cManagement of Preeclampsia and Eclampsia inObstetrical Staf

Angela Christian, DNPSchool of Nursing, Minnesota S

2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier

with fear and despair. Obstetrics, similar to other areas of

ith high levelsith little room

for mistakes or delays. Subtle cues that can lead to

acted on in order to prevent grave consequences.The terminology for hypertension during pregnancy has

evolved over the past several years; most recently, the term* Correspondi

1876-1399/$ - se

http://dx.doi.org

Clinical Simulation in Nursing (2013) 9, e369-e377The field of obstetrical nursing is full of excitement and joy,yet it can rapidly and unexpectedly turn into a crisis filled life-or-death situations need to be recognized and quicklyInc. All rights reserved.

Introduction nursing, requires the nurse to practice wof skill in an autonomous manner, wCite this article:Christian, A., & Krumwiede, N. (2013, September). Simulation enhances self-efficacy in the manage-ment of preeclampsia and eclampsia in obstetrical staff nurses. Clinical Simulation in Nursing, 9(9),e369-e377. http://dx.doi.org/10.1016/j.ecns.2012.05.006.KEYWORDSeclampsia;high-fidelity humansimulation;

human patientsimulator;

nursing education;obstetrics;preeclampsia;self-confidence;Bandura;self-efficacy;NLN/JeffriesSimulationFramework;

obstetrical RNsng author: angela.christi

e front matter 2013 Int/10.1016/j.ecns.2012.05.f Nurses

, MS, RNC*, Norma Krumwiede, EdD, MEd, MN, RNtate University, Mankato, Mankato, MN 56001, USA

AbstractBackground: Preeclampsia and eclampsia are associated with high morbidity and mortality rates,which can be greatly influenced by proactive and competent nursing care. The infrequent occurrenceof these emergencies provides limited exposure for nurses to remain highly skilled and effective.Method: This prospective cohort study investigated the impact of high-fidelity human simulationon the self-efficacy of nurses in the management of preeclampsia and eclampsia. Banduras theoryof self-efficacy and NLN/Jeffries Simulation Framework provided the foundation for this project. Pre-test, immediate posttest, and 8-week posttest single-group design was used to compare preinterven-tion data with postintervention data for family birth place staff nurses (N 49) attending thesimulation training.Results, Conclusions: Obstetric nurses overall self-efficacy with preeclampsia and eclampsia manage-ment significantly increased with high-fidelity human simulation training. More important, the level ofself-efficacy was sustained over time. Staff nurse satisfaction responses were also overwhelminglypositive regarding the training experience. This study supports the use of high-fidelity human patientsimulation as an effective training approach and suggests that other high-risk, low-incidence obstetricemergencies may also be suitable topics for simulation training.Featured Article

Simulation Enhances Self-Effian@mnsu.edu (A. Christian).

ernational Nursing Association for Clinica

006acy in the

www.elsevier.com/locate/ecsnpregnancy-induced hypertension has been replaced with

l Simulation and Learning. Published by Elsevier Inc. All rights reserved.

perfusion to the mother, theplacental-fetal unit is comprocascade is activated (Simpsontal that nurses managing preecing of the disease process. Thesigns of the disease and able topriate interventions and manaand Creehan claim this compcommon medical complicatiobirth, and postpartum; thereforis necessary to manage preecla

Preeclampsia is a common olead to the rare but seriouseclampsia. Eclampsia is assomorbidity and mortality rates1 per 2,000 births (Daniels &2008). Reporting of preeclamlenging because of the lack oof hypertension in pregnancy

tegral role in achiev-ing long-term resultsfor the nurses andimproving patientoutcomes.

Simulation Enhances Self-Efficacy in OB staff nurses e370Control and Prevention (2002) identified that pregnancy-associated hypertension was the most frequently reportedmedical risk factor, occurring in 38.8 per 1,000 live birthsin 2000. In 2004, the State of Minnesota reported thatnationally, 3.6% of all pregnancies are complicated by hy-pertension. The Global Burden of Hypertensive Disorderspregnancy.Just as the classification

of hypertension in preg-nancy is complicated, so isthe management of pre-eclampsia. Beyond the ob-vious risks of reduced organcirculation of the utero-

