Saturday, August 23, 2008

e-learning: Introducing the K2ms fetal monitoring (CTG) teaching package.

e-learning is this the way of the future? Yes, is the answer, the question is, how do we balance the present with the future? Our institution has introduced the K2ms (medical system) Fetal Monitoring ( self directed learning package. Personally I think this is a great package, it is systematic and clear, you can work at your own pace. You can repeat sections until you are satisfied that you understand the concepts being taught and you can move ahead quickly if you need to. The instructions are reasonable to follow. The program provides case studies for you to work through, it is the fun bit like a virtual game, however providing good learning examples. However I am very familiar with computers and make sure that I keep up with current trends. This program may not be so easy for someone who is not use to learning in this way.
There are some aspects of the computer world I find quite frustrating, such as, trying to add new features to my blog. Working with computer programs can be very frustrating and time consuming, and at times even a waist of time. So how does someone cope who has never used a computer?

Yes all our students now currently use computers, however if the average age of a midwife is 45yrs old - it would stand to reason that there are some midwives that will find it very challenging to move to a e-learning framework.

Do all health professionals have a personal computer? do they like using a computer, do they all use email? do they know about Facebook, myspace, Internet banking, eBay etc...... there are so many areas in life that are influenced by technology, yet e-learning is very challenging. Is this because there are issues that may influence this such as: eye strain, concentration of looking at computer screen, do they actually learn in this way if they do not like this method. For some people interaction in its self enhances the learning experience.

We have many e-learning packages, such as: Breastfeeding modules, manual handling package, emergency preparedness and the list goes on.

Are we losing the face to face teaching? is there room for both methods? do we need to ensure that both methods of teaching are still available for our health professionals?

What are some of your experiences regarding e-learning?

How can we make the transition smoother for our less technologically minded colleagues?


Lisa Barrett said...

Hope you realise they have a record of all your results. If something happened and they were questioning you at a clinical level they could pull up your results on this, especially if you have repeated somethings a few times to get it right.

I don't know why midwives need a learning tool for ctgs. There is no evidence to show they change outcome expect up the c/s rate. If things are badly wrong for the baby and it needs monitoring then interrpretation is by a medic surely.

Sarah Stewart said...

As for your questions about e-learning and midwives' use of the computer, this is a huge question - one I have been talking about for a year on my blog. I could say a heap of things about this but my main points to consider is:

don't assume that 'advanced' age means that midwives do not engage ie there is heaps of evidence now to say that older folk engage with the Internet as much as younger people.

the second point is that we must not confuse use of the computer with digital literacy - just because your student is 20 and has a facebook account does not make her able to use the internet & computer in a constructive way for learning.

infomidwife said...

Thanks Lisa for you comments. Let me answer or clear up a few issues:

The K2 program is a teaching/learning tool not a competency tool. The aim of the program is so that the learner may go over the program as many times as they like to improve their knowledge base.
Yes you are right when you say they keep the results, but that is only from the assessment tool, and there are faults with this assessment tool - the assessment tool is 25 multi-choice questions and we all know that is not a good way of measuring knowledge, its purpose is only for personal learning, not measuring competence.

Yes you are also correct when you say there is no evidence to show that CTG's improve outcomes, however, when used in conjuction with fetal blood sampling this has shown that it does improve outcomes and may even reduce C/S rate - we can only live in hope.

We all know that CTG is not recommended in low risk women, (however a fetal heart (using a doptone) needs to be documented as per RANCOG guidelines) so they are predominately used in high risk women. The woman should be fully informed to make a decision about her care.

It is important for midwives to have a good knowledge base regarding CTG if they are using it and it is also their responsibility when caring for their women to be able to detect when things are going wrong so that they can inform the appropriate people. The flip side to this coin is if the doctor is lacking in CTG education or knowledge base that the midwife will be able to advocate for the women in being able to interpretate the CTG and formulate a plan.

The Douglas Inquiry held in WA 1990 - 2000 recommended that all doctors and midwives have yearly CTG education when working in labour and birth suite. These recommendations wll be considered nationwide if not worldwide. So there are larger implications to CTG education.

We are strongly advocating that this tool is a learning tool and no punitive measures will be used, it is for education only not a measure of competence.

infomidwife said...

Thanks Sarah for your comments, yes I have been following your blog re e-learning.
I am sorry if I was sounding like I meant that all 'advanced' age meant computer illiterate, I certianly did not mean this, as it is not the case, however in my experience there are some of 'advanced age' that find it very challenging.
Yes I concur that just because you can use facebook does make you computer literate.

My question is, is e-learning the be all and end all of education?

Sarah Stewart said...

Golly, hope you don't think I was criticising - I wasn't - just making general comments.

Did Carolyn tell you about the undergraduate program we're developing in Dunedin? It's blended delivery - most theory will be delivered online, and clinical skills 'stuff' will be delivered in 'intensive' weeks. The students will stay in their locales as opposed to up rooting families to Dunedin for 3 years. They'll be supported to do their clinical in their local areas - more like an apprenticeship model. What will be telling is how things go with the e-learning aspect of the course. Not only will the students have to be digitally literate but also all the midwives supporting them. So its very much a matter of - watch this space.

infomidwife said...

