Clinical Simulation in Nursing (2013) 9, e369-e377

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Featured Article

Simulation Enhances Self-Efficacy in the

Management of Preeclampsia and Eclampsia in
Obstetrical Staff Nurses
Angela Christian, DNP, MS, RNC*, Norma Krumwiede, EdD, MEd, MN, RN
School of Nursing, Minnesota State University, Mankato, Mankato, MN 56001, USA
KEYWORDS
eclampsia;
high-fidelity human
simulation;
human patient
simulator;
nursing education;
obstetrics;
preeclampsia;
self-confidence;
Bandura;
self-efficacy;
NLN/Jeffries
Simulation
Framework;
obstetrical RNs

Abstract
Background: Preeclampsia and eclampsia are associated with high morbidity and mortality rates,
which can be greatly influenced by proactive and competent nursing care. The infrequent occurrence
of these emergencies provides limited exposure for nurses to remain highly skilled and effective.
Method: This prospective cohort study investigated the impact of high-fidelity human simulation
on the self-efficacy of nurses in the management of preeclampsia and eclampsia. Banduras theory
of self-efficacy and NLN/Jeffries Simulation Framework provided the foundation for this project. Pretest, immediate posttest, and 8-week posttest single-group design was used to compare preintervention data with postintervention data for family birth place staff nurses (N 49) attending the
simulation training.
Results, Conclusions: Obstetric nurses overall self-efficacy with preeclampsia and eclampsia management significantly increased with high-fidelity human simulation training. More important, the level of
self-efficacy was sustained over time. Staff nurse satisfaction responses were also overwhelmingly
positive regarding the training experience. This study supports the use of high-fidelity human patient
simulation as an effective training approach and suggests that other high-risk, low-incidence obstetric
emergencies may also be suitable topics for simulation training.
Cite this article:
Christian, A., & Krumwiede, N. (2013, September). Simulation enhances self-efficacy in the management of preeclampsia and eclampsia in obstetrical staff nurses. Clinical Simulation in Nursing, 9(9),
e369-e377. http://dx.doi.org/10.1016/j.ecns.2012.05.006.
2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier
Inc. All rights reserved.

Introduction
The field of obstetrical nursing is full of excitement and joy,
yet it can rapidly and unexpectedly turn into a crisis filled
with fear and despair. Obstetrics, similar to other areas of

* Corresponding author: [email protected] (A. Christian).

nursing, requires the nurse to practice with high levels

of skill in an autonomous manner, with little room
for mistakes or delays. Subtle cues that can lead to
life-or-death situations need to be recognized and quickly
acted on in order to prevent grave consequences.
The terminology for hypertension during pregnancy has
evolved over the past several years; most recently, the term
pregnancy-induced hypertension has been replaced with

1876-1399/$ - see front matter 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.ecns.2012.05.006

