The initial education of healthcare professionals has undergone a notable evolution in recent years (O'Connor et al, 2022). The COVID-19 pandemic was a landmark event that revealed the global health sector's key needs, especially in terms of human resources (Walton et al, 2020). As a result, research has multiplied to promote the health sector, starting with the gaps identified during the pandemic.
The goal of research in paramedical education is to promote the quality and safety of care (Crosetta et al, 2018). In the past decade, the emergence of simulation has challenged traditional methods of education. Simulation-based education focuses on the learner, but its central principle is the importance of ethical education in terms of the patient: ‘never the first time on a patient’ (Granry and Moll, 2012). Health simulation is an active and innovative teaching method based on experimental learning and reflective practice. It involves the use of manikins by students without exposing patients to procedures being performed on them for the first time by the student (Weller et al, 2012). In addition, it offers students the opportunity to learn from their mistakes without adverse physical and psychological consequences for them or the patient (Holmboe et al, 2011). In medical and allied health education, simulation has added educational value in promoting non-technical skills, such as communication and teamwork (Eisenmann et al, 2018).
Although many universities have adopted simulation in the training of healthcare students, it is not widely used in midwifery education (Changuiti et al, 2021). During internships or after recruitment, midwives are faced with risk situations that can endanger the life of a woman and/or her fetus. Therefore, it is imperative that a midwife has all the necessary tools to face these situations (Bremnes et al, 2018).
The use of simulation in general medical education has been documented in recent reviews (Svendsen and Achiam, 2022; Wu et al, 2022). It was found that in simulation-based medical education, the choice of simulator influences students' skills, and the simplicity of a simulation has multiple advantages (Svendsen and Achiam, 2022). As a result of the rapid development of modern computer simulation technologies, virtual simulation has emerged, with Wu et al (2022) highlighting that learning performance and acceptance of virtual simulation is lower with mandatory participation.
Exploring the use of simulation in midwifery education globally is likely to contribute to promoting more widespread use of this pedagogical method. To the best of the authors' knowledge, there has not been a recent literature review that describes simulation experiences in initial midwifery education on a global scale.
Methods
The focus of this review was the evaluation of articles describing the use of simulation in midwifery education. A search was carried out using the online database PUBMED for articles published between 22 September 2011 and 22 September 2021; these dates were selected in order to review a decade's worth of literature.
Relevant articles were identified using the keywords ‘simulation’ AND ‘midwifery’. The advanced search option was used to search for titles and abstracts containing the keywords that were any of: a case report, classical article, clinical study, journal article, letter, multicenter study, observational study, practice guideline, published erratum, evaluation study, guideline, technical report or validation study.
As shown in the PRISMA flow diagram (Figure 1), the search identified 140 articles. The titles of the publications were carefully examined and 10 articles were excluded as they were not relevant to the topic. Next, the abstracts were screened, leading to 65 articles being excluded. For 38 of the articles, exclusion was because the sample was not midwifery students, and the remaining 27 articles were out of scope. Finally, the full text of the remaining articles was screened, yielding 21 articles that did not meet the eligibility criteria. Three articles were off-topic, five were excluded as the samples were not midwifery students, nine lacked relevance to the research theme and four did not have the full text available. This left a total of 44 articles that were included in the review. A full summary of each article included in the review and its quality assessment is available from the authors on request.
Results
Assessing publications over time, the most articles published in a single year was seven in 2015, 2019 and 2020. In the final year included in the study, 2021, there were four articles published. Full details of trends in number of publications over time are shown in Figure 2.
The geographical distribution of publications by countries highlights that Australia had the highest proportion of studies (30%), followed by the USA (16%), Turkey (11%) and Iran (9%). Three of the articles (7%) were published in the UK. Further details of the geographical distribution of studies are shown in Figure 3.
Objectives
The articles were grouped according to their main aims and objectives:
- Development and evaluation of a simulation experience
- Description and/or comparison of fidelity in simulation learning experiences
- Description of a simulation experience via screens and/or remotely
- Exploration of student midwives' experiences in simulation
- The impact of simulation on student midwives
- Assessment of student midwives' satisfaction in a simulation experience.
