Neonatal Scenario Training: The Birth of a New Era of Education?

Imagine… It’s 7am in the labour ward after a busy night. Having experienced a problem-free pregnancy and labour, a healthy 28 year old woman is about to give birth to a full-term baby; the second of her children. Anticipating an uncomplicated birth, the ward manager has assigned one midwife to her care. On arrival, the 7lb baby boy is unexpectedly flat: limp and silent with poor tone.Assessing him, the midwife finds that his heart rate is slow. She calls for help from a junior doctor and a neonatal team, who arrive on the scene within just a few minutes. In the meantime, the midwife initiates resuscitation, clears the baby’s airways, wraps him in a warm, dry towel, stimulates him and notes spontaneous, if laboured breathing and good tonal response. After concisely explaining the situation to the presenting medical team, her focus is switched to the anxious new parents while further assessments and stabilisation procedures are carried out. Calmly explaining the problem, the course of action and the baby’s progress to the parents, she reassures them that everything is under control but that to ascertain the reason for the unexpected breathing difficulties, he will be taken to the SCBU for detailed observations and specialised treatment.

Great Expectations
As this scenario goes to show, the expectations on delivery staff in a labour ward are far reaching. Not only is the midwife required to have the medical knowledge and confidence to independently deliver a baby under normal circumstances, he or she is expected to recognise the symptoms of a sick neonate, administer basic resuscitation and stabilisation techniques and call for help (when necessary) at the appropriate time. In the heat of the moment, the midwife must remain calm, follow protocols, hand over the case smoothly and efficiently to clinical experts and work within a team framework. In addition to all this, a certain level of counselling skill is required to give the new parents the best experience possible – whatever the outcome of the baby.

The requirement for multiple skills, multi-disciplinary team working and medical intervention is more commonplace in midwifery and obstetrics today than ever before. Until the 1970s, almost half of all babies born in the UK were born outside hospital – either at home or in nursing homes in the care of midwives or GPs. In 1960, 30 out of every 1000 newborn babies were stillborn or died soon after delivery. Over the past 30 years, the advancement of medical science and a better understanding of the complications of pregnancy and childbirth have dramatically improved birth outcome. Today, less than 10% of babies are born outside the hospital environment and a much improved statistic of 3-4 out of every 1000 babies are stillborn or die shortly after delivery.

Room for improvement
In 2005, this statistical data translated to 3,869 neonatal mortalities (within 28 days of birth) in the UK1. Lack of communication and teamwork among staff have been repeatedly cited as a reason for poor patient outcome2. In the 2000-2002 triennium, 67 per cent of direct deaths were judged to be at least partly due to sub-standard care, and analysis of 37 adverse events and near misses in obstetrics in the North West of England between 1999 and 2000 (Ashcroft 2003) indicated that human errors were linked to clinical inexperience.

In the paper, ‘Structured Team Training in Obstetrics and Its Impact on Outcome’, Dr Joanna Crofts, Department of Women’s Health, Southmead Hospital, Bristol, explains that the growing trend for litigation and liability claims in the field of midwifery and obstetrics is a major issue. She highlights that in 2003, the cost of outstanding National Health Service Litigation Authority (NHSLA) claims for incidents that occurred on or after 1st April 1995 in Obstetrics and Gynaecology, was over £200 million. The NHSLA reports that by 2007-8, this figure had increased to £288 million.

Team training can improve patient outcome
To expect all midwives and junior doctors to demonstrate the required level of confidence and skill in an emergency, it is vital to equip them with appropriate training and experience and ensure that their knowledge and skills are retained.

Talking about current training standards for midwives and junior doctors, Dr Crofts continues, “The medical community has typically focused on training for specific, technically skilled tasks, but with the increasing multi-professional nature of healthcare provision, training for task based skills alone may be insufficient. Team training applies the paradigm that people make fewer errors when they work in effective teams. Each member of the team can understand their responsibilities when processes are planned and standardised, and team members can “look out” for one another, noticing errors before they cause an accident.”