Typo in my comment left the Z out -of RANZCOG - Royal Australian New Zealand College Obestetrics & Gynaecology

infomidwife said...

Sarah, sounds like an exciting program in Dunedin will be interesting to watch, thanks for the info.

Lorraine said...

Hi Pauline
Just wanted to comment on K2 as I will be using it next week. I must admit I am a bit apprehensive, just because this is new and the perfectionist in me will want to get it right the first time! My biggest concern is the time it takes to do, 8-10 hours, this may be a big problem for many overworked midwives.
My comment to Lisa Barrett is that as midwives we are required as part of our professional responsibility to recognize and report the abnormal. Things do not have to be badly wrong for a woman to require a CTG and as most women are cared for by midwives they are the first person to recognize an abnormality and act on it. I am a firm believer in the normality of most births but have also personally been involved in births were the CTG was the tool that prevented an adverse outcome because of early interpretation and intervention by a midwife. Just as the listening to fetal hearts in the beginning of the century changed practice so has CTG's, whether we like it or not CTG monitoring is here to stay. We as midwives when we are expert in CTG interpretation can also prevent early intervention by a doctor if we stand confident in our interpretation and we can only do that when we have been given the opportunity to learn this skill.

Suzanne said...

Hi Pauline,

Here's some feedbacks from a student. Firstly, I HATE e-learning. Secondly, what is wrong with having the human touch? Thirdly, when the website is down, its maddening or it takes forever to load.

I studied in a Polytechnic before coming to Perth to pursue my nursing studies. Thing is the topics my lecturers put up are rather dry and it just turns me off. Nonetheless, do it or risk failing your exams. I don't understand why can't we have a more humane teaching when the world is becoming digitalised.

Correct me if I am wrong, the durations and frequencies of a delivering mother is monitored by electrodes transmitted onto the monitors. What happened to the old fashion of feeling them?

On the contrary, I do agree that there are so many things to learn, its impossible to squeeze them into classrooms. Therefore the advantage of having advance technologies.

I maybe young since I fall into the Y Gen category, I still prefer to see someone talking and moving around in front of me and allowing me to ask questions then having to stare into the screen.

I have this so-called attractions to lecturers who make lectures and tutorials lively. Also, I can ask questions and get answers and everyone around learns, provided they catch it.

After a long day at work (I was working as a full time RN prior to my studies here), all I crave for is rest. I do not want to have anything that has got to do with work. Even if I can do it, my brain is too exhausted to absorb anything. What happens in my institute is that we have an hour talk after handing-over on Fridays or seminars available on any days.

Sometimes, being old fashion is good.

infomidwife said...

Hi Lorraine,

thanks for the comments. To address some of your concerns:
There is no need to be apprehensive about e-learning, it is all done in your own pace.

Yes you are right when you say the program takes 8 - 10 hrs to complete, but this is done in stages over 6 - 12 months not in one or two sessions, unless that is what you choose to do. Another way of looking at it is, that you are doing some professional development relating to CTG on a regular basis rather than in 1 or 2days straight which as you know can be a strain.

I totally agree with your comments relating to midwives being able to interpretate CTG's and preventing or divirting possible adverse outcomes.
We also have to remember that midwives working in a high risk setting are able to support and encourage a woman to birth as normally as possible within this enviroment facilating their needs.
There is nothing wrong with a high risk woman (providing she is well enough) sitting on a birthing ball attached to a CTG machine - or a woman who has a low dose epidural, CTG and conected to telemetry walking around her room -

We have to remember as midwives we can facilitate normal within in high risk setting working in collaboration with our obstetricians. We as midwives keep the obstetricians honest with our knowledge and skill.

infomidwife said...

Hi Suzanne, fantastic to get some feed back about e-learning and from a Y Generation, great! It is interesting to see you do not like e-learning, comming from the Y gen I would assume you would like it. But yes you are right we all like the human touch. Even as lecturers we are being urged to look for more dynamic, bigger, better ways of delivering lectures.
I personally like the personal touch, I like interaction and asking questions and sharing experiences. this is difentily difficult to translate into e-learning.
I totally agree with your comment "the world is becoming digitalised" and it is so frusting when the computer crashes.

Addressing your question: "..the durations and frequencies of a delivering mother is monitored by electrodes transmitted onto the monitors. What happened to the old fashion of feeling them?" By this I take it you mean the contractions the woman is having - these can be monitored by a monitor, however the more accurate way is still the old fashioned way of palpating that is feeling the (womans abdomen) contractions - this is by far the most common way when we really want to assess how the woman is progressing with her contractions. Also her body language is an accurate way of telling, however women all labour in very different ways.

Our institution will use both methods of learning, e-learning and face to face.

I feel at the end of the day in this case - start with e-learning, as all qualified midwives have a basic knowledge of CTG interpretation. When you have questions or something is unclear write the questions down and have a one on one session with an educator to clarify any points.

once again thank you for your input and yes there is nothing wrong with the old fashioned way, we just have to add some new aspects as well.

Lisa Barrett said...

