- Email: [email protected]
Evaluating the long-term effectiveness of the Maternity Emergency Care course in remote Australia
Women and Birth (2010) 23, 60—66
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
journal homepage: www.elsevier.com/locate/wombi
Evaluating the long-term effectiveness of the Maternity Emergency Care course in remote Australia Suzanne Belton a,*, Marcel Campbell b, Sally Foxley b, Bev Hamerton b, Justin Gladman b, Sally McGrath b, Neil Piller c, Nathan Saunders b, Fran Vaughan b a
Graduate School for Health Practice, Institute of Advanced Studies, Charles Darwin University, Casuarina Campus, Darwin, NT 0909, Australia b Centre for Remote Health, Alice Springs Campus, Cnr Simpson & Skinner Sts, PO Box 4066, Alice Springs, NT 0871, Australia c Department of Surgery, School of Medicine, Flinders University, GPO Box 2100, Adelaide, South Australia 5001, Australia Received 20 March 2009; received in revised form 14 August 2009; accepted 21 August 2009
KEYWORDS Maternity care; Maternity emergency; Training; Evaluation; Midwifery; Australia; Indigenous; Remote health
Summary Background: The Council for Remote Area Nurses of Australia deliver the MEC course which is the only short-course on maternity emergencies offered to non-midwifery qualified remote area nurses and Aboriginal Health Workers. The aim of the course is to improve the maternity emergency skills and knowledge of health service providers who do not have midwifery qualifications. There has been no long-term evaluation of the course since its inception. Research objective: To review the longer-term effectiveness of the maternity emergency care (MEC) course which was developed in consultation with the Australian College of Midwives (ACM) and rural and remote practitioners in 2003. Participants and methods: Fifty-seven clinicians who completed the MEC course since 2003 responded to a survey. Seven remote area health managers and two course facilitators were interviewed. Results: This study provides an evaluation of the experiences of non-midwives who manage maternity emergencies in the rural and remote setting; their perception of the skills, knowledge and confidence acquired through participation in the MEC program. Conclusions: The MEC course is valued by both remote health managers and practitioners. The learning activities, skills and knowledge gained are reported to be very beneficial and used by remote health practitioners. Crown Copyright # 2009 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives. All rights reserved.
* Corresponding author. Tel.: +61 8 8946 6896; fax: +61 8 8946 6311. E-mail address: [email protected] (S. Belton). 1871-5192/$ — see front matter. Crown Copyright # 2009 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives. All rights reserved. doi:10.1016/j.wombi.2009.08.004
‘‘MEC course in remote Australia’’
Box 1: What is already known on this subject: The MEC course immediate evaluations show the remote workforce highly value this strategy to improve the quality and safety of maternity emergency care. There is a shortage of midwives in rural and remote areas. The population served in remote areas have poorer maternal, neonatal and perinatal outcomes.
Box 2: What this study adds: Longer-term evaluation demonstrates that nurses provide midwifery care. Participants use the skills and materials provided in the MEC course. Managers and remote area nurses value the course highly.
Introduction The maternity emergency care (MEC) course aims to develop skills in the management of unexpected birth in isolated settings; recognise the complications of pregnancy, birth and the postpartum period, and provide first-line emergency care for the mother and or baby prior to transfer. It is the only short-course on maternity emergencies available to remote area nurses (RANs) and other health workers without midwifery qualifications in Australia. The MEC course is based on adult learning principles and focuses on ‘‘hands on’’ learning and was created by the Council of Remote Area Nurses of Australia (CRANA)1 in 2003 in conjunction with the Australian College of Midwives and rural and remote practitioners. The MEC course is evaluated at the end of each program session.2 Short-term evaluations indicate a high quality learning experience, an increase in confidence and a decrease in fear associated with maternity emergencies. The difficulty associated with recruiting and retaining midwives in remote locations is exacerbated by a national shortage of qualified midwives. The prime reasons for this are a shortage of training posts, costly courses, a perceived lack of professional support, poor access to ongoing education, diminished autonomy in practice and reduced job satisfaction related to medical model of care.3 The MEC course was developed by a team of expert remote area nurses/midwives based on the results of a needs-assessment survey. The course is delivered by the designers who have remained involved in its delivery and have subsequently trained other educators. There are 22 regular facilitators Australia-wide and a high demand for the 14 courses run annually. As of 2006, 175 participants had participated in 10 MEC courses delivered across Australia. Evaluation of workshop outcomes shows that the majority of participants felt that the knowledge they had gained during the course would be valuable to their practice and that the variety of teaching methods used to deliver the information was effective.2 However, there was no evaluation to inform funders and providers of the program about its longer-term impact and/or whether the course has achieved the stated goals.