Dr Crofts points out that despite repeated recommendations by the RCOG and the RCM3 for regular drill training in obstetric emergency management for all obstetric and midwifery staff; a systematic review of all obstetric emergency training in the UK, conducted in 2003, identified just six obstetric emergency courses. Nearly a decade after obstetric emergency training was first recommended in the UK, there was still neither a national curriculum nor a system for provision.

Education through Simulation
Scenario-based training is on the increase in the medical profession, particularly so in the last five years. Its ability to help students acquire valuable experience in a clinical and social context is not yet well documented, but recent and current evaluations are favourable .

In a paper issued in November 2007, Sarah Thewlis, the then Chief Executive and Registrar of the Nursing and Midwifery Council (NMC), stated that, “The findings of a recent pilot study conducted by the NMC to test whether simulation could provide a safe and effective means of learning clinical skills were encouraging. The evaluation suggests that, as an adjunct to practice learning, learning in a simulated practice setting can provide a safe and effective means of supporting learning and enhancing evidence-based direct care.” Mrs

Thewlis subsequently invited programme providers at a conference entitled “Challenging Perspectives on Simulation and Skills in Health Care Education” to “apply the contents of the circular in order to use up to a maximum of 300 hours of the 2300 hours practice component to provide clinical training within a simulated practice learning environment in support of providing direct care in the practice setting.”


SimNewB is Born!
Simulation training can be practised in either a purpose-built training centre or in-situ on the delivery ward, facilitating regular sessions in a focused and uninterruptable environment or amidst regular working conditions to suit time or budget restraints.

A number of gynecological and obstetric models are available to help midwives practice delivering babies. However, up until now, there has never been a patient simulator that presents realistic symptoms that are specific to neonates. Addressing the need for enhanced realism in neonatal emergency medical and nursing training, Laerdal Medical, the makers of Resusci Anne, Nursing Anne and SimMan (Universal patient simulator), is proud to announce the launch of SimNewB, the youngest and possibly the most emotionally engaging patient simulator in its field. Offering unprecedented authenticity, this interactive neonatal simulator is designed to replicate both simple and complex scenarios in the first ten minutes of a newborn’s life, optimising training opportunities within all neonatal training curricula.

Making simulation easier
Leading simulation into a new era, the 21 inch long, 7 lbs SimNewB presents a host of true-to-life medical challenges from the simplicity of a moving, crying, healthy infant through to a limp, cyanotic newborn with no vital signs.

The accurate anatomical representation of a full-term, female baby promotes intuitive student involvement and clinical intervention and intensifies the learning experience. Compatible with Laerdal’s Advanced Video System, SimNewB enables appropriately timed trainer interjection during the scenario, and repeatable audio/visual feedback for the ensuing debrief, which makes for valuable reflective learning. Furthermore, its unparalleled operating system and rugged construction allow the trainer to easily set up, control and diversify scenarios remotely, enabling ease of use across different units.

Dr Lidia Tyszczuk, Consulant Neonatalogist, who runs neonatal simulation courses at Queen Charlotte’s & Chelsea Hospital, London, said:

“SimNewB is a long-awaited training product. Its vital signs can be programmed to depict a number of medical signs that are apparent so trainees will not have to ask about the condition of the newborn, but will be able to make their own judgement. Because this newborn simulator breathes, cries, convulses and has varying heart and pulse rates, it really helps the trainee “buy into” the scenario. It presents new opportunities for multi-disciplinary training, gives trainees experience of handling difficult clinical and emotional situations in a pressured environment quite often with the parents present. This helps to improve communication, resuscitation and stabilisation skills. There is a real need for individual and team training for midwifery, nursing and neonatal trainees and practitioners at both a basic and advanced levels. SimNewB will help trainees to recognise a sick baby, call for help at the right time, improve clinical skills, communicate within a team and effectively manage a crisis. Scenarios with different levels clinical complexity can be presented to a multidisciplinary team thereby enabling the team to put into practice all their clinical and communication skills in a safe environment. It can only benefit training to achieve a better patient outcome.”

References

  1. ‘The Safety of Maternity Services in England’ (2007), Alex Smith and Anna Dixon of the King’s Fund that in 2005
  2. CEMACH report for the 1997-1999 triennium (Lewis et al 2001).
  3. Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives
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