Clinical site shortages, non-participating parents, sparse popuation per square mile, High fidelity Maternal Child Mannequins
I am a former OB Nurse of approximately 23 years and taught OB nursing for 2 years. What the students learn in OB clinical sites is minimal compared to what is learned when they are actually working in the specialty. What is important for them to learn is how the care of OB patients related to Med-Surg nursing is invaluable. Let's face it OB patients show up and are cared for in all sorts of settings, not just L&D or post partum. What is also important to know is that many student nurses who are exposed to OB experiences while in school inspires them to seek employment in the specialty. What needs to change is how OB is approached in nursing schools. Assign them to an OB clinic where patients receive prenatal care, where they will be assigned to an OB patient and follow them throughout their pregnancy, intrapartum, postpartum, and post discharge from where they delivered. THAT will give them the opportunity to experience the full scope of care these patients receive. It is how I learned while I was in school. I cannot understand why this approach was abandoned for strictly spending time in the clinical setting caring for a different patient(s) every week during their OB rotation.
Simulation is fine for addressing specific obstetrical situations but should never be the sole source of their clinical experience.
Thank you Mary, I agree. In difficoult situations we need a good and experienced team, not people that have been rotating every two weeks in different ward..
When nursing programs changed from hospital-based programs to college/university programs, the structure of clinical experiences changed. Students can not be made to stay in clinical more hours than the course is set up for. For example, many courses are maternal-child with 90 clinical hours which means 45 hours for OB and 45 hours for Peds. Those 45 hours of pregnancy and delivery include time in the Nursery to learn newborn care. If the patient does not go through pregnancy and delivery within the allotted hours, you cannot make them stay longer as you could with hospital-based programs.
Mary, I don't know how many hours your program has for OB clinicals but if the clinical day is 6 hours, the student can only stay for 6 hours, irregardless if the patient delivers or not. You are right in that simulation should not be the sole source of their clinical experience but sometimes it is better than nothing. OB is a specialty area which requires an extensive orientation if the graduate is hired to work there. The clinicals are only to help them understand the concepts and process of pregnancy, labor and delivery, not to provide them with the experience to work there.
When I went to nursing school in the 1970's, I had 1 day of OB experience and did not see any patients. When I graduated, I worked in L&D, PP, and the Nursery and became an NNP. Mary, you were lucky to have the experience you did but I learned the concepts I needed to learn and worked OB for many years after graduating.
As limited hours are given for clinical experience in obstetrics course,its ideal to give sufficient hours and cannot expect students to obtain expertise during their clinical postings.simulation and lab experience can only contribute to 25% of the total clinical hours of the course. during limited hours of clinical postings usually students get and opportunity to observe and assist in the care given for patients and rarely get chance to give individualised care to OB patients. complete lack of experience is definitely going to cause a decline in quality of care.
Thank you everyone! I think with simulation it is better to make mistakes in the lab setting than on a patient. The high-fidelity mannequins can expose students to less common complications as well.
No doubt simulation has a place for the reasons you give, Colleen, as well as for learning procedures in a controlled environment where the steps can be slowed and examined. Follow-through experiences as described by Mary provide something different: an insight into the family experience of pregnancy, birth and early parenting as well as the health care system.
Unless workplaces offer the opportunity for following women through their childbearing experience, this is something that only education can offer. It is a step outside the procedure-based focus of the risk paradigm into the relational paradigm that many women have for THEIR OB experience of developing a new relationship with a new person.
The concern about time that Cheryl points to might be circumvented by allowing it to be voluntary, although it still needs insurance cover. As a student nurse, I was able to attend a homebirth as part of my final semester special interest focus. I no longer recall how the hours were accounted but I wouldn't have missed it for the world, even if I had still needed to meet other requirements.
Today, I am a midwife working in a continuity of care model, after about 25 years of waiting for the opportunity and the right time and loving it. I still need the simulation experiences, but what I've learned from some of the women I've cared for has been invaluable, and not to be found in labs and textbooks. Unless the mannequins can release the pelvic floor in response to the pressure of the baby's head or actively keep their vocal cords loose during contractions...both of which I learned about from women who knew me well enough to share their approach to second stage with me. One was a primip whose labor progress was compatible with that of a multip.
Thank you. I am impressed at what the mannequin can do, but actually haven't worked with it yet. Any other opinions appreciated .
Having worked with students from BSN programs and AA programs, the students that come from the AA programs intrinsically have better skills as they have the opportunity to actually follow a patient for 11 hours compared to the BSN programs students who have only 4 1/2 hours of clinical per day and mainly "watch" while the others actually do. One group of new grads had a BSN grad who came to obstetrics and had clinical in another large hospital and said they were never allowed to hold a baby. The AA new grads were able to step in and function fully. There has to be some way of getting the straight BSN students enough clinical so that they can step in clinically up to par with the AA grads.
