Learning Outcomes of Immersive Technologies in Health Care Student Education: Systematic Review of the Literature.

BACKGROUND: There is a lack of evidence in the literature regarding the learning outcomes of immersive technologies as educational tools for teaching university-level health care students. OBJECTIVE: The aim of this review is to assess the learning outcomes of immersive technologies compared with traditional learning modalities with regard to knowledge and the participants' learning experience in medical, midwifery, and nursing preclinical university education. METHODS: A systematic review was conducted according to the Cochrane Collaboration guidelines. Randomized controlled trials comparing traditional learning methods with virtual, augmented, or mixed reality for the education of medicine, nursing, or midwifery students were evaluated. The identified studies were screened by 2 authors independently. Disagreements were discussed with a third reviewer. The quality of evidence was assessed using the Medical Education Research Study Quality Instrument (MERSQI). The review protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews) in April 2020. RESULTS: Of 15,627 studies, 29 (0.19%) randomized controlled trials (N=2722 students) were included and evaluated using the MERSQI tool. Knowledge gain was found to be equal when immersive technologies were compared with traditional learning modalities; however, the learning experience increased with immersive technologies. The mean MERSQI score was 12.64 (SD 1.6), the median was 12.50, and the mode was 13.50. Immersive technology was predominantly used to teach clinical skills (15/29, 52%), and virtual reality (22/29, 76%) was the most commonly used form of immersive technology. Knowledge was the primary outcome in 97% (28/29) of studies. Approximately 66% (19/29) of studies used validated instruments and scales to assess secondary learning outcomes, including satisfaction, self-efficacy, engagement, and perceptions of the learning experience. Of the 29 studies, 19 (66%) included medical students (1706/2722, 62.67%), 8 (28%) included nursing students (727/2722, 26.71%), and 2 (7%) included both medical and nursing students (289/2722, 10.62%). There were no studies involving midwifery students. The studies were based on the following disciplines: anatomy, basic clinical skills and history-taking skills, neurology, respiratory medicine, acute medicine, dermatology, communication skills, internal medicine, and emergency medicine. CONCLUSIONS: Virtual, augmented, and mixed reality play an important role in the education of preclinical medical and nursing university students. When compared with traditional educational modalities, the learning gain is equal with immersive technologies. Learning outcomes such as student satisfaction, self-efficacy, and engagement all increase with the use of immersive technology, suggesting that it is an optimal tool for education.

Patient perspectives of bedside teaching in an obstetrics, Gynaecology and neonatology hospital.

BACKGROUND: Osler taught doctors to "have no teaching without a patient for a text, and the best teaching is that taught by the patient himself". Bedside teaching (BST) facilitates clinical practice of skills, teaches empathy, instils confidence and builds on patient-doctor relationships. However, its use has declined dramatically due to concerns regarding privacy and autonomy. Most of the research in this area concentrates on medical student or academic opinion of BST using survey based methods. This qualitative study aimed to explore the patient's experiences and opinions of BST. METHODS: With ethical approval a qualitative study was conducted using semi-structured interviews which were examined using Thematic Analysis. Patients who had participated in a BST tutorial were invited to participate and gave written consent after discussion with a study researcher. RESULTS: Twenty-two patients were interviewed (obstetrics ante-natal [n = 10], obstetrics post-natal [n = 5] and gynaecology [n = 7]) ranging from ages 24-80 yrs. Four major themes were identified, with 11 sub-themes. The major themes included (i) Professional Mannerisms (ii) Privacy and Personal Wellbeing (iii) Quality of Patient Experience of BST and (iv) Clinical Experience and Learning Importance. The reaction of patients toward teaching at the bedside was altruistic and positive, with importance placed on learning. CONCLUSION: This research supports the concept of patient focused learning, and can reassure faculty that patients largely support its continuation as an integral component in education. Future research aims to extend this assessment to other patient groups with the aim of learning from and improving their experience.

Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster-randomised trial.