Development and evaluation of a simulation experience
A total of 10 articles aimed to develop and evaluate a simulation experience for midwives. East and Hutchinson's (2015) pilot study aimed to evaluate a filmed simulated clinical scenario, wherein most participants reported that the educational resource was more useful than the formal lecture. Students' self-assessment of learning according to Bloom's cognitive domains indicated that the filmed scenario was a valuable learning tool. Further studies (Carolan-Olah et al, 2016; Catling et al, 2016; Ruud et al, 2021) confirmed the positive contribution of simulation in preparing midwifery students to meet the demands of the clinical setting, and emphasised the resulting increase in confidence, comfort, understanding and abilities.
Phillippi et al (2015) and Pilkenton et al (2015) reported on the importance of multidisciplinary teamwork, indicating that simulation leads to improved communication and teamwork skills that ensure optimal collaborative management in high-risk situations. Similarly, Ruyak et al (2018) emphasised the importance of clear delegation of responsibilities in high-stress situations, highlighting that in simulation learning experiences, students were able to work in teams to delegate responsibilities during high-stress moments.
When describing and implementing a childbirth simulation at the University of California in San Francisco, Shaw-Battista et al (2015) suggested that developmental practices were needed, including revision of midwifery education, scenarios, optimisation of fidelity and debriefing time. They also found that adequate preparation and attention to detail increased the immersive experience for students and the benefits of the simulation. Vermeulen et al (2016) similarly described an interprofessional simulation-based educational model that enabled midwifery students to acquire competencies in accordance with national and European legislation and the International Confederation of Midwives (ICM) global standards.
Vermeulen et al (2017) aimed to validate the simulation experience satisfaction scale for use with midwifery students and assess midwifery student satisfaction. Exploratory factor analysis led to development of a three-factor model covering debriefing and reflection, clinical reasoning and clinical learning. Content analysis identified five themes: simulation-based education is valuable, the need for more simulation-based education, fidelity, students with negative feelings and preparation is vital.
Description and/or comparison of fidelity in simulation-based learning experiences
Brady et al (2013) explored fidelity in simulated learning experiences, aiming to improve knowledge about appropriate levels of simulation fidelity. They believed that the results may influence decision making regarding allocation of educational resources for simulation. In a later study, Brady et al (2015) found that progressive fidelity was more beneficial than medium fidelity. Other researchers also compared levels of fidelity. Amanak (2020) compared low-fidelity simulation techniques and hybrid simulation. The group that used hybrid simulation performed best as compared to other groups.
However, when comparing the use of low-fidelity and high-fidelity simulation İldan Çalım et al (2020) found that there was no significant difference between the two in terms of skill and satisfaction and thus reported that both methods could be recommended for midwifery education. Amod and Brysiewicz (2017) and Vermeulen et al (2017) likewise reported on the positive impact of high-fidelity simulation on skill acquisition and increased student confidence. They indicated that high-fidelity simulation promotes reflection and allows students to learn from their experience and apply their skills in a real-life situation.
Two further studies (Lindsay Miller et al, 2015; Pedersen et al, 2021) focused on hybrid simulation. Pedersen et al (2021) evaluated students' performance in interprofessionalism, finding that they appreciated the realism of the simulation session, which increased acquisition of skills, especially with the use of good practices (repetitive practice, team learning, group debriefing). Similarly, Buxton et al (2015) found that simulation with standardised patients can help students develop ethical skills. Low-fidelity simulation also improved students' confidence in skills related to second stage management of the perineum (Arias et al, 2016). The authors of this study explored the contribution of Kolb's experiential learning approach to training, to address students' deficiencies.
Description of a simulation experience via screens and/or remotely
Ackland-Tilbrook and Warland (2015) described the process of creating and implementing a visually authentic learning tool in an undergraduate midwifery programme. The goal was to facilitate student learning through visual representation of authentic real-life simulations, which showed promising results. Kordi et al (2016) compared the efficacy of web-based, simulation-based and conventional training on accuracy in the visual estimation of postpartum hemorrhage volume. They recommended the use of web-based training as a supplement to training with simulation and conventional methods.
