Sample and study design
Twenty one midwifery students have consented to experience the simulation scenario. The participants were first-year midwifery students who benefited from a theoretical course taught by their specialist teachers. Then, the students’ theoretical knowledge was assessed in a written examination at the end of the course. Twenty-five students were enrolled in the research component of the study. They agreed to participate in (i) video recordings during their simulation exercise (ii) viewing of videos during debriefing sessions to describe and analyze the practices developed (iii) a knowledge questionnaire in the form of pre- and post-tests (Supplementary file 1), and (iiii) the evaluation grids (Supplementary file 2) that were mobilized during the simulation exercise. They were divided into 2 groups ; Experimental group (group1) who received a pre-test and then a simulation session followed by a post-test the same day and control group (group 2) received the same pre-test as group 1 then was invited to review their theoretical course and after a week they received a intermediate post-test , which was followed by a simulation session the same day and then, they received the simulation post-test. Towards the end of the experiment, all the students benefited from a simulation rehearsal session (Fig.1).
The simulation experience began with a prebriefing: the contextualization phase to present the simulation exercise site and the necessary equipment (Weight scale, measuring board, floppy disk, pinard stethoscope…) to accomplish the tasks.
The briefing: the launch phase of the clinical case that was simple, basic, and clear, it was a case of a woman aged 25 years old, presented herself in a maternity unit for a second prenatal consultation, pregnancy well controlled; the biological and ultrasound examinations show a good evolution of the pregnancy; the woman is under treatment with iron as a preventive measure. She has no risk factors, no medical, surgical, obstetric or gynecological history, so the previous delivery took place in the best conditions with an inter-reproductive space of three years. The objective of this case is to practice all the necessary gestures during this consultation (measurement of vital parameters, uterine height ...) without forgetting the non technical skills (communication ...), so this step was also devoted to provide for students their roles and expectations, which were the ground rules of the simulation. Orientation to the simulation scenario included a description of the simulation process, an opportunity to experience the equipment and the space, and instructions for successful scenario completion.
Simulation Exercise: In this phase the student is inserted in the created scenario, during this scenario we adopted 2 types of simulation ; the hybrid simulation which results in an overlap of acts between a facilitator and dummy medium fidelity (Susie), and the roleplay to allow a fictional scenario that requires personal involvement and that builds on personal and professional knowledge all to give students the impressions of the patient and to increase realism by getting closer to stress conditions in the workplace.
The debriefing: firstly, it is the descriptive phase where the students were asked to express themselves freely and to tell their experiences during the simulation session, to express their opinions and impressions. Then we started the analysis phase with the help of the specialist teachers, a communication expert who evaluated the non-technical, and a professor who intervened for the technical evaluation from the display of some videos of the students, after having their consent. And lately it is the synthesis phase where we have assured the clarification and the correction of some acts without forgetting the crucial criterion during this phase is that the notion of failure does not exist, in valuing the error that opens the door to learn and improve, and most of the obstacles discovered during this phase are overcome thanks to the rehearsal session.
Data analysis
The study was carried out according to the model described above; Tests (pre- and post-test) consisted of 10 direct questions conducted during the study to assess students' knowledge, and scored according to the importance of each of them in relation to the technical act concerned by the study. Each participant in the study was evaluated individually through questions that deal with the course of the prenatal consultation with its existing standards in Morocco.
During the simulation exercise we used evaluation grids while respecting the scenario objectives and which detailed the actions required during the exercise, with a score varying between 0 and 2 for each item (done (2), not done correctly/not done at the right time (1), not done (0)). Data were analyzed using the statistical program SPSS version 17 (SPSS Incorporated, Chicago, IL, USA). To assess the performance of individual items, an item analysis was undertaken including item difficulty and item discrimination. The item difficulty and discrimination index according to Downing and Yudkowsky (6). All pair comparisons were carried out using the Wilcoxon test with a significance level =0.05.
Ethical considerations
This study is part of the research project; Simulation Pedagogy for Nursing Education and Patient Safety, which was approved by Hassan First University and the Higher Institute of Health Sciences. Twenty-five first year midwifery students were invited as volunteers to participate in this study; twenty-one (84%) of them accepted the invitation. Oral consent was obtained from all participants and they were informed that the data collected during the simulation experiment will remain confidential and anonymous and that access is limited to researchers only.