BACKGROUND: 2·6 million pregnancies were estimated to have ended in stillbirth in 2015. The aim of the AFFIRM study was to test the hypothesis that introduction of a reduced fetal movement (RFM), care package for pregnant women and clinicians that increased women's awareness of the need for prompt reporting of RFM and that standardised management, including timely delivery, would alter the incidence of stillbirth. METHODS: This stepped wedge, cluster-randomised trial was done in the UK and Ireland. Participating maternity hospitals were grouped and randomised, using a computer-generated allocation scheme, to one of nine intervention implementation dates (at 3 month intervals). This date was concealed from clusters and the trial team until 3 months before the implementation date. Each participating hospital had three observation periods: a control period from Jan 1, 2014, until randomised date of intervention initiation; a washout period from the implementation date and for 2 months; and the intervention period from the end of the washout period until Dec 31, 2016. Treatment allocation was not concealed from participating women and caregivers. Data were derived from observational maternity data. The primary outcome was incidence of stillbirth. The primary analysis was done according to the intention-to-treat principle, with births analysed according to whether they took place during the control or intervention periods, irrespective of whether the intervention had been implemented as planned. This study is registered with www.ClinicalTrials.gov, number NCT01777022. FINDINGS: 37 hospitals were enrolled in the study. Four hospitals declined participation, and 33 hospitals were randomly assigned to an intervention implementation date. Between Jan 1, 2014, and Dec, 31, 2016, data were collected from 409 175 pregnancies (157 692 deliveries during the control period, 23 623 deliveries in the washout period, and 227 860 deliveries in the intervention period). The incidence of stillbirth was 4·40 per 1000 births during the control period and 4·06 per 1000 births in the intervention period (adjusted odds ratio [aOR] 0·90, 95% CI 0·75-1·07; p=0·23). INTERPRETATION: The RFM care package did not reduce the risk of stillbirths. The benefits of a policy that promotes awareness of RFM remains unproven. FUNDING: Chief Scientist Office, Scottish Government (CZH/4/882), Tommy's Centre for Maternal and Fetal Health, Sands.

Education in Sepsis: A Review for the Clinician of What Works, for Whom, and in What Circumstances.

Sepsis is a major cause of morbidity and mortality in both the general and obstetric populations. Concerns have been raised regarding some cases of substandard care in the management of the septic and there is a real need for continuing multidisciplinary medical education in the recognition and management of the pregnant patient experiencing sepsis. This review aims to summarize studies on medical education in sepsis to both inform clinicians working in obstetrics and gynaecology and to assist in planning educational programs.

How education changes clinical documentation in early pregnancy.

The aim of this audit was to record medical history taking in the records of women attending with early pregnancy issues in order to assess the effect of training in this area. The medical education intervention comprised of a 30-min interactive tutorial. Retrospective chart review at three time points: pre education (July 2013, n = 45), immediately post-education (August 2013, n = 45) and longer term post-intervention (October 2013, n = 20). Pre-education, medical history was missing in 77.8% of charts compared to 13.4% immediately post-intervention and 10% long-term post-intervention (p < 0.05). Similar findings were noted with regard to documentation of age, surgical history, medications, allergies and last menstrual period (LMP). While there was a high rate of ultrasound investigations, the documentation of these (by placing an image in the chart) improved after the intervention. Education in requirements for medical history taking can improve documentation.

"I suppose we've all been on a bit of a journey": a qualitative study on providers' lived experiences with liberalised abortion care in the Republic of Ireland.

