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Abstract

In recent decades, simulation has become a central learning method in midwifery education. The goal is to ensure competence and create a connection between theory and practice/preparation for practice. We aimed to gain a deeper insight into how midwifery students experience that simulation, as a learning method, helps to strengthen them in the profession as midwives and to shed light on this based on the concept of Empowerment in Midwifery, that is, a feeling of ability to perform and complete tasks that have an impact and are meaningful. We therefore conducted a meta-synthesis of qualitative results to investigate whether simulation as a learning method can strengthen and prepare midwifery students to be equipped for practice. We conducted a systematic literature search for relevant qualitative studies and identified 11 articles. We used Wenger’s social learning theory as a framework for the analysis. The findings were synthesized according to the approach of Kirsti Malterud. We found that when theoretical and practical skills are integrated, deeper and more meaningful learning is achieved. Simulation further helps students feel more prepared for clinical practice, and group community engagement provides increased learning opportunities. Moreover, simulation helps to strengthen the understanding of roles and the identity of a future midwife. Knowledge of important factors that promote a positive learning experience is crucial in avoiding negative emotions such as performance anxiety, guilt, and shame. Our results illuminate that simulation is a valuable learning method that strengthens midwifery students in preparation for clinical practice, provided that important factors that promote learning are implemented. Simulation enhances control, support, recognition, and skills that strengthen empowerment in midwifery for students.

Keywords

Simulation training midwifery student midwifery education meta-synthesis

Introduction

Simulation has become a key learning method in midwifery education. The focus on improving patient safety, and the need to reduce pressure on the places of practice has led to an increased need to develop clinical skills before clinical practice (Garrett et al., 2011). Simulation is defined as a learning method that recreates an aspect of reality in a safe environment (Cioffi et al., 2005) and is a valuable strategy for teaching, learning, and evaluating clinical skills at different levels in midwifery education (World Health Organization. Regional Office for Europe, 2018).

The goal of midwifery education is to educate confident and competent midwives who are skilled in prioritization and thus ready to face challenges in clinical practice (World Health Organization, Regional Office for Europe, 2018). Lukasse and Pajalic (2016) emphasizes the importance of empowering midwives so they are “equipped for practice.” They emphasize the important role that educational institutions have in relation to contributing to the empowerment (Lukasse & Pajalic, 2016). Matthews et al. (2009) have further developed an instrument for assessing midwives’ experience of empowerment: The Perception of Empowerment in Midwifery Scale (PEMS) (Matthews et al., 2009). The researchers found that control, support, recognition, and skills were important for midwives’ experience of empowerment. A systematic review conducted by Cooper et al. (2012) showed that simulation is a beneficial learning method for developing midwifery skills. Simulation can also help create conducive learning environments where students acquire skills in a safe place with minimal risk and immediate feedback, without harming the patient (Cioffi et al., 2005; Dow, 2008). There is no evidence that simulation can replace clinical practice (Cooper et al., 2012), but it is an important component of the curriculum, where exposure to obstetric emergencies in clinical practice may be lacking (Cooper et al., 2012; Jeffries et al., 2009; Rauen, 2004).

Aim

In our study, we aimed to gain a deeper insight into midwifery students’ experiences of using simulation as a learning method to strengthen their midwifery role, and further, to frame these perspectives within the concept of Empowerment in Midwifery.

Methods

To synthesize our qualitative research results, we used Malterud’s meta-synthesis as an approximation method.

Search Strategy

We conducted a systematic literature search with a specialist librarian in four databases: MEDLINE; EMBASE; CINAHL; and MIDIRS, from April to June 2022. We used the keywords Midwifery student; Simulation; and Midwifery education, together with the following MeSH keywords: Nurse Midwives; Midwifery; Students; Simulation Training; Manikins. Finally, we conducted a manual search of the reference lists in the included primary articles, but found no more relevant articles. The search was limited to qualitative studies. The literature search and selection are illustrated in the Prisma Flowchart (Supplemental Figure S1, Table S1, Appendix 1).

Inclusion Criteria

We included qualitative studies of acute and non-acute obstetric simulations. One study with mixed methods (qualitative/quantitative) was included, but only the qualitative results from the study were extracted. The population comprised midwifery students at an educational institution or in a hospital, with a midwifery education equivalent to the Norwegian program. We included peer-reviewed studies conducted in high-income countries (i.e., Scandinavian countries/Australia/England/USA) from the year 2000 onward, published in Norwegian or English and available in full text.

