Developing a global worldview creates a foundation for understanding diversity and health inequities to help nurses provide more culturally responsive health care.1 In an era where a health crisis in one community, such as coronavirus, can quickly become a transnational concern, it becomes especially important to integrate global health concepts into nursing curricula.2,3 As global citizens, nurses need knowledge, skills, and attitudes in the global burden of disease, global determinants of health, health equity, social justice, and sociocultural and political awareness.4

Study abroad is a major way nursing students learn to be global citizens and gain global health competencies; however, international travel is not feasible for all students.5-7 Creating educational toolkits with robust activities to teach global health competencies locally is a helpful alternative for faculty.2 We suggest that simulation may be one such activity to include in global health teaching toolkits.

Simulation and Global Health

Simulation can be used to develop the knowledge, skills, and attitudes needed of health care providers to work in low-resource settings.8-10 Simulation also has the potential to prepare workers for the emotional challenges of working without the resources that they have become accustomed to.10 Helping Mothers Survive (HMS) is a simulation-based program designed to train frontline providers in areas with high maternal mortality how to respond to the most common obstetric emergencies.8,9,11 The publicly available HMS Bleeding After Birth-Complete module builds team skills on the prevention, early detection, and management of a postpartum hemorrhage.11 The learning materials include posters, flipbooks, a provider's guide, and supplemental materials. The MamaNatalie hybrid simulator can be used with the HMS modules to give students the opportunity to practice hands-on skills and team communication.11

Research shows implementation of HMS in low-resource settings is effective in increasing provider skills and decreasing maternal deaths.8,9 The purpose of this project was to examine if HMS could be used to teach global health concepts to prelicensure nursing students.

Approach

This institutional review board-approved pilot project used a pretest-posttest design and a recruited sample of 11 baccalaureate nursing students divided into 2 groups. The 50-minute learning activity included 20 minutes of prebriefing, 10 minutes of postpartum hemorrhage simulation, and 20 minutes of debriefing. During the prebriefing, students self-rated their maternal global health knowledge and skills. The facilitators then led a discussion about factors that positively and negatively affected birth outcomes in low-resource countries including lack of transportation, education, and cultural beliefs. The discussion also provided information on stopping a postpartum hemorrhage. The prebriefing concluded with an orientation to the simulation.

The simulation room was modified to resemble a rural clinic with the HMS algorithm posters displayed on the walls. The scenario used a standardized patient wearing the MamaNatalie birthing simulator. The patient presented with heavy bleeding after giving birth 3 hours ago at home. She was seated on a chair holding her baby, wearing blood-soaked clothes, and reporting dizziness. Two students, who had completed a maternity nursing course, were assigned to be nurses in each session, whereas the other participants observed from the debriefing room. Based on the HMS algorithm, students were expected to assist the patient to a supine position, complete an assessment, keep her warm, begin fundal massage, administer intramuscular oxytocin, and reassess the effectiveness of the interventions. The simulation was followed by a debriefing that focused on what participants experienced while trying to provide nursing care with limited resources.

Pretest and posttest data were collected on a tool created for the project based on the domains of global health competencies developed by Jogerst and colleagues.4 The 11-item questionnaire asked participants to self-rate their maternal global health knowledge and skills on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Sample items were "I understand the major causes of maternal morbidity and how they vary worldwide," and "I can design maternal health interventions based on situation analysis." Data analysis was completed using paired t tests. Results were considered significant at P < .05 (2-tailed).

Outcomes

Ten females and 1 male participated in the pilot project. The distribution by class was 2 seniors, 3 freshmen, and 6 juniors. Overall self-perceptions of maternal global health knowledge and skills increased significantly from the pretest (mean, 35.55 +/- -4.78) to the posttest (mean, 46 +/- 7.73; P < .001).

Overwhelmingly, the students were grateful for the experience and thought their peers would benefit from participation in the simulation. During the debriefing, participants reported how stressful it was working without all the equipment and materials that they are used to. One participant explained: "It was helpful to revisit the basics of care. Oftentimes we are so used to being able to fall back on tools that in reality we may not always have."

Discussion

A teaching strategy based on HMS, which includes discussion on global maternal inequities, simulating a postpartum hemorrhage in a low-resource setting, and debriefing, was effective in increasing global health knowledge, skills, and attitudes. Prior to this project, coverage of maternal global health in our curriculum was done primarily through lecture. Simulation, when done in a hybrid format with a standardized patient, offers the advantage over readings or lecture in that it provides a dynamic experience that exposes students to some of the authentic psychological and emotional needs health care workers might face.12

This simulation was relatively easy to implement and can be recreated anywhere using the HMS learning resources. From a faculty standpoint, one of the most challenging aspects of the scenario was modifying the room to eliminate medical equipment that would not be available in a low-resource setting. However, accurately reflecting the equipment is critical when trying to create simulations to train global health workers.10 Students benefited from the time the room setup took. In the debriefing, they repeatedly commented on how the lack of equipment helped them to understand barriers to care.

Diligence is critical to create sustainable interventions to improve health in low-resource countries.10 Perhaps the greatest take-away lesson students gained from the session was that simple low-technology solutions are often effective in improving maternal-newborn outcomes. HMS is an exemplar of a high-impact, low-technology, culturally sensitive intervention to reduce maternal deaths. When the project is revised, we plan to create a presimulation assignment that describes other low-technology solutions such as rural area birthing homes.

Repeated exposure is needed to help students develop global health competencies.4 Teaching nursing students to be global citizens can take place locally if faculty use robust strategies.2,7 Nurse educators can help students understand how to apply the skills of working with vulnerable populations locally and abroad.1,7 Simulation may be particularly effective for helping students develop knowledge, skills, and attitudes related to some of the ethical challenges workers might face working in a low-resource area such as inability to pay or preference to work with local healers.

Conclusion

This was a small, single-site pilot project. Any attempts to generalize the findings should be done with caution. Still, we concluded that using a simulation based on HMS was an effective and engaging way to teach global health competencies to prelicensure students. Future research is needed to understand how HMS and other simulations used for training international workers can be used to develop global health knowledge, skills, and attitudes in nursing students.

References