To Lorraine, Please provide me with the evidence that continuous ctg improves outcomes as you are suggesting.
Also I'd like to know where continous monitoring is part of recognising and collaborating over the abnormal.
I would also be interesting in when you think things are not going badly wrong but a woman would require a ctg.
I agree that an abnormality in a fh may require further investigation but ctg is not a first line diagnostic tool. Nor is it a crutch to good old fashioned hands on woman centred care.

Lorraine said...

Hi Lisa
Thanks for your comment.
The evidence in the use of CTG monitoring not improving outcomes has only been proven for the low risk woman so unless you work only in a home birth or birth centre setting midwives will be using CTG on a regular basis, as midwives are the primary carer of women in labour and that includes women with risk factors. This also means they will be working collaboratively with doctors.
The evidence for women with risk factors is not clear and never will be as there can't ethically be a randomised controlled trial to get conclusive proof, so as I said like it or not we as midwives are required to use CTG whether we like them or agree with there use, because in most birthing units around the world they are a reality. Therefore I as a midwife want to expert in their interpretation. Only last Saturday I interpreted a CTG that required immediate intervention, the baby's Apgar score was low at birth but it's cord gases where OK, showing that the intervention was required and timely. Reduced variability which is the best indicator of hypoxia in the fetus will not be picked with a Doptone or a pinnards and it was this feature which alerted me this baby required immediate intervention.
Just because a woman has a CTG on it doesn't mean you don't do "good old fashioned hands on woman centred care." This woman I cared got both. The art of midwifery in the modern world requires we keep what's important and use all our skills as a midwife whether the labour requires the use of CTG or not.

Lisa Barrett said...

Even Cochrane the obstetric data base says there is no evidence to support ctg as improving outcomes. I Birth with women of all risk not low risk none of them actually require continuous monitoring. Can you just clarify what high risk woman would require continuous monitoring ( excluding induction or epidural which is obstetric risk taking) I beg to differ about lack of variability it is possible to tell from intermittent monitoring if there is lack of variability.
If a cord ph is normal it means that there was no need for intervention. A low apgar can easily be caused by unnecessary intervention as trauma from forcep ventouse or section. A normal ph indicates that prior to birth the baby was in no distress at all. I'm sure you know from your own research that 2to5% of fetal distress is misdiagnosed by ctg.

Modern midwifery is no different than it has always been, However obstetric nursing is a modern phenomenon.

Lorraine said...

Hi Lisa
Is there evidence that decreased variability can be picked up on a doptone or a pinnards?
High risk includes severe pre-eclampsia, IUGR.
Sorry about the mistake I got it around the wrong way the APGAR was normal and the gases abnormal.
Please don't assume all midwives are obstetric nurses just because we work in areas where the vast majority of women choose to birth. Most of us work with the best interests of the woman at heart, in sometimes very difficult circumstances and help the woman achieve an empowered birth experience. When most of the women choose a home or birth centre to birth their baby, that's where most midwives will work, after all it's still the woman's choice

Lisa Barrett said...

Here is a good article. But it's not randomised or controlled.

I don't assume that all midwives working in the hospital are Obstetric nurses, but focus on machinery for outcome does give that impression. Just as you assume that birth centres homebirth is all low risk. I Know excellent midwives who work inside the system. I think most midwives don't work in the community or in birth centres because they carry fear surrounding birth in those environments. I think the service is lead by midwives and if more worked in a woman centred philosophy then women would follow.
Most women chose the medical model of care due to lack of education and fear of their own, this is often fed by midwives, especially here in Australia. I must admit this doesn't happen in the same way in the UK.

I don't think IUGR is a good reason for continuous monitoring and I have good personal research on this as one of my own babies ( now 12) had a very low birth weight at term. 5lb 1oz to be exact. We knew she was small and I did lots of reading around the subject. Pre eclampsia only covers 3%of the population.

Lorraine said...

Hi Lisa
It sounds to me like we are both trying to achieve the same goal, we both want to empower, support, guide and serve women during pregnancy and birth. I have to do that in a setting that requires me to use CTG, so I want to be expert in it's use. I still practice intuitively and I used that intuition last Saturday as well as the CTG as my tools, the CTG and cord gases just confirmed my intuition thats all.
I agree totally with about the fear surrounding childbirth by both women and the professionals caring for them. It is now in epidemic proportions and needs to be urgently addressed.
Fear is a belief that something will cause harm or threat (Oxford dictionary) so it's working at the level of beliefs that will bring about change. Women's beliefs around childbirth are most often made even before they can remember, these form their core beliefs. I have a strong core belief that birth is a natural process as I'm sure you do and certainly the women who choose freebirthing do and nothing can sway us from that belief no matter what we may see and hear.
Most women are not so lucky, they have their core belief around childbirth that birth is dangerous and this is confirmed by family, friends, professionals and the biggest influence in the last 10 years has been the media and the amount of information available via the internet. I have been working with women over the last 3 years giving them tools and techniques to change their beliefs around childbirth and therefore eliminate their fear and this then changes their perceptions and outcomes. It's very satisfying work.
If you are interested visit my web site It's in constant development so any feedback would be appreciated.

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