mised, and the coagulationand Creehan, 2008). It is vi-lampsia have an understand-nurse needs to be alert to therespond quickly with appro-gement strategies. Simpsonlicated disease is the mostn during pregnancy, labor,e, adequate training of staffmpsia effectively.bstetrical condition that canobstetrical complication ofciated with high maternaldespite occurring in onlyParness, 2008; Ellis et al.,psia epidemiology is chal-f conformity in definitions. The Centers for Diseasegestational hypertension. According to Simpson andCreehan (2008), if the woman has gestational hypertensionand proteinuria, her condition is classified as preeclampsia.Further classifications based on accompanying symptomsdelineate preeclampsia as severe when blood pressures

exceed 160/110 mmHg.Other key symptoms maybe seen in renal lab resultsand also include complaintsof cerebral or visualdisturbances and epigastricdistress. When severe pre-eclampsia is accompaniedby seizures, it is calledeclampsia. Preeclampsiacan also be accompaniedby the disease processdiagnosed by hemolysis, el-evated liver enzymes, andlow platelets (HELLP).Women can also havechronic hypertension, whichmay or may not have beendiagnosed before

Key Points HFHS can enhancenursesself-efficacy re-garding preeclampsiaand eclampsia man-agement and suggeststhat management ofother high-risk, low-in-cidence obstetric emer-gencies can also beimproved.

Staff nurses arehighly satisfied withHFHS training whichwill increase activeparticipation and im-proved learning.

HFHS can play an in-pp e369-of Pregnancy in the Year 2000 report (World HealthOrganization, 2003) revealed that 2.3% of all preeclampsiacases resulted in eclampsia, and these hypertensive disor-ders are responsible for 13% of maternal deaths. Unfortu-nately, the United States has not improved maternalmortality rates in more than two decades; furthermore,the rates in the United States are higher than in most otherdeveloped countries (Daniels & Parness, 2008). AsThompson, Neal, and Clark (2004) stated, the outcomefrom eclampsia is directly related to efficient identificationand appropriate treatment by a skilled nurse providing careto the woman. Since experience managing preeclampsiaand eclampsia may be limited because of these conditionslow incidence, it is challenging to develop competency intheir identification and management without the use ofsimulation (Ellis et al., 2008).

The Joint Commission has estimated that 66% of the 75infant deaths that occur each day in the United States canbe attributed to deficiencies in the human factors ofcommunication and competency (State Obstetric andPediatric Research Collaboration, 2007). According to thePreeclampsia Foundation, infant mortality is a devastatingconsequence of preeclampsia, with an estimated 10,500babies dying nationally and half a million worldwide yearlyfollowing preeclampsia. Preeclampsia is responsible for20% of all preterm births worldwide (PreeclampsiaFoundation, n.d.). Miller, Riley, Davis, and Hansen(2008) estimated that 22,980 adverse obstetrical medicalevents occur annually, affecting approximately 1.5% ofobstetric patients nationally. Daniels and Parness (2008)identified embolism, hemorrhage, and pregnancy-inducedhypertension (preeclampsia) as the three leading causes ofpregnancy-related deaths, resulting in an overall mortalityof 11.8 maternal deaths per 100,000 births. Preeclampsiaand eclampsia contribute to 16% of these deaths, 33% ofwhich are believed to be preventable (Daniels & Parness,2008). The low frequency of obstetric patients who advanceto eclampsia or other high-risk conditions does not allowthe practitioner to use the relevant knowledge and skillsfrequently enough to maintain proficiency. The low inci-dence combined with limited resources in smaller hospitalsfurther complicates the high-risk nature of obstetrics,including the management of preeclampsia and eclampsia.

Purpose of the Study and Research Question

The purpose of this clinical practice research project was todetermine whether high-fidelity human simulation (HFHS)is an effective strategy for training obstetrical staff nurses inthe management of preeclampsia and eclampsia. DiCenso,Guyatt, and Ciliska (2005) offered a method for describingthe clinical practice question using the categories of popu-lation, intervention, comparison, and outcome. The re-search question for this project stated in this format is,Among obstetrical staff nurses involved in continuing edu-cation in a birthing center, can high-fidelity simulatione377 Clinical Simulation in Nursing Volume 9 Issue 9

Simulation Enhances Self-Efficacy in OB staff nurses e371training for preeclampsia and eclampsia management in-crease nurses self-efficacy levels and foster satisfactionwith this training approach? This question was answeredby evaluating preepost self-efficacy levels regarding themanagement of these high-risk obstetric episodes. Nursessatisfaction with the simulation experience was obtainedthrough an overall training evaluation collected by theclinical site.

