"No patient should die of PPH just for the lack of training!" Experiences from multi-professional simulation training on postpartum hemorrhage in northern Tanzania: A qualitative study

Background Postpartum hemorrhage (PPH) is a major cause of maternal morbidity and mortality. In Tanzania, PPH causes 25% of maternal deaths. Skilled attendance is crucial to saving the lives of mothers and their newborns during childbirth. This study is a follow-up after multi-professional simulation training on PPH in northern Tanzania. The purpose was to enhance understanding and gain knowledge of important learning features and outcomes related to multi-professional simulation training on PPH. Methods The study had a descriptive and exploratory design. After the second annual simulation training at two hospitals in northern Tanzania, ten focus group discussions comprising 42 nurse midwives, doctors, and medical attendants, were carried out. A semi-structured interview guide was used during the discussions, which were audio-taped for qualitative content analysis of manifest content. Results The most important findings from the focus group discussions were the importance of team training as learning feature, and the perception of improved ability to use a teamwork approach to PPH. Regardless of profession and job tasks, the informants expressed enhanced self-efficacy and reduced perception of stress. The informants perceived that improved competence enabled them to provide efficient PPH management for improved maternal health. They recommended simulation training to be continued and disseminated. Conclusion Learning features, such as training in teams, skills training, and realistic repeated scenarios with consecutive debriefing for reflective learning, including a systems approach to human error, were crucial for enhanced teamwork. Informants’ confidence levels increased, their stress levels decreased, and they were confident that they offered better maternal services after training.publishedVersio

Impact of multi-professional, scenario-based training on postpartum hemorrhage in Tanzania: A quasi-experimental, pre- vs. post-intervention study

Background Tanzania has a relatively high maternal mortality ratio of 410 per 100,000 live births. Severe postpartum hemorrhage (PPH) is a major cause of maternal deaths, but in most cases, it is preventable. However, most pregnant women that develop PPH, have no known risk factors. Therefore, preventive measures must be offered to all pregnant women. This study investigated the effects of multi-professional, scenario-based training on the prevention and management of PPH at a Tanzanian zonal consultant hospital. We hypothesized that scenario-based training could contribute to improved competence on PPH-management, which would result in improved team efficiency and patient outcome. Methods This quasi-experimental, pre-vs. post-interventional study involved on-site multi-professional, scenario-based PPH training, conducted in a two-week period in October 2013 and another 2 weeks in November 2014. Training teams included nurses, midwives, doctors, and medical attendants in the Department of Obstetrics and Gynecology. After technical skill training on the birthing simulator MamaNatalie®, the teams practiced in realistic scenarios on PPH. Each scenario was followed by debriefing and repeated scenario. Afterwards, the group swapped roles and the observers became the participants. To evaluate the effects of training, we measured patient outcomes by determining blood transfusion rates. Patient data were collected by randomly sampling Medical birth registry files from the pre-training and post-training study periods (n = 1667 and 1641 files, respectively). Data were analyzed with the Chi-square test, Mann-Whitney U-test, and binary logistic regression. Results The random patient samples (n = 3308) showed that, compared to pre-training, post-training patients had a 47% drop in whole blood transfusion rates and significant increases in cesarean section rates, birth weights, and vacuum deliveries. The logistic regression analysis showed that transfusion rates were significantly associated with the time period (pre- vs. post-training), cesarean section, patients tranferred from other hospitals, maternal age, and female genital mutilation and cutting. Conclusions We found that multi-professional, scenario-based training was associated with a significant, 47% reduction in whole blood transfusion rates. These results suggested that training that included all levels of maternity staff, repeated sessions with realistic scenarios, and debriefing may have contributed to reduced blood transfusion rates in this high-risk maternity setting.publishedVersio

Multi-professional simulation training on postpartum hemorrhage in Tanzania and Norway