Simulation Enhances Self-Efficacy in OB staff nurses

e370

gestational hypertension. According to Simpson and

Creehan (2008), if the woman has gestational hypertension
and proteinuria, her condition is classified as preeclampsia.
Further classifications based on accompanying symptoms
delineate preeclampsia as severe when blood pressures
exceed 160/110 mmHg.
Other key symptoms may
Key Points
be seen in renal lab results
 HFHS can enhance
and also include complaints
nurses self-efficacy reof cerebral or visual
garding preeclampsia
disturbances and epigastric
and eclampsia mandistress. When severe preagement and suggests
eclampsia is accompanied
that management of
by seizures, it is called
other high-risk, low-ineclampsia.
Preeclampsia
cidence obstetric emercan also be accompanied
gencies can also be
by the disease process
improved.
diagnosed by hemolysis, el Staff
nurses
are
evated liver enzymes, and
highly satisfied with
low platelets (HELLP).
HFHS training which
Women can also have
will increase active
chronic hypertension, which
participation and immay or may not have been
proved learning.
diagnosed
before
 HFHS can play an inpregnancy.
tegral role in achievJust as the classification
ing long-term results
of hypertension in pregfor the nurses and
nancy is complicated, so is
improving
patient
the management of preoutcomes.
eclampsia. Beyond the obvious risks of reduced organ
perfusion to the mother, the circulation of the uteroplacental-fetal unit is compromised, and the coagulation
cascade is activated (Simpson and Creehan, 2008). It is vital that nurses managing preeclampsia have an understanding of the disease process. The nurse needs to be alert to the
signs of the disease and able to respond quickly with appropriate interventions and management strategies. Simpson
and Creehan claim this complicated disease is the most
common medical complication during pregnancy, labor,
birth, and postpartum; therefore, adequate training of staff
is necessary to manage preeclampsia effectively.
Preeclampsia is a common obstetrical condition that can
lead to the rare but serious obstetrical complication of
eclampsia. Eclampsia is associated with high maternal
morbidity and mortality rates despite occurring in only
1 per 2,000 births (Daniels & Parness, 2008; Ellis et al.,
2008). Reporting of preeclampsia epidemiology is challenging because of the lack of conformity in definitions
of hypertension in pregnancy. The Centers for Disease
Control and Prevention (2002) identified that pregnancyassociated hypertension was the most frequently reported
medical risk factor, occurring in 38.8 per 1,000 live births
in 2000. In 2004, the State of Minnesota reported that
nationally, 3.6% of all pregnancies are complicated by hypertension. The Global Burden of Hypertensive Disorders

of Pregnancy in the Year 2000 report (World Health

Organization, 2003) revealed that 2.3% of all preeclampsia
cases resulted in eclampsia, and these hypertensive disorders are responsible for 13% of maternal deaths. Unfortunately, the United States has not improved maternal
mortality rates in more than two decades; furthermore,
the rates in the United States are higher than in most other
developed countries (Daniels & Parness, 2008). As
Thompson, Neal, and Clark (2004) stated, the outcome
from eclampsia is directly related to efficient identification
and appropriate treatment by a skilled nurse providing care
to the woman. Since experience managing preeclampsia
and eclampsia may be limited because of these conditions
low incidence, it is challenging to develop competency in
their identification and management without the use of
simulation (Ellis et al., 2008).
The Joint Commission has estimated that 66% of the 75
infant deaths that occur each day in the United States can
be attributed to deficiencies in the human factors of
communication and competency (State Obstetric and
Pediatric Research Collaboration, 2007). According to the
Preeclampsia Foundation, infant mortality is a devastating
consequence of preeclampsia, with an estimated 10,500
babies dying nationally and half a million worldwide yearly
following preeclampsia. Preeclampsia is responsible for
20% of all preterm births worldwide (Preeclampsia
Foundation, n.d.). Miller, Riley, Davis, and Hansen
(2008) estimated that 22,980 adverse obstetrical medical
events occur annually, affecting approximately 1.5% of
obstetric patients nationally. Daniels and Parness (2008)
identified embolism, hemorrhage, and pregnancy-induced
hypertension (preeclampsia) as the three leading causes of
pregnancy-related deaths, resulting in an overall mortality
of 11.8 maternal deaths per 100,000 births. Preeclampsia
and eclampsia contribute to 16% of these deaths, 33% of
which are believed to be preventable (Daniels & Parness,
2008). The low frequency of obstetric patients who advance
to eclampsia or other high-risk conditions does not allow
the practitioner to use the relevant knowledge and skills
frequently enough to maintain proficiency. The low incidence combined with limited resources in smaller hospitals
further complicates the high-risk nature of obstetrics,
including the management of preeclampsia and eclampsia.