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Literature review Any evaluation of the MEC course must be within the context of the ongoing demand for maternity services in rural and remote areas and the existing number of staff considered qualified to deliver the care. The three types of practitioners trained to provide comprehensive maternity care in Australia are: midwives; general practitioner-obstetricians; and obstetricians. There is a critical shortage of midwives in Australia.4,5 In 2006, the Australian College of Midwives and the Australian Health Workforce Advisory Committee estimated the national shortage to be between 1800 and 1850.3 Several nursing labour workforce studies have predicted a decrease in midwifery workforce participation related to the average age of the labour source (41.9 years) and the estimated number who are likely to retire in the near future. Furthermore, a significant number of midwives (68.2%) work in part-time positions.6,7 However, a literature review from 2000 onwards failed to reveal any publications describing the service provision areas or locations in which the shortages are most acute. It is difficult to determine how many health services in remote areas have been unable to recruit sufficient numbers of qualified midwives. As Tracy et al.8 point out: ‘One of the most alarming features is the lack of comprehensive data on midwives. Where data is available it demonstrates the shortage of midwives and the lack of consistency in educational programs for midwives within states and nationally. It is difficult to form a national picture with published sources of data because there are differences in definition and a lack of relevant information.’8 p.78 There are diminished birthing choices for women who live in rural/remote areas due to the closure of small birthing centres and the difficulties in recruiting and retaining midwives.9,10 These women have the highest fertility rates in Australia,11 are largely Indigenous, and have maternal mortality rates 2.5 higher than that of their non-indigenous counterparts.12 Most Australian state and territory nursing and midwifery regulatory authorities (NMRAs) have position statements regarding non-midwives providing maternity care and the course designers state that: ‘The MEC course is not intended to encourage nurses or Indigenous health workers to provide midwifery care, but rather to provide them with the skills and knowledge necessary to identify and refer pregnant women and to respond to unexpected births and maternity emergencies.’2 p.113 The theoretical framework that underpins this training is adult learning.13 Adult learning contains five core principles. Adults are able to learn independently and are self-directed; adults have past experiences and gained knowledge that adds to the learning experience; adults value learning that is relevant to their life; adults like to solve relevant problems rather then receive information; and adults desire to respond their inner drive to learn than other external drives. Simulation is recognised as an effective method in clinical teaching. In a nursing context, simulation allows participants
62 to refine and develop clinical skills within a specific clinical environment. Simulation is a teaching tool that has been adopted by most clinical disciplines and encourages students to be an active participant in the learning process and not merely an observer.14 The advantages of simulation are many and varied. Simulation focuses the learner’s attention on the problem thus decreasing distraction from outside sources. It permits controlled manipulation of the patient care situation with predictable results. The patient care situation can be altered depending on the desired learning outcomes, and learners can make mistakes which enhance the learning environment. However, the learner is free from any real consequences. Finally, simulation can be used to measure affective learning as well as cognitive learning.15 Bradshaw16 highlights the association that exists between simulation and discovery learning. Through trail and error, students are equipped with problem solving skills that are based on practical examples and enhance the student’s level of understanding. The model called situated learning17 has been used in the development of many midwifery courses. The model of situated learning is underpinned by the principles that skill development and knowledge is contextually based and is impacted on by the activity, context, and the culture in which the skills and knowledge is used; in this case midwifery services in a rural setting. The characteristics of the model are: reflection, coaching, multiple practices, articulation of learning that is relevant, embedded in evidence based practice and relevant to the learner. The integration of adult learning principles and the model of situated learning through simulation provide for a deep learning approach that is contextual, practical, controlled and enhances cognitive learning whilst providing a link between skills development and theory. Previous evaluation feedback of the MEC course provided at the completion of the course was very positive, with participants commenting on the high quality of the learning experience, an increase in confidence and a decrease in fear associated with maternity emergencies. Until now there has been no long-term evaluation of the MEC course with a view to discovering if the participants have used the knowledge and skills gained, or whether they remain confident to handle maternal emergencies.
Aim This study is intended to measure the sustained effects of the MEC course, particularly if it had improved maternity emergency care (as perceived by course participants and the managers) within remote area health centres.
Participants and methods Ethical permission for the study was granted from Flinders University Social and Behavioural Research Ethics Committee (#3566). The study was partially funded and supported by the Centre for Remote Health in Alice Springs and CRANA. The survey was developed by a group of remote health professionals (two of whom had completed the MEC course), the course designers, academics from Charles Darwin and Flinders Universities. The survey was pilot tested with five
S. Belton et al. remote practitioners. The survey was divided into four sections, general information such as demographics; impressions of the course; impact of the course on recent practice; and recommendations suggested by participants. Six questions required a short, written answer with all others requiring tick box responses. Fax was the most common means of distribution and return of surveys. Data collection commenced in May 2006 and was completed in June 2007.
Sample All participants were purposively sampled. Only those who undertook the course between 2003 and 2006 were invited to participate. The major groupings were as follows. Nurse participants The Council of Remote Area Nurses staff identified 114 nurses who had completed the MEC course since 2003 and who were not midwives. These 114 nurses were then invited to complete the survey. Descriptive statistics and thematic analysis was used to provide collective details. Remote area health managers Six remote health centre managers who employ RANs and have specific knowledge about the workforce, were questioned, using a structured interview, on the quality of service provision in remote Australia. They were asked to make judgements about how the course has influenced, the performance of non-midwife RANs in identifying and dealing with risks and managing emergency maternal and neonatal episodes of care. Course designers Two course designers were interviewed about the content, intentions and implementation of MEC course. Transcripts of interviews were analysed thematically.
Results Nurses Out of 114 nurses 57 RANs (including five males) returned the survey giving a response rate of 50% (Table 1). The state distribution was: Northern Territory 16, Western Australia 12, Tasmania 9, Queensland 9, South Australia 6, New South Wales 3 and Victoria 2. Forty six (81%) worked in communities of less than 2000 people. Thirty three (58%) of nurses had practiced in a remote setting for more that 16 years indicating a high level of experience. Eleven (19%) had Table 1
Year attended course.
Year
Frequency
2003 2004 2005 2006
3 14 28 10
6 25 51 18
Total
55
100
Missing data 2.
Percent
‘‘MEC course in remote Australia’’
Figure 1
63
Perception of the impact of MEC on recent practice to manage maternity care.
attained a Masters level of education. Thirty nine (68%) reported they always or often worked without a midwife or doctor in their practice setting. Forty-eight (82%) respondents indicated they initiated taking the MEC course themselves while six (11%) indicated the course was a compulsory part of their university study or their workplace (3) required it. Seven (12%) said the course was recommended by their colleagues. Individual respondents indicated their reasons for undertaking the course to be ‘maternity phobic’, ‘want to work in a developing country’, ‘often work without a midwife’, ‘handle numerous preterm births’, ‘solo practitioner’, and ‘to be prepared!’
Educational strategies and actual practice Fig. 1 shows that 56 nurses responded to questions about developing skills, recognising complications and responding to emergencies. All ‘‘strongly agreed’’ or ‘‘agreed’’ that their skills were increased and they were more competent to deal with maternity emergences. Two were unsure whether they were ‘‘more able to recognise complications’’. All or all but one respondent indicated feeling skilled and confident to undertake routine and emergency antenatal care, birth and postpartum care, often despite the time since completing the course. The following figure shows this was not just a perception but in reality as those responding were providing routine midwifery care.
