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Is simulation a substitute for real life clinical

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Nurse Education Today

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t

Is simulation a substitute for real life clinical experience in midwifery? A qualitative

examination of perceptions of educational leaders
Lisa McKenna a,, Fiona Bogossian b, Helen Hall c, Susannah Brady d, Stephanie Fox-Young b, Simon Cooper e
a

Monash University, School of Nursing & Midwifery, Clayton, Victoria, Australia

The University of Queensland, School of Nursing & Midwifery, Herston Campus, Queensland, Australia
Monash University, School of Nursing and Midwifery, Peninsula Campus, Victoria, Australia
d
The University of Queensland, School of Nursing & Midwifery, Brisbane, Queensland, Australia
e
Monash University, School of Nursing & Midwifery, Churchill, Victoria, Australia
b
c

a r t i c l e

i n f o

Article history:
Accepted 28 February 2011
Keywords:
Midwifery
Qualitative
Simulation
Clinical education
Curricula

s u m m a r y
This paper describes the perceptions of midwifery educational leaders concerning the potential for simulation
to provide a realistic experience in midwifery education. A qualitative design was employed using focus
groups which were audio-taped and transcribed verbatim. Data were analysed using thematic analysis.
Eleven focus groups were conducted with 46 key midwifery academics across Australia. Three main themes
emerged relating to realism and simulation in midwifery practice: we already use a lot of simulation, level of
realism of manikins, and some things cannot be simulated.
Simulation is currently widely used in midwifery education, but this is limited due to realism of available
models and equipment. Despite this, within a woman-centred, holistic approach to care there are many
aspects of midwifery practice that cannot be easily simulated. There is a need for research and development of
realistic simulation approaches to support the enhanced use of simulation. Furthermore, strategies for
developing approaches that reect midwifery care provision need to be developed.
Crown Copyright 2011 Published by Elsevier Ltd. All rights reserved.

Introduction
In 2010, the Australian Commonwealth government created
Health Workforce Australia (HWA) with an aim to address health
workforce issues, including the provision of clinical education to
support increasing numbers of health professional students. As part of
this, the use of Simulated Learning Environments (SLEs) is being
explored as one means for optimising clinical placements. This paper
reports on part of a larger study exploring key midwifery academic
perceptions on the use of simulation in midwifery education.
Background
Midwifery education in Australia has evolved over recent decades.
In the early 2000s, Bachelor of Midwifery (direct entry) programmes
were offered for the rst time. Prior to this, people wishing to become
midwives were required to rst become registered nurses then
undertake postgraduate studies in midwifery. With the introduction
of undergraduate midwifery programmes and national course

Corresponding author. Tel.: +61 3 9905 3492; fax: +61 3 9905 4837.
E-mail addresses: lisa.mckenna@monash.edu (L. McKenna), f.bogossian@uq.edu.au
(F. Bogossian), Helen.hall@monash.edu (H. Hall), s.brady@uq.edu.au (S. Brady),
s.foxyoung@uq.edu.au (S. Fox-Young), simon.j.cooper@monash.edu (S. Cooper).

accreditation, course requirements have expanded to include twenty

continuity of care (follow-through) experiences (averaging twenty
hours with each woman across the maternity care experience), 100
antenatal and 100 postnatal visits, being with forty women giving
birth, caring for forty women with complex needs across pregnancy,
labour and birth, and the postnatal period, care of babies with special
needs and experience in women's health (Australian Nursing and
Midwifery Council (ANMC), 2009, p.19).
The contemporary landscape of Australian midwifery practice has
also experienced signicant change in recent years. Annual birth
numbers are increasing (Laws & Sullivan, 2009) at the same time as
the midwifery workforce ages and there is an increasing trend
towards part time work (Australian Health Workforce Advisory
Committee (AHWAC), 2002). In addition, clinical placement shortages
are impacting on delivery of academic programmes across the health
professions (Barnett et al. 2008, National Health Workforce Taskforce
(NHWT), 2009), including midwifery. In midwifery, quality clinical
placements are fundamental, not only to meet registration requirements, but also to develop midwifery expertise through hands-on
experience working alongside midwives (Licqurish and Seibold,
2008), and for future career planning (McCall et al., 2009). Tensions
clearly exist between sufcient clinical exposure and changing
practice contexts, that simulation may have the potential to ease.
Simulation in midwifery education is not a new concept. Madame
de Coudray, a royal midwife commissioned by King Louis XV, travelled

