title: Clinical decision-making: midwifery students' recognition of, and response to, post partum haemorrhage in the simulation environment.
abstract: BACKGROUND
  This paper reports the findings of a study of how midwifery students responded to a simulated post partum haemorrhage (PPH). Internationally, 25% of maternal deaths are attributed to severe haemorrhage. Although this figure is far higher in developing countries, the risk to maternal wellbeing and child health problem means that all midwives need to remain vigilant and respond appropriately to early signs of maternal deterioration.
  
  
  METHODS
  Simulation using a patient actress enabled the research team to investigate the way in which 35 midwifery students made decisions in a dynamic high fidelity PPH scenario. The actress wore a birthing suit that simulated blood loss and a flaccid uterus on palpation. The scenario provided low levels of uncertainty and high levels of relevant information. The student's response to the scenario was videoed. Immediately after, they were invited to review the video, reflect on their performance and give a commentary as to what affected their decisions. The data were analysed using Dimensional Analysis.
  
  
  RESULTS
  The students' clinical management of the situation varied considerably. Students struggled to prioritize their actions where more than one response was required to a clinical cue and did not necessarily use mnemonics as heuristic devices to guide their actions. Driven by a response to single cues they also showed a reluctance to formulate a diagnosis based on inductive and deductive reasoning cycles. This meant they did not necessarily introduce new hypothetical ideas against which they might refute or confirm a diagnosis and thereby eliminate fixation error.
  
  
  CONCLUSIONS
  The students response demonstrated that a number of clinical skills require updating on a regular basis including: fundal massage technique, the use of emergency standing order drugs, communication and delegation of tasks to others in an emergency and working independently until help arrives. Heuristic devices helped the students to evaluate their interventions to illuminate what else could be done whilst they awaited the emergency team. They did not necessarily serve to prompt the students' or help them plan care prospectively. The limitations of the study are critically explored along with the pedagogic implications for initial training and continuing professional development.
authors.affiliation: Centre for Nursing and Midwifery Research, University of Brighton, Mayfield House, Village Way, Brighton, UK.
authors.forename: Julie
authors.initials: J
authors.lastname: Scholes
authors.forename: Ruth
authors.initials: R
authors.lastname: Endacott
authors.forename: MaryAnne
authors.initials: M
authors.lastname: Biro
authors.forename: Bree
authors.initials: B
authors.lastname: Bulle
authors.forename: Simon
authors.initials: S
authors.lastname: Cooper
authors.forename: Maureen
authors.initials: M
authors.lastname: Miles
authors.forename: Carole
authors.initials: C
authors.lastname: Gilmour
authors.forename: Penny
authors.initials: P
authors.lastname: Buykx
authors.forename: Leigh
authors.initials: L
authors.lastname: Kinsman
authors.forename: Rosemarie
authors.initials: R
authors.lastname: Boland
authors.forename: Jan
authors.initials: J
authors.lastname: Jones
authors.forename: Fawzia
authors.initials: F
authors.lastname: Zaidi
mesh_terms: D002983:Clinical Competence; D003657:Decision Making; D004638:Emergency Treatment; D006801:Humans; D008880:Midwifery / Q000193:education*; D016544:Patient Simulation; D006473:Postpartum Hemorrhage / Q000628:therapy*; D013334:Students / Q000523:psychology