The effect of competency-based education in obstetric emergencies on midwifery students in clinical skill lab, based on Kirkpatrick evaluation model: A randomized controlled trial

Background Obstetric emergency is one of the most important causes of maternal and neonatal mortality, and competency-based education is one of the efficient approaches to cover this. Objective structured clinical examination is one of the valid methods in measuring students’ competency and performance. Kirkpatrick evaluation model is a great method to assess a training impact. Objectives This study was designed to determine the effect of competency-based education on midwifery students based on Kirkpatrick evaluation model. Design Randomized controlled trial Setting Nursing and Midwifery School in Islamic Republic of Iran (Iran University of Medical Sciences) Participants eighty students in third to fifth term of associate and bachelor’s degree in midwifery (intervention group=40, control group=40) Methods Using stratified random sampling, research team trained learners of intervention group in 4 sessions, 5 hours/day in a month in emergency obstetric cares. Both groups had been receiving the routine schedule of the faculty. Knowledge, skills, and self-confidence were assessed three times, before, immediately and 6 weeks after training by researcher made questionnaire, Objective Structured Clinical Examination (OSCE) and self-reported questionnaire respectively. Data were analyzed with descriptive, inferential statistics. Results The level of knowledge, skills, and self-confidence increased significantly in the intervention group, in immediate and 6 weeks after intervention (P<0.001). In intervention group, Mean ± S.D of all variables were 5.05±2.074, 143.30±12.146 and 11.65±2.045, which increased to 10.17±1.318, 527.70±19.995 and 18.97±1.980 and remained at the same levels 6 weeks later, 9.37±2.215, 521.80±19.784 and 19.00±2.631; in the control group, this trend was not significant (P=0.380, P=0.455 and P=0.191). Conclusion Competency-based education can be used in midwifery education and in-service training. We need to use new educational approaches such as competency-based to have a valuable impact on knowledge skills and self-confidence. This may affect health indexes indirectly.


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One of the most important causes of maternal and neonatal mortality is the low quality  Learners 'training by using manikins in a quiet environment before entering the hospital, 83 can decline stress and enhance self-confidence and self-efficacy (11)(12)(13) This study is a randomized controlled trial with a control group which investigated the 101 effect of competency-based education in obstetric emergencies in midwifery 102 undergraduate students. Using stratified random sampling, learners were divided into 103 two groups by researcher. To control information bias, the evaluation of control group 104 were completed before intervention started. Both groups received regular midwifery 105 emergency obstetric care topics by the faculty members in accordance with the 106 approved syllabus of this country ministry of ministry of health and medical education.

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Participants and setting 108 All midwifery students in semester 3 to 5, associate and bachelor 'degrees in nursing 109 and midwifery faculty, informed by posters or directly by the researcher. These students 110 who do not have especial experience in practical skills except internship were eligible to 111 participate. Not participating even in one session was the criterion for exclusion.

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Sample size: 113 To determine the sample size for each objectives, the sample size separately was 114 calculated using the following formula; in which the confidence level (1-α), 95 percent, 115 the test power (1-β), 80 percent, standard deviation (σ) 12.1 and accuracy, 0.5 were 116 considered (17); so the sample size in each group was 40 people.  was calculated at each station which was more than 0.7 in various stations.

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The research team conducted the training in 4 sessions which every session duration 139 was 5 hours, once a week, and the assessment was carried out before, immediately questions. Every correct answer had one score and the overall score was 12. Self-161 confidence questionnaire was measured by Likert range of three options from score 1 6 162 for "no self-confidence" to 3 for "fully self-confident". Skills assessed by OSCE in 7 163 stations. The stations included: Using partograph, episiotomy and its repair, shoulder 164 dystocia, neonatal resuscitation, uterine bimanual compression, manual removal of 165 placenta, and shock management. The assessments were conducted by trained 166 assessors using checklists. Each step was scored by Likert 'range of 5 options, from 167 score 1 "completely unsatisfactory" to 5 "completely satisfactory". The total score in The level of significance was considered P<0.05.

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Characteristics of participants 177 From 86 participants, (43 students in control and 43 in intervention group), 6 participants 178 excluded from the study; in the control group, 3 students due to illness and unwillingness 179 to continue the study, and in the intervention group, one student due to overlapping the 180 course with her training in hospital and 2 students due to unwillingness to be evaluated 181 had not continued the course and its evaluation. In conclusion, data analysis was carried 182 out on 80 students, 40 participants in each group ( Knowledge, skills and self-confidence of intervention group increased significantly in 197 immediately and 6 weeks after intervention compared to the control group (Table 3). In groups had a significant difference (P<0.001).
203 In comparison between groups, the score of knowledge, skill and self-confidence in all had been done as in-service courses, but our research conducted on students. As half 243 of the students participated in this study were international trainees and they were 244 supposed to return to their country (Afghanistan), it was needed to use a special 245 method which can enhance health indexes such as MMR. Data analysis revealed that knowledge, skill, and self-confidence increased significantly 261 in immediate and 6 weeks assessments after the intervention. The study by Ameh et al. 262 (2018) in which, knowledge and skill retention after emergency obstetric care training 263 with "skills and drills" approach, was investigated, their result was the same as ours; 264 knowledge and skill levels increased significantly immediately and three months after 265 training (P<0.01). The improvement in skill scores was much higher than knowledge 266 and previous job experience more than 13 years caused lower retention and more drop 267 in scores, especially in skill assessment (22). This reduction seems to be due to more 268 skill retention with passing time and increasing experience. This is one of the reasons to 269 start this course during university days, not after graduation or in-service.

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This approach leads to competency achievement for all students after the intervention have the best impact in results.

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The coincidence between teaching and learning education of clinical skills in skill lab by 280 practicing them with a simulation-based approach can improve retention of knowledge 281 and skill as well as self-confidence of students in performing clinical skills. walker et al.

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study (2015) was conducted with a simulation approach and group practices, an 283 increase and retention of knowledge in a self-report evaluation were observed (24).

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Their results were in the same line with our study. The results of Walker et al. (2013), 285 showed growth in scores of knowledge and confidence, immediately after intervention; 286 but significant fall within 6 weeks after training (6). Also, the study by Tang et al. (2015) 287 aimed to improve obstetric emergencies 'knowledge and skills in Malawi also led to an 288 increase in knowledge and skill after intervention (P<0.001), but 6 months after training, showed that evidence-based knowledge in the management of obstetric emergencies 341 could be increased with an inter-professional and simulation-based approach, 342 immediately and 3 months after training, followed by self-efficacy. Some evidence 343 suggested that self-efficacy improved as a result of increased self-confidence to 344 diagnose and manage obstetric emergencies (33).

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Considering that in-service training has significant costs for the hospital and the This study was the results of MSc midwifery thesis and due to lack of time, we could not 357 assess the impact of our study in hospitals. It is recommended that the next study would 358 be conducted in this area.