Quality Assessment

Two authors reviewed the eligible articles, using the Consolidated criteria for reporting qualitative research (COREQ) checklist, to critically appraise the studies (Tong et al., 2007). Following the recommendation of Malterud (2017), we assessed the results based on relevant descriptions, sustainable data, and a strategic selection (Malterud, 2017). We included a total of 11 primary studies in the study. The studies are presented in a literature matrix, summarizing the most important characteristics (Supplemental Table S1, Appendix 2).

Analysis and Synthesis

We adopted a deductive approach in the analysis, using the framework of Wenger’s social learning theory (Wenger, 1998). This pedagogical framework enabled us to identify and elucidate the different dimensions of learning theory in literature, that is, practice, community, identity, and meaning (Wenger, 1998). In the analysis and synthesis, we used Malterud’s meta-synthesis as an approximation method (Malterud, 2017). Based on relevant themes and metaphors, we evaluated how the primary articles’ results were related by organizing the empirical material in an analysis matrix (Malterud, 2017). We then compared the studies by performing a systematic review and organizing the results text, so-called Translation (Malterud, 2017). We emphasized similarities and differences in terminology and identified meaning units, so-called First-order concepts (Malterud, 2017).

We further synthesized the translations by developing an overall translation that covered all themes and metaphors in a new expression. The syntheses that provided an original and independent understanding of the findings were referred to as the Second-order concepts and are presented in the results section (Malterud, 2017). Finally, we conveyed the synthesis in the text by elaborating and justifying the meaning of the expressions from the synthesis that are reproduced in the new translation: The Third-order concepts (Malterud, 2017).

Ethical Considerations

The study was conducted following the Declaration of Helsinki (World Medical Association, 2013). We made a sound assessment of the research ethics basis in the primary studies used in our study.

Results

The following four main topics, that is, second-order concepts, were developed from the analysis (Supplemental Table S2, Appendix 3): (i) when theoretical and practical skills are integrated, deeper and more meaningful learning is achieved; (ii) simulation helps midwifery students feel more prepared for clinical practice; (iii) community in a group provides increased learning; and (iv) simulation helps to strengthen the understanding of roles and the identity of a future midwife. The results from the four second-order concepts are presented in categories based on the four central components of Wenger’s learning theory, that is, meaning, practice, community, and identity (Wenger, 1998).

Meaning: When Theoretical and Practical Skills Are Integrated, Deeper and More Meaningful Learning is Achieved

We found that, despite negative emotions and unexpected stress reactions that could occur, simulation was seen as a positive and valuable learning method (Barry et al., 2012; Deegan & Terry, 2013; Dow, 2012a; Kumar et al., 2017; Lendahls & Oscarsson, 2017; Lindsay Miller et al., 2015; Vermeulen et al., 2017). The midwifery students found that simulation creates a connection between theory and practice (Deegan & Terry, 2013; Dow, 2012a, 2012b, 2012c; Lendahls & Oscarsson, 2017; Vermeulen et al., 2017). The translation between the studies also showed that several students feel that simulation promotes the development of midwifery skills (Deegan & Terry, 2013; Dow, 2012a, 2012b; Kumar et al., 2017; Lendahls & Oscarsson, 2017; Lindsay Miller et al., 2015).

Practice: Simulation Helps Students Feel More Prepared for Clinical Practice

The analyses illuminated that after simulation situations, the students’ self-confidence increased, and they felt more prepared for clinical practice (Deegan & Terry, 2013; Dow, 2012b; Kumar et al., 2017; Lendahls & Oscarsson, 2017; Lindsay Miller et al., 2015). The importance of acquiring basic knowledge and skills before clinical exposure in practice was emphasized to a large extent (Barry et al., 2012; Deegan & Terry, 2013; Dow, 2012a, 2012b, 2012c; Kumar et al., 2017; Lendahls & Oscarsson, 2017; Lindsay Miller et al., 2015; Vermeulen et al., 2017). The students experienced a realistic approach to the clinical reality through simulation, and thus increased awareness of what to encounter in the field of practice (Dow, 2012a, 2012c).

