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An Innovative Approach: Using Simulation to Teach Primary Care Gynecologic Procedures

Hellier, Susan D. PhD, DNP, FNP-BC, CNE; Ramponi, Denise R. DNP, FNP-C, ENP-C, FAANP, FAEN; Wrynn, Alexander BSN, RN; Garofalo, Stephanie BSN, RN

Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: August 2017 - Volume 12 - Issue 4 - p 268–273
doi: 10.1097/SIH.0000000000000213
Technical Reports
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Introduction In response to the growing body of evidence that simulation is a satisfactory way to instruct procedural skills, we developed an innovative model to teach common gynecologic procedures such as cervical cancer screening, cervical polyp removal, intrauterine device removal, and endometrial biopsy. The objectives of this study were to describe the construction of the model and to assess participants' satisfaction and confidence in applying the learning objectives to their clinical practice.

Methods The researchers created the model with reusable and readily available materials. During a hands-on skills workshop, practicing clinicians performed simulated cervical cancer screening, endocervical polyp removal, intrauterine device removal, and an endometrial biopsy on a low-fidelity gynecologic model. Using convenience sampling, each participant completed a survey designed to measure satisfaction with the workshop and self-confidence in their newly acquired skills.

Results All (N = 30,100%) of the participants agreed at the “agree” or “strongly agree” level that the gynecologic skills workshop using lecture and a hands-on model was a satisfying and self-confidence–building experience.

Conclusions An easily reproducible and reusable gynecologic procedure simulator was highly rated as a means of teaching common primary care gynecologic procedures. The simulated model provided an opportunity for hands-on skills learning for clinicians who wish to expand their gynecologic procedure skill set.

From the Robert Morris University School of Nursing and Health Sciences (S.D.H., D.R.R. A.W., S.G.), Moon Township, PA.

Reprints: Susan D. Hellier PhD, DNP, FNP-BC, Robert Morris University School of Nursing and Health Sciences, 6001 University Blvd, Moon Township, PA 15108 (e-mail: hellier@rmu.edu).

The authors declare no conflict of interest.

A variety of therapeutic and diagnostic gynecologic procedures can be safely performed in the office or clinical setting by trained and proficient providers.1 Today's healthcare environment demands attention to patient safety, cost, and satisfaction. With less oversight than formal health care profession training programs, the quality and intent of continuing education for practicing clinicians must also be considered.2 Furthermore, the Institute of Medicine calls for stakeholders in healthcare education to demonstrate the relationship between the education of healthcare providers and the quality of care.3 Formal healthcare profession training programs may provide inconsistent exposure to procedures and learning opportunities.4 Furthermore, integration of new procedures and equipment may be difficult for the practicing clinicians to gain experience. Of concern is how practicing clinicians may acquire new skills, skills not adequately covered in formal training or if the clinicians desire to expand their own skill sets. “On-the-job” proctored experiences are nonstandardized, demanding of time and resources, and are often not practical.2,4,5

As discussed in the Institute of Medicine's seminal work, “To Err Is Human,”6 simulation is offered as a tool to improve patient safety and reduce errors; however, the literature is sparse with regard to simulation's role in the context of professional development for practicing clinicians. The evidence supports simulation in formal training healthcare programs as a safe, anxiety-reducing, and confidence-building method to deliver education.7–10 The evidence suggests that low-fidelity simulation models may provide an adequate venue to learn procedural skills.2,5,8,11–13 Moreover, when compared with more expensive and less available high-fidelity models or manufactured static training models, low-fidelity models may provide equivalent results for procedural skill training.5,14 Simulation allows for a minimal level of competency before transitioning to performing procedures on real patients.2

Providing routine gynecological care in an outpatient primary care venue may expedite diagnosis and treatment of a problem in a convenient setting.1 By avoiding unnecessary and costly specialty practice referrals, patients may find performance of routine gynecologic procedures by a known provider more comfortable, thereby providing the patient with a better healthcare experience.1,15 Furthermore, using female patients to learn invasive procedures is simply less acceptable than in the years past.5

The purpose of the article is to provide detailed information about our innovative model designed to provide routine gynecologic procedure training for practicing clinicians. Secondly, the article provides participants' self-perceived satisfaction and confidence in applying the learned simulated skills in clinical practice. When coupled with lecture in a workshop setting with immediate feedback,16 the easily reproducible, reusable, and cost-effective model provides a satisfactory low-fidelity simulation experience for cervical cancer screening, cervical polyp and intrauterine device (IUD) removal, as well as endometrial biopsy. Through experiential learning provided in a “hands-on” skills workshop setting, the clinician is given the opportunity to apply acquired knowledge in the clinical area.8

