Simulation is defined as ‘a technique, not a tech nology, to replace or amplify real experi ences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner’ (Gaba, 2004: 1). Simu lation in midwifery provides learners with a unique opportunity to practise hands-on skills and competencies and allow them to learn from mistakes in repeated teaching activities, integrating new knowledge rapidly and without putting a woman or infant at risk (Scholes et al, 2012). The use of simulation in midwifery predominates in obstetric emergencies such as shoulder dystocia and cord prolapse emergencies (Merién et al, 2010; Cooper et al, 2012), rather than more routine training such as how to perform a full antenatal consultation.
The antenatal consultation is of particular interest because it is a major part of midwifery, incorporating elements of bio-psychosocial screening, prevention, health promotion and professional skills. However, its teaching is sometimes underestimated, and educators tend to favour training in obstetric complications (Pairman, 2006; Klima et al, 2009; Fullerton et al, 2016). In nursing and medical science, authors advocate that simulated learning encompasses the cognitive, psychomotor and affective domains of learning to accommodate the preferences of all nursing students and enable them to provide holistic care (Ricketts, 2011; Vyas et al, 2011). A standardised approach to simulated learning in nursing education, with the development of clinical scenarios linked to relevant theory and lectures, would offer measurable learning outcomes to meet professional and regulatory requirements (May et al, 2009). Simulation in midwifery education with simulated patients (SPs) is useful when psychomotor and cognitive skills are taught in an integrative manner with communication and relationship competencies (Cooper et al, 2012). There is a clear benefit of simulation in terms of communication and relationship skills.
Simulation-based education is consistent with national and international trends and professional standards regarding patient safety, multidisciplinary models of care, and quality care improvement, and has shown substantial effects on the development of clinical competencies, particularly in the fields of medicine and nursing (Issenberg et al, 2005; McGaghie et al, 2010). SP methodology is an effective teaching tool for simulation-based education; an SP is a lay person trained to portray a patient with a specific con dition in a realistic, standardised and reproducible way (Barrows, 1987). SPs can collaborate for teaching and assessment of students including clinical competencies and professionalism. They can also collaborate to give feedback and evaluate students' performance in such teaching activities (Cleland et al, 2009; Nestel et al, 2011).
Feedback to improve students' performance
Feedback is defined as information describing the performance of the student in an activity that guides future performance in a similar activity (Ende, 1983). The purpose of feedback is for the student to detect his or her own mistakes, overcome obstacles and implement new strategies to achieve the learning aims. One of the main characteristics of good teaching practice through simulation is that feedback takes an important place in the acquisition of professional skills (McGaghie et al, 2010). These skills include clinical examinations, clinical reasoning, communication and relationship-building. In their literature review, Issenberg et al (2005) noted that the feedback given in the context of training seems to strengthen the acquisition and maintenance of professional skills, in addition to slowing the decline in skills over time. Bokken et al (2009) indicated that oral structured feedback was highly appreciated by students in undergraduate medical education. SPs' feedback may include different domains of competencies, such as communication or physical examination (Wallace, 2009). There are few studies comparing the effects of different modalities of feedback given by SPs in medical education, but they show promising effects on the development of professional skills (Johnson, 2016).
Immediate versus delayed feedback
Immediate and delayed types of feedback were of particular interest because they are most often performed in teaching facilities, but it is not known which of the two is most favourable to the development of students' professional skills. Literature reflects that immediate feedback helps develop professional skills such as history-taking skills, self-assessment and physical examination (Elman et al, 2004; Yudkowsky et al, 2009). However, several experimental studies have shown that delayed feedback is also beneficial and allows the memory to perform maximum retention, therefore providing time for learners to reflect on their performance (Brackbill et al, 1963; Pennaforte et al, 2016). Immediate feedback and its proactive nature may interfere with the recognition of a mistake and could slow down the required skill acquisition; after being under the pressure of the teaching activity, participants sometimes forget or inaccurately recall their performance (Kulik and Kulik, 1988; Pennaforte et al, 2016). Meanwhile, delayed feedback contains no proactive elements, and a mistake is often spontaneously detected by the student during the period of time during which the student receives the feedback. Furthermore, delayed feedback has been shown to support the development of technical skills, non-technical skills such as knowledge, safe and reflective judgement, and effective decision-making (Vadnais et al, 2012; Madani et al, 2016). There is little evidence of the extent to which immediate or delayed feedback would be most beneficial for integration of professional skills and competencies (Kulhavy and Anderson, 1972). This has implications because simulation training can be very resource-intensive. In order to optimise educational design and evaluate the added value of simulation, it is essential to better evaluate practice with immediate or delayed feedback to ensure that the most efficient method is chosen for the specific teaching activity (Madani et al, 2016). There are several limitations in current research on simulation. Firstly, the available studies have been conducted in the context of medical education; no studies in the field of other health professionals were identified on the subject. Secondly, studies involving the use of simulation with SPs are mostly undertaken in the USA, UK and Australia, and may not be generalisable to other countries (May et al, 2009).