The aim of this study was to explore service providers' lived experiences with abortion care in the Republic of Ireland following liberalisation in 2018 via public referendum. Data were collected using semi-structured interviews conducted between February 2020 and March 2021. Thirteen interviews were completed with providers who were directly involved in caring for patients accessing liberalised abortion care in the Republic of Ireland. The sample includes six general practitioners, three midwives, two obstetricians, and two nurses. Interpretative phenomenological analysis identified five super-ordinate themes in the providers' lived experiences: (1) public reactions to liberalised abortion care; (2) lessons from the service implementation; (3) getting involved in abortion care; (4) moments of moral doubt; and (5) remaining committed to the provision of care. Following liberalisation, providers recalled isolated experiences with anti-abortion sentiments, particularly from those who continue to oppose abortion care. They believed that implementation has been mostly successful in delivering a safe, robust, and accessible service in general practice, though identified ongoing challenges in Irish hospitals. Personally, the providers supported access to care and began providing because they perceived a duty to facilitate access to care. Many, however, reported occasional moral doubts about their work. Despite these, none had considered leaving abortion care and all were proud of their work. They said that patients' stories were a constant reminder about the importance of safe abortion care. Further work is required to ensure that abortion is fully integrated and normalised and that all providers and patients have access to supports.

Patients' attitudes to bedside teaching after the COVID-19 pandemic.

BACKGROUND: Bedside teaching (BST) is a method of structured clinical teaching where the patient is central in education. We had previously explored the patients' perceptions of BST using both a qualitative research study and validation of a questionnaire, both showing strong support by patients for BST once basic rules of respect and confidentiality are followed. With the COVID-19 pandemic, clinical education transitioned to online/virtual learning. AIM: The aim of this study was to explore patients' attitudes towards reintroduction of BST as the pandemic restrictions have lifted. METHODS: Patients were invited to complete a validated questionnaire exploring their attitudes towards BST. A descriptive analysis was performed. Results were compared to a previous study performed before the COVID-19 pandemic. RESULTS: Four hundred patients consented to complete the questionnaires. Participants included women attending for antenatal (40%), postnatal (33%) and gynaecology issues (28%). Most patients (> 94%) reported that they were happy to be involved in BST. Patients believed that they should not be asked to participate in BST should they feel stressed or unwell (69%). These findings were the same as our previous study, performed prior to the pandemic. CONCLUSION: This study shows extensive and persisting patient support for BST. BST is unique in that it allows students to gain a deeper understanding of the disease which are hard to elicit through online/virtual methods.

The effect of clinician education on blood transfusion practice in obstetrics: completing the audit cycle.

BACKGROUND: With blood products being a limited and expensive resource within the healthcare system, there is an ever-increasing emphasis on judicial and appropriate use. AIMS: To evaluate whether implementing contemporary society recommendations on restrictive transfusion policies would reduce inappropriate use of red blood cell transfusions, by evaluating the effect of a staff educational campaign. METHODS: An audit of peri-partum red cell concentrate (RCC) transfusion practice within a tertiary obstetric unit was undertaken, covering a 1-year period (2015), examining data related to transfusion prescribing practices. Subsequently, an educational programme was held for clinical and laboratory staff which aimed to bring practice in line with society guidelines. A repeat audit covering another 1-year period (2018) was undertaken. RESULTS: The number of RCC units of transfused reduced by 49% between 2015 and 2018 (426 to 218). The number of patients receiving transfusion dropped from 166 in 2018 (1.8% of births) to 119 in 2015 (1.5% of births). Among stable patients who were transfused, the proportion receiving a single unit increased from 6.9 to 53.9%. (p < 0.001). Haematological reassessment between units rose from 13.8 to 80.4% (p < 0.001). Written consent documentation improved (68% in 2018 vs. 38% in 2015) (p < 0.001). CONCLUSIONS: The implementation of guidelines has resulted in substantial reduction in RCC transfusions between 2015 and 2018. Fewer women received a blood transfusion, and those who did received fewer units. There is a higher proportion of patients being reassessed between units and receiving single unit transfusions. Recording of consent has improved.

Virtual reality learning: A randomized controlled trial assessing medical student knowledge of fetal development.

