This document discusses implementing a simulation experience on a women's services unit to train nurses to recognize and manage postpartum hemorrhage (PPH). A literature review found that simulation is now the educational standard and can improve outcomes. A decision-making team determined simulation was the most effective learning strategy. The proposed solution is to provide education on PPH and conduct a simulation where a nurse cares for a simulated patient experiencing PPH. Havelock's change theory will guide implementing and stabilizing the simulation program.

1. Running head: K. MOODY, POSTPARTUM HEMORRHAGE SIMULATION 1
Integrating Simulation for Postpartum Hemorrhage
Kourtney Moody
Tarleton State University
NUR 412 Nursing Leadership and Management
Donna Steen, RN, MSN
20 April 2013

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Problem
Will introducing a simulation experience in the women’s services unit at Texas Health
Resources (THR) Cleburne increase clinical competency and patient safety through prevention
and early detection of postpartum hemorrhage?

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Postpartum Hemorrhage
Postpartum hemorrhage (PPH) is defined as blood loss from the uterus of more than 500
milliliters (mL) following a vaginal delivery or more than 1,000 mL following a cesarean
delivery (Murray & McKinney, 2010). PPH is an infrequent but potentially life-threatening
event. It has been estimated that 2.9% of women who give birth in the United States will suffer
from PPH (Bingham & Jones, 2012).
If this blood loss occurs during the first 24 hours after delivery it is considered early PPH.
Eighty to 90% of the cases of early PPH are due to uterine atony, or failure of the uterine
muscles to contract around blood vessels left open from the detachment of the placenta. Other
causes of early PPH are trauma to the birth canal, adherence of placental fragments to the uterine
wall, or abnormalities in coagulation (Murray & McKinney, 2010).
PPH that occurs 24 hours following delivery is considered to be late PPH. The most
common cause of late PPH is subinvolution of the uterus. Subinvolution occurs when the uterus
returns to its normal size less quickly than expected. The most common causes of uterine
subinvolution are pelvic infection and retained placental fragments (Murray & McKinney, 2010).
The most severe complication is hypovolemic shock. When blood loss from PPH is
excessive the body’s organs are not adequately perfused with oxygen. Vital organs, such as the
brain, heart, and kidneys, can suffer greatly from even a brief period of hypoxia (Murray &
McKinney, 2010).
Synopsis of the Problem
PPH is the leading cause of maternal death in the United States, and 54% to 93% of these
deaths may have been preventable through early recognition (Bingham & Jones, 2012). Common
factors that predispose women to PPH include overdistention of the uterus (as seen with multiple

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gestation or large infants), many previous pregnancies, labor and delivery that occurs to quickly,
labor and delivery that does not occur quickly enough, cesarean birth, manual removal of the
placenta, chorioamnionitis (infection and inflammation of the membranes surrounding the fetus),
and preexisting clotting disorders (Murray & McKinney, 2010).
Nurses working in birthing and postpartum units should be able to identify the mother at
risk for PPH so that excessive bleeding can be anticipated and minimized (Murray & McKinney,
2010). They need to have strong assessment skills and a thorough understanding of the life-saving
interventions needed for PPH (Retskin, 2012). Assessment of the mother at risk must be
done frequently and thoroughly. A delay in assessment and treatment can result in a great deal of
blood loss (Murray & McKinney, 2010).
The America College of Obstetricians and Gynecologists report that 140,000 maternal
deaths occur each year and approximately 25% of those deaths can be attributed to PPH
(Retskin, 2012). One of the goals for Healthy People 2020 is to decrease maternal deaths from
13.3 to 11.4 per 100,000 live births ("Healthy People 2020 - Improving the Health of
Americans").
To align with this initiative, the purpose of this project is to integrate a simulation
experience to produce better outcomes for mothers who experience PPH and increase clinical
competency of nurses on the Women’s Services unit at THR Cleburne. An interview was
conducted with Diana Kunce-Collins, a Master’s prepared Registered Nurse Certified in
Maternal Newborn Nursing (RNC-MNN) with 35 years of obstetric nursing experience at THR
Cleburne. In this interview, Kunce-Collins stated she believed there was room for improvement
on her unit in responding to a PPH crisis. She further stated that a simulation experience
focusing on PPH would be an effective way to train nurses in her department to effectively

