الفهرس 
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Abstract
Helmy Mourad, Manal Hassan Ahmad.
Childbirth is a universal phenomenon and it is the most important event that constitutes a powerful and unique experience in women’s lives and lives of their families. All childbirth-related experiences are fixed into women’s memories and outline their identities as mothers. Concurrently it is a period that imposes intense stress on the woman’s life that may affect her physical, mental & emotional status. This requires adequate and continuous health supervision, evaluation and appropriate intervention from the skilled birth attendant or midwife throughout the labor and delivery process in order to promote a positive outcome for women and their families.
The most common causes of maternal deaths are: postpartum hemorrhage (PPH) (31%), hypertension (20%), obstructed labor (7%) sepsis (1%), and unsafe abortions (1%). PPH is considered a major cause of maternal morbidity and one of the top three causes of maternal deaths in high and low-income countries. Worldwide PPH accounts for at least 150,000 maternal deaths and 20 million morbidities every year, 28% of these deaths are in developing countries. Traditionally PPH is defined as any amount of blood loss that affects the general condition of the woman after delivery. While, the most recent accepted definition according to the American College of obstetrician and gynecologist (ACOG) 2017 is defined it as cumulative blood loss greater than 1000 mL with signs and symptoms of hypovolemia (hypotension, tachycardia, cold clammy skin &confusion) within 24 hours of the birth process, regardless of the route of delivery. The prevention and management of PPH will be achieved through the comprehensive and multidisciplinary cooperation of health care providers.
Simulation in nursing education has become a standard practice in many parts of the world, but there remain issues related to instructor preparedness, resources, and appropriate curricular integration. The use of simulation as either a primary educational approach or as a supplement for both didactic teaching and clinical experience has now become standard practice across much of the world. Munangatire (2017) had defined it as ’’situations where models are used for practice and to gain experience that will enhance students’ practical skills’’.
This study aimed to:
Determine the effect of using hybrid simulator on intern students’ skills regarding nursing management of atonic postpartum hemorrhage.
Research hypothesis
Intern students who are trained by using hybrid simulator demonstrate higher skills level than those who don’t.
Materials and method:
The study was conducted in the training unit at El Shatby Maternity University hospital. Subjects: A simple random sampling technique was used to select the needed number of study subjects (80 interns). This was done according to Epi-info. The 80 subjects were divided randomly to two equal groups, study and control (40 for each).
Tools
Two tools were used:
Tool I: - Intern students’ knowledge regarding nursing management of atonic postpartum hemorrhage questionnaire.
This tool was developed by the researcher after extensive review of recent, current & relevant literatures. It included two parts:
Part I: Intern students’ socio-demographic and professional profile such as: age, GPA (grade point average) etc………
Part II: Intern students’ knowledge about postpartum hemorrhage.
Tool II-Intern students’ skills regarding nursing management of atonic postpartum hemorrhage observational checklist. This tool was adapted from the WHO guideline (2017) ’’ to appraise the intern students’ skills regarding the management of atonic PPH.
The program was developed through the following phases:
Phase (1): Assessment:
- The study and control groups were given a pretest for the knowledge and skills by using tool I (Appendix II) and tool II (Appendix III).
Phase (2): Preparation:
The researcher prepared the needed content depending on the pretest results: The content of theoretical part about PPH and the needed equipment for the simulated clinical environment as - Hybrid simulator and accessories in addition to various simulation scenarios.
Phase (3): Implementation of training:
- Study group: was divided randomly into eight subgroups; each includes 5 intern students’.
I. Theoretical part: it was carried out in two lectures combined with power point presentation about the nursing management of atonic PPH.
Session (1): (2hours): It included basic knowledge about PPH as definition, types, causes etc..
Session (2): (2hours): It included general nursing management of PPH etc…
II. Training skills:
A. The researcher demonstrated the nursing management of atonic PPH by using hybrid simulator with various scenarios in the training unit to the intern students.