OBJECTIVE: To investigate whether a virtual reality learning environment (VRLE) enhanced student understanding and knowledge compared with a traditional tutorial. METHOD: A randomized controlled trial involving medical students from University College Dublin, Ireland. Participants were assigned to an intervention (VRLE involving a 15-min learning experience on the stages of fetal development) or control (PowerPoint tutorial on the same topic) group. Multiple choice questionnaires (MCQs) assessed knowledge at three time points: preintervention, immediately postintervention, and 1 week postintervention. Primary outcomes were differences in MCQ knowledge scores postintervention between groups. Secondary outcomes included attitudes on the learning experience assessed using the Student Satisfaction and Self-Confidence in Learning Scale (SCLS) and the Virtual Reality Design Scale (VRDS). RESULTS: No statistically significant between-group differences were found in the primary outcome assessing postintervention knowledge scores. Within-group differences in knowledge scores were significant among the three time points for both the intervention (P < 0.01 [95% confidence interval, 5.33-6.19]) and control (P = 0.02 [95% confidence interval, 5.74-6.49]) groups. Mean levels of satisfaction and self-confidence in learning were higher in the intervention group compared with the control group: 54.2 (standard deviation, 7.5) and 50.5 (standard deviation, 7.2), respectively (P = 0.21). CONCLUSION: VRLEs are a learning tool that can support knowledge development.

Maternal and fetal cocaine- and amphetamine-regulated transcript in diabetic and non-diabetic pregnancy.

Cocaine- and amphetamine-regulated transcript (CART) is a leptin-regulated anorectic neuropeptide. Increased levels of leptin in cord blood of diabetic mothers have previously been described. The aim of this study was to quantify maternal and fetal serum CART levels in type 1 diabetes mellitus (T1DM, n = 10) and non-diabetic pregnancy (n = 10). Matched maternal serum samples (n = 20) were obtained at 36-weeks gestation and cord samples from the umbilical vein at delivery (n = 20), CART was quantified using a competitive enzyme immunoassay. Statistical analysis was performed using Spearmans correlation and t test. There was no difference in maternal CART levels at 36-weeks gestation between T1DM (mean = 331.13 pg/ml, Standard Error of the Mean (SEM) = 114.54) and non-diabetic pregnancy (mean = 195.01 pg/ml SEM = 29.37) (p = 0.106). Fetal CART levels in the umbilical vein were similar in T1DM (mean = 199.27 pg/ml, SEM = 39.81) and non-diabetic pregnancy (mean = 149.76 pg/ml, SEM = 26.08) (p = 0.143). Maternal serum CART levels measured at 36-weeks gestation correlated with maternal BMI at booking (Spearmans ρ = 0.332) (p = 0.001) irrespective of diabetes. Serum CART can be detected in both diabetic and non-diabetic human pregnancy and may play an important role in body mass regulation in pregnancy.

Trans-vaginal ultrasound simulation: An exploratory qualitative research study focused on the end-users perception of learning.

OBJECTIVE: Simulation has been shown to be beneficial and effective in the intimate educational setting of trans-vaginal ultrasound (TVUS). In addition, quantitative work has shown dyad learning (learning in pairs) to be non-inferior to independent learning simulation in this setting. This study aims to explore trainees' perceptions of learning in TVUS using qualitative research methods. A second aim was to study trainees' perceptions of the method of training, (learning in pairs (dyads) or as individuals). STUDY DESIGN: A three-hour training session using the transvaginal simulator and teaching programme was offered to participants, who either trained individually or as a dyad. Participants were then interviewed using a semi-structured interview technique. Interviews were recorded, transcribed, entered a qualitative research database (NVivo) to allow coding, structured analysis of data and development of themes using Thematic Analysis. RESULTS: Fifteen doctors with no previous experience in TVUS were assigned simulation training either as individuals (n = 7) or dyads (n = 4 pairs, eight people in total). All participants reported the beneficial nature of simulation training and felt they had sufficient time to meet their learning needs. Some frustration was reported with feedback and the repetitive nature of the simulation. For dyad learning, participants perceived the value of the use of a second person to act as a "sound board", to problem solve and to encourage each other. Independent learners reported frustration and difficulty in understanding if and how something went wrong. However, individual learners had the advantage of being able to go at their own pace. CONCLUSION: Previous studies have shown that simulation is effective for training in transvaginal ultrasound. This qualitative research study supports findings of previous quantitative studies by showing that participants appreciated the value of simulation and provided feedback for improvement in educational content. Clinicians and educators providing transvaginal simulation training could consider dyad training as an efficient and educational option, with individual training reserved for those who may need more time.