Table 2
Respondents had managed routine and emergency antenatal and postpartum care and delivered a baby. Twenty two (45%) indicated they had managed a maternity emergency since completing the course and 19 (34%) reported being the most experienced clinician at the time. All reported that the MEC course had made a positive and strong impact on their ability to manage maternity emergencies. All respondents felt that it would be necessary to refresh their skills, 46 (82%) thought this refresher should occur 2 or 3 yearly. Five (9%) suggested that they would not need to refresh their skills if they were working with a midwife. When asked whether the course met their needs and if the reference material was appropriate, 48 (86%) ‘‘strongly agreed’’ or ‘‘agreed’’ that the course met their needs and 52 (93%) thought the reference material appropriate. There were non-responses. No one disagreed. Fifty one (91%) had used the reference material and 11 (20%) reported using it regularly. Five (9%) said they had never referred to the resource material since completing the course. The practical approach using skill stations (91%) and case simulations (92%) also received favourable feedback, with the majority strongly agreeing or agreeing with the methods of teaching. Fifty three (95%) said they would do the course again and recommend others to do it. Twenty respondents (42%) said the course encouraged them to consider taking a tertiary level midwifery course.
Description of health services whose managers were interviewed.
Location
No. of health centres
ARIA code
NT 1 NT 2 NT 3 WA SA QLD
8 23 10 10 6 + 3 Outstations Not stated
3—5 Various 1—5 3—5 4—5 3—5
Total
No. of RANs 20 54 80 15 18 15 202
No. of midwives 2 20 Not known 4 4 6 36+
64
S. Belton et al.
Managers Six health service clinical managers were interviewed regarding the perceived value of the MEC course to their health service. The features of the health centres they represent are summarised in Table 2. Most health service managers interviewed stated that the vast majority of their health centres fell into categories moderately accessible to remote in the accessibility/remoteness index of Australia. The total number of RANs employed by the six health services was 202 (range 15—80). Five managers of multiple health services stated they had 36 midwives. Five managers felt that at least one midwife per health centre location was ideal and in some cases (such as in larger communities or town-based health centres), two would be preferred. One health service manager was not able to say how many qualified midwives were employed in the health service. All six managers were familiar with the MEC course and all recommended that non-midwife nursing staff attend. None of the managers had attended the course themselves but three managers were midwives. Most managers were unable to accurately quantify the number of RANs that had attended the MEC course since its introduction, but all knew of staff that had attended the course. When asked if the MEC course had changed the standard of services offered by non-midwives, only one of four managers who responded felt that antenatal care had improved. No managers felt that the standard of postnatal care had improved. For unknown reasons, four of the six managers felt unable to comment. Three of the four managers who commented on the standard of care in unplanned labour and birth felt that the standard of care had improved. One manager described a strength of the course: Dealing with birthing is consistently a worry to non-midwives. This course relieves some of those anxieties.
RANs in the same course as female Aboriginal Health Workers (AHW). They felt that male RANs needed access to maternity emergency skills if they are to work in remote areas, but the cultural sensitivities of the AHWs who believe that birthing is sacred women’s business needed to be respected. The coordinators had to ensure that a male RAN was never in the same skills station as a female AHW. Other challenges included the logistics of travelling to the course both for presenters and participants, with equipment having to be transported around Australia. One interviewee spoke of the concerns of the Australian College of Midwives and NMRAs about unqualified practitioners being provided the skills to operate outside their scope of practice. She emphasised that the MEC course was to be seen as a safetynet for non-midwives and women and that best practice demands that qualified midwives perform these functions whenever possible. When asked what about facilitating the course surprised them, one interviewee cited the number of RANs who had indicated an interest in undertaking midwifery studies after completing the MEC course. The other interviewee declared that the number of RANs who remained terrified of an emergency birth even after completing the course. She also cited a problem in RANs not encouraging mothers to adopt non-supine positions for their labour. The strengths of the course were discussed by both respondents. One suggested that: This course was designed for remote practice by experienced remote nurse/midwives who know and understand the context of remote practice. We are clinically skilled, our practice is current, and evidenced based. Other strengths were thought to be the locations of courses, the atmosphere of safety for participants to ask questions and express fears, and extensive discussions around cultural safety in maternity care.
This sentiment was echoed by another manager who said: Skilling non-midwives in unplanned birthing which often ‘freaks’ those non-midwives out is the most important. None of the managers were able to quantify how many obstetric emergencies had been handled by their staff and, of those, how many were managed by non-midwives. All managers were positive about the course and related positive experiences by participants. A consistent theme in the feedback was that participants and managers felt that the MEC course had increased their confidence to manage obstetric emergencies. The managers recommendations for improving the course included additional skills around routine antenatal and postnatal care, the provision of more courses in more locations, running courses on weekdays and providing refresher courses.