This study has, therefore, been designed to improve knowledge on the best time to provide feedback to students and to evaluate student competencies in the context of midwifery education following a teaching activity with an SP. There is a growing interest in integrating simulation into undergraduate and postgraduate education in the health professions, but the impact of the use of SPs in teaching basic professional skills and competencies of midwives has rarely been documented (Dow, 2008).
Aims
The aim of this study is to explore whether immediate individual feedback (IIFB) is more effective than delayed group feedback (DGFB) in relation to the development of students' clinical and communication skills and competencies, and which feedback method is associated with a higher level of student satisfaction. The study's objectives were:
Methods
This educational intervention was integrated in the University Of Health Sciences Of Lausanne. A mixed-methods design with quantitative and qualitative data collection was used. Data were collected via a 39-item grid developed by lecturers to evaluate students' clinical and comm unication performances, and a questionnaire using 12 closed and open-ended questions for students to evaluate the quality of the feedback and the overall teaching activity.
Participants
The participants were students were in their first year of BSc in Midwifery at the University of Health Sciences in Lausanne, Switzerland (HESAV). The evaluation of the teaching activity was undertaken in 2011 and 2012 in order to maximise the number of students recruited (n = 51). Study participants were aged 21–45 years old. To determine when simulation would have the greatest impact during the student pro gramme, the simulation post with SP station was organised in the first year, at the end of a theoretical module of ‘Normality in pregnancy’, and after 1 month of practice either in the labour ward, postnatal ward or antenatal clinic. All the students on the midwifery programme were invited to participate in this formative assessment; the questionnaire was anonymous and study participation was on a voluntary basis.
Procedure
Scenario
The objective of the teaching activity is that students are able to autonomously lead a physiological antenatal care session at any time of pregnancy. To demonstrate students' com petencies in autonomously guiding a holistic antenatal care session, the individual formative module assessment has been built around a scenario: a healthy woman in her third pregnancy with no risk factors in her medical or obstetric history comes for a routine 32-week consultation with her midwife. The woman's pregnancy is uncomplicated but at this consultation she has two complaints: tiredness and abdominal pain.
After the teaching activity, the students were randomly allocated to receive either IIFB or DGFB at time T0 (T-zero). After a period of 18 weeks (T + 18 weeks), the students were asked to attend a second teaching activity and again demonstrate their competence in leading a physiological antenatal care session with a similar scenario, where the woman complains of tiredness and leg pain. Students' skills and competencies were evaluated at T0 and T + 18 weeks after receiving IIFB or DGFB. Students continued to undertake their usual academic courses (clinical placement and lectures) during the 18-week period.
Feedback
Evaluation grids
Clinical and communication grids were adapted from the Calgary-Cambridge Referenced Observation Guide on communication, and were completed by the lecturer during the student's performance:
The clinical grid includes 26 items including calculation of the esti mated due date, an enquiry about the woman's com plaints, and working with the woman to identify meth ods for relieving her problems, taking into account her lifestyle and family situation. It also covers routine antenatal checks such as fetal movements, evaluation of contractions, uterine height, Leopold's manoeuvres adapted to gestational age, estimation of fetal weight and amniotic liquid as well as fetal heart rates with Pinard horn. An observation of the woman's physical behaviour and an examination of the physical signs related to the complaint were also part of the grid. The elements to be assessed were marked as realised, partially realised or not realised; an ordinal value of 2, 1 or 0 was attributed to each element.
The communication grid comprises 13 items evaluating non-verbal communication, such as: creation of a suitable atmosphere that allows the woman to discuss her concerns and needs; recognition of the solutions expressed by the woman; the use of clear and adapted vocabulary; respect for privacy; obtaining consent before abdominal palpation; and warming up hands before touching the woman's abdomen. The content validity was examined by an expert panel (two midwifery lecturers and an expert in simulation programmes), tested and then modified by the lecturers.
An additional questionnaire was com pleted. The first section evaluated satisfaction with the teaching activity—for example, the credibility of the SP and the scenario, the difficulty of the scenario, the organisation of the room and the student's satisfaction with the teaching activity. The second section allowed for comments on the students' experience during the teaching activity and how it could be improved. This questionnaire included eight closed questions using a 5-point Likert scale from ‘strongly agree’ to ‘strongly disagree’, and four open-ended questions. The questionnaire was given to all students after their IIFB or DGFB.