0260-6917/$ see front matter. Crown Copyright 2011 Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2011.02.014

L. McKenna et al. / Nurse Education Today 31 (2011) 682686

across France in the 1700s teaching midwives with life size models
she made by hand in leather, bones and fabric (Gelbart, 1998). Over
centuries of midwifery education, models have been used to teach
particular skills, including torsos for abdominal palpation and birthing, dolls and pelvises for mechanisms of labour, and neonatal models
for birth and resuscitation simulation, yet little has been documented
around the educational effectiveness of these. In one study, Davis et al.
(2009) examined the midwifery students' and educators' perceptions
of using a childbirth simulator. This was seen to be valuable in
assisting students to prepare for practice, yet believed not to be
suitable for replacing actual clinical practice.
In recent years, only scant research has explored simulation
effectiveness in midwifery and this has been used largely to examine
development of particular attributes such as decision-making or
obstetric emergency skills. Ciof et al. (2005) employed a randomised
controlled trial to examine postgraduate midwifery students' clinical
decision making skills around normal labour and physiological
jaundice. They found that students who had received education
using simulation collected more clinical data, were more condent
and arrived at decisions more quickly. Other studies have examined
simulation in teaching of emergency obstetric skills to midwives, such
as shoulder dystocia (Crofts et al., 2006, 2007), post partum
haemorrhage (Maslovitz et al., 2008) and eclampsia management
(Ellis et al., 2008) and reported positive learning outcomes.
The nursing literature on simulation has been much more plentiful
over recent years than in midwifery, but provides a relevant context
around its potential benets and limitations. Simulation is argued to
offer opportunities to promote nursing students' critical thinking and
increase condence (Curtin & Dupuis, 2008) as well as skill levels
through providing a safe learning environment where patient safety is
not compromised (Cant & Cooper, 2009; Clancy, 2008; McCaughey &
Traynor, 2010). It also offers opportunities for skills practice where
clinical experiences are infrequent (Moule et al., 2008; Ricketts, 2011this issue). However, simulation can be costly and resource intensive
(Grady et al., 2008) and realism may be difcult to achieve (Mole &
Lafferty, 2004).
It has been argued that simulation offers potential to overcome
challenges associated with shortages of quality clinical placement
experiences for students (Parsh, 2010). Baillie and Curzio (2009)
compared learning of undergraduate nursing students using simulation and regular clinical placements. These authors concluded that
replacing some clinical placement hours with simulation did not
disadvantage students and was viewed positively by students and
facilitators. In response to the increasing demand for quality clinical
placement outcomes, Health Workforce Australia (HWA, 2010)
commissioned a series of projects to examine ways of using SLEs to
enhance clinical preparation, with midwifery being one of the rst
disciplines to be studied by a joint team from the University of
Queensland and Monash University.
Methods
This paper reports on one key activity undertaken in the larger
HWA midwifery SLE project. Initially, the researchers developed key
operational denitions for simulation-related activities, given there
was a lack of consensus within the literature. These denitions were
continuously rened until nal denitions were agreed. For the
purposes of this study, simulation was dened according to Decker et
al's (2008) reworking of Gaba's (2004) denition as an educational
technique in which elements of the real world are appropriately
integrated to achieve specic goals related to learning or evaluation
(Decker et al., 2008, p. 75). In addition, generic technical, midwifery
technical and generic non-technical skills were distinguished. The
second activity involved undertaking a systematic review of the
literature around simulation based learning in midwifery and relevant
obstetrics. The review sought to identify relationships between the