Review of Literature

The National League for Nurses and the Institute ofMedicine emphasized that educational reform within nursingmust involve innovative pedagogies (Brown, Kirkpatrick,Greer, Matthias, & Melvin, 2009). Innovative competencytraining will enhance health care delivery, thereby improvingpatient safety and outcomes (Robertson et al., 2009). To beinnovative and facilitate the clinical training competenciesin the obstetric arena, HFHS may be a promising teachingstrategy to ensure that nurses experience realistic situationsand practice the skill sets essential for meeting for the criticalneeds of obstetrical patients (Larew, Lessens, Spunt, Foster,& Covington, 2006).

The State Obstetric and Pediatric ResearchCollaboration Obstetrics Safety Initiative (2007) is attempt-ing to revolutionize global health by improving obstetricsafety through research and innovative technologies. Itsgoal is to bring simulation and teamwork training into ob-stetrics units to improve obstetric care, especially in smallregional hospitals. Care delivery in a small hospital oftenrequires the nurse to manage complicated obstetric emer-gencies despite the infrequency of the critical episode andlimited resources. The low frequency of obstetrical crisisdoes not diminish the risk to the mother and baby; however,it does complicate the training of new obstetric nurses andcompetency maintenance of existing clinical nurses.

The literature supports the use of HFHS to train newnurses to obtain competencies; however, less emphasis hasbeen placed on the use of HFHS in the maintenance orimprovement of existing competence for staff nurses. Therecommendations for using HFHS in the obstetrical arenaare numerous. Black and Brocklehurst (2003) systemati-cally reviewed training for obstetric emergencies and iden-tified several recommendations for crisis and teamworktraining to reduce errors in the field of obstetrics. Thereis a need to maintain the competence of obstetrical staffto avert, identify, and manage obstetrical complications todecrease fetal and maternal morbidity and mortality.Birch et al. (2007) emphasized that additional training isnecessary because of the lack of exposure to actual emer-gencies, which prevents nurses from gaining and maintain-ing competency in managing these critical episodes.Radhakrishnan, Roche, & Cunningham, (2007) emphasizedthat because HFHS provides the opportunity to engage, ittherefore improves critical thinking abilities (Nehringet al., 2004; Rauen, 2004).pp e369-Although nurses may be oriented to critical events suchas shoulder dystocia, umbilical cord prolapse, placentalabruption, and eclampsia, nurses may spend extendedperiods without the opportunity to practice these skills.HFHS has the major advantage that the learner canparticipate in it at any time and learn interactively ina risk-free environment with immediate feedback (Haskvitz& Koop, 2004; McCausland et al., 2004; Nehring et al.,2004; Rauen, 2004). Jeffries, Bambini, Hensel, Moorman,and Washburn (2009) support the use of HFHS to improvesafety outcomes for obstetric patients by providing a non-threatening opportunity for nurses to increase their commu-nication skills and their clinical competence in makingquick assessments, preparing for emergency deliveries,and reducing critical complications.

The most applicable research in the literature reviewconsisted of simulation studies based specifically on thecritical episodes of preeclampsia and eclampsia. Croftset al. (2008) reported that multiprofessional obstetric emer-gency training for shoulder dystocia, postpartum hemor-rhage, and preeclampsia improved the simulationparticipants perception of their care delivery during thesesimulations. Ellis et al. (2008) cited the necessity for simu-lation as a rehearsal for treating eclampsia. Simulation isnecessary because medical providers may have exposureonly to one case of eclampsia during their 5-year training;therefore, they lack experience and competence. Specifi-cally, Ellis et al. reported better management of eclampsia,and specifically, a 23% increase in completion of tasks aftersimulation. Nurses not only administered the magnesiumsulfate loading dose 31% more often but also did it ina shorter time frame and with higher median teamworkscores. Daniels and Parness (2008) also found HFHS en-hanced training for preeclampsia and eclampsia and offeredthe opportunity to identify specific performance deficits.These data provide strong support for simulation trainingfor preeclampsia.

