Simulation and nurse-mentoring in a statewide nurse mentoring program in Bihar, India: diagnosis of postpartum hemorrhage and intrapartum asphyxia

Background: Mentoring programs that include simulation, bedside mentoring,
and didactic components are becoming increasingly popular to improve
quality. These programs are designed with little evidence to inform the
ideal composition of mentoring activities that would yield the greatest
impact on provider skills and patient outcomes. We examined the
association of number of maternal and neonatal emergency simulations
performed with the diagnosis of postpartum hemorrhage (PPH) and
intrapartum asphyxia in real patients. Method: Prospective
cohort. Between- and within-facility comparisons over time.
Setting: 320 public facilities in the state of Bihar, India May
2015 – 2017. Participants: Deliveries and livebirths.
Interventions: Mobile nurse-mentoring program with simulations,
teamwork and communication activities, didactic teaching, demonstrations
of clinical procedures and bedside mentoring including conducting
deliveries. Nurse mentor pairs visited each facility for one
week, covering four facilities over a four-week period, for seven to nine
consecutive months. Outcome measures: Diagnosis of PPH and
intrapartum asphyxia. Results: Relative to the bottom one-third
facilities that performed the fewest maternal simulations, facilities in
the middle one-third group diagnosed 26% (IRR = 1.26, 95% CI: 1.00, 1.59)
more cases of PPH in real patients. Similarly, facilities in the middle
one-third group, diagnosed 25% (IRR = 1.25, 95% CI: 1.04, 1.50) more cases
of intrapartum asphyxia relative to the bottom third group that did the
fewest neonatal simulations. Facilities in the top one-third group (i.e.,
performed the most simulations) did not have a significant difference in
diagnosis of both outcomes, relative to the bottom one-third group.
Conclusion: Findings suggest a complex relationship between
performing simulations and opportunities for direct practice with
patients, and there may be an optimal balance in performing the two that
would maximize diagnosis of PPH and intrapartum asphyxia.