Purpose of the Study and Research Question

The purpose of this clinical practice research project was to
determine whether high-fidelity human simulation (HFHS)
is an effective strategy for training obstetrical staff nurses in
the management of preeclampsia and eclampsia. DiCenso,
Guyatt, and Ciliska (2005) offered a method for describing
the clinical practice question using the categories of population, intervention, comparison, and outcome. The research question for this project stated in this format is,
Among obstetrical staff nurses involved in continuing education in a birthing center, can high-fidelity simulation

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training for preeclampsia and eclampsia management increase nurses self-efficacy levels and foster satisfaction
with this training approach? This question was answered
by evaluating preepost self-efficacy levels regarding the
management of these high-risk obstetric episodes. Nurses
satisfaction with the simulation experience was obtained
through an overall training evaluation collected by the
clinical site.

Review of Literature
The National League for Nurses and the Institute of
Medicine emphasized that educational reform within nursing
must involve innovative pedagogies (Brown, Kirkpatrick,
Greer, Matthias, & Melvin, 2009). Innovative competency
training will enhance health care delivery, thereby improving
patient safety and outcomes (Robertson et al., 2009). To be
innovative and facilitate the clinical training competencies
in the obstetric arena, HFHS may be a promising teaching
strategy to ensure that nurses experience realistic situations
and practice the skill sets essential for meeting for the critical
needs of obstetrical patients (Larew, Lessens, Spunt, Foster,
& Covington, 2006).
The State Obstetric and Pediatric Research
Collaboration Obstetrics Safety Initiative (2007) is attempting to revolutionize global health by improving obstetric
safety through research and innovative technologies. Its
goal is to bring simulation and teamwork training into obstetrics units to improve obstetric care, especially in small
regional hospitals. Care delivery in a small hospital often
requires the nurse to manage complicated obstetric emergencies despite the infrequency of the critical episode and
limited resources. The low frequency of obstetrical crisis
does not diminish the risk to the mother and baby; however,
it does complicate the training of new obstetric nurses and
competency maintenance of existing clinical nurses.
The literature supports the use of HFHS to train new
nurses to obtain competencies; however, less emphasis has
been placed on the use of HFHS in the maintenance or
improvement of existing competence for staff nurses. The
recommendations for using HFHS in the obstetrical arena
are numerous. Black and Brocklehurst (2003) systematically reviewed training for obstetric emergencies and identified several recommendations for crisis and teamwork
training to reduce errors in the field of obstetrics. There
is a need to maintain the competence of obstetrical staff
to avert, identify, and manage obstetrical complications to
decrease fetal and maternal morbidity and mortality.
Birch et al. (2007) emphasized that additional training is
necessary because of the lack of exposure to actual emergencies, which prevents nurses from gaining and maintaining competency in managing these critical episodes.
Radhakrishnan, Roche, & Cunningham, (2007) emphasized
that because HFHS provides the opportunity to engage, it
therefore improves critical thinking abilities (Nehring
et al., 2004; Rauen, 2004).

Although nurses may be oriented to critical events such

as shoulder dystocia, umbilical cord prolapse, placental
abruption, and eclampsia, nurses may spend extended
periods without the opportunity to practice these skills.
HFHS has the major advantage that the learner can
participate in it at any time and learn interactively in
a risk-free environment with immediate feedback (Haskvitz
& Koop, 2004; McCausland et al., 2004; Nehring et al.,
2004; Rauen, 2004). Jeffries, Bambini, Hensel, Moorman,
and Washburn (2009) support the use of HFHS to improve
safety outcomes for obstetric patients by providing a nonthreatening opportunity for nurses to increase their communication skills and their clinical competence in making
quick assessments, preparing for emergency deliveries,
and reducing critical complications.
The most applicable research in the literature review
consisted of simulation studies based specifically on the
critical episodes of preeclampsia and eclampsia. Crofts
et al. (2008) reported that multiprofessional obstetric emergency training for shoulder dystocia, postpartum hemorrhage, and preeclampsia improved the simulation
participants perception of their care delivery during these
simulations. Ellis et al. (2008) cited the necessity for simulation as a rehearsal for treating eclampsia. Simulation is
necessary because medical providers may have exposure
only to one case of eclampsia during their 5-year training;
therefore, they lack experience and competence. Specifically, Ellis et al. reported better management of eclampsia,
and specifically, a 23% increase in completion of tasks after
simulation. Nurses not only administered the magnesium
sulfate loading dose 31% more often but also did it in
a shorter time frame and with higher median teamwork
scores. Daniels and Parness (2008) also found HFHS enhanced training for preeclampsia and eclampsia and offered
the opportunity to identify specific performance deficits.
These data provide strong support for simulation training
for preeclampsia.