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METHODS

The Simulated Vagina

Using poly vinyl chloride (PVC) pipe to simulate a vaginal model is not new17; however, our model reflected modifications. Our model was mounted on a 20 × 20-cm plywood board, which allowed desktop use (Figs. 1–3). A 4-cm PVC DWV hub x SJ trap adapter was glued to the plywood with construction grade adhesive. Next, a 9-cm-long piece of 5-cm diameter PVC was glued into the DWV hub x SJ trap adapter. The top anterior portion of the model was constructed with 8-cm diameter sewer drain sanitary tee piece PVC fitting that allowed insertion of a vaginal speculum. The posterior aspect of the 5-cm diameter sewer drain sanitary tee piece PVC fitting was fitted with a removable PVC sewer drain cap. The outside diameter of the cap was lined with masking tape, which allowed for a snug fit into the back of the model. This removable cap allowed for placement and removal of the uterine/cervical model from the rear of the model. The posterior cap secured the uterine/cervical model in place. The model was designed to break down into individual pieces for ease of cleaning and storage (Fig. 4). By being constructed in pieces, the model plywood and PVC base was able to be changed to a smaller-diameter top piece for use in a proceeding rectal procedure workshop. One PVC vaginal model was shared by two workshop participants: one participant to perform the procedures and the other to hold the model to prevent slippage on the workspace.

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

FIGURE 3

FIGURE 3

FIGURE 4

FIGURE 4

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The Uterus and Cervix

Reflecting our own innovation, a red racquetball served as the “uterus” and “cervix.” This simulated uterus and cervix served as a medium for multiple simulated gynecologic procedures including cervical cancer screening, endocervical polyp removal, IUD removal, and endometrial biopsy. Using a drill press, a 0.6-cm hole was drilled into the racquet ball on the side opposite of the brand stamp (Fig. 5). Red gelatin dessert reconstituted according to package directions simulated the endometrial lining to be sampled. Using a 60-mL syringe with an 18-gauge needle attached, 20 mL of the red gelatin dessert was placed into the racquetball through the drilled pressed hole, which served as the cervical os. A sample IUD, supplied by a pharmaceutical representative, was placed into the cavity of the ball and the strings trimmed to 3 cm. To simulate an endocervical polyp, a thin-walled tiny red balloon was used. The balloons were obtained in the water toy section of a local retail store. The balloon was filled with 1 mL of water and tied off. The firm edge of the balloon behind the knot was trimmed off with scissors. The researchers found the firm balloon edge made removal of the balloon difficult and resulted in an unrealistic “snap” when removed with ring forceps. Using hemostats to hold the balloon, it was placed into the simulated cervical os. The knot was placed on the interior aspect of the racquet ball and the water-filled portion dangled from the simulated cervical os. The knot of the balloon was sufficient to hold the “endocervical polyp” in place. The uterine/cervical model was then placed in a commercial egg container and stored in the refrigerator to allow the gelatin to set (Fig. 6). Uterus and cervical models were assembled 3 days before the workshop and stored in the refrigerator until just before use.

FIGURE 5

FIGURE 5

FIGURE 6

FIGURE 6

Immediately before the workshop, the racquetball “cervix and uterus” was placed into the PVC vagina through the model's posterior access, then the cap was replaced (Fig. 7). The PVC vagina allowed the placement of the speculum through which all procedures were performed. Firstly, workshop attendees removed the “cervical polyp” with ring forceps. Secondly, the IUD was removed, followed by the simulated cervical cancer screening collection. Lastly, a tenaculum was placed into the racquetball's anterior “cervical lip,” followed by inserting an endometrial sampling device to obtain the gelatin “endometrial tissue.” After the workshop, the gelatin was squeezed out of the uterus through the cervical os. The model was rinsed with tap water to allow reuse of the device in future workshops.

FIGURE 7

FIGURE 7

All workshop attendees were attending a larger 3-day skills workshop in which the gynecologic procedures skills was one of the multiple specialty options based on conference attendees' choice. Attendees received a 3-hour PowerPoint lecture with clear learning objectives.12,16 An expert women's health clinician with extensive experience in health care education developed and delivered the learning objectives and lecture. All workshop instructors were expert women's health clinicians. In the didactic portion, attendees were given evidence-based indications and instructions for the procedures, as well as clinical pearls. Attendee to instructor ratio was 8:1.16 After the didactic portion for each procedure, simulation of the procedure ensued. Attendees worked in pairs, each in turn completing the simulation with the instructors offering insight and help (Fig. 8). Attendees shared a vaginal model, but each had their own simulated uterus/cervix. They were afforded multiple opportunities to practice the simulated procedures.

FIGURE 8

FIGURE 8

The study received exempt status from Robert Morris University's institutional review board. Workshop attendees were recruited to participate in the study. After obtaining informed consent, study participants completed The National League for Nursing's (NLN) Student Satisfaction and Self-Confidence in Learning Tool18 at the conclusion of the workshop. The NLN's Student Satisfaction and Self-Confidence in Learning Tool is a 13-item instrument designed to measure student satisfaction (five items) with the simulation activity and self-confidence in learning (eight items) using a five-point scale. Reliability was tested using Cronbach α: satisfaction, 0.94; self-confidence, 0.87. In addition, the researchers obtained participants' demographics as to be able to describe the sample. To encourage participation, we randomly awarded US $50.00 gift cards to two study participants.