PhD thesis in Health, medicine and welfareThere is a continuous drama going on worldwide, where women are fighting for their lives on the battlefield of childbirth. Every day, 830 mothers are dying during pregnancy and childbirth, or 300 000 mothers annually (WHO, 2016). Out of these deaths, 99% occur in low-resource countries (WHO, 2015b). Of the 830 deaths daily, 250 are dying because of postpartum hemorrhage (PPH) (Afnan-Holmes et al., 2015). For every mother dying, another 20-30 women are suffering from complications causing long-lasting sequelae (UNFPA, 2016). According to WHO, most of the maternal deaths are preventable (WHO, 2015b). There is an inequity regarding access to skilled birth attendance, due to the fact that 78% of the world’s total births have access to less than 42% of the world’s midwives, nurses and doctors (UNFPA, 2014). Two thirds of the mothers who are developing PPH, have no known risk factors. Active management of third stage of labor is expected to contribute to reduced maternal mortality (POPPHI, 2007), including an intramuscular injection of oxytocin 10 international units after the birth of the newborn (Gulmezoglu et al., 2012). However, birth attendants have to be alert and able to identify and treat PPH accordingly. Most studies on clinical outcomes after PPH-training have used estimated blood loss after birth as outcome measure (Shoushtarian, Barnett, McMahon, & Ferris, 2014; Sorensen et al., 2011; Spitzer et al., 2014). Visual estimation is known to be inaccurate and an unreliable measurement, with a tendency of underestimation (Al-Kadri et al., 2014; Bose, Regan, & Paterson-Brown, 2006; Hancock, Weeks, & Lavender, 2015). Different courses have been established in low- and high-resource countries to prepare midwives, nurses and doctors for obstetric emergencies like PPH (Bergh, Baloyi, & Pattinson, 2015; Dao, 2012; Dresang et al., 2015; Evans et al., 2014; Spitzer et al., 2014; The PROMPT Maternity Foundation, 2008). Obstetrical health care is considered a complex system, and an intervention must pay attention to the constantly changing interconnections and relationships (Dekker, Bergström, Amer-Wåhlin, & Cilliers, 2013; van Schaik, Plant, & O'Brien, 2015). Simulation training on PPH was associated with increased confidence level compared to traditional lectures (Andrighetti, Knestrick, Marowitz, Martin, & Engstrom, 2012; Birch et al., 2007). The participants’ previous clinical experiences together with their acquired experiences from simulation training, are likely to influence their self-efficacy, understood as judgment of own exercise of control, and collective efficacy, being the belief in the capability to solve a problem through unified efforts. Perceived efficacy beliefs are important for future performance (Bandura, 1997). Educational interventions have resulted in improved perinatal outcomes (Draycott et al., 2006; Mduma et al., 2015; Spitzer et al., 2014). Literature searches did not identify any educational intervention that led to significant reduction in blood transfusion rates after birth, as an indirect marker for reduced blood loss (Dumont et al., 2013; Sorensen et al., 2011). No follow- up studies were identified exploring the informants’ experiences after participation in an educational intervention on PPH-management. It seemed feasible and timely to investigate whether an educational intervention emphasizing teamwork and reflective practice, could contribute to new knowledge and understanding of crucial learning features and learning outcomes for improved PPH-management and maternal health. The implementation of multi-professional training on PPH-management was carried out in Tanzania and Norway, organized by the local management, faculty and research team. All cadres were involved in the training, which included realistic and relevant PPH-scenarios. The scenarios were followed by debriefing sessions to optimize reflective learning. By combining pedagogical and obstetrical academic traditions with midwifery practice emphasizing the promotion of normal birth, the overall aim was to investigate the effects of this educational intervention. We hypothesized that simulation training would contribute to increased efficacy beliefs and reduction in blood transfusion rate after birth. The investigation included assessment of how this simulation training may influence individual and collective efficacy beliefs. Another aim was to exploreparticipants’ experiences related to learning features and learning outcomes ofthe training in multi-professional teams. An issue discussed throughout the project, was how to measure outcomes from the educational intervention related to maternal health, with valid inference of the findings. Finally, blood transfusion rate as dependent variable was chosen as an indirect measurement of blood loss after birth. Mixed methods design was chosen to investigate staff’s experiences, efficacy beliefs and patient outcomes at four study sites: Stavanger University Hospital, University Hospital of North Norway, Kilimanjaro Christian Medical Centre(KCMC) and Mawenzi Hospital, both Tanzania

En kvalitativ studie av forholdet mellom opplæring og krav til handlingskompetanse ved akutte tilstander i skandinavisk fødselsomsorg