Theoretical Framework

Banduras self-efficacy theory (Bandura & Adams, 1977)served as the theoretical foundation for this project. Bandurabased his theory on social cognitive theory and recognizedthe strong relationship between person, behaviors, and theenvironment. Self-efficacy is the measurement of choicefor our study, based on Banduras (1989) claim that per-ceived self-efficacy contributes to improved performanceand productivity. The self-efficacy theory has evolved overtime and often supports nursing education, practice, and re-search. Self-efficacy is grounded in the assumptions associ-ated with the interactive-integrated paradigm, or the beliefthat individuals change in an interactive manner and haveinfluence over their actions and behaviors (Resnick, 2008).Individuals exhibit various levels of self-efficacy dependingon the situation (Bandura, 2006). Resnick (2008) definesself-efficacy as an individuals judgment of his or here377 Clinical Simulation in Nursing Volume 9 Issue 9

Sampling Plan

Simulation Enhances Self-Efficacy in OB staff nurses e372capabilities to organize and execute courses of action(p. 183). For example, an experienced nurse in the field ofmedicalesurgical nursing may have a very high sense ofself-efficacy in that area; however, the nurse may havea very low sense of self-efficacy when placed in an emer-gency department. The underlying assumption of this theoryis that what people think, believe, and feel affects how theybehave (Resnick, 2009, p. 118). Thus, performing a behav-ior or observing someone else perform a behavior increasesan individuals perceived capabilities, enhances the individ-uals self-efficacy expectations, and promotes a positivechange in behavior.

Self-Efficacy Processes and Simulation

The theory of self-efficacy aligns well with the construct ofHFHS. Resnick (2008) discussed how peoples self-efficacyexpectations are linked to the way they believe they cansuccessfully accomplish the task at hand. These conceptsregarding perceived expectations, capabilities, and behav-iors determine the nursing actions performed to success-fully assess, identify, and manage preeclampsia andeclampsia. Bandura (1989) noted that expectations do notprovide enough incentive to change behavior or improveefficacy, especially when resources are inadequate. Thesuccessful birth of a healthy newborn can serve as a greatincentive for behavior change for the obstetrical nurses car-ing for families during critical times.

According to Bandura (1995), individuals develop andverify how they feel about themselves through four pro-cesses that align very well with NLN/Jeffries SimulationFramework (Jeffries, 2007). The first process refers to thedirect experiences that actually affect how they act. Partici-pating in the simulation scenario provides the nurse withthe direct experience. The second process is the vicariousexperiences, or performing the action through someoneelses actually doing it. The observation portion of the sim-ulation will provide this opportunity. The third process, re-flecting on judgments of others, is well supported by thedebriefing phase of the scenario. The final process, gainingfurther knowledge through inferences that can be drawnfrom rules, is accomplished during the introduction phaseof the simulation review of the preeclampsia and eclampsiamanagement guidelines. Gaining further knowledge isaddressed as remediation is done to enforce the rulesor appropriate actions to support evidence-based guidelinesand the protocols and orders established by the clinical site.

Measurement of Self-Efficacy

Bandura (2006) affirmed there is no all-purpose method tomeasure self-efficacy. As Resnick (2008) noted, whena researcher is using a self-efficacy tool, it is essential tomaintain behavioral specificity. This can be done by creatingvery specific connections between the behavior beingconsidered with respect to efficacy and the expectedpp e369-All Family Birth Place nurses attending a mandatory annualeducation training (n 49) were invited to participate inthe research portion of the project. The Family Birth Placeis an obstetrical and birthing unit in a regional medical cen-ter in the Midwest and delivers between 1,200 and 1400babies per year. All nurses were women between the agesoutcome. The measurement items need to address the con-struct of interest, which is self-efficacy of nurses in termsof preeclampsia and eclampsia management. Our studyused a self-efficacy tool specifically adapted to measureself-efficacy in relationship to preeclampsia and eclampsiamanagement.