683

use of simulation, learning outcomes and subsequent clinical practice

change. This was followed by a series of Australia-wide focus groups
to examine the perceptions and experiences of midwifery academics
in using simulation to achieve clinical learning outcomes. Finally, an
online survey was conducted with coordinators of midwifery
education programmes across Australia regarding use of simulation
within their programmes (Bogossian et al., in press). This paper
specically reports on the ndings in relation to realism in
midwifery simulation emerging from the focus groups with key
midwifery academics. Issues surrounding barriers and enablers to
simulation also arose and are being prepared for reporting in a
separate paper.
Following ethical approval from the respective university human
ethics committees, invitations were sent to all heads of Australian
university schools conducting accredited midwifery preparation for
practice courses, both undergraduate and postgraduate, to nominate
key midwifery academics to participate in a focus group. The purpose
of the focus group was to examine the perceptions and experiences of
midwifery academics in using simulation to achieve clinical learning
outcomes. In total, eleven focus groups were conducted with
midwifery academics across all Australian states and territories,
with 46 people consenting to participate and all schools offering
midwifery courses represented. Focus groups were guided by a series
of key questions (Appendix 1).
Focus groups were facilitated by researchers, including one
midwife, from outside each particular state or territory. Focus groups
lasted between 60 and 90 min in duration, were audiotaped and later
transcribed verbatim. Thematic analysis was conducted to identify
trends emerging through the interviews. Thematic analysis was used
to allow categories to emerge from the data itself, rather than
determining groupings prior to commencing analysis (Ezzy, 2002).
Open coding was performed initially through deconstructing each
element of text and then applying codes to the data. Subsequent axial
coding facilitated the grouping of similar codes to allow categories to
develop (Ezzy, 2002; Liamputtong, 2009). Transcripts and themes
were reviewed by all members of the research team in order to
validate the interpretations and conclusions drawn.
Results
Following rigorous data analysis, three main themes relating to the
realism of simulation in midwifery emerged: We already use a lot of
simulation, Level of realism of manikins, and Some things cannot be
simulated.
We already use a lot of simulation
Across the focus groups, it was clear that simulation was an
established practice in midwifery education, as participants described
extensive use of simulation within their courses, and related that this
was the way in which education had been delivered for a long period
of time. Discussions highlighted for some participants that they used
simulation more than they realised, such as with breech birth:
we've been doing it for much longer in the universities, I don't
think we've actually looked at how much we are actually doing that
is simulation. (F.G. 6). There is an awful lot of simulation going on,
that is already being done. (F.G. 8).
Simulation was used for many aspects of technical skill delivery in
midwifery programmes, however, was seen as fundamental for
teaching emergency skills along with others that are seen less
commonly in clinical practice, such as vaginal examinations:
Simulations are fabulous for building your basic skills and things, and
you have to be able to do simulations for emergency drillsYou can't

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L. McKenna et al. / Nurse Education Today 31 (2011) 682686

do it any other way (F.G. 8). It's identifying the aspects of their
practice that we know they're going to nd confronting or difcult or
have to be on top of really quickly, or the other times we use it is
where we know that they're infrequent but high risk situations (F.G.
5)obstetric emergencies are things you're not going to see often
enough that you just need to practiceso the best way to do it is in a
simulated world (F.G. 7).
Discussions in the interviews revealed a range of simulation
activities currently embedded in midwifery curricula.
We use a mix of simulation types, mostly low delity; mostly
traditional partial mannequins e.g. a model called Sophie to
demonstrate birthing. Not holistic only part bodywe use high
delity simulation models in an ad hoc way. Improvise by using bits
of different models put together. (F.G. 9). We have partial task
trainers that the students work on. We do a lot of peer to peer, so
they role play in labs every weekwe have birthing models and
babies that they can tube [intubate] and things like that. (F.G. 2).
Student roleplay was commonly reported as being employed for
communication skills and antenatal history taking:
one of them [students] would be the woman and one of them
would be the midwifethey write their script and then act out the
role play (F.G. 6).
It also became evident that participants commonly used creative
approaches to simulating aspects of midwifery practice for which
there was no suitable model available. Numerous examples were
described including:
we use the simulation equipment that's in the hospital, which is
not specically obstetric based. So the mannequin, we are very
artistic with, inventive, to make her obstetric as possible. (F.G. 8)
we have an actor who wears [specically designed] items of clothing
that allow us to do vaginal examinations and we've made lots of
pieces of clothing. (F.G. 10)we did speculum examination and very
simply I got lots of little foam blocks, made a vagina into each of them
and got the students to put it between their legs, to lie on the bed and
another student would do a speculum examination.they said they
felt vulnerable, they felt what it was like to lie there and know the
speculum was going in and from the student's perspective they felt
they were talking to the womenit just became more real. (F.G. 10).
You can use a cardboard box and a doll, one of those plastic ones. Cut
the head so you've got the fontanellesget a shoebox that you can
simulate a pelvis and then put it through. Start to feel how that
baby's head islike if they're doing vaginal examinations. (F.G. 8).

