Family planning staff could learn a lot about contraceptive patient care from realistic simulation sessions.
Researchers found positive changes in clinicians’ knowledge and confidence when they practiced inserting intrauterine devices (IUDs), removing them, and counseling patients in a realistic family planning simulation.1
For removing IUDs, researchers used a hybrid simulator called PartoPants with an IUD task trainer inside the pants. An actor — often a staff member — would wear the pants and device and follow a script in portraying a patient.1,2
For some women, cost and access to trained clinicians are barriers to using IUDs. Reproductive health organizations can reduce this barrier by using simulation to educate providers on IUD insertion, removal, and counseling.
“We undertook this initiative where we partnered with community partners across the state and Title X clinics, and we helped train them and support them,” says Rebecca Simmons, PhD, MPH, study co-author and an assistant professor in the division of family planning at the University of Utah in Salt Lake City. “We gave them no-cost devices so they could give devices to people who couldn’t afford family planning, and we’re supporting them for two years. This simulation was developed as one of those strategies to understand, across the entire health system, where the intervention was going well and where it was going off course.”
They used the simulation at each of their sites, measured the results, and assessed what they learned from the experience.
“The simulation scenarios are high fidelity and low tech,” says Susanna Cohen, DNP, CNM/MSN, FAAN, an associate professor in the LIFT Simulation Design Lab at the University of Utah. “The simulation scenario follows — as realistically as possible — what happens inside the clinic. It just uses PartoPants, which was developed [for] midwife and nursing training.”
The actors portraying the patients wear the pants and simulator so clinicians can practice placing an IUD. This allows them to sharpen their technical skills in the presence of a real person.1
The pants contain a simulated vagina and an IUD task trainer, which is a plastic box that looks like a vulva and a cervix for placing the IUD. The box is placed inside the pants that the patient actor wears while lying on the exam table for the simulated IUD insertion.
The traditional way of using the cervix boxes is by placing them on a table for clinicians to use. By placing the boxes inside the pants of a real person lying on an exam table, it more closely simulates the experience of inserting an IUD in a patient.
“What we know about simulation is it increases provider confidence and skills, and when done in context of a clinic or team, it enhances team communication,” Cohen says.
Recently, the healthcare industry has begun to use simulation more often as a way to acquire critical skills without clinicians practicing on real patients. “This is a way for learners to increase self-efficacy on skills and confidence without practicing on real patients,” Cohen says.
The simulation exercises build confidence in technical skills as well as knowledge and confidence in counseling skills because of the realistic patient-provider interactions. “Not only do we have a written scenario with a persona for the actress, we give her a back story on how to act,” Cohen explains. “If the provider says something awkward or uncomfortable or offensive, she’ll act as if it’s those things; if the provider makes her feel safe, she’ll act like that as well.”
The actress and facilitator were aware of the simulation’s objectives. When necessary, the facilitator would communicate with the actress using predetermined hand signals and prompts on a white board that only the actress could see.
“The facilitator supports the actress during the scenario to provide feedback on what the provider is actually doing,” Cohen adds. “In every simulation, there is a debriefing session about what went well, how they could do better, and what they want in place next time.”
The actress, often part of the research team, would answer questions from providers and talk about her experience. “In different settings, we’ve used patient actors by either hiring someone or — most of the time — using a member of the clinic staff so they can have the experience of being a patient in their own setting,” Cohen says. “Folks getting IUDs placed or removed experience many different things. Some say it’s a great experience where the provider respected their privacy. Other folks find it very painful, and it can be retraumatizing for those who experienced sexual abuse.”
When clinicians can speak with a real person during the procedure, they can better learn and practice trauma-informed care and confidentiality.
The simulation can help clinicians work with patients who are switching their contraceptive method, particularly when they are removing an IUD and switching to a less effective method, such as relying on condoms.
“Sometimes patients make decisions about their contraceptive journey that are different than what the provider would make for them,” Cohen says. “We don’t want the provider to make the decision.”
Researchers wanted to know if providers are biased toward more effective contraceptive methods even in cases where contraceptive efficacy is not a patient’s priority. The simulation included a patient who decides to have the IUD removed and to use condoms for her contraception method.