Master's thesis in Health and social sciencesFødselshjelpere møter forventninger fra vordende foreldre og deres familier, myndighetskrav om faglig forsvarlig tjeneste og pasientsikkerhet, arbeidsgivers krav til faglig dyktighet og i tillegg egen mestringsforventning. I akutte situasjoner utfordres fødselshjelpere på ivaretakelsen av brukernes involvering i en situasjon med fare for mors og/eller barnets liv og helse, samtidig som de i tverrfaglige team skal kunne vise ulike former for handlingskompetanse. Hensikten med studien var å besvare hvorfor handlingskompetanse er et godt mål på resultatet av opplæringen ved akutte tilstander. I oppgaven ble handlingskompetanse definert som en kombinasjon av fagkompetanse, ledelseskompetanse, lærings- og metodekompetanse og sosial kompetanse. Konteksten tok blant annet utgangspunkt i de spesifikke kravene som myndighetene stiller til jordmødre og leger tilknyttet norske fødeinstitusjoner, som obligatorisk praktisk trening og teoretisk gjennomgang av akutte situasjoner minimum to ganger per år. Tall fra Norsk Pasientskadeerstatning tilsa at kun 3 % av alle erstatningssøksmål gjaldt fødselshjelp. Likevel utgjorde erstatningsutbetalingene i forbindelse med fødselshjelp nesten 20 % av det totale beløpet. I konteksten beskrev jeg fire akutte tilstander som postpartumblødning, skulderdystoci, eklampsi og nyfødtresuscitering, og i hvilken grad disse tilstandene krever ulik tilnærming i klinisk arbeid og i opplæringsøyemed. Jeg knyttet også aspekter som brukerperspektiv og pasientsikkerhet opp mot de utfordringene de fire tilstandene representerer. Resultatet av litteratursøket ble presentert som tidligere forskning. Ny forskning på tverrfaglig opplæring på akutte tilstander vektla opplæring på både tekniske og ikke-tekniske ferdigheter. Slik regelmessig opplæring gav signifikant effekt på økt kunnskap, signifikant økte ferdigheter som vedvarer inntil et år etter øvelsene, og signifikant effekt på Apgar score og redusert forekomst av hjerneskade hos nyfødte. Opplæringen ble hovedsakelig gitt i tverrfaglige grupper på et læringssenter, men noen av studiene beskrev in situ øvelser med autentiske rammer og ressurser i avdelingene. Bruk av pasientmarkør gav større fokus på pasientrelasjonen enn ved bruk av fødesimulator. Jeg valgte kvalitativ metode med bruk av forskningssamtaler for å kunne besvare hvorfor handlingskompetanse er et godt resultatmål på denne opplæringen. Samtalene med syv skandinaviske informanter gav delvis svar på hvorfor de hadde valgt sine respektive undervisningsopplegg, og hvordan de vurderte utfordringene knyttet til opplæring på akutt fødselshjelp, brukerinvolvering og målet om pasientsikkerhet. En intervjuguide utviklet for formålet var til stor nytte i bestrebelsen på å beholde fokuset på opplæring.. Det syntes som en fordel å ha informanter fra hele Skandinavia, også for å dempe betydningen av min egen forforståelse. Resultatene fra forskningssamtalene viste at skandinaviske fødselshjelpere fikk tilbud om praktiske øvelser på arbeidsplassen ved ferdighetstrening eller simulering, men at øvelsene var avhengig av tydelig ledelsesforankring. I tider med omorganisering eller innsparinger ble opplæringstilbudene svekket. Handlingskompetanse som et mål for opplæringen var i liten grad uttalt. Læremål som fagkompetanse, sosial kompetanse og ledelseskompetanse gav økt fokus på kunnskap, samarbeid, kommunikasjon og ledelse i akutte situasjoner. På spørsmål om hvorvidt handlingskompetanse var et betegnende begrep for hva de ønsket å oppnå med den opplæringen de gav, bekreftet mange av informantene dette. Forskningssamtalene avdekket at brukerinvolvering forblir en utfordring i akutte situasjoner. Dette aspektet ved opplæringen gav mye refleksjon under samtalene, og endte med flere konkrete forslag til tiltak for å fremme brukerinvolvering ved akutte tilstander. Informantene understreket viktigheten av å være ærlige i sin kommunikasjon med foreldrene etter en feil eller uønsket hendelse, uansett hvor vanskelig og krevende det kunne være. Mange av artiklene understreket viktigheten av å måle pasientutkomme som resultat av praktiske øvelser. Få av informantene viste til resultattall som en følge av ferdighetstrening eller simulering. Hvorfor skulle jordmødre og leger med så mye kunnskap og erfaring, ha behov for praktiske øvelser på akutte situasjoner? Informantene hadde mange ulike erfaringer med akutte, kompliserte situasjoner, erfaringer som har fulgt dem på godt og vondt siden. De fortalte om nestenhendelser eller fatale hendelser, og understreket særlig behovet for sosial kompetanse, fag- og ledelseskompetanse. Mange hadde erfaring med kaos på fødestuen, der ansvarlig personell ikke klarte å skape trygghet. Informantene vektla ro på fødestua, god informasjon og tydelig nærvær. Noe av artiklene som beskrev studier på ikke-tekniske ferdigheter, bekreftet inntrykket fra informantene. Informantenes undervisning på akutte situasjoner ivaretok både trening i forkant av en antatt krevende klinisk situasjon ”just in time”, generell trening på akutte situasjoner for å kunne være forberedt ”just in case” og praktiske øvelser med tanke på bedret pasientsikkerhet ”just for sure”. Noen av informantene utrykte ønske om i sterkere grad å kunne ivareta brukerfokuset i opplæringen ”just for you”. Handlingskompetanse er et godt mål på resultatet av opplæringen ved akutte tilstander. Artiklene beskrev intervensjon med kurs som fokuserte både på tekniske og ikke-tekniske ferdigheter. Lukket sirkel-kommunikasjon gav signifikant mer effektive team. Regelmessig trening på akutte situasjoner over tid gav signifikant bedret utkomme for nyfødte, og mengdetrening på skulderdystoci resulterte i signifikant økte tekniske ferdigheter som vedvarte minst et år. Informantene bekreftet den samme opplevelsen. Tverrfaglige øvelser styrket samarbeid og kommunikasjon, og ferdighetstrening gav større trygghet og handlekraft i akutte situasjoner. Studien ender opp med noen anbefalinger som ble utledet av artiklene og forskningssamtalene: bruk felles refleksjon etter akutte situasjoner, innarbeid brukernes informasjonsbehov i prosedyrene, samle brukererfaringer og sett kravene til opplæring i Et trygt fødetilbud i system