Theoretical Framework
Banduras self-efficacy theory (Bandura & Adams, 1977)
served as the theoretical foundation for this project. Bandura
based his theory on social cognitive theory and recognized
the strong relationship between person, behaviors, and the
environment. Self-efficacy is the measurement of choice
for our study, based on Banduras (1989) claim that perceived self-efficacy contributes to improved performance
and productivity. The self-efficacy theory has evolved over
time and often supports nursing education, practice, and research. Self-efficacy is grounded in the assumptions associated with the interactive-integrated paradigm, or the belief
that individuals change in an interactive manner and have
influence over their actions and behaviors (Resnick, 2008).
Individuals exhibit various levels of self-efficacy depending
on the situation (Bandura, 2006). Resnick (2008) defines
self-efficacy as an individuals judgment of his or her

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capabilities to organize and execute courses of action

(p. 183). For example, an experienced nurse in the field of
medicalesurgical nursing may have a very high sense of
self-efficacy in that area; however, the nurse may have
a very low sense of self-efficacy when placed in an emergency department. The underlying assumption of this theory
is that what people think, believe, and feel affects how they
behave (Resnick, 2009, p. 118). Thus, performing a behavior or observing someone else perform a behavior increases
an individuals perceived capabilities, enhances the individuals self-efficacy expectations, and promotes a positive
change in behavior.

outcome. The measurement items need to address the construct of interest, which is self-efficacy of nurses in terms
of preeclampsia and eclampsia management. Our study
used a self-efficacy tool specifically adapted to measure
self-efficacy in relationship to preeclampsia and eclampsia
management.

Method
Design

The theory of self-efficacy aligns well with the construct of

HFHS. Resnick (2008) discussed how peoples self-efficacy
expectations are linked to the way they believe they can
successfully accomplish the task at hand. These concepts
regarding perceived expectations, capabilities, and behaviors determine the nursing actions performed to successfully assess, identify, and manage preeclampsia and
eclampsia. Bandura (1989) noted that expectations do not
provide enough incentive to change behavior or improve
efficacy, especially when resources are inadequate. The
successful birth of a healthy newborn can serve as a great
incentive for behavior change for the obstetrical nurses caring for families during critical times.
According to Bandura (1995), individuals develop and
verify how they feel about themselves through four processes that align very well with NLN/Jeffries Simulation
Framework (Jeffries, 2007). The first process refers to the
direct experiences that actually affect how they act. Participating in the simulation scenario provides the nurse with
the direct experience. The second process is the vicarious
experiences, or performing the action through someone
elses actually doing it. The observation portion of the simulation will provide this opportunity. The third process, reflecting on judgments of others, is well supported by the
debriefing phase of the scenario. The final process, gaining
further knowledge through inferences that can be drawn
from rules, is accomplished during the introduction phase
of the simulation review of the preeclampsia and eclampsia
management guidelines. Gaining further knowledge is
addressed as remediation is done to enforce the rules
or appropriate actions to support evidence-based guidelines
and the protocols and orders established by the clinical site.