Level of realism in manikins

Discussions across each of the focus groups demonstrated an
overwhelming agreement that perceived low levels of realism in the
available educational models limited the degree to which simulation
could be used in midwifery education.
A major challenge is making simulation as high delity and as
realistic as possible. Simulation models are not lifelike and students
nd it hard to see beyond the plastic model. (F.G. 9). There are certain
limitations that are imposed by the gear that we have. (F.G. 8).
The model that we have [for abdominal palpation] isn't quite as taut as
it should be, it's a little bit oppy, and no fetal heart rate is attached
to it. (F.G. 2). I would like better quality simulatorsa whole mother,
not just the chopped off bit. (F.G. 4).

As a result of limited realism in simulation resources, a number of

participants described how they creatively constructed their own part
task trainers or adapted existing mannequins:
the mannequin we are very artistic with, to make her as obstetric as
possible. (F.G.8)pig's trottersteaching the students how to suture.
(F.G. 1). Improvise by using bits of different models put together
depends on the ingenuity of the lecturer. (F.G.9). [For simulating birth]
you can use a cardboard box and doll, one of those plastic ones. Cut the
head so you've got the fontanellesget a shoebox that you can simulate
as a pelvis and then put it through (F.G.3).

Some things cannot be simulated

Discussions revealed elements of midwifery practice that were
perceived as challenging to simulate. Non-tangible practice elements
were seen as crucially important for midwives to develop, yet almost
impossible to simulate. These occurred within and outside of the
context of performing technical skills. The level of closeness and
intimacy developed in the midwifewoman relationship was seen as
one of these aspects beyond actual technical skills:
it's that closeness to a person. You're never that close to anyone
and you are with a pregnant woman when you're doing a
palpationit's that communication and feeling comfortable in that
environment (F.G. 7). There is a whole dynamic there that you can
never replicate. It will be the person at that moment and her state
in a real midwifery situation you walk into that room and it's that
relationship that you build with that person that determines the
outcome in a lot of respects how actually that situation goes. (F.G. 8).
Furthermore, the midwifery philosophy of being with woman
throughout her birthing experience was highlighted as something
that could not be simulated. This included the concept of holistic,
woman-centred care provision.
midwifery philosophy, women-centred care and all the different
sorts of women and partners and families and environments that
they're going to be inyou can't simulate that. (F.G. 5). You can't
simulate people in that context, that holisticwe're trying to get our
students to see the woman and her baby attached to the family, and
that whole, her values, what makes her, and how that's going to
inuence her carewhen it's real, it is someone's life. (F.G. 9). I don't
believe you need to simulate the birth process on a plastic model, I
actually think it has to be experienced in reality. (F.G. 10)she
[student] was scared just watching the vagina stretching up, that it
freaked her out completely Now you can't simulate that in a
classroom and say this is what is going to happen. (F.G. 3).
Participants articulated that often, unlike other practice-based
disciplines such as nursing, midwifery involved not having hands-on,
but rather standing back and observing. This meant that there were
fundamental aspects that did not lend themselves to simulation.
The difference between nursing and midwifery is nursing is doing, doing,
doing, midwifery is thinking, thinking, thinking, and knowing when not
to do, when you actually have to sit on your hands and let it unfolda
simulation environment doesn't lend itself to sitting and waiting and
watching, and letting something unfold. (F.G. 8). They'll just never learn
the dynamics of sitting with somebody and watching them labour and
everybody's labour changes in a different way. (F.G. 8)nothing is
going to prepare you for walking into a labour room with a woman
screaming and yelling and jumping up and down. You go up, put your
hand on her and say, settle down. (F.G. 8).