Course designers When asked about the challenges of the course, both course designers spoke about the challenge of having ‘rusty’ midwives in the course. They felt that the course was not designed to update skills of midwives and that their presence distracted from the focus of the course which was on unqualified staff. Another identified challenge was having male
Discussion The MEC course is popular, useful and receives positive feedback several years after participants have used their skills. The RANs who responded thought the course had improved their knowledge and skills and many reported actively using them. The adult learning and practical focus was appreciated by respondents long after they had finished the course. As there is a shortage of midwives across Australia and it is notable that the MEC course appeared to stimulate nonmidwives to consider studying midwifery. This is an unintended but welcome outcome of the course. There is no national data on the numbers of pregnant women who reside and receive antenatal care in remote communities in comparison to how many midwives are available to provide that care. However, it is known that despite higher fertility rates of approximately 12—20% than their urban counterparts, women who live in rural and remote Australia have considerably less access to quality maternity services. This is concerning considering the increased morbidity and mortality in Indigenous women and babies.18 Furthermore, the New South Wales Framework for Maternity Services (2002) acknowledges the convincing body of evidence that mothers and babies from disadvantaged groups
‘‘MEC course in remote Australia’’ are likely to have poorer maternal health outcomes than the population as a whole.19 A number of socio-cultural factors, which include but are not restricted to, cultural and physical isolation from families, language barriers, inappropriate use of biomedical models of care and difficulty in accessing services, as well as the negative influences of poverty, poor nutrition and sub-standard living conditions are cited in the literature as being directly related to poor obstetric outcomes.20 Paradoxically those women with the poorest outcomes are cared for by remote health practitioners who have limited qualifications in maternity care. All of our respondents reported providing routine antenatal and postpartum care despite not being midwives. It should be our concern that safe, reliable and culturally appropriate maternity services are given to these women. There is a tension between providing training to remote health practitioners to relieve their fears and providing the maternity care that women need. The MEC course is underpinned by adult learning principles and convergent theory, that is matching the learning environment with the context of which the newly acquired skills will be applied. Respondents highlighted that contextual learning was paramount in addressing concerns and culminating with increased skills and knowledge of participants. The MEC course capitalises on a number of adult learning principles. Most participants self-initiated in undertaking the course and saw the course as an important selfdevelopment activity and a necessary skill in rural and remote practice. The success of the course has been driven by the participants’ intrinsic motivation to undertake professional development training. This supports Knowles et al.21 adult learning principle, in that internal forces rather then external forces, drive adults in the learning process. The MEC course enables participants to contribute to the learning environment by sharing personal and professional experiences that adds to the group learning and helps to develop professional networks. One of the driving forces for participants is the fear of maternal emergencies. Simulation is a tool widely used in stress inoculation training and enables participants to practice and implement intervention strategies that will give the participants a framework to operate from in maternal emergencies. Furthermore, we know that when clinicians are placed in stressful situations they will often revert to their original training in given topic. At the conclusion of the course, participants commented on increased confidence and decreased fear if faced with a maternal emergency. The course not only addressed the concerns of the participants before commencing the course but also gave them an operational framework that can be implemented during maternal emergencies. The MEC course is not only an opportunity to develop professional skills but also to develop professional networks that are integral in supporting practitioners in rural and remote areas. Professionals who work in isolation and with decreased professional development opportunities, experience greater staff turn-over and poorer recruitment outcomes. The implementation of courses such as MEC that involve RANs from different geographical areas is one strategy to increase staff retention by developing support networks and up-skill staff. The MEC course not only benefits
65 individual RANs and assists in improving the maternal health outcomes in rural and remote communities.
Conclusion The MEC course is valued by both remote health managers and practitioners. The learning activities and the skills and knowledge taught are reported to be very beneficial and used by remote health practitioners years after completing the course. The national shortage of midwives is highly visible in remote areas and many indigenous women who live in fourth-world conditions are unable to access qualified antenatal and postnatal care. The women and their babies also have poorer outcomes than mainstream urban Australians. While we should aim for skilled midwives, non-midwives and Aboriginal Health Workers, can and do provide maternity services in the bush. The MEC course is an important quality and safety strategy to support this workforce and contributes positively to rural and remote maternity care.
Acknowledgements The authors would like to thank the Centre for Remote Health and the Council of Remote Area Nurses of Australia for financial and personnel assistance, Sabina Knight and Lesley Barclay for expert advice, and Joseph Mc Donnell for statistical advice. Sue Kildea and Sue Kruske also contributed to designing the survey. Contributors: Suzanne Belton–—co-ordinator and designer of research study, contributed to survey and interview design, lead data analysis and writing. Marcel Campbell–— designed questionnaire, conducted interviews, analysed and contributed to knowledge transfer at public fora. Sally Foxley–—lead literature review, designed questionnaire, conducted interviews, analysed data, contributed to writing and presented findings at public fora. Bev Hamerton, Sally McGrath and Nathan Saunders–—lead literature review, designed questionnaire, conducted interviews, analysed data, and contributed to writing. Justin Gladman–—lead literature review, designed questionnaire, conducted interviews, analysed data, contributed to writing and coordination. Neil Piller–—co-ordinator and designer of research study, lead analysis and contributed to writing. Fran Vaughan–—lead literature review, designed questionnaire, conducted interviews, cleaned and entered the raw data, analysed data, and contributed to writing.
References 1. Council for Remote area Nurses of Australia. About the Maternity Emergency Care course; 2009 [cited; Available from: http:// courses.crana.org.au/6-page-about-the-maternity-emergencycare-course-crana.html]. 2. Kildea S, Kruske S, Bowell L. MEC: a short course in maternity emergencies for remote area health staff with no midwifery qualifications. Australian Journal of Rural Health 2006;14: 111—5. 3. Australian Health Workforce Advisory Committee. The Midwifery Workforce in Australia 2002—2012. AHWAC Report 2002.2. Sydney; 2002.
66 4. Barclay L, Brodie P, Tracy S, Leap N. Australian midwifery action project final report. Sydney: Centre for Family Health and Midwifery, University of Technology Sydney; 2002. 5. Brodie P. Addressing the barriers to midwifery–—Australian midwives speak out. Australian Journal of Midwifery 2002;15(3): 5—14. 6. AIHW. Rural regional and remote health: a study on mortality (summary of findings). Canberra: Australian Institute of Health and Welfare; 2003. [rural health series number three]. 7. AIHW. Australia’s health 2004: the ninth biennial report of the Australian Institute of Health and Welfare. Canberra: Australian Institute of Health and Welfare; 2004. 8. Tracy S, Barclay L, Brodie P. Contemporary issues in the workforce and education of Australian midwives. Australian Health Review 2000;23(4). 9. Banscott Health Consulting Pty Ltd.. Maternity services review in the Northern Territory Darwin. Department of Health and Community Services; 2007. 10. Hirst C. Re-Birthing: Report on the Review of Maternity Services in Queensland. Brisbane: Queensland Government Queensland Health; 2005. 11. ABS. Year Book Australia, 2003, Aboriginal and Torres Strait Islander population 2004; 26.5.04 [cited 2004 24 September]; Available from: http://www.abs.gov.au/ausstats/[email protected]/ Lookup/2F6A3D06D66A12A5CA256CAE00053F9C.