“We saw many providers who said, ‘Great, let’s get you condoms and show you how to use them effectively,’” Cohen says. “Other providers strongly discouraged the removal of the IUD and use of condoms, and in some cases got a little assertive that the patient should keep the IUD and not use condoms.”
The patient in this scenario would feel uncomfortable and coerced into keeping the IUD. “In the debrief, we got into a talk about how the counseling went, and we talked about their bias toward efficacy and how we might support a patient in decision-making,” Cohen explains.
The simulation exercises also brought up the common misconceptions that both patients and healthcare professionals had about the way two common emergency contraceptives (ECs) work.
“In one of the situations, the patient decides to have condoms and the IUD is removed,” Simmons says. “The patient asks the provider about getting emergency contraception, and the provider gives the patient a prescription to get ulipristal acetate [Ella].”
Unlike the EC levonorgestrel (Plan B), which is sold over the counter, Ella requires a prescription. Patients have to meet with pharmacists to fill the EC prescription.
The research showed that pharmacists often believed and/or told patients that taking the EC would cause an abortion, even though scientific evidence shows this is not true.3,4
“That opened up a good conversation about what is the mechanism of action for [Ella] and for Plan B, and what does it mean to be an abortifacient,” Simmons says. “This was informative to all the team and not just the pharmacist because everybody was sort of misinformed and didn’t know how it worked. It was insightful to us to learn that people don’t understand how these methods work and how they should talk to patients about them.”
Misconceptions about emergency contraception were common among medical providers, nurse practitioners, nurses, and front desk staff, as well as pharmacists. “I was surprised at how universal the misunderstanding seemed to be across the entire team,” Cohen says. “Both Plan B and Ella work to delay ovulation. What happens is you keep the eggs tight for another week until the sperm die off, so if you take it in the first three to five days [after intercourse], it allows your body to keep hold of that egg so it’s not releasing that egg into a body with living sperm.” People who already are pregnant are not affected by EC.
“As a program, we were surprised at how few clinicians thought to talk about emergency contraception or provide it,” Simmons says. “The patient actress had to ask about it all the time. There wasn’t a single scenario where the provider said, ‘If your condom breaks, you can use emergency contraception.’”
The problem is that ulipristal acetate is more effective than levonorgestrel, particularly for women who weigh more than 165 pounds, but it requires planning. A woman has only a day or so to find a provider and fill the prescription. It would be helpful if reproductive health providers offered patients a prescription for the EC before they need it. They could fill it and keep it at home until it is needed.
“Even for people at lower body weight, ulipristal acetate is effective for five days instead of three, so it might be appealing to someone who is traveling out of the country and struggling to get access to care,” Simmons says. “Providers can give patients both options and let patients decide.”
Since EC is not considered a regular contraceptive method, clinicians might not counsel patients the same way they would about other contraceptives. But they should counsel about EC in the exact same way and let patients decide early enough that they are prepared and are confident in their method, Simmons says.
“The PartoPants approach in teaching IUD insertion is fascinating,” says Robert A. Hatcher, MD, MPH, chairman of the Contraceptive Technology Update editorial board. “It offers the program teaching IUD insertion the opportunity to deal with the important information in the above article. The script provided to the person wearing the pants and the device could include the question ‘How long is my IUD effective?’ In the case of a training for Liletta or Mirena, the proper answer by the staff would be, ‘Your IUD is effective for at least eight years.’”
REFERENCES
- Cohen SR, Baayd J, Garcia G, et al. Family-based simulation as a programmatic tool for implementing a statewide contraceptive initiative. BMC Health Serv Res 2022;22:965.
- PartoPants Birth Simulator. 2022.
- Dao A, Caliendo T. Addressing barriers to emergency contraceptive access. US Pharm 2021;46:8-12.
- Haeger KO, Lamme J, Cleland K. State of emergency contraception in the U.S., 2018. Contracept Reprod Med 2018;3:20.
Family planning staff could learn a lot about contraceptive patient care from realistic simulation sessions. Researchers found positive changes in clinicians’ knowledge and confidence when they practiced inserting IUDs, removing them, and counseling patients in a realistic family planning simulation.
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