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recognize and manage this condition (D. Kunce-Collins, personal communication, April 15,
2014).
Review of the Literature
Retskin, in her peer reviewed article “Postpartum Hemorrhage: Are You Prepared?”
published by the Journal of Obstetric, Gynecologic & Neonatal Nursing, discussed the initiative
programs taking place in hospitals across the United States. One program discussed included
professionals from The John Hopkins Hospital, Medical Center Portsmouth, and other top ranked
hospitals. The Interprofessional Obstetric Team Simulation Program created and implemented
simulation scenarios of PPH and other obstetric emergencies. The program provided an
opportunity for staff to practice the management of high-risk, low occurrence event. After
participating, the staff evaluated their learning experience and gave suggestions to the simulation
team. Retskin notes, “As the simulation planning team worked to increase the complexity and
realism of the clinical scenarios, staff voiced increased satisfaction in their evaluations (Retskin,
2012)”.
Another peer reviewed article published in the Journal of Obstetric, Gynecologic &
Neonatal Nursing discussed the recent obstetric simulation experiences implemented at Riverside
Methodist Hospital in Columbus, Ohio. Newhouse, Yeager, and Englehart, authors of “Obstetric
Emergency In Situ Simulation: Practice Leads to Change”, instituted monthly in situ simulation
drills for labor and delivery staff. They reported “As a result of doing in situ drills, many
opportunities to implement change were discovered (Newhouse, Yeager, & Englehart, 2012)”.
Among these opportunities for change were problems with the wireless communication, role
confusion, and errors when operating equipment. As a result of the simulations the noise level
has decreased with more effective communication, the charge nurse and physician roles were

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clarified, nurses learned how to work the operating table, system processes where improved, and
“physicians and nurses state they work more effectively as a team (Newhouse, Yeager, &
Englehart, 2012)”.
In a comparative randomized controlled trial of 100 participants, authors Sorensen et al.
studied in situ simulation versus off-site simulation in obstetric emergencies including PPH and
their effect on knowledge retained. Participants were health-care professionals in the department
of obstetrics at Rigshospitalet, Copenhagen in Denmark. The participants were given the same
simulation with the experimental group working on the obstetric unit and the control group
working at an off-site simulation environment. The results of the trial were inconclusive as to
which environment created a better learning experience. This trail was the first of its kind. As
such, the researchers recognize the need for further trials regarding off-site and on-site
simulation experiences (Sorensen et al., 2013).
Magee, Shields, and Nothnagle, authors of the peer reviewed study “Low Cost, High
Yield: Simulation of Obstetric Emergencies for Family Medicine Training”, created low-cost
simulations for PPH using human actors and relatively inexpensive simulation equipment. The
simulations were implemented at a small underserviced hospital in Rhode Island. Twenty family
medicine residents were randomly assigned to the intervention group or the control group. The
intervention group completed a simulation on PPH followed by debriefing. The control group
was presented with a lecture on PPH. When tested regarding knowledge of management of PPH
the group assigned to simulation scored significantly higher than the group presented with the
lecture. One-hundred percent of the intervention group participants stated that the simulation was
extremely useful. This trial demonstrated the feasibility of low-cost obstetric PPH simulation and

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found that further simulations may result in persistent increases in trainee knowledge (Magee,
Shields, & Nothnagle, 2013).
Summary of Literature Review
There is an abundance of information regarding obstetric simulation programs and their
efficacy in the learning environment. The articles mentioned give a brief look into what
simulation can offer when improving response to the PPH crisis. Simulation in the hospital unit
where the participants are employed not only provide effective training but give opportunities for
improvement within system processes. There are options to simulation that can save money and
set up time. Many of these options should be further explored when a simulation experience is
approved for the unit. The overall consensus of the research articles presented above is in favor
of a simulation experience for PPH. Simulation can hold great things for the future of our
department.
Decision Making Tool
Researchers Magee, Shields, and Nothnagle state that “Training using simulation is now
the educational standard (Magee, Shields, & Nothnagle, 2013)”. However, in order to decide
what learning experience would be the most effective learning strategy for THR Cleburne, a
team of staff members was assembled. This team of decision makers was made up of two RNs,
the nurse educator, and the obstetric unit charge nurse. Many learning options were considered
and weighted using the paired comparison analysis tool, before proposing the need of education
regarding PPH to the budget review board and administration.
The Paired Comparison Analysis tool is a grid or worksheet that is made and filled out as
follows:
1. Each learning strategy was assigned a letter.