S. Belton et al. 12. Kildea S. Maternal deaths high for indigenous women. Women and Birth 2008;21:175—6. 13. Knowles M. The adult learner: a neglected species. Houston: Gulf Publishing; 1984. 14. Beyea SC, Kobokovich LJ. Human patient simulation: a teaching strategy. Association of Perioperative Registered Nurses 2004;80(4):738—42. 15. Dooling SL. Developing computer simulations for staff nurse education. Journal of Medical Systems 1986;10(2):139—49. 16. Bradshaw P. Teaching and assessing in clinical nursing practice. London: Prentice Hall; 1989. 17. Lave J, Wenger E. Situated learning legitimate peripheral participation. Cambridge University Press; 1991. 18. Kildea S. Risky business–—contested knowledge over safe birthing services for Aboriginal women. Health Sociol Rev )2006;(Special issue). 19. Health Department NSW. The NSW Framework for Maternity Services. Sydney: NSW Health Department; 2000. 20. Herceg A. Improving health in Aboriginal and Torres Strait Islander mothers, babies and young children: a literature review. Canberra: Australian Government Department of Health and Ageing; 2005. 21. Knowles MS, Holton EF, Swanson RA, Holton E. The adult learner: the definitive classic in adult education and human resource development. 5th ed. Houston, TX: Gulf; 1998.
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
journal homepage: www.elsevier.com/locate/wombi
Evaluating the long-term effectiveness of the Maternity Emergency Care course in remote Australia Suzanne Belton a,*, Marcel Campbell b, Sally Foxley b, Bev Hamerton b, Justin Gladman b, Sally McGrath b, Neil Piller c, Nathan Saunders b, Fran Vaughan b a
Graduate School for Health Practice, Institute of Advanced Studies, Charles Darwin University, Casuarina Campus, Darwin, NT 0909, Australia b Centre for Remote Health, Alice Springs Campus, Cnr Simpson & Skinner Sts, PO Box 4066, Alice Springs, NT 0871, Australia c Department of Surgery, School of Medicine, Flinders University, GPO Box 2100, Adelaide, South Australia 5001, Australia Received 20 March 2009; received in revised form 14 August 2009; accepted 21 August 2009
KEYWORDS Maternity care; Maternity emergency; Training; Evaluation; Midwifery; Australia; Indigenous; Remote health
Summary Background: The Council for Remote Area Nurses of Australia deliver the MEC course which is the only short-course on maternity emergencies offered to non-midwifery qualified remote area nurses and Aboriginal Health Workers. The aim of the course is to improve the maternity emergency skills and knowledge of health service providers who do not have midwifery qualifications. There has been no long-term evaluation of the course since its inception. Research objective: To review the longer-term effectiveness of the maternity emergency care (MEC) course which was developed in consultation with the Australian College of Midwives (ACM) and rural and remote practitioners in 2003. Participants and methods: Fifty-seven clinicians who completed the MEC course since 2003 responded to a survey. Seven remote area health managers and two course facilitators were interviewed. Results: This study provides an evaluation of the experiences of non-midwives who manage maternity emergencies in the rural and remote setting; their perception of the skills, knowledge and confidence acquired through participation in the MEC program. Conclusions: The MEC course is valued by both remote health managers and practitioners. The learning activities, skills and knowledge gained are reported to be very beneficial and used by remote health practitioners. Crown Copyright # 2009 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives. All rights reserved.
* Corresponding author. Tel.: +61 8 8946 6896; fax: +61 8 8946 6311. E-mail address: [email protected] (S. Belton). 1871-5192/$ — see front matter. Crown Copyright # 2009 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives. All rights reserved. doi:10.1016/j.wombi.2009.08.004
‘‘MEC course in remote Australia’’
Box 1: What is already known on this subject: The MEC course immediate evaluations show the remote workforce highly value this strategy to improve the quality and safety of maternity emergency care. There is a shortage of midwives in rural and remote areas. The population served in remote areas have poorer maternal, neonatal and perinatal outcomes.
Box 2: What this study adds: Longer-term evaluation demonstrates that nurses provide midwifery care. Participants use the skills and materials provided in the MEC course. Managers and remote area nurses value the course highly.
Introduction The maternity emergency care (MEC) course aims to develop skills in the management of unexpected birth in isolated settings; recognise the complications of pregnancy, birth and the postpartum period, and provide first-line emergency care for the mother and or baby prior to transfer. It is the only short-course on maternity emergencies available to remote area nurses (RANs) and other health workers without midwifery qualifications in Australia. The MEC course is based on adult learning principles and focuses on ‘‘hands on’’ learning and was created by the Council of Remote Area Nurses of Australia (CRANA)1 in 2003 in conjunction with the Australian College of Midwives and rural and remote practitioners. The MEC course is evaluated at the end of each program session.2 Short-term evaluations indicate a high quality learning experience, an increase in confidence and a decrease in fear associated with maternity emergencies. The difficulty associated with recruiting and retaining midwives in remote locations is exacerbated by a national shortage of qualified midwives. The prime reasons for this are a shortage of training posts, costly courses, a perceived lack of professional support, poor access to ongoing education, diminished autonomy in practice and reduced job satisfaction related to medical model of care.3 The MEC course was developed by a team of expert remote area nurses/midwives based on the results of a needs-assessment survey. The course is delivered by the designers who have remained involved in its delivery and have subsequently trained other educators. There are 22 regular facilitators Australia-wide and a high demand for the 14 courses run annually. As of 2006, 175 participants had participated in 10 MEC courses delivered across Australia. Evaluation of workshop outcomes shows that the majority of participants felt that the knowledge they had gained during the course would be valuable to their practice and that the variety of teaching methods used to deliver the information was effective.2 However, there was no evaluation to inform funders and providers of the program about its longer-term impact and/or whether the course has achieved the stated goals.
