 In this presentation, making discoveries through research, media-free students' perceptions of their role when caring for pregnant women who misuse substances, neonatal stimulators as creative pedagogy. The presentation is being done by Dr. Luisa, the city butler, and Dr. Humira Hussain. Luisa has been a midwife for 30 years. Prior to that, was a nurse and underwent her training in South Africa. She undertook her media-free training in the UK in 1988 and qualified in 1990. She's currently a senior lecturer in media-free in Bournemouth University and lectures at undergraduate and postgraduate levels, including master's. Her scholarship in practice is focused on newborn issues and is the lead at the University in relation to examination of the newborn and area of practice that was once predominantly undertaken by pediatricians that has now been largely reclaimed by midwives as an essential part of normal midwife's care. Her research interests are around preterm infants and women's experiences. Her PhD study explored women's experiences of caring for a late preterm infant from a feminist perspective. She considered herself a radical feminist. Humira Hussain is a lecturer in health sciences at Bournemouth University and interim deputy head of nothing. She has a strong academic and research background in health, clinical, and educational psychology. She completed a doctorate in professional practice between 2004 and 2010, looking at the impact of job strain and burnout from the inclusion of disruptive students in mainstream teaching with secondary school teachers. This has led into more health education and promotion research base around the use of interactive digital technology in health and social care setting. She's the lead researcher on a number of research projects in Bournemouth University Center of Bid by Free, maternal and prenatal health, working in collaboration with Bournemouth University Science, Technology, and Pool Hospital, MHS Foundation Mathematical Services. Welcome, Luisa and Humira. The floor is yours. Thank you. Welcome everybody to our presentation. I'd just like to say that this is one part of a bigger study we undertook, which the other part was a survey that we put for the students and looking around FAES and DAS pre and post lecture. And that research will be published in another journal. We looked at social work and other students as well. We're going to compare and contrast the Bid by Free students with other students and the faculty at Bournemouth University and the University of Soland and near Southampton. So before we start, could we have the next slide? I would like to ask you a few questions. Maybe we don't have spent too much time on answering them if you don't want to. Carol, can you move the slide? Am I going to move the slide over? Next slide, okay. So what is the risk of harm to the baby if a woman has drunk any small amount of alcohol before she knew she was pregnant or during pregnancy? Any answers to that? Do you like them to have it in the public chat? Yeah, they can just say a few words. So for example, no safe limits. The risk of harm as opposed to the safe limits. What is the risk of harm? What is the small amount? Interesting, yeah. Okay, well, we can come back to that. Unknown, we cancel against any alcohol. Research changes its mind. Yes, that's true. Actually, the risk of harm is likely to be low according to the evidence. Are there any barriers that prevent or inhibit you from advising pregnant women to abstain from alcohol? Nope, says Linda. Language, nope, says Debbie. Nope, okay, brilliant. So you're quite happy to talk to women in terms of discussing the research. Does suggest that some midwives are inhibited in giving advice, which is interesting. Did you receive any education, alcohol and pregnancy during your undergrad training? Nope, yes. Small amount, yes. Lots, great, nope, Denise King. Lovely, so mixed picture there. And so how many hours of education did you receive? Some more pertinent to cycle sessions, weekly effects. For example, in our university, we only do one session, really, in relation to the effects. So the hours are not huge. Whole module, fantastic, Linda. We need to link up. Okay, so let's talk about the background to the study. We know from research that pregnant women are conflicting advice from midwives in relation to alcohol during pregnancy. So the research suggests that midwives reported wanting more information on the effect of teratogens on fetal development. So we also know that the education around fares, for example, appears to be not standardized. And a researcher recommends that midwives need to expand on their knowledge to be confident in their knowledge around the effects of alcohol to improve on alcohol twice. As can be seen from the slide, advice from official bodies is also conflicting. So how do women and midwives navigate through this minefield? The chief medical officer, 2016, says for women who do drink that small amount, the risk to their babies is likely to be low. But nevertheless, we cannot rule out the risks altogether. When we did some PPI, which spoke to some midwives I was teaching recently, they had never heard of the CMO guidelines. So what advice are midwives giving to women? The general consensus is that no level of alcohol is safe. So recent research by Sholam Airtile in 2019 discovered that 69% of midwives had received fewer than four hours of alcohol training pre-qualification. 