L. McKenna et al. / Nurse Education Today 31 (2011) 682686

Extrinsic, sensory and cultural experiences in midwifery practice

were also perceived as difcult to simulate:
one of the difculties is things like vaginal examinations where
you're teaching on really hard boxy things and then you've got the
other that's kind of rubberyYou can't simulate the smell, you can't
simulate the adrenaline rush, you can't simulate your heartbeat
going faster, you can't simulate the noises, there's a lot that you can't
simulate. (F.G. 3)you're going to miss the culture, you're going to
miss the social aspects, the psychological aspects, so there's a lot you
can't capture. (F.G. 3).
Discussion
The focus groups revealed that simulated learning was already
commonplace in Australian midwifery education programmes, predominantly for communication and technical skills. As little previous
work has been done in this area, new insights were gained as to how
simulation was used, and challenges faced, by midwifery academics in
teaching using simulation. Clearly, available models for teaching are
currently not sufciently well developed to support enhanced
simulated learning. Midwifery is a very tactile discipline. Different
types of touch are used in different contexts, for example, in
abdominal assessment, in assessing the strength of contractions,
vaginal examination, as well as therapeutic touch such as stroking and
massage (Stillerman, 2008). The feel of models was seen to be
particularly problematic with currently available models. There is a
need for research and development strategies aimed towards
developing manikins and models that are more life-like and able to
effectively simulate technical aspects of midwifery practice for
simulated learning opportunities to develop further. The use of
simulated patients to teach these skills (Crofts et al. 2008) also
warrants further investigation.
The focus groups also uncovered rich data about the nature and
complexity of midwifery practice that makes simulated learning
challenging. Much of the discussions resonated with what is
considered the art and philosophy of midwifery, including working
in partnership with women and the holistic nature of care (ICM,
2005a, 2005b). Woman-centred care, as dened by Leap (2009) is a
concept that includes the baby and all the people in the woman's
family and community who she denes as important to her. (p.14).
Participants highlighted the importance of midwifewoman relationships, being with women and expressed how difcult these would be
to teach in the context of a simulated learning environment. Technical
skills were seen to form part of midwifery practice, however, these are
rarely isolated in practice but integrated parts within a holistic
approach to care. While competence at performing emergency skills is
important, these are not everyday events. Midwifery is underpinned
by a philosophy that pregnancy and birth are normal events in a
woman's life (Pairman & McAra-Couper, 2006) and this was reected
in discussions. Knowing when not to intervene, but stand back and
observe, are as important as actively managing some situations. These
aspects can be particularly challenging to teach within a simulated
environment.
This study contributes new understandings around simulation in
midwifery education in Australia. However, while it contributes
knowledge into a very limited literature base, ndings are not
generalisable. While much has been published in nursing, further
research is needed that explores simulation in midwifery education in
other countries. Such research has the potential to drive needed
developments in this area on an international basis.
Conclusion
Simulation offers educational opportunities to support the
development of competent midwives. Currently, simulation is used

685

extensively in Australian midwifery education and the potential for

further use is limited by lack of realism in available models and
manikins. In addition, there are also elements of midwifery practice
that may be impossible to simulate. Further research on a more global
base is needed to fully understand potential synergies between the
complex nature of midwifery care and simulated learning environments and how this nexus contributes to education outcomes of the
midwife and the quality of maternity care provided to mothers and
their infants.
Acknowledgements
This study was funded by a Health Workforce Australia Simulated
Learning Environment (SLE) grant. The authors are grateful for the
valuable contributions of the midwifery academics who participated.
Appendix 1. Focus group questions
Can you describe how simulation is currently used in your
midwifery course?
Do you have a dedicated clinical skills area/laboratory for teaching
midwifery skills?
What challenges do you currently face with using simulation?
Do you feel there is an appropriate/ideal amount of simulation in
proportion to clinical time?
Are there aspects currently managed in clinical placements that
may be able to be taught by simulation?
What potential do you see for the increased use of simulation in
your programme?
What would be needed to increase the use of simulation in your
course?
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