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Literature review Any evaluation of the MEC course must be within the context of the ongoing demand for maternity services in rural and remote areas and the existing number of staff considered qualified to deliver the care. The three types of practitioners trained to provide comprehensive maternity care in Australia are: midwives; general practitioner-obstetricians; and obstetricians. There is a critical shortage of midwives in Australia.4,5 In 2006, the Australian College of Midwives and the Australian Health Workforce Advisory Committee estimated the national shortage to be between 1800 and 1850.3 Several nursing labour workforce studies have predicted a decrease in midwifery workforce participation related to the average age of the labour source (41.9 years) and the estimated number who are likely to retire in the near future. Furthermore, a significant number of midwives (68.2%) work in part-time positions.6,7 However, a literature review from 2000 onwards failed to reveal any publications describing the service provision areas or locations in which the shortages are most acute. It is difficult to determine how many health services in remote areas have been unable to recruit sufficient numbers of qualified midwives. As Tracy et al.8 point out: ‘One of the most alarming features is the lack of comprehensive data on midwives. Where data is available it demonstrates the shortage of midwives and the lack of consistency in educational programs for midwives within states and nationally. It is difficult to form a national picture with published sources of data because there are differences in definition and a lack of relevant information.’8 p.78 There are diminished birthing choices for women who live in rural/remote areas due to the closure of small birthing centres and the difficulties in recruiting and retaining midwives.9,10 These women have the highest fertility rates in Australia,11 are largely Indigenous, and have maternal mortality rates 2.5 higher than that of their non-indigenous counterparts.12 Most Australian state and territory nursing and midwifery regulatory authorities (NMRAs) have position statements regarding non-midwives providing maternity care and the course designers state that: ‘The MEC course is not intended to encourage nurses or Indigenous health workers to provide midwifery care, but rather to provide them with the skills and knowledge necessary to identify and refer pregnant women and to respond to unexpected births and maternity emergencies.’2 p.113 The theoretical framework that underpins this training is adult learning.13 Adult learning contains five core principles. Adults are able to learn independently and are self-directed; adults have past experiences and gained knowledge that adds to the learning experience; adults value learning that is relevant to their life; adults like to solve relevant problems rather then receive information; and adults desire to respond their inner drive to learn than other external drives. Simulation is recognised as an effective method in clinical teaching. In a nursing context, simulation allows participants
62 to refine and develop clinical skills within a specific clinical environment. Simulation is a teaching tool that has been adopted by most clinical disciplines and encourages students to be an active participant in the learning process and not merely an observer.14 The advantages of simulation are many and varied. Simulation focuses the learner’s attention on the problem thus decreasing distraction from outside sources. It permits controlled manipulation of the patient care situation with predictable results. The patient care situation can be altered depending on the desired learning outcomes, and learners can make mistakes which enhance the learning environment. However, the learner is free from any real consequences. Finally, simulation can be used to measure affective learning as well as cognitive learning.15 Bradshaw16 highlights the association that exists between simulation and discovery learning. Through trail and error, students are equipped with problem solving skills that are based on practical examples and enhance the student’s level of understanding. The model called situated learning17 has been used in the development of many midwifery courses. The model of situated learning is underpinned by the principles that skill development and knowledge is contextually based and is impacted on by the activity, context, and the culture in which the skills and knowledge is used; in this case midwifery services in a rural setting. The characteristics of the model are: reflection, coaching, multiple practices, articulation of learning that is relevant, embedded in evidence based practice and relevant to the learner. The integration of adult learning principles and the model of situated learning through simulation provide for a deep learning approach that is contextual, practical, controlled and enhances cognitive learning whilst providing a link between skills development and theory. Previous evaluation feedback of the MEC course provided at the completion of the course was very positive, with participants commenting on the high quality of the learning experience, an increase in confidence and a decrease in fear associated with maternity emergencies. Until now there has been no long-term evaluation of the MEC course with a view to discovering if the participants have used the knowledge and skills gained, or whether they remain confident to handle maternal emergencies.
Aim This study is intended to measure the sustained effects of the MEC course, particularly if it had improved maternity emergency care (as perceived by course participants and the managers) within remote area health centres.
Participants and methods Ethical permission for the study was granted from Flinders University Social and Behavioural Research Ethics Committee (#3566). The study was partially funded and supported by the Centre for Remote Health in Alice Springs and CRANA. The survey was developed by a group of remote health professionals (two of whom had completed the MEC course), the course designers, academics from Charles Darwin and Flinders Universities. The survey was pilot tested with five
S. Belton et al. remote practitioners. The survey was divided into four sections, general information such as demographics; impressions of the course; impact of the course on recent practice; and recommendations suggested by participants. Six questions required a short, written answer with all others requiring tick box responses. Fax was the most common means of distribution and return of surveys. Data collection commenced in May 2006 and was completed in June 2007.
Sample All participants were purposively sampled. Only those who undertook the course between 2003 and 2006 were invited to participate. The major groupings were as follows. Nurse participants The Council of Remote Area Nurses staff identified 114 nurses who had completed the MEC course since 2003 and who were not midwives. These 114 nurses were then invited to complete the survey. Descriptive statistics and thematic analysis was used to provide collective details. Remote area health managers Six remote health centre managers who employ RANs and have specific knowledge about the workforce, were questioned, using a structured interview, on the quality of service provision in remote Australia. They were asked to make judgements about how the course has influenced, the performance of non-midwife RANs in identifying and dealing with risks and managing emergency maternal and neonatal episodes of care. Course designers Two course designers were interviewed about the content, intentions and implementation of MEC course. Transcripts of interviews were analysed thematically.
Results Nurses Out of 114 nurses 57 RANs (including five males) returned the survey giving a response rate of 50% (Table 1). The state distribution was: Northern Territory 16, Western Australia 12, Tasmania 9, Queensland 9, South Australia 6, New South Wales 3 and Victoria 2. Forty six (81%) worked in communities of less than 2000 people. Thirty three (58%) of nurses had practiced in a remote setting for more that 16 years indicating a high level of experience. Eleven (19%) had Table 1
Year attended course.
Year
Frequency
2003 2004 2005 2006
3 14 28 10
6 25 51 18
Total
55
100
Missing data 2.
Percent
‘‘MEC course in remote Australia’’
Figure 1
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Perception of the impact of MEC on recent practice to manage maternity care.
attained a Masters level of education. Thirty nine (68%) reported they always or often worked without a midwife or doctor in their practice setting. Forty-eight (82%) respondents indicated they initiated taking the MEC course themselves while six (11%) indicated the course was a compulsory part of their university study or their workplace (3) required it. Seven (12%) said the course was recommended by their colleagues. Individual respondents indicated their reasons for undertaking the course to be ‘maternity phobic’, ‘want to work in a developing country’, ‘often work without a midwife’, ‘handle numerous preterm births’, ‘solo practitioner’, and ‘to be prepared!’