The COVID-19 pandemic was the basis of several studies. Prasad et al (2020) described an obstetric and neonatal simulation workshop conducted in a distance learning format where students demonstrated positive interaction during the experience. Michelet et al (2020) described the impact of computer debriefing after on-screen simulation training. Student midwives were divided into two groups: experimental and control. In the second simulation session, the experimental group that received debriefing achieved higher non-technical competence and self-efficacy scores than the control group, who did not receive computer debriefing.
Exploration of student midwives' experiences in simulation
Burns et al (2021) evaluated students' experiences in interprofessional simulation workshops with midwifery and medical students. This allowed students to improve their ability to work in a collaborative practice setting. Students added that learning to work as a team in a safe environment allowed them to appreciate the scope of practice and responsibilities of each team member in an emergency situation. Similarly, Kumar et al (2018) assessed student learning through a simulation programme using a pre-test and post-test format. Post-test scores were significantly higher than pre-test (P<0.001). Students described the benefits of assessment on learning and reflection on performance, cementing previous learning as a post-assessment effect.
Three further studies (Scholes et al, 2012; Lendahls and Oscarsson, 2017; Maskálová et al, 2018) demonstrated links that simulation created between theory and practice, especially in crisis situations, such as postpartum haemorrhage. They also demonstrated the role of simulation for students to practice their skills and abilities repeatedly in a safe environment, without risk to patients. Furthermore, the simulation was an opportunity for the teacher to provide students with instruction and feedback. In addition, simulation training was found to motivate students to interact, support hands-on training in the clinical setting and increase students' satisfaction in training and their confidence when entering clinical practice (Tyer-Viola et al, 2012).
Simulation's impact on student midwives
A total of 13 articles reported on the impact of simulation on midwives. The areas assessed included their:
- Knowledge
- Skills
- Perceptions
- Confidence
- Comfort
- Creative thinking.
Changuiti et al (2021) demonstrated the positive impact of simulation on midwifery students' learning in eutocic and dystocic situations. The post-test results after simulation were high compared to pre-test results, emphasising the experiential component of the simulation established through repetition in learning. Coyer et al (2014) added that simulation had a positive impact on knowledge retention and perpetuation of confidence after a few months of practice.
Simulation training was noted as a recruitment facilitator in one third of the 13 articles that assessed the impact of simulation. Similarly, Forster and Donovan (2016) showed that simulation helps students develop and reflect on their skills. They also highlighted the need to equip students with self-care strategies to manage their personal reactions in highly emotional situations, such as neonatal death. Gueneuc (2019) recommended the use of simulation to supplement clinical internships in view of the great interest shown in the experience of obstetric ultrasound.
Guler et al (2018) and McKelvin and McKelvin (2020) reported on the positive impact of immersive simulation training on students' confidence in performing skills in episiotomy and basic life support, especially in real-life scenarios of stress where there was a danger of morbidity and mortality. Khadivzadeh and Erfanian (2012) published a study examining the effect of a simulation-based course using simulated patients and gynaecological models on students' anxiety and comfort when practicing providing intrauterine device services. They found significant differences between students in simulation and traditional learning groups in terms of two aspects of anxiety and comfort (P=0.001) when providing services.
In an interprofessional simulation session McLelland et al (2017), assessed students' self-efficacy and confidence in their ability to successfully facilitate a birth in an unplanned setting. They found that the session significantly improved students' abilities after 1 month (P<0.001), and this improvement was maintained after an additional 3 months. Additionally, student satisfaction with the simulation experience was consistently high. Several studies (Gönenç and Yılmaz Sezer, 2019; Karakoc et al, 2019; Stoodley et al, 2020; Hakimi et al, 2021) agreed that students' knowledge, confidence and skills significantly increases after a simulation activity (P<0.001), despite the presence of stress. The key aspects that contributed to student learning were level of knowledge, expertise and how up-to-date the demonstrator's practice was, as well as the role the student assumed in the simulation activity.