Some students found that simulation activities had a positive impact on knowledge and could be a catalyst for further learning in clinical practice (Dow, 2012a, 2012c; Lendahls & Oscarsson, 2017). In the translation of the studies, we found that the importance of being able to make mistakes without fear of affecting patient safety was highly appreciated (Barry et al., 2012; Deegan & Terry, 2013; Kumar et al., 2017; Lendahls & Oscarsson, 2017). In particular, the possibility to repeat the scenario in a safe and secure environment was important for a positive learning experience (Carolan-Olah et al., 2018; Kumar et al., 2017; Lendahls & Oscarsson, 2017; Vermeulen et al., 2017, 2021). Adequate preparation before simulation was essential to reduce negative emotions (Barry et al., 2012; Vermeulen et al., 2017).

There was an agreement across the results in the included studies that simulation cannot replace clinical practice completely, especially in terms of communication and interpersonal skills (Barry et al., 2012; Vermeulen et al., 2017). To strengthen context-dependent memory, the students emphasized that the environment in the simulation should reflect the clinical environment where it was to be performed (Carolan-Olah et al., 2018; Deegan & Terry, 2013; Dow, 2012a, 2012b; Vermeulen et al., 2017, 2021). These so-called high-fidelity simulations (HFS) and realism in the simulation scenario created a stronger connection between the simulation and clinical practice (Deegan & Terry, 2013; Dow, 2012a, 2012b; Vermeulen et al., 2017, 2021).

Community: The Community in the Group Provides Increased Learning

A key finding was that the group community was fundamental to the students’ learning (Barry et al., 2012; Carolan-Olah et al., 2018; Dow, 2012a, 2012c; Kumar et al., 2017; Lindsay Miller et al., 2015; Vermeulen et al., 2021). The students experienced that cooperation, reflection, and critical thinking in a group increased their learning ability (Barry et al., 2012; Deegan & Terry, 2013; Dow, 2012a, 2012b, 2012c; Lendahls & Oscarsson, 2017; Lindsay Miller et al., 2015; Vermeulen et al., 2017).

A mutual experience of respect and trust was crucial to contributing to safety and strengthening the learning environment in the group (Lendahls & Oscarsson, 2017; Vermeulen et al., 2021). Getting feedback from fellow students helped in identifying one’s own strengths and weaknesses, which in turn motivated the learning process (Dow, 2012a; Lendahls & Oscarsson, 2017). Some students highlighted the role of the teacher in relation to encouraging reflection and facilitating a safe and open environment in the group (Carolan-Olah et al., 2018; Lendahls & Oscarsson, 2017).

The students in the studies described the opportunity to collaborate in teams as key to becoming aware of the importance of clear leadership, communication, delegation of tasks, and situational awareness (Carolan-Olah et al., 2018; Kumar et al., 2017; Lendahls & Oscarsson, 2017; Lindsay Miller et al., 2015). However, simulation in groups sometimes evoked unexpected negative emotions (Deegan & Terry, 2013). Students who were unable to handle the tasks as expected sometimes experience emotional reactions such as guilt and shame, even long after the incident (Deegan & Terry, 2013; Vermeulen et al., 2017). Thorough preparation and planning, alongside immediate debriefing, were highlighted as crucial in limiting negative learning experiences in simulation (Deegan & Terry, 2013). The students emphasized that debriefing after the scenario was essential to achieve a positive learning experience and to identify knowledge gaps (Carolan-Olah et al., 2018; Deegan & Terry, 2013; Lendahls & Oscarsson, 2017; Lindsay Miller et al., 2015; Vermeulen et al., 2017). The students further emphasized the importance of a well-planned and structured debriefing when carrying out simulations, and that enough time was set aside for the debrief (Deegan & Terry, 2013; Vermeulen et al., 2017).

Identity: Simulation Helps to Strengthen the Understanding of Roles and Identity as a Future Midwife

The translation of the studies showed that simulation contributed to professional development and increased awareness of the midwifery role, through role play and collaboration in teams (Carolan-Olah et al., 2018; Dow, 2012a; Lendahls & Oscarsson, 2017; Vermeulen et al., 2017). After simulations, the students indicated an increased sense of security, skills, and competence (Carolan-Olah et al., 2018). We also found indications that simulation confronted students with their own performance opportunities, abilities, and knowledge (Vermeulen et al., 2017), and that the students felt confident about stepping into their future professional roles (Lendahls & Oscarsson, 2017).