Educational strategies and actual practice Fig. 1 shows that 56 nurses responded to questions about developing skills, recognising complications and responding to emergencies. All ‘‘strongly agreed’’ or ‘‘agreed’’ that their skills were increased and they were more competent to deal with maternity emergences. Two were unsure whether they were ‘‘more able to recognise complications’’. All or all but one respondent indicated feeling skilled and confident to undertake routine and emergency antenatal care, birth and postpartum care, often despite the time since completing the course. The following figure shows this was not just a perception but in reality as those responding were providing routine midwifery care.
Table 2
Respondents had managed routine and emergency antenatal and postpartum care and delivered a baby. Twenty two (45%) indicated they had managed a maternity emergency since completing the course and 19 (34%) reported being the most experienced clinician at the time. All reported that the MEC course had made a positive and strong impact on their ability to manage maternity emergencies. All respondents felt that it would be necessary to refresh their skills, 46 (82%) thought this refresher should occur 2 or 3 yearly. Five (9%) suggested that they would not need to refresh their skills if they were working with a midwife. When asked whether the course met their needs and if the reference material was appropriate, 48 (86%) ‘‘strongly agreed’’ or ‘‘agreed’’ that the course met their needs and 52 (93%) thought the reference material appropriate. There were non-responses. No one disagreed. Fifty one (91%) had used the reference material and 11 (20%) reported using it regularly. Five (9%) said they had never referred to the resource material since completing the course. The practical approach using skill stations (91%) and case simulations (92%) also received favourable feedback, with the majority strongly agreeing or agreeing with the methods of teaching. Fifty three (95%) said they would do the course again and recommend others to do it. Twenty respondents (42%) said the course encouraged them to consider taking a tertiary level midwifery course.
Description of health services whose managers were interviewed.
Location
No. of health centres
ARIA code
NT 1 NT 2 NT 3 WA SA QLD
8 23 10 10 6 + 3 Outstations Not stated
3—5 Various 1—5 3—5 4—5 3—5
Total
No. of RANs 20 54 80 15 18 15 202
No. of midwives 2 20 Not known 4 4 6 36+
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S. Belton et al.
Managers Six health service clinical managers were interviewed regarding the perceived value of the MEC course to their health service. The features of the health centres they represent are summarised in Table 2. Most health service managers interviewed stated that the vast majority of their health centres fell into categories moderately accessible to remote in the accessibility/remoteness index of Australia. The total number of RANs employed by the six health services was 202 (range 15—80). Five managers of multiple health services stated they had 36 midwives. Five managers felt that at least one midwife per health centre location was ideal and in some cases (such as in larger communities or town-based health centres), two would be preferred. One health service manager was not able to say how many qualified midwives were employed in the health service. All six managers were familiar with the MEC course and all recommended that non-midwife nursing staff attend. None of the managers had attended the course themselves but three managers were midwives. Most managers were unable to accurately quantify the number of RANs that had attended the MEC course since its introduction, but all knew of staff that had attended the course. When asked if the MEC course had changed the standard of services offered by non-midwives, only one of four managers who responded felt that antenatal care had improved. No managers felt that the standard of postnatal care had improved. For unknown reasons, four of the six managers felt unable to comment. Three of the four managers who commented on the standard of care in unplanned labour and birth felt that the standard of care had improved. One manager described a strength of the course: Dealing with birthing is consistently a worry to non-midwives. This course relieves some of those anxieties.
RANs in the same course as female Aboriginal Health Workers (AHW). They felt that male RANs needed access to maternity emergency skills if they are to work in remote areas, but the cultural sensitivities of the AHWs who believe that birthing is sacred women’s business needed to be respected. The coordinators had to ensure that a male RAN was never in the same skills station as a female AHW. Other challenges included the logistics of travelling to the course both for presenters and participants, with equipment having to be transported around Australia. One interviewee spoke of the concerns of the Australian College of Midwives and NMRAs about unqualified practitioners being provided the skills to operate outside their scope of practice. She emphasised that the MEC course was to be seen as a safetynet for non-midwives and women and that best practice demands that qualified midwives perform these functions whenever possible. When asked what about facilitating the course surprised them, one interviewee cited the number of RANs who had indicated an interest in undertaking midwifery studies after completing the MEC course. The other interviewee declared that the number of RANs who remained terrified of an emergency birth even after completing the course. She also cited a problem in RANs not encouraging mothers to adopt non-supine positions for their labour. The strengths of the course were discussed by both respondents. One suggested that: This course was designed for remote practice by experienced remote nurse/midwives who know and understand the context of remote practice. We are clinically skilled, our practice is current, and evidenced based. Other strengths were thought to be the locations of courses, the atmosphere of safety for participants to ask questions and express fears, and extensive discussions around cultural safety in maternity care.
This sentiment was echoed by another manager who said: Skilling non-midwives in unplanned birthing which often ‘freaks’ those non-midwives out is the most important. None of the managers were able to quantify how many obstetric emergencies had been handled by their staff and, of those, how many were managed by non-midwives. All managers were positive about the course and related positive experiences by participants. A consistent theme in the feedback was that participants and managers felt that the MEC course had increased their confidence to manage obstetric emergencies. The managers recommendations for improving the course included additional skills around routine antenatal and postnatal care, the provision of more courses in more locations, running courses on weekdays and providing refresher courses.