Shirazi et al (2020) focused on the importance of promoting students' creative thinking with new techniques in order to foster innovation in an enjoyable educational atmosphere. Their study aimed to determine the effect of technical simulation using the goldfish bowl method. Based on the results of their study, they recommended the use of this technique in teaching midwifery students to promote creative thinking.
Assessment of student midwives' satisfaction in a simulation experience
Only one article focused exclusively on assessing midwifery students' satisfaction in a simulation experience (Jamie and Mohammed, 2019). The authors found that students who considered the number of skill demonstrations per semester to be sufficient were 2.3 times more likely to be satisfied with simulation-based instruction. From this, they were able to prove the role of faculty effort in student satisfaction during simulation-based instruction.
Discussion
To the best of the authors' knowledge, this is the first systematic review undertaken to look at the application and integration of simulation in midwifery education on a global scale. A thorough search of published literature revealed only one other paper that explored studies published from 2000 to 2010, where the authors were limited to studies that focused only on emergency obstetric situations using simulation (Cooper et al, 2012). The present review explored all research published in the last decade related to simulation and initial midwifery education.
The authors provided feedback on the simulated scenarios through description of the simulation experiments (Shaw-Battista et al, 2015). The reviewed studies highlighted the benefits of simulation in communication, self-confidence, comfort, teamwork and collaborative management (Carolan-Olah et al, 2016; Catling et al, 2016; Ruud et al, 2021), in addition to its role in preparing students for an internship (Phillippi et al, 2015; Pilkenton et al, 2015).
Some of the reviewed studies compared different levels of fidelity, with conflicting results. Some preferred high-fidelity simulation, as it was felt to be closer to reality (Vermeulen et al, 2017; Amod and Brysiewicz, 2019). In contrast, other authors focused on hybrid simulation and justified the level of realism that it provides, adding that it allows students an opportunity for multidisciplinary teamwork (Lindsay Miller et al, 2015; Pedersen et al, 2021). Low-fidelity simulation was explored in only one study, which confirmed its positive impact in improving student confidence (Arias et al, 2016).
In addition to other forms of simulation, virtual simulation was examined by several studies. Ackland-Tilbrook and Warland (2015) described a visually authentic learning tool and confirmed its specificity in digitising a care environment. Similarly, Kordi et al (2016) proved the importance of computer debriefing in simulation. The COVID-19 pandemic caused widespread disruption to education delivery and prompted a move to online alternatives. This prompted several studies on the use of simulation in midwifery education (Michelet et al, 2020; Prasad et al, 2020).
When exploring students' experiences, it was found that most students expressed satisfaction with a simulation. Burns et al (2021) valued the importance of simulation in projecting theoretical learning into the clinical setting. Similarly, other researchers reported that simulation provided an an opportunity for learners to develop skills through repetition (Scholes et al, 2012). Simulation was not limited to the benefits it presented to students, as it also offered faculty the opportunity to provide continuous feedback (Tyer-Viola et al, 2012).
Limitations
This study was limited to searching only one database for articles. Expanding the search by including other databases would be useful, however the authors weighed the benefits/risks, and limited the search to PubMed as it had the largest number of articles in the study area. Searches of other databases would likely yield duplicate articles, increasing the time it would take to screen and analyse search results. Thus, only one database was searched, to ensure results were published in a timely manner.
Conclusions
This review examined studies on simulation in midwifery education on a global level. Significant effort is needed to improve quality of care and patient safety. This review forms a starting point for exploring simulation use in midwifery education, as it provides a general overview of the literature from the last decade.
Key points
- Simulation experiences help prepare students for a clinical environment.
- Educators can choose the type of simulation according to session objectives.
- Exploring the use of simulation in midwifery education worldwide may contribute to the widespread use of this educational method.
CPD reflective questions
- Did you participate in simulations as part of your midwifery education? If so, how was it useful?
- How might the type of simulation affect midwifery education?
- How can feedback on simulation experiences be used to inform ongoing simulation use in midwifery education?