The Effect of Web-based and Simulation-based Education on Midwifery Students’ Self-Confidence in Postpartum Hemorrhage Management

Introduction

Midwifery is a profession requiring various clinical skills (1). Midwifery students, who are newly introduced to health care systems, should acquire these clinical skills (2, 3). Studies conducted on graduate students have shown that these students have no competence at workplace and encounter different stressors and tensions in clinical settings, which lead to high anxiety. Anxiety can encumber acquisition, reduce self-

confidence, and lead to ineffective communication during the learning process. It could be also responsible for the feeling of inadequacy in performance and skill acquisition (4).

Self-confidence, as one of the key elements of clinical competence (5), is accompanied by continuous self-evaluation and self-judgment. It is a fine realistic feeling (6), which reflects one’s belief in himself and his worthiness; it also significantly affects the quality of one’s actions and behaviours.

Self-confidence empowers midwives, who are responsible for women’s health care (7). McDermott et al. showed that only 58% of midwives have high self-confidence in managing postpartum complications (8). Postpartum hemorrhage, as one of the most prevalent complications after delivery, is a common cause of maternal mortality, worldwide (9). Around 25% of total maternal mortality and almost half of postpartum deaths are directly related to postpartum hemorrhage (10).

There are still debates about the prediction and diagnosis of postpartum hemorrhage. The related deaths have been associated with late diagnosis and improper management (11). Therefore, one of the most necessary skills of midwives is proper and urgent decision-making in emergency situations.

Ineffective clinical decision-making could lead to adverse health consequences. Clinical decision-making considerably affects health care outcomes and is related to education and self-confidence (12). Therefore, selection of proper instructional methods could be effective in increasing students’ self-confidence (5).

Today, medical education needs to be reformed and fundamentally revised in terms of educational methods and processes. Through these reforms, schools can train students to gain self-confidence and competence for playing their professional roles (13). Over the last two decades, simulators and models have provided the opportunity for students to learn both communication skills and technical procedures in a safe environment, before being introduced to actual clinical settings (14, 15).

 The advantages of simulation-based methods (such as use of simulation mannequins and standard patients) are anxiety reduction, increase in self-confidence, and skill acquisition (15). Application of integrated/blended approaches and multimedia can be effective, considering the large number of students, the scope of required skills, and the scarcity of learning opportunities.

One of the self-directed instructional methods is web-based education in which not only texts, but also educational tables, animations, and videos are presented altogether (16). This method could lead to increased decision-making capacity and critical thinking, which are crucial for the improvement of psychomotor skills (17). Web-based education by presenting synchronous texts, graphics, sounds, images, and movies, along with the simulation of real scenarios, can break physical boundaries and time limitations (18).

This mode of education increases the speed of learning and provides opportunities for using accessible sources, based on one’s personal skills. Through the application of this method, learners can skip the subjects they are familiar with and move to new materials; in addition, in case they do not learn the given subject, they can refer to it at a proper time.

Implementation of web-based methods, similar to many other recently-introduced phenomena, is accompanied by various limitations, particularly in developing countries. For instance, lack of face-to-face interactions between the instructors and learners may negatively influence the success rate of students in the educational courses (19, 20). Although web-based education has become increasingly widespread, our knowledge about this learning experience is still limited.

Previous research has indicated that cyberspace could both positively and negatively affect one’s efficiency and achievement. It is necessary to be assured about the learning progress and effectiveness of training (21). In this regard, Valizadeh et al. (2013) conducted a study to determine the effect of simulation-based education on the self-confidence of MSc students of nursing in pediatric intravenous catheterization; as the results indicated, simulation could increase the self-confidence of these students (22). In addition, Curran et al. (2006) showed that continuous web-based education might increase physicians’ self-confidence (7).

Therefore, the current study was conducted to compare the effects of web-based training and educational simulation on midwifery students’ self-confidence in postpartum hemorrhage management.

Materials and Methods

This experimental study was conducted on midwifery students of Mashhad University of Medical Sciences. The approval of the university ethics committee was obtained and ethical considerations were respected throughout the study.

 By using a pilot study and mean comparison formula, the sample size was estimated to be 20 subjects per group. Considering the 10% dropout rate, 22 students were enrolled in each group. The population consisted of BSc and MSc students of Mashhad School of Nursing and Midwifery, who met the inclusion criteria.

 The inclusion criteria were as follows: 1) willingness to participate in the study; 2) passing the theoretical course of “abnormal pregnancies and childbirths”, based on the course plan of Mashhad School of Nursing and Midwifery (this course is presented in 5^th and 7^th semesters for BSc students and in 1^st and 7^th semesters for MSc students); 3) no stressful events such as the death of first-grade relatives; 4) serious family conflicts; and 5) no financial problems in the past three months.

The exclusion criteria were as follows: 1) using the website less than 30 minutes; 2) lack of participation in the educational sessions; and 3) not completing the C-scale before and after the intervention.

Students, who met the inclusion criteria, were stratified based on their educational semester and were randomly assigned to two groups. The students were assigned to either web-based or simulation group, using the table of random numbers. If the random number fell in the range of 0-4, the first subject was allocated to the web-based group and the second to the simulation group; if the random number was between 5 and 9, the first person was assigned to the simulation group and the second to the web-based group.

At the beginning of the study, each group consisted of 22 students. However, during the study, three students from the web-based group and one student from the simulation group were excluded due to absence from the post-test.

The researcher introduced himself to the students and briefly explained the research objectives. If the students were willing to participate in the study, they were asked to complete the forms of sample selection, demographic data, and self-assessment, measured by a visual analogue scale (consisting of one statement, graded by a 5-point Likert scale). The minimum and maximum scores were 0 (poor self-assessment) and 100 (excellent self-assessment), respectively. The informed consents were obtained through interview.

 Afterwards, the C-scale was used to measure self-confidence. This scale was developed by Susan Erin Grundy in 1993 for testing self-confidence in psychomotor skills (23) and consisted of 5 statements on a 5-point scale (1: indicating lack of self-confidence, 5: indicating the highest self-confidence). The minimum and maximum scores were 5 (low self-confidence) and 25 (high self-confidence), respectively. The validity of this scale was confirmed via content validity and its reliability was affirmed using Cronbach's alpha (α= 0.70).

 Educational contents, which were based on the national guidelines, were similar for both groups. In the simulation group, the study subjects were introduced verbally, using PowerPoint presentations and an educational movie at the skill laboratory (45 minutes). Then, the researcher illustrated how to estimate the volume of blood loss and trained the students in third-phase management, uterine atony management, and uterine distortion after delivery on a mannequin (the session lasted 4 hours). In the web-based group, a one-hour session (related to postpartum hemorrhage management) was held by the researcher about using the website.

All students were given usernames and passwords, and the website was accessible to students for one month. After one month, the usernames and passwords were expired, and the students’ access was blocked. During this time, both groups were in contact with the researcher via E-mail or face-to-face interactions.

Before starting the educational session, the researcher and a cameraman captured a video on the following subjects: different volumes of blood loss, steps of active management during the third stage of delivery, uterine atony management, and techniques of bimanual massage after delivery (performed on a mannequin in the lab).

 The researcher recorded his voice and explained the different steps of management. The soundtrack was added to the movie, and the video was uploaded to the educational website. Immediately after one month (expiration of students’ access to the website), both groups were evaluated via C-scale. Descriptive analysis, Fisher's exact test, Mann-Whitney, and Friedman test were performed, using SPSS version 11.5.