The research design was a prospective cohort study that

explored how HFHS influences nurses self-efficacy. The
within-participants design allowed for comparisons of the
study variable at three different times among the same
study participants. The Self-Efficacy for Obstetric Critical
Episodes Evaluation was used to measure self-efficacy
levels in this project. The tool for this study was adapted,
with permission to revise and publish, from Ravert (2004),
who used the measure to examine nursing students using
HFHS to learn various obstetrical skills, including management of preeclampsia. The tool was revised to include more
specifics regarding management of preeclampsia and
eclampsia, as well as more advanced skill sets as they pertain to the practicing nurse. The revised content of the SelfEfficacy for Obstetric Critical Episodes Evaluation and the
simulation scenarios were guided by evidence-based guidelines and unit protocols. They were reviewed by the clinical
stakeholders to ensure content validity before we presented
them to the staff nurses. Both Raverts tool and the SelfEfficacy for Obstetric Critical Episodes Evaluation used
Cronbachs alpha to verify internal consistency estimates
of reliability. Raverts tool had a Cronbachs a .88, and
the revised tool used for this project had a Cronbachs
a .93; therefore both indicated high internal consistency.
The Self-Efficacy for Obstetric Critical Episodes Evaluation, a 5-point Likert-type scale evaluation tool
(Figure 1), was administered presimulation, immediately
after the simulation, and again 8 weeks postsimulation.
Overall participant satisfaction surveys were also collected
by the clinical site. Since the demographic variables within
this population are fairly consistent and the information
gathered was analyzed as an aggregate, no demographic
variables were collected. Ethical considerations were
addressed as the research study was approved by the University and the clinical agencys institutional review boards.

Measurement of Self-Efficacy

Sampling Plan

Bandura (2006) affirmed there is no all-purpose method to

measure self-efficacy. As Resnick (2008) noted, when
a researcher is using a self-efficacy tool, it is essential to
maintain behavioral specificity. This can be done by creating
very specific connections between the behavior being
considered with respect to efficacy and the expected

All Family Birth Place nurses attending a mandatory annual

education training (n 49) were invited to participate in
the research portion of the project. The Family Birth Place
is an obstetrical and birthing unit in a regional medical center in the Midwest and delivers between 1,200 and 1400
babies per year. All nurses were women between the ages

Self-Efficacy Processes and Simulation

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Employee #_________

Pre-Questionnaire
Self-Efficacy for Obstetric Critical Episodes Evaluation
DIRECTIONS: Individuals do many different things to help themselves perform well in
different situations. I am interested in how confident you are in performing each of the following
skills. For example for the skill: I can run a marathon, I would rank my confidence as very
confident as I have trained for 6 months but this is my first marathon. Record your first
reaction: do not spend a lot of time thinking about how well you do the skill- just how confident

1 = Not At All
Confident

2 = Slightly
Confident

3 = Moderately
Confident

confidence to perform the skill.

4 = Very
Confident

Please check the appropriate column indicating your level of

5 = Extremely
Confident

you are that you can do it.

1. Assessing vital signs (T, P, R, BP)

2. Assessing reflexes (patellar, brachial, and clonus)
3. Completing full obstetrical admission physical assessment
4. Completing postpartum assessment
5. Inserting IV
6. Administering IV push medication
7. Administering intravenous piggyback
8. Calculating magnesium sulfate loading doses
9. Monitoring fluid levels
10. Administering blood products

11. Understanding pre-eclampsia lab values

12. Monitoring for CNS involvement with pre-eclampsia
13. Managing antepartum patient with disease/condition of
pre-eclampsia
14. Managing active labor patient with disease/condition of
pre-eclampsia
15. Managing patient with disease/condition of HELLP
Syndrome
16. Managing patient with eclamptic seizure
17. Managing patient with disease/condition of postpartum
hemorrhage (PPH)
18. Managing antepartum patient with disease/condition of
gestational diabetes (GDM)
19. Managing postpartum patient with disease/condition of
gestational diabetes (GDM)
20. Managing patient with disease/condition of DIC
21. Managing patient with shoulder dystocia
Comments:
*Evaluation tool adapted with permission from P. Ravert (2004) dissertation project: Use of a human patient
simulator with undergraduate nursing students: A prototype evaluation of critical thinking and self-efficacy.

Figure 1

Prequestionnaire.