The researchers analysed the quantitative data using SPSS software (version 19). Descriptive statistics were used to compare the groups receiving either IIFB or DGFB; different tests were used depending on whether the data were normally distributed (parametric tests such as the t-test or F-test were applied) or not normally distributed (non-parametric tests such as Mann– Whitney U test for binary data, Kruskal–Wallis test for multiple categories), using a statistically significant P-value usually set at < 0.05.
Qualitative findings were analysed using thematic analyses. Each category was written on a table until saturation of the themes was achieved. There was inter-judge content agreement with the three experts. Three main results were highlighted from descriptive analyses.
Simulated patients and training
Five SPs were trained to play this scenario. These women had all experienced pregnancy and childbirth, but the lecturers selected only SPs who did not have a history of pregnancy loss or any other severe perinatal complication, as the experience could be detrimental for them. The SPs were paid for the time spent on training and performance on a local pay scheme, funded by the university.
Information for students
The students received a short briefing (both orally and by email) on what to expect during the formative assessment, 1 week in advance. Each student was asked to play a student midwife who autonomously leads the antenatal care session in the senior midwife's short absence, but could call another midwife for advice if needed. After spending 15 minutes preparing a consultation using the woman's antenatal record, the student conducted a complete antenatal appointment within 30 minutes, which is the usual time required to lead an autonomous visit.
Findings
Clinical skills
From lecturer's grid: quantitative results
The researchers grouped the 26 items of the clinical grid into four sections, which were tested:
Students' communication skills during the consultation were also evaluated.
Kruskal–Wallis non-parametric tests on independent samples were undertaken and showed a significant difference (P = 0.034) between students who had IIFB and DGFB with scenario 1 and scenario 2 in relation to history-taking (Figure 1). Improvement of their competencies in history-taking was found in the following elements: enquiring about the woman's complaints; obtaining a clearer description of the complaint (either abdominal pain, leg pain or tiredness); identifying what remedy the woman has used for her complaints; exploring the woman's lifestyle context. In order to eliminate as many confounding factors as possible, the researchers excluded students who gained additional experience during their clinical placements in antenatal care clinics between T0 and T + 18 weeks; therefore, the initial sample of 51 women was reduced to 20. The researchers acknowledge that this process inevitably reduced the sample size, but this was deemed the best way to determine the significant effect of the IIFB.
Data analysis showed two statistically non-significant results (P = 0.071) in relation to introduction of the consultation (e.g. introduction to the woman and calculation of the gestation) (Figure 2) and communication (e.g. invite the woman to talk about her needs, respect the woman's views, listen to the woman, use a non-jargon terms) (Figure 3). Although these results are not statistically significant, they nevertheless show that students who had IIFB improved their skills in these areas to a greater extent than those who had DGFB.
The Kruskal–Wallis test conducted on clinical examination and the end of the consultation yielded non-significant P-values of 0.312 and 0.173, respectively.
Students' evaluation: quantitative and qualitative results
Quantitative findings revealed that students who received IIFB were significantly more satisfied with the timing of the feedback they received than those who had DGFB (4 vs 2.33; P < 0.001).
Students were significantly more satisfied about the length of time dedicated to them during the IIFB compared to the DGFB (P = 0.0003) even though the overall time was longer with the DGFB (2.5 hours with DGFB compared to 30 minutes with IIFB). In addition, the students felt that IIFB was significantly more constructive than DGFB (P < 0.001). Overall, both groups were satisfied by the way their feedback was given (3.57 for IIFB; 2.34 for DGFB) but those who received IIFB were significantly more satisfied compared with those who received DGFB (P < 0.001) (Table 1).
| Item | Immediate individual feedback | Delayed group feedback | ||||
|---|---|---|---|---|---|---|
| Mean | SD | Median | Mean | SD | Median | |
| What is your satisfaction concerning the way the feedback was given for this teaching activity in general? | 3.57 | 0.87 | 4 | 2.34 | 1.22 | 2 |
| Are you satisfied by the feedback given by the SP? | 3.73 | 0.6 | 4 | n/a | n/a | n/a |
| Was the time dedicated to feedback sufficient? | 3.63 | 0.64 | 4 | 2.92 | 1.19 | 3 |
| Was the feedback you received constructive? | 4 | 0 | 4 | 2.88 | 1.12 | 3 |
| Was the feedback given at a convenient moment for you? | 4 | 0 | 4 | 2.33 | 1.01 | 3 |
SD–standard deviation; SP–simulated patient
Students reported the importance of the practice of simulation in improving their clinical skills, with 89% reporting improvement regardless of the type of feedback. In addition, students said this teaching activity helped them to develop competencies such as history-taking, precision of clinical examination and taking initiative, which are directly transferable to clinical practice. Finally, all students believed feedback from the SP was important, highlighting that personal feedback should not be provided by the lecturer alone but should be supplemented by that from the SP (Table 2).