19% had received none. And only 1% of the midwives provided information about the effects of alcohol consumption in pregnancy to pregnant women. So that goes back to my original question. Why are the midwives not giving information to women? There are some barriers to that information provision. There's a similar picture in relation to list of drug use during pregnancy. So we do know that it's challenging for both midwives and students to care for these women. And we need to be empowering our students to have this knowledge before they qualify. Again, research has indicated that women who misuse alcohol and drugs funded challenging to engage with maternity services, fearing judgemental attitudes from the midwives, sympathy, and also hostile environments. Stalk attitudes matter more than the medical care received. So all these important points highlights the importance of midwives feeling confident in the provision of care information on substance misuse during pregnancy and that this should start at undergrad level. Amira? Thank you very much. Lovely. Okay, on this slide we talk about what happened and the use of simulators, which is my area of expertise. So what we found from looking at our research was that within the undergraduate midwifery curriculums, lots of teaching strategies have been put forward recently where simulation has been used in terms of oskies and other formats. And they're used to enable students to gain the relevant knowledge and skills around safe women-centered care. So that's wonderful news to hear. And within that, sort of the idea of different types of simulators can come forward. And there's a wealth of research around the different types. So they range from static or low fidelity, we call them LFS, medium fidelity MFS, or fully interactive high fidelity simulators. Okay, right. So basically, just to give you an example then, I was doing some research with the high fidelity simulators at a local school in the UK and the high fidelity simulators were basically full-born neonates, which teenage students took away home to practice practical parenting. And it worked, it was fabulous. The students understood the difficulties of being a teenage mother and on the whole understood the importance of contraception and other factors about sexual relations and the need to carry on with their education. So the use of the simulator was very, very effective. And they did educate school students in a practical method, a practical pedagogical tool for teenage parenting. So in that respect, both low fidelity and high fidelity have been used in different situations and have been highly valued by nursing students and also assist them to develop safe practice with increased self-efficacy. So really within midwifery, the simulation-based learning is definitely gaining momentum and we're very pleased about that. And according to Vermeulian 2016, and really it's all about developing clinical skills in a safe environment where you're not actually harming or addressing a patient straight away, but you're looking at obstetric emergencies in a safe environment. So basically we're looking at simulation as a vital pedagogical resource to help midwifery core skills and proficiencies in that safe environment. And in that respect, it improves the confidence for the midwife in terms of practice skills, improves the quality of maternity care, and it's a really, really effective pedagogical method to use with students. However, we do recognize, and a lot of researchers have recognized the idea it cannot replace clinical practices. You do need to be in front of the woman and have the understanding of the holistic women-sensitive care, which is obviously central to midwifery. However, lots of research, and we also advocate this, that the use of simulators tends to bridge the gap between simulation and life practice. And therefore, that's what we, and myself as a healthcare researcher, are interested in doing. So basically, and just talking about this in recognition of the real-world impact to the mother and the baby, lots of researchers have recommended that the undergraduate midwifery curricula should address midwifery students' knowledge with the aim of improving the quality of antenatal advice given, and the support, which will lead to better prevention, intervention, recognition of the signs and symptoms of disorders like fetal alcohol syndrome and that of drug misuse. And what we found is that there was a gap in the literature about the use of neonate simulators, in particular the FAS and DAS dolls, which is my area of interest and research. And so Louisa and I got together and conducted this research. So there is this gap, as we've said, in the midwifery education and the student midwife knowledge in relation to understanding the impact of teratogens on fetal development, as well as the short-term impact on the newborn baby. And the dolls are amazing, they're really interesting, and we'll talk about that in the following slides. And as I say, there's been minimal research using those dolls and having students interact with the neonatal simulators in the form of creative pedagogy. And that's why we feel that our research is so novel, it's new, it's not been done before and we're very excited to share that with you. So in terms of our objectives then, we enabled our midwifery students here showing the picture to interact with the fetal alcohol and the drug-affected neonate simulators as a means of co-constructing their knowledge. We want to understand what their perception of handling the doll from a kinesthetic perspective was. It was really important to gain their experiences and their understanding around that and also to understand what they kind of gained from the understanding of substance misuse during pregnancy and postnatally. So in terms of our methods then, we obviously gained ethical approval from our university. 