Medical students' attitudes towards the teaching of cervical and ovarian cancer screening protocols in Ireland: a qualitative study.

BACKGROUND: Screening programmes decrease the incidence of colorectal, breast and cervical cancer. As such, it is imperative that medical health professionals are educated on the screening programmes available and are aware of the research basis justifying them. AIMS: To establish the attitudes of final-year medical students to a gynaecological cancer screening teaching session, provided as part of their core Obstetrics and Gynaecology module. METHODS: A 3-h workshop, aimed to critically appraise research papers, reviewed cervical and ovarian cancer screening methods. The workshop was facilitated by a Consultant in Gynae-oncology Surgery. Anonymous evaluation was requested from two hundred nine students attending during the 2018/2019 academic year. Qualitative research with thematic analysis of content was performed. RESULTS: One hundred fifty-six students gave evaluation on the workshop itself (74.6%). Three main themes were identified-support for the importance of teaching screening methods, appreciation of the importance of understanding cervical screening and a wish for further teaching in Critical Appraisal. Students identified that there was a need to understand screening, that it was "..important for us to consider the value of screening programmes". The teaching on Cervical screening was "..helpful, especially with cervical screening". CONCLUSIONS: Medical students expressed a wish to understand the research basis of a common clinical screening programme (for cervical cancer) as well as the research basis for not providing screening to low risk populations (for ovarian cancer). Further research in this area may include exploring how this is taught in other medical schools.

Aerobic or Resistance Exercise for Improved Glycaemic Control and Pregnancy Outcomes in Women with Gestational Diabetes Mellitus: A Systematic Review.

Exercise is often recommended in addition to diet and medication in the management of gestational diabetes mellitus (GDM). Our aim was to determine if strength training compared with aerobic exercise had an impact on glycaemic control, maternal and neonatal outcomes. The Cochrane library, Embase, PubMed, CINAHL, Medline, Google Scholar, and OpenGrey were searched. Over 758 pregnant women (mother-baby pairs) from 14 studies are included in this systematic review. Interventions ranged from cycling, aerobic exercises, walking, yoga, or combined aerobic and resistance exercises. Of the studies identified, none directly compared aerobic exercise with strength training. Half of the studies showed benefit in glycaemic control with additional exercise compared with usual physical activity. There was largely no impact on obstetric or neonatal outcomes. Studies on exercise in GDM have reiterated the safety of exercise in pregnancy and shown mixed effects on maternal glycaemic control, with no apparent impact on pregnancy outcomes. The heterogenicity of reported studies make it difficult to make specific recommendations on the optimum exercise modality for the management of GDM. The use of a core outcome set for GDM may improve reporting of studies on the role of exercise in its management.

Assessing standards for prevention of early onset group B streptococcal (GBS) disease in Ireland.