Method

Design

The research design was a prospective cohort study thatexplored how HFHS influences nurses self-efficacy. Thewithin-participants design allowed for comparisons of thestudy variable at three different times among the samestudy participants. The Self-Efficacy for Obstetric CriticalEpisodes Evaluation was used to measure self-efficacylevels in this project. The tool for this study was adapted,with permission to revise and publish, from Ravert (2004),who used the measure to examine nursing students usingHFHS to learn various obstetrical skills, including manage-ment of preeclampsia. The tool was revised to include morespecifics regarding management of preeclampsia andeclampsia, as well as more advanced skill sets as they per-tain to the practicing nurse. The revised content of the Self-Efficacy for Obstetric Critical Episodes Evaluation and thesimulation scenarios were guided by evidence-based guide-lines and unit protocols. They were reviewed by the clinicalstakeholders to ensure content validity before we presentedthem to the staff nurses. Both Raverts tool and the Self-Efficacy for Obstetric Critical Episodes Evaluation usedCronbachs alpha to verify internal consistency estimatesof reliability. Raverts tool had a Cronbachs a .88, andthe revised tool used for this project had a Cronbachsa .93; therefore both indicated high internal consistency.The Self-Efficacy for Obstetric Critical Episodes Evalua-tion, a 5-point Likert-type scale evaluation tool(Figure 1), was administered presimulation, immediatelyafter the simulation, and again 8 weeks postsimulation.Overall participant satisfaction surveys were also collectedby the clinical site. Since the demographic variables withinthis population are fairly consistent and the informationgathered was analyzed as an aggregate, no demographicvariables were collected. Ethical considerations wereaddressed as the research study was approved by the Uni-versity and the clinical agencys institutional review boards.e377 Clinical Simulation in Nursing Volume 9 Issue 9

Pre-QuestionnaireSelf-Efficacy for Obstetric Critical Episodes Evaluation

DIRECTIONS: Individuals do many different things to help themselves perform well in different situations. I am interested in how confident you are in performing each of the following skills. For example for the skill: I can run a marathon, I would rank my confidence as very confident as I have trained for 6 months but this is my first marathon. Record your first reaction: do not spend a lot of time thinking about how well you do the skill- just how confident you are that you can do it.

Please check the appropriate column indicating your level of confidence to perform the skill.

5 =

Extr

emel

y C

onfid

ent

4 =

Ver

y C

onfid

ent

3 =

Mod

erat

ely

Con

fiden

t

2 =

Slig

htly

C

onfid

ent

1 =

Not

A

t All

Con

fiden

t

1. Assessing vital signs (T, P, R, BP)

2. Assessing reflexes (patellar, brachial, and clonus)3. Completing full obstetrical admission physical assessment

4. Completing postpartum assessment

5. Inserting IV

6. Administering IV push medication

7. Administering intravenous piggyback

8. Calculating magnesium sulfate loading doses

9. Monitoring fluid levels

10. Administering blood products

Comments:

11. Understanding pre-eclampsia lab values 12. Monitoring for CNS involvement with pre-eclampsia

13. Managing antepartum patient with disease/condition of pre-eclampsia

14. Managing active labor patient with disease/condition ofpre-eclampsia

15. Managing patient with disease/condition of HELLP Syndrome

16. Managing patient with eclamptic seizure

17. Managing patient with disease/condition of postpartum hemorrhage (PPH)

18. Managing antepartum patient with disease/condition ofgestational diabetes (GDM)

19. Managing postpartum patient with disease/condition of gestational diabetes (GDM)

20. Managing patient with disease/condition of DIC

21. Managing patient with shoulder dystocia

Employee #_________

*Evaluation tool adapted with permission from P. Ravert (2004) dissertation project: Use of a human patient simulator with undergraduate nursing students: A prototype evaluation of critical thinking and self-efficacy.

Figure 1 Prequestionnaire.

Simulation Enhances Self-Efficacy in OB staff nurses e373

pp e369-e377 Clinical Simulation in Nursing Volume 9 Issue 9

in a debriefing session after completing the simulation ex-perience. During the debriefing, the group used a tool sim-ilar to Jeffries (2007), as well as the observation checklistthey had completed earlier. The debriefing phase also in-cluded the remediation phase. Based on deficits notedduring the simulations, this phase took place after our pro-ject was completed.

Data Analysis

The data were coded, entered into SPSS Version 12, andreviewed for accuracy. Paired samples t tests wereconducted on all survey ratings to analyze differences be-tween the pre, post, and final self-efficacy ratings. The out-comes measure of self-efficacy score included two scores,total and intervention specific. The total was based on allquestions in the evaluation tool, whereas the intervention-specific score was derived only from skills that were di-rectly related to the training regarding preeclampsia andeclampsia (Skills 1, 2, 7-8, and 11-17 in Figure 1).

Results

Table 2 presents the descriptive statistics and the pairedt tests for this study. Both measures that were analyzedfor this clinical project yielded significant increases in

Simulation Enhances Self-Efficacy in OB staff nurses e374of 22 and 65 years, and all but one was White. All thenurses participated in simulation activities; 48 consentedto be in the study and completed the first survey beforethe training began. The nurses were then asked to completea survey immediately after the simulation, before leaving(n 47), and then 8 weeks later, the nurses were senta link through SurveyMonkey to complete the third sur-vey (n 33). In addition, the clinical site asked the nursesto fill out an evaluation of the entire development day.