Discussion

Our findings illuminate several factors that are crucial to providing a positive learning experience in simulation and thus strengthening midwifery students’ understanding of roles and identity as midwives. In the following, we will discuss the four second-order concepts from the analysis, in light of the concept of Empowerment in Midwifery.

When Theoretical and Practical Skills Are Integrated, Deeper and More Meaningful Learning is Achieved

Our findings confirm that simulation as a learning method creates a connection between theory and practice, thus contributing to midwifery students feeling more prepared for clinical practice. When theoretical and practical skills are integrated, deeper and more meaningful learning is achieved. Previous studies show that simulation helps to expand and strengthen students’ knowledge, and builds bridges between theory and practice, so that acquired knowledge has value and relevance (Dillard et al., 2009; Foronda et al., 2013; Weaver, 2011; World Health Organization, Regional Office for Europe, 2018). Simulation helps to promote the development of midwifery skills and provides increased self-confidence and security in the midwifery role, which can be linked to empowerment. Students experience simulation, which is a positive and valuable learning method (Cioffi et al., 2005; Pilkenton et al., 2015).

However, our findings also showed that simulation as a learning method could trigger negative emotions such as performance anxiety, guilt, and shame in the students. This can be an obstacle to learning and coping. Students’ self-confidence has an impact on their clinical skills and ability to respond to patient needs (World Health Organization. Regional Office for Europe, 2018). A study conducted by Corbally et al (Corbally et al., 2007) showed that individual factors such as self-confidence, belief in one’s own capacity and strength, as well as interpersonal relationships that involve interactions with others, influenced midwives’ and nurses’ experience of empowerment (Corbally et al., 2007). Thorough preparation and planning before the scenario were highlighted by the students as key factors in limiting a negative learning experience when simulating.

Simulation Helps Students Feel More Prepared for Clinical Practice

We found that the opportunity for the student to make mistakes without consequences for patient safety was highly valued. Simulation in a safe and secure environment was key to a positive learning experience and for increased benefit from the simulation. This was also found by Hughes et al. (2014) in their study, where the students experienced increased security, knowledge, and self-confidence, because the simulation took place in a safe environment for learning, with the opportunity for feedback and reflection (Hughes et al., 2014). In their study, Lukasse and Pajalic highlight Norwegian midwives’ experience of empowerment and being “equipped for practice” as a topic. Factors such as skills, education, support from colleagues, and certainty about the scope of the work to be carried out are important work tools for midwives to feel “equipped for practice” in their daily work (Lukasse & Pajalic, 2016). The researchers therefore emphasize the important role of educational institutions in relation to strengthening midwives (Lukasse & Pajalic, 2016).

Community and cooperation in the group formed a basis for students to acquire midwifery skills. Group reflections were useful for identifying one’s own strengths and limitations and motivated the learning process. However, our findings illuminated that the students could experience anxiety due to their fear of the unknown and feedback from fellow students. A previous study reported that a supportive culture in a group reduces anxiety (McCormack & McCance, 2010). Knowledge of factors that are important for strengthening community and collaboration in a simulation group is key to achieving results, and the responsible teacher has an important role in facilitating a safe and open climate in the group (McCormack & McCance, 2010).

The Community in the Group Provides Increased Learning

Translations of our findings confirmed that mutual respect and trust were important in strengthening the community and learning environment in the group. Ntlokonkulu et al. (2018) reported that teams where students have confidence in each other ensure good results. This finding further highlights the importance of the learning environment in the group (Davis et al., 2009; LeBlanc & Posner, 2022; McCallum, 2007; Ntlokonkulu et al., 2018; Reilly & Spratt, 2007). By collaborating in groups, students are made aware of the importance of leadership, communication, delegation of tasks, and situational awareness (Cioffi et al., 2005; Hughes et al., 2014; Ntlokonkulu et al., 2018).

However, we found that simulation could also provoke negative reactions such as stress and performance anxiety. Therefore, to better provide support to students, simulation teachers need to gain more knowledge about the critical role emotions play in how the individual interacts with the environment (LeBlanc & Posner, 2022). Our study shows that implemented debriefing is crucial for the learning experience in simulation, and that enough time is devoted to the debrief. Debriefing after simulation was key for clarifying incidents, identifying one’s own knowledge gaps, and developing new learning. A study by Northcott (2002) also showed that simulation could lead to negative emotions in the long term, which could be an obstacle to learning. This clarifies the teacher’s responsibility in relation to taking care of the student in a simulation situation.