BACKGROUND: Early onset group B streptococcal (GBS) disease can cause significant neonatal morbidity and mortality. There is currently no Irish national guideline for GBS screening, and protocols vary across maternity units. Polymerase chain reaction (PCR) testing at induction or labour onset informs triage for antibiotic prophylaxis; however, there are human and infrastructural resource requirements to enable widespread implementation. AIM: Our aim was to identify current standard practices for GBS prevention in Irish obstetric and neonatal services and to utilise this data to inform the need for, and potential impact of implementation of, a national guideline. METHODS: A questionnaire on GBS screening, management and existing resources was completed by an informed staff member from each of the 19 Irish maternity units, including questions regarding timing and method of screening, antibiotic usage, and neonatal management. RESULTS: One unit (5.2%) performs routine GBS screening at 35-37 weeks of gestation. Twelve units (63%) screen for GBS following spontaneous rupture of membranes (SROM) after 37 weeks, of which two (17%) perform PCR and ten (83%) culture testing. Seventeen units (89.3%) have access to a GeneXpert PCR machine, and of these, two (11.7%) use the machine for rapid GBS testing. Two units screen patients for GBS at either the start of labour or induction of labour. Four units (21%) use the neonatal early onset sepsis (EOS) calculator. Sixteen units (84%) do not treat asymptomatic infants born to GBS-positive mothers.  CONCLUSION: There is a lack of consistency in the methods for GBS screening and disease prevention across the country, highlighting the need for a national guideline accompanied by an implementation plan and budget to standardise care.

Women's experience of pregnancy and birth during the COVID-19 pandemic: a qualitative study.

BACKGROUND: The COVID-19 pandemic has changed how maternity care services are provided worldwide. To contain the virus, many providers reduced the number of face-to-face visits for women. In addition, partner attendance was prohibited in many circumstances to protect staff, and other service users, from potential infection. AIMS: To explore women's experience of pregnancy and birth in the Republic of Ireland during the COVID-19 pandemic. METHODS: A qualitative study with 14 women was conducted using a grounded theory approach. Data were collected between April and July 2020, and in-depth interviews were conducted either in pregnancy or in the first 12 weeks after the birth. RESULTS: Six categories emerged: loss of normality, navigating "new" maternity care systems, partners as bystanders, balancing information, uncertainty, and unexpected benefits of pregnancy during the pandemic. While benefits were reported (working from home and additional time spent with partners during the "fourth trimester"), in general, the themes were of increased anxiety and uncertainty. CONCLUSION: The pandemic caused additional anxiety for pregnant women. This was exacerbated by uncertainty about the effects of COVID-19 on pregnancy and unclear messaging about restrictions. More interactive and personalized communication is required to support women to cope with uncertainty during a pandemic. The birth partner plays an important role as an advocate for women and excluding them from pregnancy care caused additional anxiety for pregnant women. Containment strategies for a pandemic should be developed with this in mind, to view the family as a unit rather than the woman in isolation.

Exploring providers' experience of stigma following the introduction of more liberal abortion care in the Republic of Ireland.

OBJECTIVE: To explore if abortion care providers in the Republic of Ireland experience abortion-related stigma. STUDY DESIGN: The survey was distributed to abortion care providers working in community and hospital units nationwide. We measured stigma using the 35-item version of the Abortion Providers Stigma Scale (APSS). We also collected data on demography, professional involvement in providing abortion care, and risk of burnout (measured by the Maslach Burnout Inventory). RESULTS: Of the 309 providers invited to take part, 156 (50.5%) completed the survey between January to May 2020. The sample reported a mean score of 70.9 on the total scale of the APSS. This was comparable with the scores of providers in a Massachusetts-based study but was lower than a sample of providers from across the USA. Linear regression analyses found that the Irish hospital-based obstetricians (b = 10.51, 95% CI 3.16-17.86) and midwives/nurses (b = 10.88, 95% CI 2.3-19.47) reported higher stigma than their colleagues working in general practice. CONCLUSIONS: Comparing the scores of the current sample to published studies highlight the factors that may drive stigma in the Irish context. The Irish providers reported fewer issues in disclosing their abortion work than providers in the USA, which may be explained as they also reported fewer experiences of judgment and discrimination. They did, however, report higher levels of social isolation. Additionally, the findings suggest that providing surgical and/or later-gestation abortion care and providing within the hospital environment may present additional challenges for staff which increase level of stigma. IMPLICATIONS: Despite widespread support for the expansion of the abortion care services, providers in Ireland still experience stigma related to this work. Our findings suggest that Irish providers, particularly those working in hospitals, may benefit from supports to reduce abortion-related isolation and challenges posed by collegial interactions or later-gestation care.