Simulation Intervention

The simulation framework by Jeffries (2007) provided thefoundation for most aspects of planning and implement-ing the simulation intervention. The implementation ofthis HFHS intervention used two different scenarios andoccurred through five phases: prebrief, simulation, obser-vation, debriefing, and remediation. During the first phase,prebrief, the nurses were given a presentation on pre-eclampsia and eclampsia that encompassed recent re-search findings. The complications associated withpreeclampsia, such as eclampsia, HELLP, and reversibleposterior encephalopathy syndrome, were discussed,along with the appropriate diagnostic, assessment, andmanagement strategies for these disease processes. Thenurses were then given an orientation to the simulatorand the various roles. A short labor scenario was com-pleted with all participants. The participants were then di-vided into groups of 3-6 nurses and placed into either theobservation, simulation participation, or debriefingphases. During observation, the nurses observed a liveHFHS scenario by another group. The observers useda checklist of skills that should have been performed bythe simulation participants. Table 1 contains this Simula-tion Evaluation Checklist. This list was based on currentevidence-based practice guidelines obtained from the Na-tional Guidelines Clearinghouse, the Association ofWomens Health and Neonatal Nursing (2008), and thePregnancy Care Councils guidelines and standards ofcare regarding the management of preeclampsia andeclampsia. The participants then moved into one of twosimulation scenarios, different from the scenario theyhad observed earlier. During the simulations, the nursesplayed the role of either the primary nurse, the chargenurse, or a family member. The first simulation scenarioinvolved a laboring patient with preeclampsia. This simu-lation prompted nurses to implement the essential nursingactions for a patient with preeclampsia, such as recogniz-ing the disease and starting a magnesium sulfate load, andprogressed to the management of an eclamptic seizure anddelivery. The second simulation scenario began with thepostpartum aspect of the management of the mother andcompromised newborn. During this simulation, nurseswere expected to manage a postpartum hemorrhage andan overdose of magnesium sulfate, along with the stabili-zation of the compromised infant. All groups participatedpp e369-area. (Not all are applicable to every scenario.), Correctly performed blood pressure, Assessed CV: heart and lungs, edema, look for S/S pulmonary

edema, Assessed CNS: DTRs and clonus, hand grasps, LOC, headache,

visual changes, behavior, Assessed GI system: nausea/vomiting, epigastric pain

(RUQ pain), Sufficient fetal monitoring, Notified provider in timely manner and gave accurate report, Obtained IV access in timely manner, Administered accurate magnesium sulfate in timely manner, Administered calcium gluconate in timely manner, Monitored appropriate lab values, Took necessary seizure precautions, Performed assessments frequently enough, Used antihypertensive medications appropriately, Managed fluid balance appropriately, Planned for delivery appropriately, Managed PP period effectively for mother, Managed PP period effectively for newborn, Accurate information was relayed to the patient, Any other assessments/interventionsTable 1 Simulation Evaluation Checklist

Simulation evaluationObserver intervention checklist

Check all that were performed correctly. Make notesregarding things that could have been improved with eache377 Clinical Simulation in Nursing Volume 9 Issue 9

Simulation Enhances Self-Efficacy in OB staff nurses e375self-efficacy. The total, or overall, self-efficacy ratings onthe posttest (M 81.70) were significantly higher thanthe ratings on the pretest (M 76.24), t(45) 4.83,p < .001. The total, or overall, self-efficacy ratings onthe final posttest (M 83.61) were significantly higherthan ratings on the pretest (M 77.76), t(32) 2.94,

Table 2 Paired Samples T Test and Descriptive Statistics forSelf-Efficacy Scores

N M SD

Paired Differences

M SD t p

TotalPre to 46 76.24 11.97 5.46 7.66 4.83

the skill sets necessary to care for the critical needs of

training. Simulation in Healthcare, 3(1), 42-46. http://dx.doi.org/10.

1097/01.SIH.0000290632.83361.4b.

Simulation Enhances Self-Efficacy in OB staff nurses e376obstetrical patients. Incorporation of HFHS training in thespecialty of obstetrical nursing provides a low-risk envi-ronment for nurses to practice and refine appropriatemanagement of preeclampsia and eclampsia. Through thisevidence-based clinical practice research project, severalimplications for nursing practice have emerged.