50 female year one midwifery students were rolled up to do the study, they were involved in a lecture on protecting the newborn. They were third of the way through their first year of the undergraduate curriculum and they were approached by Louisa being the lead midwife there on the letter of invitation and participation information sheet. I then, when they all signed up, I then stepped in and ran a talk session on protecting the unborn environment where they interacted with the simulators and there were lots of different planned activities were undertaken and it was really a qualitative approach to data gathering being undertaken. So really we did gain their verbal and non-verbal consent. They interacted with the adults. There were lots of different activities including post-it notes and padlock questions. Okay, so just wanted to finish off. So post-it note activity questions were around educating pregnant women on drug and alcohol misuse and the impact of the baby. The padlock was an online resource. Students could look at the hyperlink and go on and answer questions about their knowledge on teratogenic impacts to fetal development and their future role as the midwife. So in this slide we took a picture of our dolls, the neonate simulators. The arrow is pointing to the static doll. It's a non-interactive fetal alcohol simulator doll. It's a low-fidelity simulator but it's demonstrating the impact of the effect of alcohol on a newborn baby. And then on the side we've got next to it we have the DAZ doll demonstrating the neonate abstinence syndrome and both of these dolls are manufactured by reality works in America. Okay, so the FAZ doll as illustrated by the picture here illustrates typical facial features that a newborn or a child would develop in the womb and then would have that permanent feature as they grow up. And the typical sort of characteristics are the thin upper lip or known as the philtrum. The lips are very, very thin. They've small eyelid profusions and these are the three main characteristics of a child growing up with FAZ or born with FAZ. And obviously FAZ can be mild to very, very extreme. There's a spectrum of FAZ but fully blown FAZ you're gonna end up with all three of these facial features and deformities as is illustrated in the picture here. Okay, the drug affected doll is basically a medium fidelity doll with an on off switch back and the idea behind the doll I will just play a record if I hope you can hear this is there's a shrill cry that comes from the doll. Basically it's a painful facial expression. They emit a cry of drug affected baby suffering from neonate abstinence syndrome withdrawal and withdrawal symptoms by turning on the switch, which is located on the back you can then have a very, very shrill cry. So I have this on my mobile phone but it's quite low. So I'll put it near my mic, see if it works. Okay, so I hope you heard that. So this was a recording, I made a small video I didn't bring the actual dolls home with me on the lockdown, which is such a shame but basically when you turn the switch on the doll emits this very shrill, painful cry and it is quite difficult to sort of handle and also the doll vibrates continuously mimicking the idea of the withdrawal symptoms and it can be quite horrible to see. Okay, Louise, over to you. Okay, brilliant. So we had a six stage framework offered by Braun and Clark and we use which we use to thematically analyze the students commentaries from the taught session activities. Both Himera and I coded the or analyst independently and came together and met up to discuss preliminary findings. The codes were then codified into themes by examining in-depth patterns and similarities. And basically we had three broad findings or three broad themes, which were identified as kinesthetic learning in their shoes and that were free role in educating others. I don't have the, I can't move it on. Can somebody move it on for me? Okay. So the first major theme is the kinesthetic learning and the majority of student responses indicated that they've valued interacting with both neonatal simulators and the simulators appeared to enhance their knowledge as the quotes demonstrate. In addition, the students were easily able to identify the features of a baby affected by fares by using the following terminology. Thin upper lip protruding lips mouth, prominent forehead, flat nose, lack of a philtrum, small and skinny. And finally, searching the dares doll button enabled the students to hear the shill cry and feel the tremors. A quote from a student was hearing the doll crying had an impact on learning. It made me think more about the importance of educating women. Next slide, please. So this theme is called in their shoes. And within this theme, students appear to demonstrate higher order thinking as they were able to simulate how the teratogens