Curricular Quality Improvement in Midwifery: Simulating Unexpected Perinatal Loss.

INTRODUCTION: Caring for families experiencing perinatal loss is a fundamental component of midwifery practice, but little attention is paid to perinatal palliative care in midwifery curricula. Lack of educational preparation and self-care resources negatively impacts midwifery students and health care teams caring for families experiencing stillbirth. PROCESS: A private, urban university conducted a curricular quality improvement project to integrate perinatal palliative care into the midwifery curriculum using a high-fidelity, branching simulation pedagogy. Simulation objectives were developed from curricular gap analyses and the Core Competencies for Basic Midwifery Practice. Development of the Unexpected Perinatal Loss Simulation was guided by the International Nursing Association for Clinical Simulation and Learning Outcomes and Objectives and Design Standards. The Unexpected Perinatal Loss Simulation was revised based on qualitative data from student focus groups and expert content validation. OUTCOMES: Qualitative data yielded 4 key domains: presimulation, simulation skills, prior experience/personal reflections, and recommendations. Simulation procedures and scenario content were revised, after which 8 expert clinicians in the fields of midwifery, palliative care, and psychiatry validated the scenario content using the Lynn method. Two items did not meet the content validity index (CVI) threshold of 0.78, necessitating review by stakeholders; however, the overall scenario CVI threshold was met (0.82). DISCUSSION: Through this project, faculty integrated perinatal palliative care into the midwifery program using a novel approach of high-fidelity, branching simulation, structured debriefing, and an introductory self-care skills workshop. Potential clinical impact includes skillful perinatal palliative care with effective communication skills to mitigate how families experience and remember a traumatic loss and facilitate the grieving process. Students voiced insights into how they would process loss and seek support to mitigate their own grief as future midwives.

Structure, Process, and Outcomes of Liberian National Nursing and Midwifery Curricular Revisions.

Background: The Republic of Liberia has had major disruptions to the education of its health care cadres. Post Ebola, the Resilient and Responsive Health Systems (RRHS) initiative began a new era of capacity building with the support of PEPFAR and HRSA. Nursing and Midwifery serve as the largest healthcare cadres in Liberia. The national nursing and midwifery curricula were overdue for the regulated review and revisions. Methods: The Science of Improvement was used as the framework to accomplish this multilateral activity. The Institute for Healthcare Improvement's (IHI) stages of improvement included: 1) Forming the team, 2) Setting the aims, 3) Establishing measures, 4) Selecting measures, 5) Testing changes, 6) Implementing changes, and 7) Spreading changes. These stages served as the blueprint for the structures and processes put into place to accomplish this national activity. Findings: The RN, Bridging, and BScM curricula all had redundant content that did not reflect teaching pedagogy and health priorities in Liberia. Courses were eliminated or reconfigured and new courses were created. Development of Nursing and Midwifery Curricular Taskforces were not as successful as was hoped. Two large stakeholder meetings ensured that this was the curricula of the Liberian faculty, deans and directors, and clinical partners. Monitoring and evaluation tools have been adopted by the Liberian Board for Nursing and Midwifery to serve as another improvement to check that the new curricula are being implemented and to identify gaps that may require future cycles of change for continued quality and improvement. Conclusions: Developing trust among the multilateral partners was critical to the success of this activity. Networks have been expanded, and a proposed pilot with the Ghana Board of Nursing and Midwifery and the US academic partner will examine the feasibility of implementing electronic licensing examinations for nurses and midwives.

Normal Physiologic Birth Continuing Professional Development: From a National Health Priority to Expanded Capacity.

Background: The Republic of Liberia has experienced many barriers to maintaining the quality of its healthcare workforce. The Resilient and Responsive Health Systems (RRHS) Initiative supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has responded to Liberian identified health priorities. Liberia's maternal morbidity and mortality rates continue to rank among the highest in the world. Recent country regulations have put forth required continuing professional development (CPD) for all licensed healthcare workers for re-licensure. Methods: The Model for Improvement was the guiding framework for this CPD to improve midwifery and nursing competencies in assisting birthing women. Two novel activities were used in the CPD. We tested the formal CPD application and approval process as this is a recent regulatory body policy. We also included the use of simulation and its processes as a pedagogical method. Over a two-year period, we developed a two-day CPD module, using didactic training and clinical simulation, for Liberian midwives. We then piloted the module in Liberia, training a group of 21 participants, including midwives and nurses, including pre- and post-test surveys as well as observational evaluation of participant skills. Findings: There were no significant changes in knowledge acquisition noted in the post-test. Small tests of change were implemented during the program, supporting the stages of the Model of Improvement. Observation of skill acquisition was done; however, using a formal observation checklist, such as an Observed Structured Clinical Evaluation (OSCE), would add more robust findings. The CPD and follow-up activity highlighted the need for human and financial support to maintain the simulation kits and to create sustainability for future trainings. Videotaping the didactic and simulation two-day continuing professional development train-the-trainer workshop expands the sustainability beyond newly prepared trainers. Simultaneous with this CPD, the Liberian Board for Nursing and Midwifery (LBNM) worked with a partner to create a CPD portal. The CPD partners created modules from the videos and have uploaded these modules to the LBNM's new CPD portal. Conclusions: Using a quality improvement model as a framework for developing and implementing CPDs provides a clear structure and supports the dynamic interactions in learning and clinical care. It is too soon to determine measurable health outcomes resulting from this project. Anecdotal feedback from clinicians and leaders was not directly related to the content of the CPD; however, it does demonstrate an increased awareness of examining changes in practice to support expanded health outcomes. Further research to examine methods and processes to determine the quality and safety outcomes of CPD trainings is necessary.