Clinical practice nurses self-efficacy with preeclampsiaand eclampsia management increases with HFHS training.Increased self-efficacy is linked to improved skill perfor-mance; therefore, it can be anticipated that HFHS trainingimproves the management of preeclampsia and eclampsiain an actual clinical situation.

HFHS is beneficial in the training of clinical practicenursing staff to deal with obstetrical emergencies. Inaddition, the nurses increased self-efficacy with pre-eclampsia and eclampsia management is sustained overtime. This benefit is very encouraging, especially forsmaller obstetrical units that have limited exposure toobstetrical emergencies but can now benefit from exposurethrough HFHS training. HFHS is a useful teaching strategyto increase nursing confidence and performance in high-risk, low-incidence obstetric emergencies.

HFHS is a teaching strategy that promotes high levels ofsatisfaction among the obstetrics nursing staff. Nurses whoparticipated in this learning activity were highly satisfiedwith the HFHS experience and expressed a desire forcontinuing education to include more training with HFHS.The nurses gained knowledge of the management of pre-eclampsia and eclampsia, as well as increased self-efficacythrough the direct and vicarious experiences associated withthe simulation. Thus, HFHS has the potential to improvematernal, neonatal, and nursing outcomes through improvedmanagement of high-risk maternal situations. In addition,HFHS can provide a clinical site with information regardinggaps in practice, thereby allowing for performance enhance-ment and improved patient outcomes. The transfer ofknowledge is less threatening and more acceptable throughthe use of HFHS for clinical practice nurses and agencynurse leaders.

Conclusions

In conclusion, this clinical practice research project hasdemonstrated HFHS can positively affect nurses self-efficacy regarding preeclampsia and eclampsia manage-ment and suggests that management of other high-risk,low-incidence obstetric emergencies can also be improvedand management of preeclampsia and eclampsia. The coop-eration of the stakeholders, as well as the institutions will-ingness to embrace this innovative change process, wasinstrumental in this clinical practice study on simulationinnovation.

HFHS is a promising teaching strategy to ensure clinicalpractice nurses experience realistic situations and practicepp e369-DiCenso, A., Guyatt, G., & Ciliska, D. (2005). Evidence-based nursing: A

guide to clinical practice. St. Louis, MO: Elsevier Mosby.

Ellis, D., Crofts, J. F., Hunt, L. P., Read, M., Fox, R., & James, M. (2008).

Hospital, simulation center, and teamwork training for eclampsia

management: A randomized controlled trial. Obstetrics and Gynecology,

111(3), 723-731. http://dx.doi.org/10.1097/AOG.0b013e3181637a82.

Haskvitz, L. M., & Koope, E. C. (2004). Students struggling in clinical? A

new role for the patient simulator. Journal of Nursing Education, 43,

181-184.

Jeffries, P. (2007). Simulation in nursing education: From conceptualiza-

tion to evaluation. New York: National League for Nursing.

Jeffries, P., Bambini, D., Hensel, D., Moorman, M., & Washburn, J. (2009).

Constructing maternal-child learning experiences using clinical simula-

tions. JOGNN, 38, 613-623. http://dx.doi.org/10.1111/j.1552-6909.

2009.01060.x.through the use of this clinical teaching strategy. Increasedself-efficacy has been linked to improved proactive nursingperformance and outcomes. The use of HFHS, in trainingobstetrical nurses in the management of high-risk situationsthat occur infrequently, can improve care delivery to thisvulnerable population, especially in smaller hospitals,where the rarity of such emergencies makes actual clinicalmanagement experience less likely. HFHS can play anintegral role in achieving long-term results for the nurses,patients at the birthing center, hospital agencies as a whole,and the community at large in reducing morbidity andmortality rates associated with preeclampsia and eclampsia.

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Simulation Enhances Self-Efficacy in OB staff nurses e377pp e369-e377 Clinical Simulation in Nursing Volume 9 Issue 9

Simulation Enhances Self-Efficacy in the Management of Preeclampsia and Eclampsia in Obstetrical Staff NursesIntroductionPurpose of the Study and Research QuestionReview of LiteratureTheoretical FrameworkSelf-Efficacy Processes and SimulationMeasurement of Self-Efficacy

MethodDesignSampling PlanSimulation InterventionData Analysis

ResultsLimitations

DiscussionStakeholders and Readiness for Simulation

ConclusionsReferences