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2. Learning strategies were then placed on both the row and column headings of the
worksheet.
3. Comparisons were made of each learning strategy in the row with the option in the
column.
4. A vote was taken to decide which of the two strategies would be the most effective.
5. The letter of the most effective option was written in the blank cell under each
column.
6. The differences of efficacy of each learning strategy were scored using a scale of zero
to three (0-3); with zero being no difference or of equal effectiveness and three being
major difference or that one option is much more effective than the other.
7. The values for each learning strategy was added and ranked appropriately (Mind
Tools.com).

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The options with the highest number represents what the team felt would be the most
effective option. The simulation learning strategy received a score of 11, outscoring the other
options by at least eight points. Simulation was the most preferred learning strategy and is
perceived to be the most effective strategy by the team.
A survey to further assess the efficacy of simulation was given to junior level nursing
students at Tarleton State University in April of 2014. The survey showed that 100 percent of the
students had participated in a postpartum hemorrhage simulation at the Tarleton Nursing
Simulation Laboratory. Ninety-eight percent of the students surveyed stated that they believed
the simulation was effective. Furthermore, 98% of the students surveyed reported that they think
a simulation in the hospital setting would help them as RNs working in a hospital unit.
Proposed Solution
After the conclusion was made that simulation was the best learning strategy, an effort
was made to gain further information regarding simulation. Cheryl Hunter, Simulation
Coordinator at Tarleton State University, was contacted and interviewed by our team to gain
insight concerning the simulation program and to learn the best way to implement simulation to
meet the needs of the facility represented by the team (C. Hunter, personal communication, April
14, 2014).
Hunter suggested that visiting established simulation programs would be the best way to
discover how to implement the simulation at THR, Cleburne. The nurse manager was chosen to
be the representative that will visit simulation programs. She will begin this process three months
prior to the simulation experience that will be offered on her unit. Additionally, the nurse
manager will research the prices to purchase or rent the equipment needed for the simulation.

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Beginning one month prior to the simulation and continuing bi-weekly for two weeks, in-service
lectures concerning PPH will be held on the Women’s services unit. In-service lectures
will give in depth information on assessing for PPH and recognizing early warning signs of PPH.
the Nursing interventions will be reviewed as well as medications and how to call for help. The
PPH emergency box, pictured below, will be reviewed and left open so the staff nurses can
become familiar with its contents.
Post-tests will be administered to assess understanding following the in-service.
The manikin will be placed in a patient room and the simulation will be run by the nurse
manager or nurse educator via a laptop computer in the same room. The day the simulation will
take place will be kept from the staff. They will, however, be told that if the manikin is given to
them as a patient it is to be treated as a real patient.

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On the day of simulation the manikin will be assigned to an oncoming nurse. The nurse
will receive report on all her patients including the manikin as she would any other shift. The
report will include patient history that should alert the nurse to recognize pre-disposed risk
factors of PPH. The nurse will be expected to report to each patient room to do a full
assessment. The nurse will be evaluated on his or her assessment of the manikin, ability to
recognize early signs and symptoms of PPH and respond accordingly. Below is a picture of one
of the Labor/Delivery/Recovery rooms at THR Cleburne, where the simulation will take place.
Change Strategy
Havelock’s six phases of planned change (Yoder-Wise, 2011) will be used to identify
potential complications and model our change initiative. This change theory’s problem solving
process seeks to have change agents “organize their work so that successful innovation will take
place (Yoder-Wise, 2011)”. Havelock’s six stage theory is as follows:

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1. Buiding a relationship. This step is already completed, as the nurse manager, or change
agent, has a professional relationship with the staff nurses, nurse educator, and charge nurse on
her unit.
2. Diagnosis the problem. The problem was made known by the goals of healthy people
2020 “to decrease maternal deaths from 13.3 to 11.4 per 100,000 live births ("Healthy People
2020 - Improving the Health of Americans)". In order to align the unit with the initiative of
fewer maternal deaths, a change in PPH care delivery must be made.
3. Acuiring relevant resources. We have completed this step by seeking out today’s best
practice for PPH and current education trends.
4. Choosing the solution. The learning method most praised in recent years is that of
simulation. Magee, Shields, and Nothnagle (2013) stated that “simulation is now the educational
standard for emergency training […] and is particularly useful on a labor and delivery unit,
which is often a stressful environment for learners given the frequency of emergencies. ”
Simulation was chosen as the solution because it was the most preferred learning strategy by
chosen our team.
5. Gaining acceptance. The most anticipated challenge surrounds gaining acceptance for
the simulations efficacy for learning and relevance to nursing practice. Not only must learner
bias be overcome, but the biases of the educator must be changed. New technology can pose
threats to those belonging to an older generation and it can have flaws which will take time and
patience to work out. Hunter discussed these challenges in depth with the nurse manager. (C.
Hunter, personal communication, April 14, 2014).
6. Stabilizing the innovation and generating self-renewal. Once we have gained
acceptance within our simulation program we hope to bring new aspects of simulation into our

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hospital. These changes could be other maternal complications or newborn afflictions. The hope
is to one day have clinical competency ran strictly by simulation methods.
Conclusion
In keeping with the goals of Healthy People 2012, it would be wise to implement a
simulation experience to prepare the nurses on the women’s services unit at THR Cleburne to
recognize and correctly care for a patient with PPH. Simulation will allow the nurses to achieve
a greater understanding of the steps that must be taken to prevent injury and death to post-partum
women. With the use of a simulation experience, true to life experiences are availabe to
nurses allowing them to learn from their successes and mistakes, without risking the life of a
patient. Additionally, this can all be done at a relatively low cost to the hospital, and has the
potential of saving many lives.

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References
Bingham, D., & Jones, R. (2012). Maternal Death from Obstetric Hemorrhage. JOGNN: Journal
Of Obstetric, Gynecologic & Neonatal Nursing, 41(4), 531-539.
Healthy People 2020 - Improving the Health of Americans. (n.d.). Retrieved April 2, 2014, from
http://www.healthypeople.gov/2020/default.aspx
Labardee, R. M., & Mitch, R. (2012). Improving Care during a Postpartum Hemorrhage: A
Patient Safety Initiative. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal
Nursing, 41S82-3.
Magee, S. R., Shields, R., & Nothnagle, M. (2013). Low Cost, High Yield: Simulation of
Obstetric Emergencies for Family Medicine Training. Teaching & Learning In
Medicine, 25(3), 207-210.
Mind Tools - Management Training, Leadership Training and Career Training. Mind Tools –
Management Training, Leadership Training and Career Training. Retrieved from
http://www.mindtools.com/index.html
Newhouse, L., Yeager, R., & Englehart, M. (2012). Obstetric Emergency In Situ Simulation:
Practice Leads to Change. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal
Nursing, 41S81.
Retskin, C. M. (2012). Postpartum Hemorrhage: Are You Prepared?. JOGNN: Journal Of
Obstetric, Gynecologic & Neonatal Nursing, 41S85-6.
Sorensen, J., Van der Vleuten, C., Lindschou, J., Gluud, C., Ostergaard, D., LeBlanc, V., & ...
Ottesen, B. (2013). 'In situ simulation' versus 'off site simulation' in obstetric emergencies
and their effect on knowledge, safety attitudes, team performance, stress, and motivation:
study protocol for a randomized controlled trial. Trials, 14220.

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Yoder-Wise, P.S. (2011). Leading and Managing in Nursing (5th ed.). St.Louis: Mosby