Never allowed to hold a baby? That sounds unbelievable. I take it you mean Associate Degree programs? The local AD program has the same clinical sites as the local BSN program, so the lack of exposure is common to both. My concern is for supplementing for students have plenty of clinical hours but the mom's and babies aren't always there, or family first -with rooming in or declining to having a student.
We found it incredible also. It was at a well known, large teaching hospital in Southern Cal that she had her OB clinical from her BSN program. My program, many, many years ago was Associate of Arts in Nursing. We are a smaller hospital, but there are always moms & babies there even if not actively delivering. Perhaps because we are nearly "maxed" out ratio wise most of the time, the students get plenty of hands on. When I have students assigned to me, rarely have I had a patient refuse a student. We have a very wide socioeconomic range for our patients as well. Actually I don't ask the patient, but tell them they will be getting twice the amount of attention and I don' recall them turning down a student when I approach it in that manner. I also take advantage of the first day. I have had students from the BSN program say they were just going to observe the first day. My response has been that we will be "doing" not just watching and I have them do simultaneous assessments with me. We stand on opposite sides of the the bed, I listen to breath sounds & lung sounds on the right, while they listen on the left, then we reach across each other and both listen to the opposite side. I check reflexes, clonus, edema, etc on the right, they check on the left. For baby assessments we do them at the same time for the first one, then after, I let them do the next one on their own and then do mine right after they do theirs and confirm their findings. We also catch the babies in the OR, then they are taken to an intermediate area until the mom comes out of surgery, so I have them help do the bath and assessment right then with me as well. I don't think they learn as much "just watching" and if they are assigned to me I let them know we will be "doing" not just watching.
As a theory and clinical instructor in an ADN program in Southern California, I have had the pleasure of watching students make the application of theory concepts to clinical in our hospital rotations. A goal is to incorporate principles from across our curriculum and demonstrate their presence in the specialty areas. Students must learn concepts, apply concepts, and evaluate outcomes. This comes from hands on learning. Our ADN students graduate with strong bedside skills and are able to communicate well with the healthcare team including the patients, nurses, doctors. OB may be their most "hands-on" rotation. However, lately, hospitals are limiting the hands-on experiences. Our students are no longer allowed to give most IM medications and immunizations. Starting IVs has also been limited.. These experiences are always done under direct instructor supervision. It is a shame when our hospital cohorts complain that students are graduating with minimal skill experience, when it is the hospital procedures that are limiting the students from gaining these experiences. With the trend now focused on the BSN prepared nurse, we are having more and more difficulty securing sites for our ADN clinicals. This frustrates me because I know our students will get in there and work and learn from the actual experience. As a patient and a team mate, I would prefer this over a student who "observes" and contemplates the spiritual impact this experience is having on the patient.
Gail,
You are so right. It is unfortunate that the people who are forcing the changes do not understand the differences between the ADN and BSN nurse. The hospitals in South Carolina have always stated they prefer hiring the ADN graduate as they are ready to take care of patients without the extensive orientation needed by the BSN graduate. Not everyone needs a BSN to provide caring, competent nursing care to patients.
I teach OB/Peds in an ADN program in Pennsylvania. I always hope that my students get exposed to interesting patients during the course of their clinical day. Unfortunately, as stated before, it doesn't usually occur. Our program utilizes "Sim Man", and our students have very intense simulated situations. They are very realistic and I have seen students learn a great deal from the simulations. Many students are able to take the simulation very seriously and view the experience as a "real life" scenario. I would much rather my students be exposed to, say, a postpartum hemorrhage on a "Sim Man" and learn through "making the decisions and providing the care" than by learning from the "observation only" of a real life situation (our OB students are not permittted to give medications or to really do very much in L&D). Clearly, they learn from actual scenarios, but in the absence of the opportunity, simulations provide a very good tool for teaching concepts and evaluating skills.
I, myself had limited experience in OB while in school, but it never prevented me from attaining a position in L&D and it certainly did not impede me in any way. There are many patient scenarios that students will never be exposed to during training, but they learn them on the job from other seasoned nurses and then go on to teach them to others. I am proud of the nurses that our program puts out into the field and although I encourage all of them to continue on with their education I do not believe that they are "below" BSN graduates.
What is the impact of a lack of clinical experiences in obstetrics in BSN nursing education? Clinical site shortages, non-participating parents, sparse popuation per square mile, High fidelity Maternal Child Mannequins.