Course designers When asked about the challenges of the course, both course designers spoke about the challenge of having ‘rusty’ midwives in the course. They felt that the course was not designed to update skills of midwives and that their presence distracted from the focus of the course which was on unqualified staff. Another identified challenge was having male
Discussion The MEC course is popular, useful and receives positive feedback several years after participants have used their skills. The RANs who responded thought the course had improved their knowledge and skills and many reported actively using them. The adult learning and practical focus was appreciated by respondents long after they had finished the course. As there is a shortage of midwives across Australia and it is notable that the MEC course appeared to stimulate nonmidwives to consider studying midwifery. This is an unintended but welcome outcome of the course. There is no national data on the numbers of pregnant women who reside and receive antenatal care in remote communities in comparison to how many midwives are available to provide that care. However, it is known that despite higher fertility rates of approximately 12—20% than their urban counterparts, women who live in rural and remote Australia have considerably less access to quality maternity services. This is concerning considering the increased morbidity and mortality in Indigenous women and babies.18 Furthermore, the New South Wales Framework for Maternity Services (2002) acknowledges the convincing body of evidence that mothers and babies from disadvantaged groups
‘‘MEC course in remote Australia’’ are likely to have poorer maternal health outcomes than the population as a whole.19 A number of socio-cultural factors, which include but are not restricted to, cultural and physical isolation from families, language barriers, inappropriate use of biomedical models of care and difficulty in accessing services, as well as the negative influences of poverty, poor nutrition and sub-standard living conditions are cited in the literature as being directly related to poor obstetric outcomes.20 Paradoxically those women with the poorest outcomes are cared for by remote health practitioners who have limited qualifications in maternity care. All of our respondents reported providing routine antenatal and postpartum care despite not being midwives. It should be our concern that safe, reliable and culturally appropriate maternity services are given to these women. There is a tension between providing training to remote health practitioners to relieve their fears and providing the maternity care that women need. The MEC course is underpinned by adult learning principles and convergent theory, that is matching the learning environment with the context of which the newly acquired skills will be applied. Respondents highlighted that contextual learning was paramount in addressing concerns and culminating with increased skills and knowledge of participants. The MEC course capitalises on a number of adult learning principles. Most participants self-initiated in undertaking the course and saw the course as an important selfdevelopment activity and a necessary skill in rural and remote practice. The success of the course has been driven by the participants’ intrinsic motivation to undertake professional development training. This supports Knowles et al.21 adult learning principle, in that internal forces rather then external forces, drive adults in the learning process. The MEC course enables participants to contribute to the learning environment by sharing personal and professional experiences that adds to the group learning and helps to develop professional networks. One of the driving forces for participants is the fear of maternal emergencies. Simulation is a tool widely used in stress inoculation training and enables participants to practice and implement intervention strategies that will give the participants a framework to operate from in maternal emergencies. Furthermore, we know that when clinicians are placed in stressful situations they will often revert to their original training in given topic. At the conclusion of the course, participants commented on increased confidence and decreased fear if faced with a maternal emergency. The course not only addressed the concerns of the participants before commencing the course but also gave them an operational framework that can be implemented during maternal emergencies. The MEC course is not only an opportunity to develop professional skills but also to develop professional networks that are integral in supporting practitioners in rural and remote areas. Professionals who work in isolation and with decreased professional development opportunities, experience greater staff turn-over and poorer recruitment outcomes. The implementation of courses such as MEC that involve RANs from different geographical areas is one strategy to increase staff retention by developing support networks and up-skill staff. The MEC course not only benefits
65 individual RANs and assists in improving the maternal health outcomes in rural and remote communities.
Conclusion The MEC course is valued by both remote health managers and practitioners. The learning activities and the skills and knowledge taught are reported to be very beneficial and used by remote health practitioners years after completing the course. The national shortage of midwives is highly visible in remote areas and many indigenous women who live in fourth-world conditions are unable to access qualified antenatal and postnatal care. The women and their babies also have poorer outcomes than mainstream urban Australians. While we should aim for skilled midwives, non-midwives and Aboriginal Health Workers, can and do provide maternity services in the bush. The MEC course is an important quality and safety strategy to support this workforce and contributes positively to rural and remote maternity care.
Acknowledgements The authors would like to thank the Centre for Remote Health and the Council of Remote Area Nurses of Australia for financial and personnel assistance, Sabina Knight and Lesley Barclay for expert advice, and Joseph Mc Donnell for statistical advice. Sue Kildea and Sue Kruske also contributed to designing the survey. Contributors: Suzanne Belton–—co-ordinator and designer of research study, contributed to survey and interview design, lead data analysis and writing. Marcel Campbell–— designed questionnaire, conducted interviews, analysed and contributed to knowledge transfer at public fora. Sally Foxley–—lead literature review, designed questionnaire, conducted interviews, analysed data, contributed to writing and presented findings at public fora. Bev Hamerton, Sally McGrath and Nathan Saunders–—lead literature review, designed questionnaire, conducted interviews, analysed data, and contributed to writing. Justin Gladman–—lead literature review, designed questionnaire, conducted interviews, analysed data, contributed to writing and coordination. Neil Piller–—co-ordinator and designer of research study, lead analysis and contributed to writing. Fran Vaughan–—lead literature review, designed questionnaire, conducted interviews, cleaned and entered the raw data, analysed data, and contributed to writing.
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66 4. Barclay L, Brodie P, Tracy S, Leap N. Australian midwifery action project final report. Sydney: Centre for Family Health and Midwifery, University of Technology Sydney; 2002. 5. Brodie P. Addressing the barriers to midwifery–—Australian midwives speak out. Australian Journal of Midwifery 2002;15(3): 5—14. 6. AIHW. Rural regional and remote health: a study on mortality (summary of findings). Canberra: Australian Institute of Health and Welfare; 2003. [rural health series number three]. 7. AIHW. Australia’s health 2004: the ninth biennial report of the Australian Institute of Health and Welfare. Canberra: Australian Institute of Health and Welfare; 2004. 8. Tracy S, Barclay L, Brodie P. Contemporary issues in the workforce and education of Australian midwives. Australian Health Review 2000;23(4). 9. Banscott Health Consulting Pty Ltd.. Maternity services review in the Northern Territory Darwin. Department of Health and Community Services; 2007. 10. Hirst C. Re-Birthing: Report on the Review of Maternity Services in Queensland. Brisbane: Queensland Government Queensland Health; 2005. 11. ABS. Year Book Australia, 2003, Aboriginal and Torres Strait Islander population 2004; 26.5.04 [cited 2004 24 September]; Available from: http://www.abs.gov.au/ausstats/[email protected]/ Lookup/2F6A3D06D66A12A5CA256CAE00053F9C.
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