would impact on the child in the longterm, such as when going to school and on the family in terms of medical care. And the three, the first three quotes illustrate this thinking from the students. The students were also aware of their role and responsibility when considering the impact that teratogens may have on the woman herself and the fetus. And you can see from the last quote where they're thinking do be sensitive, do not judge or make them feel bad. And as well as to be aware of the signs and symptoms to be able to identify a baby suffering withdrawal, perhaps for a mother who hasn't disclosed substance abuse. Next slide, please. And finally, in this theme, other students weren't so willing to put themselves into the shoes of women by stating that the simulators could be used as a visual shock, as a visual aid to shock pregnant women. These two quotes really illustrate what's happened there. These two quotes really illustrate the shock tactics that the sport might work with women. And we can talk about that a bit later on in relation to some product research that we are going to do. Next slide, please. And finally, the third theme was midwifery role in educating others. So this overall theme had two sub, or several sub themes, which are related to using the simulators to educate a wider audience around the impact of substance misuse during pregnancy. So one of the sub themes is around visual aid to enhance knowledge. So for example, the students had some suggestions to use the simulators to educate women starting at school level. So some students felt that it was too late when the women were pregnant to start talking about vases and dares. And many students identified that the knowledge around the impact of pteratogens needed to be known long before the woman was planning for pregnancy, including education in schools and colleges. And also have used the dolls for a specialized services such as use the simulators to educate women at the pregnancy booking visit and also anti-natural classes. Next slide, please. Tamara? Yeah, that's fine, thank you. Okay, so in this discussion then, the students engaged better in the talk session really due to this kinesthetic impact and the effect of being able to hold and touch and feel and listen to the simulators. It made the lessons so much more rewarding. There was so much more student engagement. It was almost I would say that one of the best sessions I'd run in terms of teaching. They really, the student engagement was just off the scale, it was amazing. So lots of comments were coming out verbally and in their responses on the padlet and through posted activities that they could really appreciate the physical, the behavioral and the psychological impact for the baby. Students felt quite scared in a way to hold that, the DAS doll and turn the switch on and feel the vibrations and the tremors which are quite severe when you're holding the baby. And then for them to think that this is actually a recording of a live baby with that situation was quite heartening, disheartening for them and they really felt quite a lot of empathy towards children born with this problem. So, and they thought about the developing child and what would happen in school and bullying and how would they make friends and what their social life be and how would their physical demeanour, what it would look like and how it impact on the family and the finance. And so there was a lots of discussion about socio-psychological determinants within the because of the impact of FAS and DAS on the baby. And so one of the questions we asked them really was to look at how would you help a family with the situation? What would you do now to educate the public and people around you or peers? So lots of ideas were given forward. They included providing information video, putting it into antenatal waiting rooms, targeting young people at secondary school, visual aids to helping pregnant women, basically trying to increase the pregnant woman's knowledge by having lots of different ways of like video and pamphlets and leaflets and giving them, physically giving them the adults to hold. Lots of really interesting and valid discussions were held by the students. Okay, thank you, Himera. One of the other discussion points that we put forward was that many students wondered why the FAS simulator was static and not interactive as compared to the DAS simulator, which obviously, as Himera has said, cried and had tremors. Himera herself had a similar finding in her search in which she undertook with teenagers who used and she used those proper dolls, baby dolls and were considered to be half-fidelity baby simulators. The students did state that the simulator was nothing like a real baby and not realistic. In our study, however, the new medical simulators appeared to provide the first-year students with a realistic clinical picture, as Himera has alluded to, and wasn't originals of increasingly confidence in the provision of information. Should they have access to women at the booking visit and should they or possibly disclose any substance abuse? In terms of the shock element around the use of the dolls, many students were able to put themselves into the shoes of these women and empathize with the situation. But the ones who wanted to shock the woman felt they're talking about it was not good enough that you actually had to show them the impact