I'm interested to engage to your posted question. Please enumerate Obstetric related learning experiences/activities in the clinical settings that your students failed to accomplish due to clinical site shortages, non-participating parents, sparse population per square mile, and high fidelity Maternal Child Mannequins. May I ask in what setting your students perform the following related learning experiences:
1. Prenatal assessment
2. Obstetric Scoring: AOG, GP Scoring, TPAL Scoring
2. Blood Pressure Monitoring
3. Weight Monitoring
4. Fundal height measurement
5. Leopold's Maneuver
6. Auscultation of FHB
7. Charting
8. Biophysical Profile
9. Monitoring of Labor
10. Bishop Scoring
11. Transferring Patient from LR to DR
12. Preparation for Delivery
13. Handling actual delivery
14. Postpartum Care
15. Family Planning - Natural Method and Artificial Method
In the Philippine BSN curriculum our students are allowed to give medications with close supervision by our clinical instructor except meds through IV. We require our students to do drug study and to submit the drug study together with nursing care plan before they start their bed side nursing care. Our school policy in the clinical practice is "No drug study No care plan NO clinical practice. Our BSN students are required to complete 5 actual normal deliveries, 5 assists in normal delivery, and 5 actual cord dressing. We call it 555 requirements for graduation and for the Philippine Nurse Licensure Exam.
It is quite interesting to read the different responses to this question. having been an instructor for both ADN and BSN/MSN programs. I will agree that clinical sites are getting to be a challenge these days and yes, some sites have restrictions on what students can and cannot do, but the instructors for those students need to be the person that actively take charge of making the experience happen for them. Students are already robbed of valuable clinical hours, so spend time and make it be worthwhile. My students were given six twelve hour days in OB which was one day a week for six weeks but prior to taking them to the hospital our school of nursing simulated a real life situation which begins in the community close to the school of nursing, there is an ambulance involved with a live patient but the actual delivery process is done on the pregnant mannequins, and our classroomsare setup like a hospital with emergency room, triage area, labor rooms and delivery rooms. Students are assigned to different areas along with faculty members up to the point of actually delivering the baby where the student would receive the infant and place him/her in the radiant warmer; of course her/his instructor is right there to help students in all areas while having students verbally state what's happening and what assessments are being done. The first time, some students were assigned to the mother and the others to the baby, then they switch places and those who were with mother then go to the baby and vice versa. This simulation is done over a few days at different times of the day until all students are checked off.
This is actually done to create the urgency that student may experience in the actual delivery rooms. I found with this prepping, students both ADN and BSN/MSN students were equipped to work alongside the nurses in the delivery rooms because I could not be in all the rooms, they were assigned to nurses who were specially trained to work with students. We have never had parents refusing students. because students were introduced as such but as mentioned above, not as a request but as "this student and I will be your caregiver this shift." As Patients are assessed, I will do the first one that first day speaking through what I am looking at, then subsequent assessments are done by the student under my supervision. The same goes for the babies; of course, if it is a baby that is depressed, then the NICU team would be on spot and the student would observe their care. Students attend C/Sections and also receive babies without any issues. Some of these students loved the areas so much so that they applied for internship and were accepted after which they were hired on as staff members.
So in all this, I just wanted to say, it depends on the facility how friendly they are towards students, and to add, instructors do make a difference in students' lives. If students are made to be the responsibilities of the staff on the units, they may be resented by staff but for instructors to be available and flexible to assist wherever and whenever necessary. Not only is there a challenge to get training sites but there are not enough faculty members for all these students.
To address the statement about ADNs and BSNs both I have found that both groups have done very well, it always depends on the motivation and the encouragement that they receive during their training. Sorry about the length of this response.
This is an addition to my previous answer to your question. I would like to answer your posted question with question. Are you saying that lack of clinical experiences in Obstetrics due to clinical site shortages, non-participating parents, sparse population per square mile, high fidelity Maternal Child Mannequins results to poor quality nursing education? If your answer is yes, I would like to suggest to review the learning objective, related learning experiences, nursing core competencies, teaching-learning resources, and learning evaluation base on learning objective. The size of student enrolment should be in accordance with the availability of teaching-learning resources of the institution.
We have 3 different programs that come to our hospital. We do an average of 190 deliveries per month. The students have plenty of opportunity for hands on experience. The problem we encounter is that the BSN students are not on the unit for report (they wait in the lobby until their instructor arrives at 7) and then leave at 1 pm. The ADN students from 2 other programs have their assignments made BEFORE report, are ready for report at 645 and do not leave until 5 pm. The BSN students have a completely different day, but their program is not set up to have the same hospital hands on time. You can have all the simulations and mannequins, but nothing accounts for actual real time experience. Simulations can absolutely help prepare. It's just a sad state to see the more educated nurse have sub par clinical skills.
Thanks everyone @ Marietta ... I agree that clinical hours are shortened in many programs which can be due to legal, hospital or academic program restrictions with the necessity of having an instructor present for all hands on clinical interventions. I am no longer teaching. One program I taught in had just bought a high-fidelity mannequin and I was curious if it would be a good supplement to the sometimes hit and miss OB clinical experiences students had. I was also looking at whether it would impact Assessment Test Scores. I wanted to compare if the class prior to the High-fidelity mannequin experiences had different test scores than the ones that participated with the mannequin. I wasn't able to complete the project as the Assessment Test (ATI) had changed the same year so I did not pursue the project further. It was an interesting topic to research which was the original reason I posted the question. I am glad to see it still stimulates discussion. @ Florencia, I missed your posts... I hope this explains my question rationale better. Thanks all.
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