Tools for establishing a sustainable safety culture within maternity services. A retrospective case study

Objective: This article reports the findings from a single case study on the long-term sustainability of a quality system in a large maternity unit. Method: The empirical basis is an analysis of documents related to the development, implementation, maintenance and outcome of the system over two decades. The main elements of the quality system are reported as findings, and the possible effects of the different elements are presented and discussed based on theories on safety management and leadership. Result: The findings suggest that the quality system served as the basis for a meaningful workplace community. The structure of meetings, research, training and budget input were all central factors for the development of the system. It resulted in systematic ongoing improvement, participation from all levels of the organization and trust within the organization. The effects of the system may still be seen after the end point of this study. Conclusions: It remains the responsibility of the management to ensure an adequate professional standard of services by a continuous internal quality assurance system for enhanced patient safety

The perspectives of nurse-midwives and doctors on clinical challenges of prolonged labor: A qualitative study from Tanzania

INTRODUCTION Globally, evidence suggests that one-third of nulliparous women experience delay in the first stage of labor with an increased risk of poor maternal and neonatal outcomes. With this study, we explore how clinical challenges related to prolonged labor are perceived by nurse-midwives and doctors in Tanzania. METHODS A qualitative study with group interviews of either nurse-midwives (7 interviews) or doctors (2 interviews). A total of 37 respondents, among them 32 registered nursemidwives and 5 doctors participated, all with experience from labor wards. A qualitative content analysis was performed. The study setting comprised one zonal consultant university hospital and one regional referral hospital in Northern Tanzania. RESULTS Clinical challenges were expressed in relation to: 1) various ways of understanding prolonged labor, manifested by variations in expected duration of labor and the usage of different terms to describe prolonged labor; 2) assessing progress in labor, the partograph being described as an important tool but also a template defining a too narrow normal; 3) appropriate intervention at the appropriate time, the respondents reflect on the correct time for artificial rupture of membranes, oxytocin augmentation and cesarean section; 4) monitoring fetal heart rate, distrust in the monitoring equipment with experiences of surprisingly poor neonates; and 5) working as a team, where the perception of urgency varies and distrust is present. CONCLUSIONS Nurse-midwives and doctors in Tanzania face major challenges related to diagnosing prolonged labor, monitoring fetal heart rate and providing high quality health services as a team

Clinical decision-making with user involvement during childbirth; a scoping review protocol

Protocol for a scoping review on decison-making during childbirt