Berit Woetmann Pedersen, Hanne Kjærgaard, Cees van der Vleuten. Published in BMJ Open 2015;5:e008345. CHAPTER 8 Twelve tips for choice of simulation setting and design of simulation-based medical education 183 Jette Led Sørensen, Doris Østergaard, Vicki Leblanc, Bent Ottesen, Lars Konge, Peter Dieckman, Cees van der Vleuten. Submitted, September 2015. CHAPTER 9 Discussion 199 CHAPTER 10 Summary in English 219 Samenvatting (summary in Dutch) 225 Dansk resume (summary in Danish) 233 Acknowledgement 241 Valorisation 245 Curriculum vitae 255 SHE dissertations series 257 CHAPTER 1 Introduction 9 CHAPTER 1 Introduction The intrinsic dual function of a labour ward in creating a relaxed atmosphere for normal childbirth while simultaneously being prepared for life-threatening emergencies makes it a challenging workplace that requires flexible, highly knowledgeable staff skilled in clinical problem solving and ability to multi-disciplinary cooperation [1-4]. A high level of communication and excellent cooperation skills are also necessary when interacting with labouring women [1,3,5-7]. Simulation-based medical education is a complex in- tervention and despite the growing number of studies, knowledge gaps still exist and many key elements of simulation-based training remain to be analysed in depth to improve the field. This thesis addresses how various aspects of obstetric simulation- based medical education interfere and impact outcomes. What is simulation? Simulation-based medical education can be broadly and simply defined: ‘‘... a person, device, or set of conditions which attempts to present education and evaluation prob- lems authentically. The student or trainee is required to respond to the problems as he or she would under natural circumstances” [8]. Simulation technologies can, for in- stance comprise products such as high-tech virtual reality simulators, full-scale manne- quins, plastic models, instructed patients, animals, animal products and human cadav- ers. The key advantages of simulation-based medical education include avoidance of pa- tient risks, the needs of the participants and team determine the training agenda, the environment is safe and failing is permissible. Tasks and scenarios can be created ac- cording to demand, training can be tailored to individuals or teams and skills can be practised repeatedly. In addition, learning can focus on a particular team, on the whole procedure or on specific components of a procedure [8-14]. The literature highlights specific principles in simulation-based team training, including critical aspects such as identifying teamwork skills to focus training content, allowing the desired team-based learning outcomes and organisational resources to guide the process, and ensuring the relevance of training to the transfer environment [10,15,16]. In addition applying feedback, assessing learning and behaviours on the job and doing evaluations based on clinical outcomes are also important [15,16]. Multi-professional and multi-disciplinary obstetric simulation This thesis focuses specifically on simulation-based medical education in obstetric emergencies, e.g. clinical management of shoulder dystocia, severe postpartum bleed- ing, severe preeclampsia, neonatal resuscitation and emergency caesarean section. Labour wards are challenging workplaces where patient safety and medical litigation are high on the agenda [17]. In emergency situations, managing labouring women may 10 INTRODUCTION require the involvement of several healthcare professional groups. The primary care team in the delivery room consists of a midwife and an auxiliary nurse. In the event of an obstetric emergency more experienced midwives and obstetricians are called upon. As an obstetric emergency unfolds, involvement of an anaesthesiologist, a nurse anaes- thetist, operating room nurses and a neonatologist may become necessary. When the parturient woman is severely ill, involvement of both medical and surgical specialists may be required to deal with an ordinary situation that has become potentially life threatening and calls for multi-professional and multi-disciplinary clinical management (figure 1.1). Teams created for specific clinical situations are known as ad hoc on-call teams [18,19]. Figure 1.1 Illustration of patient journey when the labouring woman undergoes either an emergency caesar- ean section or experiences postpartum bleeding. The three columns represent the physical space (delivery ward, operation theatre, postnatal ward) where communication and handover between various healthcare professionals are necessary. The circles and ovals represent the individual healthcare professionals involved in care of the patient and illustrate how some staff works solely on a specific ward while others work across wards. Grey colour represents