| Question | IIFB | DGFB | Comments from students | ||
|---|---|---|---|---|---|
| Yes | No | Yes | No | ||
| Is simulation a good teaching activity for you to learn the skills required? | 89.7% | 10.3% | 89% | 11% | ‘It is very good to make links between theory and practice. The situation is really real and I am directly confronted with my gaps [in skills], it's very constructive.’ |
| During this session did you develop competencies that you could integrate into your practice? | 92% | 8% | 89% | 11% | ‘I developed my communication skills, how to conduct the consultation, how to make the woman at ease.’ |
| Is it important for your training to receive feedback from the SP? | 100% | 0% | 100% | 0% | IIFB student: ‘IIFB is a necessity. We can immediately know what is appropriate or not. The feedback is given in a personal [way] and focuses on important elements. Feeling and comments are more detailed, that's why I can better adjust my actions afterward.’ |
DGFB–delayed group feedback; IIFB–immediate individual feedback; SP–simulated patient
Discussion
Simulation in midwifery of holistic antenatal care with the participation of SPs is not common; it has not been evaluated nor published in literature (May et al, 2009; Cooper et al, 2012). This study has offered a specific angle on how two common types of feedback, usually provided by lecturers, may have an impact on the development of clinical and communication skills and student satisfaction. The results of this study can, therefore, support an academic decision to accommodate IIFB rather than DGFB according to the objectives of the teaching activity.
Some results directly related to the student curriculum were found. First, IIFB significantly improved students' competencies in carrying out the SP's history-taking (P = 0.034) and there was a clear emphasis that having the opportunity to receive this feedback significantly supported the development of skills compared with receiving DGFB. Feedback given immediately after the performance of the activity, along with repetition of the teaching activity a few weeks later, enhances a student's ability to structure and obtain relevant information from the SP in the subsequent teaching activity. Positive trends were highlighted in the introduction of the consultation and in communication; again, IIFB seemed to improve these sections of the antenatal consultation more than DGFB. These findings reinforce results from Elman et al (2004) and Yudkowsky et al (2009), that immediate feedback improves competencies in anamnestic skills and physical examination— and this applies not only in medical education but also in midwifery, in the context of a physiological antenatal care consultation. In addition, this study strengthens the findings from Bokken et al (2009), that students reported in midwifery education, just as in medical education, a higher level of satisfaction after immediate feedback compared to delayed feedback.
Narrative comments from students exemplified some of the strengths of simulation as a teaching activity, including being able to reinforce what was learned during the theory modules and put these elements into practice. Considering the lack of clinical placements (Murray et al, 2008; Rappaz, 2012) and some students being particularly anxious when going to their first placement (Stunden et al, 2015), this finding is important as this kind of teaching activity could provide additional experience to current clinical placement in antenatal care clinics that might be difficult to secure in the future (Rodriguez, 2013; Levett-Jones et al, 2015). Finally, students reported the value of obtaining feedback from the SP on how she perceived her consultation as being a rare opportunity during clinical placements; the chance to obtain structured and constructive feedback from a SP on the student's individual performance was considered highly satisfying.
Limitations
The authors acknowledge that it is difficult to know whether the difference in findings was related to the feedback being immediate vs delayed, or individual vs group. We anticipated this confounding factor but had to take into consideration the time and resources of lecturers available. Additionally, the sample size was small (n = 51), despite the participants being recruited over a period of two academic years.
IIFD seem more satisfactory to students and showed some significant improvements in clinical skills. However, time and resource restrictions can be limitations to the implementation of such a teaching activity. Therefore, lecturers must consider the number of students and the time allocated to them to provide IIFB.
Conclusion
After this experience of implementing a clinical scenario played by simulated patients, students discovered an innovative strategy that helped them to significantly improve specific clinical competencies and their level of satisfaction in the teaching activity. The authors feel that simulation in midwifery, especially regarding holistic antenatal care, offers an innovative approach that complements other learning strategies, and integrates into the midwifery curriculum all the required competencies expected of student midwives during a complex antenatal care visit. Simulation can be adapted to any aspect of midwifery education and offers an innovative feature to assess and teach the complexity of a holistic antenatal care session.
This study found that students' clinical skills in relation to history-taking, introducing a consultation and communication were improved to greater effect after having immediate feedback on a one-to-one basis than after having delayed group feedback. Students who received immediate feedback also reported greater satisfaction with the timing of the feedback. This study, therefore, concludes that immediate feedback may be preferable for midwifery students following a teaching activity with a simulated patient.