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of 22 and 65 years, and all but one was White. All the
nurses participated in simulation activities; 48 consented
to be in the study and completed the first survey before
the training began. The nurses were then asked to complete
a survey immediately after the simulation, before leaving
(n 47), and then 8 weeks later, the nurses were sent
a link through SurveyMonkey to complete the third survey (n 33). In addition, the clinical site asked the nurses
to fill out an evaluation of the entire development day.

Table 1

,
,
,

Simulation Intervention
,

The simulation framework by Jeffries (2007) provided the

foundation for most aspects of planning and implementing the simulation intervention. The implementation of
this HFHS intervention used two different scenarios and
occurred through five phases: prebrief, simulation, observation, debriefing, and remediation. During the first phase,
prebrief, the nurses were given a presentation on preeclampsia and eclampsia that encompassed recent research findings. The complications associated with
preeclampsia, such as eclampsia, HELLP, and reversible
posterior encephalopathy syndrome, were discussed,
along with the appropriate diagnostic, assessment, and
management strategies for these disease processes. The
nurses were then given an orientation to the simulator
and the various roles. A short labor scenario was completed with all participants. The participants were then divided into groups of 3-6 nurses and placed into either the
observation, simulation participation, or debriefing
phases. During observation, the nurses observed a live
HFHS scenario by another group. The observers used
a checklist of skills that should have been performed by
the simulation participants. Table 1 contains this Simulation Evaluation Checklist. This list was based on current
evidence-based practice guidelines obtained from the National Guidelines Clearinghouse, the Association of
Womens Health and Neonatal Nursing (2008), and the
Pregnancy Care Councils guidelines and standards of
care regarding the management of preeclampsia and
eclampsia. The participants then moved into one of two
simulation scenarios, different from the scenario they
had observed earlier. During the simulations, the nurses
played the role of either the primary nurse, the charge
nurse, or a family member. The first simulation scenario
involved a laboring patient with preeclampsia. This simulation prompted nurses to implement the essential nursing
actions for a patient with preeclampsia, such as recognizing the disease and starting a magnesium sulfate load, and
progressed to the management of an eclamptic seizure and
delivery. The second simulation scenario began with the
postpartum aspect of the management of the mother and
compromised newborn. During this simulation, nurses
were expected to manage a postpartum hemorrhage and
an overdose of magnesium sulfate, along with the stabilization of the compromised infant. All groups participated

,
,
,
,
,
,
,
,
,
,
,
,
,
,
,

Simulation Evaluation Checklist

Simulation evaluation
Observer intervention checklist
Check all that were performed correctly. Make notes
regarding things that could have been improved with each
area. (Not all are applicable to every scenario.)
Correctly performed blood pressure
Assessed CV: heart and lungs, edema, look for S/S pulmonary
edema
Assessed CNS: DTRs and clonus, hand grasps, LOC, headache,
visual changes, behavior
Assessed GI system: nausea/vomiting, epigastric pain
(RUQ pain)
Sufficient fetal monitoring
Notified provider in timely manner and gave accurate report
Obtained IV access in timely manner
Administered accurate magnesium sulfate in timely manner
Administered calcium gluconate in timely manner
Monitored appropriate lab values
Took necessary seizure precautions
Performed assessments frequently enough
Used antihypertensive medications appropriately
Managed fluid balance appropriately
Planned for delivery appropriately
Managed PP period effectively for mother
Managed PP period effectively for newborn
Accurate information was relayed to the patient
Any other assessments/interventions

in a debriefing session after completing the simulation experience. During the debriefing, the group used a tool similar to Jeffries (2007), as well as the observation checklist
they had completed earlier. The debriefing phase also included the remediation phase. Based on deficits noted
during the simulations, this phase took place after our project was completed.

Data Analysis
The data were coded, entered into SPSS Version 12, and
reviewed for accuracy. Paired samples t tests were
conducted on all survey ratings to analyze differences between the pre, post, and final self-efficacy ratings. The outcomes measure of self-efficacy score included two scores,
total and intervention specific. The total was based on all
questions in the evaluation tool, whereas the interventionspecific score was derived only from skills that were directly related to the training regarding preeclampsia and
eclampsia (Skills 1, 2, 7-8, and 11-17 in Figure 1).