B. The training skills were done in 6 sessions in 3 days 2 sessions / day and 4Hr /day.
C. The training skills were carried out as a role play for each session as follows:
Session (1): (2hours): The researcher demonstrated the nursing skills regarding the assessment and early detection of PPH through general and local examination, estimation of amount of blood loss as well as making call for help and resuscitation of the woman.
Session (2): (2hours): The intern students re-demonstrated the nursing skills regarding the assessment and early detection of PPH through general and local examination, estimating the amount of blood loss as well as making call for help.
Session (3): (2hours): The intern students re-demonstrated the nursing skills regarding the process of woman’s resuscitation through assessment of (ABC) airway, breathing and circulation, then insertion of two intravenous lines 14 and 16 size, followed by giving crystalloid IV fluids.
Session (4): (2hours): The researcher demonstrated the nursing skills regarding arresting the bleeding through performing uterine massage, internal and external bimanual uterine compression. In addition, monitoring and investigating the woman’s general condition as well as evaluating and documenting all procedures.
Session (5): (2hours): The intern students re-demonstrated the nursing skills regarding arresting the bleeding through performing uterine massage and bimanual uterine compression.
Session (6): (2hours): The intern students re-demonstrated the nursing skills to monitor and investigate the woman’s general condition through estimation and interpretation of arterial blood gases, assessment of fundal height regularly, firmness of uterus and documenting the intake and out-put and woman’s level of consciousness.
- The training skills were implemented in 16 weeks by the researcher. Each subgroup covered 2 weeks. The program started from 3-10-2018 until 30-1-2019.
- Each student rotated her role in four sessions to take the chance of practicing all four roles.
Phase (4): Debriefing:
Closely, following each simulation session, the researcher provided a debriefing as an intuitive activity. Handout about management of PPH was distributed after implementation of the simulation training.
- As for the intern students in the control group were oriented and trained through the hospital routine about the management of atonic PPH.
Phase (5): Evaluation:
- The researcher then assessed the knowledge and skills of nursing management of atonic PPH for both groups (study &control) as post-test by using tools I&II.
Main finding:
A. Socio-demographic characteristics:
The present study revealed that: No statistically significant differences were observed between the study and control groups regarding their Socio-demographic characteristics.
B. knowledge about nursing management of PPH:
1- No statistically significant differences were observed between the study and control groups regarding their knowledge level before simulation training.
2. The vast majority of the study group (90%) compared to none (0.0%) of the control group had a good total knowledge level after one month while, As much as 75% of the study group compared to none (0.0%) of the control group had a good total knowledge level after three- months from simulation training.
3. There was a statistically significant differences were found between the study and control groups regarding their knowledge level after one and three- months from simulation training.
C. Skills about nursing management of PPH:
1. No statistically significant differences were observed between the study and control groups regarding their skills level before simulation training.
2. The vast majority of the study group (90%) compared to (5.0%) of the control group had a good skills level after one month while, Slightly more than three- quarters (77.5%) of the study group compared to only (2.5%) of the control group had a good total skills level after three- months from simulation training.
3. There was a statistically significant differences were found between the study and control groups regarding their skills level after one and three- months from simulation training.
D. The Conclusion:
E. According to the study results the hypothesis is accepted and the hybrid simulation training program had a significant effect on skills performance among the study group after one and three- months from conducting the simulation training program regarding all items such as call for help, resuscitation, arresting the bleeding, monitoring& investigations as well as evaluation & documentation.
Recommendations
Based on the findings of this study, the following recommendations were suggested:
1. Incorporating simulation training program in the basic nursing curriculum to help nursing students to acquire the essential knowledge and practice.
2. Conduct an interdisciplinary simulation training program on a regular basis for maternity nurses about the emergency obstetrics.
3. Continuous monitoring of maternity nurses performance about their role in active management of the third stage of labor by nursing supervisors.
For further researches
1. Replication of the same study in different Egyptian faculties of nursing especially to introduce the concept of simulation and explore its importance for nursing students.
2. Focus on evaluating the effectiveness of simulations on students’ skill performance regarding the management of PPH.
3. Comparison between the retention of skill performance over time based on differences in the simulation experience (high fidelity and low fidelity simulation).