Simulation is most effective when it reflects the environment in which it is to be performed. Simulation in realistic environments strengthens contextual memory. The students in our study found that simulation is more valuable the more realistic and realistic it is. This is consistent with the findings of Labrague et al. (2019) showing that high-fidelity in simulation created a stronger correlation between the simulation scenario and clinical practice.

Simulation Helps to Strengthen the Understanding of Roles and the Identity as a Future Midwife

The students found that simulation scenarios contributed to an increased degree of confidence and mastery and prepared them for practice. Experience of control, support, recognition, and skills were important for midwives’ experience of empowerment (Matthews et al., 2009). Our study found that simulation had a positive impact on learning in practice and was a catalyst for learning. Simulation contributed to the development of one’s own understanding of roles. Through role-playing, a professional awareness of the midwifery role was developed. An overall goal is to educate skilled and confident midwives who experience mastery in the role (World Health Organization, Regional Office for Europe, 2018). Midwives need to feel mastery in the midwifery role and experience empowerment to provide the best possible care for women in pregnancy, childbirth, and postnatal care (Lukasse & Pajalic, 2016), which simulation as preparation for practice, can contribute to.

Strengths and Limitations of the Study

Two authors collaborated on this study, which strengthened the study as meta-synthesis requires advanced planning. Results from all the materials were first reviewed separately, then together, to ensure an equal understanding of the study’s results. The collaboration enabled us to reflect and discuss the ongoing process.

We conducted a thorough and systematic literature search in four databases. In addition to a manual search, the reference literature for our selected primary articles. Structured searches in relevant databases were conducted together with the librarian. We assessed that the 11 primary articles included in our study contained enough sustainable material to perform a proper meta-synthesis. Our common understanding, based on the same professional background as midwives and practice teachers, may have influenced our sample.

Using Wenger’s learning theory as a framework in the analysis enabled us to see the results in light of the components: Meaning, practice, community, and identity (Wenger, 1998). Using this pedagogical method as a framework in the analysis matrix enabled us to identify and elucidate the different dimensions of learning theory in the literature.

In our study, we have elucidated the results based on the concept of Empowerment in Midwifery. We have investigated how simulation as a learning method during education can help strengthen and prepare midwifery students to be equipped for practice. The significance of what this term entails has contributed to a larger extent to elucidating our results in this study.

It is important to consider the empirical variation of the findings when assessing the transferability of the study (Malterud, 2001). Our selection of primary studies extends from the period 2012 to 2021. However, several of the studies are from the first part of this period. We have not received material from recently updated research conducted in the area. Nevertheless, even though recent studies could shed further light on the topic, we consider that the principles of simulation are still highly relevant.

Conclusion

In this meta-synthesis, we found that midwifery students find simulation as a learning method to help strengthen their midwifery role. Simulation, control, support, recognition, and skills can strengthen Empowerment in Midwifery. This assumes that key factors that promote learning are implemented. Knowledge and awareness of factors strengthening empowerment and increasing learning in preparation for clinical practice are, therefore, key in using simulation as a learning method to prepare for clinical practice. This knowledge is important to prepare appropriate simulation situations in midwifery education and hence strengthen and develop the students’ midwifery role.

Implications for Practice

Raising awareness and knowledge of how the students’ experience of learning methods prepares them for clinical practice is key in midwifery education. By contributing to empowerment in midwifery, the student’s experience of being strengthened in their professional role can promote further learning. The results of our study provide important knowledge and awareness of factors that strengthen self-esteem and promote learning in preparation for clinical practice. The results of this study are important to implement and prioritize simulation in midwifery education and can further be used to prepare simulations in a way that strengthens empowerment in midwifery and equips the students for clinical practice.

Supplemental Material

sj-docx-1-php-10.1177_23733799251394727 – Supplemental material for Midwifery Students’ Experiences With Simulation as a Learning Method: A Meta-Synthesis

Supplemental material, sj-docx-1-php-10.1177_23733799251394727 for Midwifery Students’ Experiences With Simulation as a Learning Method: A Meta-Synthesis by Christine Skår, Ann Nesse and Karolina S. Mæland in Pedagogy in Health Promotion

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Karolina S. Mæland

Supplemental Material

Supplemental material for this article is available online at .

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