Results
Table 2 presents the descriptive statistics and the paired
t tests for this study. Both measures that were analyzed
for this clinical project yielded significant increases in

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Table 2 Paired Samples T Test and Descriptive Statistics for

Self-Efficacy Scores
Paired Differences
N
Total
Pre to 46
Post 1 46
Pre to 33
Post 2 33
Intervention
Pre to 47
Post 1 47
Pre to 33
Post 2 33

SD

76.24
81.70
77.76
83.61

11.97 5.46 7.66

13.27
12.47 5.85 11.41
12.82

SD

environment was less threatening, along with comments

such as This is better than trying to figure it out with a patient [who] is compromised, and others affirmed the
nurses appreciation for this training approach.

Limitations

35.51
42.57
36.67
42.94

6.25 7.06
7.50
6.11 6.27
7.88

4.83 <.001
2.94

.006*

4.70 10.30 <.001

6.27

5.75 <.001

Note. Total scores on all 21 questions.

Intervention scores on intervention-specific questions (1, 2, 7, 8,
11-17).
Pre self-efficacy score before any training.
Post 1 self-efficacy score immediately following training.
Post 2 self-efficacy score 8 weeks following training.
* p < .05, two-tailed.

p < .001, two-tailed.

self-efficacy. The total, or overall, self-efficacy ratings on

the posttest (M 81.70) were significantly higher than
the ratings on the pretest (M 76.24), t(45) 4.83,
p < .001. The total, or overall, self-efficacy ratings on
the final posttest (M 83.61) were significantly higher
than ratings on the pretest (M 77.76), t(32) 2.94,
p < .05. The intervention specific self-efficacy ratings on
the immediate posttest (M 42.57) were significantly
higher than those ratings on the pretest (M 35.51),
t(46) 10.30, p < .001. The intervention specific selfefficacy ratings on the final posttest (M 42.94) were
significantly higher than the ratings on the pretest (M
36.67), t(32) 5.75, p < .001.
This project was implemented as part of the annual
education program at the birthing center. This day also
included training in four other areas: lactation, level II
nursery management, documentation updates, and annual
unit-specific education requirements. All five parts of the
training day were rated on a 4-point Likert-type scale, with
higher scores indicated greater satisfaction. These results
(n 38) were collected by the clinical site and shared with
the project lead. The simulation portion of the training day
had a mean score of 3.97 while the other four portions received mean scores between 3.13 and 3.84. This evaluation
included areas in which participants were able to provide
narrative comments on the most helpful aspects of the training. Five nurses listed the simulation and the preeclampsia
presentation, five nurses listed the simulation and debrief,
and 18 listed simulation. Under the general comments section, 10 nurses wrote that they wanted more simulation in
the future. Comments to the effect that the learning

Although our project showed sustained self-efficacy over

time, it was only for a period of up to 8 weeks. Because of the
time constraints of this project, it was not possible to reassess
self-efficacy levels after approximately 6 months, which
would be a more optimal time to sustain skills in this field.
The ultimate goal of training obstetrical nurses is to improve
patient outcomes. Evaluating long-term patient outcomes
related to improved management of preeclampsia and
eclampsia would be ideal. The sample was also very
homogeneous. Further study is needed to determine whether
simulation training is an effective training approach for the
population of nurses at large. Because of the researchers
past roles as leader at the clinical site, there is also the
possibility of a Hawthorne effect on the results, which was
not controlled for. The last limitation is in the framework
selected for the simulation. Although Jeffries (2007) provided a great deal of solid guidance for the project, the
framework lacked any reference to the importance of family
in caring for patients. Further study should include concepts
of family-based nursing in the simulation framework.