The researchers performed all calculations and statistical analysis using SPSS data-analytic software Version 22. Descriptive statistical analysis of the participants' demographics was calculated, as well mean scores and standard deviation of the tool results.

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RESULTS

All participants were practicing advanced practice clinicians or students (Table 1). All workshop attendees (N = 30, 100%) completed the NLN's Student Satisfaction and Self-Confidence in Learning simulation questionnaire.18 The participants' average age was 37.9 years and all were female. All (N = 30, 100%) of the participants agreed at the “agree” or “strongly agree” level that the model was an enjoyable, helpful, motivating, and effective method to learn. Moreover, all (N = 30, 100%) of the participants agreed at the “agree” or “strongly agree” level that the simulation workshop built confidence. Similarly, all (N = 30, 100%) of the participants agreed at the “agree” or “strongly agree” level built confidence in mastery of skills and obtained the required knowledge to perform the procedures in a clinical setting. Almost all (n = 29, 97%) of the participants agreed at the “agree” or “strongly agree” level that they knew how to obtain help with concepts they did not understand as a result of the simulation. In addition, all (N = 30,100%) of the participants agreed at the “agree” or “strongly agree” level that it was their own responsibility to learn what they needed to know from the simulation activity. Finally, all (N = 30, 100%) of the participants agreed at the “agree” or “strongly agree” level that the simulation model was a helpful resource to learn gynecologic procedural skills.

TABLE 1

TABLE 1

Limitations of the study included a large number of advanced practice student participants who have limited clinical experience. The researchers envisioned all potential participants as experienced advanced practice clinicians looking to introduce new skills into their existing practice. Advanced practice students may be too inexperienced to know whether the simulation workshop would lead to increased confidence in actual performance of the simulated procedures on real patients. Furthermore, advanced practice students may not have the opportunity to perform the newly acquired skills on real patients. Another limitation for consideration was collecting self-reported data. The participants may have answered survey questions in a manner deemed more desirable or acceptable to the researchers. In addition, the sample size was small and limited to one workshop venue, which limits generalizability of the findings. Finally, the participants reported satisfaction with the workshop and increased confidence in skill acquirement; however, actual learning was not measured.

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DISCUSSION

The purposes of this article are to provide information about a simulation model to teach routine gynecologic skills and to demonstrate participant satisfaction with a workshop teaching methodology. In agreement with previous studies,2,5,8,11–13 we found our low-cost and reusable model to be a valuable tool in introducing and teaching common skills in a workshop setting. High-fidelity and commercially produced static models are expensive, less accessible, and impractical for larger groups of learners, making the development of low-cost models an emerging trend in medical education.19 As acknowledged in previous model simulation research,5 there is some sacrifice of realism when not using a real patient. Despite the lack of realism, models such as ours offer numerous benefits. The model is reusable, portable, and cost-effective. Our gynecologic skills workshop combines auditory, visual, and kinesthetic learning that serves all types of learners.5 In a healthcare environment increasingly focused on providing safe care and improving patient satisfaction, our simulation model used in a workshop setting provides a practical venue for skill acquisition before real clinical practice. In simulation, learners can make mistakes without the worry of harming a real patient. Furthermore, unlike performing procedures on real patients, clinicians can repeat the procedure multiple times.

The survey results offered a greater depth and understanding of the participants' perceptions of the training. In agreement with previous findings,5,10 our results support the use of gynecologic models to provide a satisfying and confidence-building experience. In our study, the participants' perceptions of the simulation workshop were overwhelmingly positive.

In agreement with previous research,5,19 our simulated model represents versatility of use. We believe that our simulated model may be used to teach routine gynecologic procedures to other healthcare professionals, such as medical students, resident physicians, practicing physicians, and advanced practice students. The simulated PVC pipe vaginal model and racquetball uterus and cervix appear to be a useful model because they are reusable, cost-effective, durable, easy to assemble, clean, and store.

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CONCLUSIONS

Simulation removes training from the clinical environment and provides a safe environment to practice skills with immediate instructor feedback.16 Simulation allows practicing clinicians the opportunity to learn new skills to facilitate integration into clinical practice. Despite the acknowledged limitations, our study demonstrates simulation as a satisfying, realistic, and confidence-building method for educating practicing clinicians in performing common gynecologic procedures. Furthermore, simulation gives healthcare educators the tools to properly instruct clinicians without needing to use costly and sparsely available high-fidelity or static gynecologic mannequins. This innovative model may also be used in formal healthcare educational programs for gynecologic procedure instruction. We suggest further studies to objectively measure whether learning outcomes were met.

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ACKNOWLEDGMENTS

The authors wish to extend a sincere thank you to the Regional Research and Innovation in Simulation Education (RISE) Center at Robert Morris University and Practitioner Education Associates, LLC for support of our work.

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REFERENCES

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Keywords:

Simulation; Gynecology; Women's health; Continuing education; Advanced practice; Procedures

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