Discussion
Stakeholders and Readiness for Simulation
Rogerss (1995) diffusion of innovation theory provided
guidance for implementation of the innovative changes
this project encompassed. Anticipatory guidance in easing
the diffusion of practice within the clinical site was
provided by Rogerss five characteristics of innovation:
knowledge, persuasion, decision, implementation, and confirmation. In various meetings before this project began, an
analysis of stakeholders and the institutions readiness for
change was completed through several discussions with the
key stakeholders. The key stakeholders identified for this
change were the family birth center staff nurses,
administration, physicians, certified nurse midwives, and
nurse educators for the medical center, all of whom can directly affect preeclampsia and eclampsia outcomes. These
health care providers then can have a positive impact on entire families with pregnancy complications. In the past, the
stakeholders had been involved with minimal exposure to
HFHS with the management of neonatal resuscitation and
shoulder dystocias. These past positive experiences were
helpful in this change proposal. The analysis for change
for this clinical site revealed that all participants were ready
to adopt this HFHS intervention to effectively train
obstetrical staff nurses in the assessment, identification,

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and management of preeclampsia and eclampsia. The cooperation of the stakeholders, as well as the institutions willingness to embrace this innovative change process, was
instrumental in this clinical practice study on simulation
innovation.
HFHS is a promising teaching strategy to ensure clinical
practice nurses experience realistic situations and practice
the skill sets necessary to care for the critical needs of
obstetrical patients. Incorporation of HFHS training in the
specialty of obstetrical nursing provides a low-risk environment for nurses to practice and refine appropriate
management of preeclampsia and eclampsia. Through this
evidence-based clinical practice research project, several
implications for nursing practice have emerged.
Clinical practice nurses self-efficacy with preeclampsia
and eclampsia management increases with HFHS training.
Increased self-efficacy is linked to improved skill performance; therefore, it can be anticipated that HFHS training
improves the management of preeclampsia and eclampsia
in an actual clinical situation.
HFHS is beneficial in the training of clinical practice
nursing staff to deal with obstetrical emergencies. In
addition, the nurses increased self-efficacy with preeclampsia and eclampsia management is sustained over
time. This benefit is very encouraging, especially for
smaller obstetrical units that have limited exposure to
obstetrical emergencies but can now benefit from exposure
through HFHS training. HFHS is a useful teaching strategy
to increase nursing confidence and performance in highrisk, low-incidence obstetric emergencies.
HFHS is a teaching strategy that promotes high levels of
satisfaction among the obstetrics nursing staff. Nurses who
participated in this learning activity were highly satisfied
with the HFHS experience and expressed a desire for
continuing education to include more training with HFHS.
The nurses gained knowledge of the management of preeclampsia and eclampsia, as well as increased self-efficacy
through the direct and vicarious experiences associated with
the simulation. Thus, HFHS has the potential to improve
maternal, neonatal, and nursing outcomes through improved
management of high-risk maternal situations. In addition,
HFHS can provide a clinical site with information regarding
gaps in practice, thereby allowing for performance enhancement and improved patient outcomes. The transfer of
knowledge is less threatening and more acceptable through
the use of HFHS for clinical practice nurses and agency
nurse leaders.

Conclusions
In conclusion, this clinical practice research project has
demonstrated HFHS can positively affect nurses selfefficacy regarding preeclampsia and eclampsia management and suggests that management of other high-risk,
low-incidence obstetric emergencies can also be improved

through the use of this clinical teaching strategy. Increased

self-efficacy has been linked to improved proactive nursing
performance and outcomes. The use of HFHS, in training
obstetrical nurses in the management of high-risk situations
that occur infrequently, can improve care delivery to this
vulnerable population, especially in smaller hospitals,
where the rarity of such emergencies makes actual clinical
management experience less likely. HFHS can play an
integral role in achieving long-term results for the nurses,
patients at the birthing center, hospital agencies as a whole,
and the community at large in reducing morbidity and
mortality rates associated with preeclampsia and eclampsia.

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