of substance misuse during pregnancy. And they felt they would be much more impactful for the woman. However, if you look at research about Sholonetel, the more experienced qualified midwives become, the notion of using shock tactics is overridden by building more trust in relationships as a way to tackle these issues. So therefore, we felt that first-year student midwives are still in the early stages of learning how to communicate in the person-centered managed use framework with pregnant women who misuse substances. And this shock tactic is one of the areas we're going to be following up in the next stage of our research to ask the student midwife who are now on their second year as to whether they would still think about using a shock tactic to inform women about the problem. And then finally, as Humaira said, they are student midwives could think reflectively about their role in the future to help educate pregnant women as prevention is key. And many students realize that once the signs of fares or dares were recognized, then the damage had already been done and all they could do was be supported and compassionate to those women. Next slide. Okay. So in terms of our conclusion then, we really emphasize the idea of involving your students as researchers in the development of their own knowledge and the importance of interacting with the simulators. It was a very effective form of creative pedagogy and the students, I can't tell you how much they appreciated that lesson. And they really had such a big impact on them. It was a really good method for enhancing their knowledge and also for them to be able to understand and as a means of building new knowledge. So using the dolls in relation to the talk session from the PowerPoint and having interactive activities of the post-it note and the Padlet really enlivened that lesson. Students were so much more engaged. It was an excellent teaching session actually. And what we found was that our research helped bridge that disconnect between the teaching and the research and the practice. Students began to really reflect about how they would help others and what their future roles as midwives would be. And it really uncovered a couple of sensitive issues really about themselves. It began to reflect about their own pregnancies and a couple of students actually revealed to me that they did drink during their pregnancy and they were concerned about their child. And so it was just really important for them. And I kept emphasizing the fact that this was not about them, it was about their future and future pregnant women. And it was good knowledge gained to help others and educate family members and others around them and to carry that on in the future. And it was really interesting because Louise's slide about the guidelines about the alcohol consumption were in some cases quite conflicting. We found that the Royal College of Obstetricians and Gynecologists said that, if you limited it to one glass per week for three months, you were okay. And then some others were saying that no alcohol at all was relevant. So when we presented that information about FAS and DAS to the students, they understood that the latest guidelines about no alcohol at all during pregnancy is really important. And then using the dolls or some format in preconceptual understanding of education is really important. So that was really effective. The point also is that the use of these simulators were able to bridge the known theory practice gap because the new natural simulators can be used to prepare students to confront situations that they may only face when qualified. Obviously when they students, they're working under the provision of their qualified practice. And so they're not gonna be doing masses of interventions in the early stages but they may never come across a woman depending on the area that they're working and they may never see a woman who has misuse substances. In a way they can build on the knowledge that they use that they learned in their first year to help them in their future role as Miqvah. So the next part of our study aims to capture whether the students remember the teaching and the use of the simulators and knowledge retention and also whether they've been able to use the knowledge that they gained in practice and whether there were any barriers in relation to using the knowledge whilst practicing. And we also going to run it at the same time speak to third year students and ask them about their knowledge around educating women in relation to misuse of substances. Unfortunately the COVID-19 pandemic, 20 pandemic has put a bit of a stop on to our research because we were hoping to do focus groups with our students but now we're gonna have to try and do all that online. And many of us third year students are going into practice. So whereas before they were kept of audience instead of spreading their wings and hopefully we're gonna try and get them to come and partake in our online focus groups. We're gonna finish off with a couple of questions for the audience again. Would you find it acceptable to use the simulators at any point in the antenatal period to explore fairs and dares with women? If no, could you explain why just briefly? So it would be a sort of a varied response to question. So we have some yes, some no. We have made a good case for the use of neonatal simulators. I think what we'd like to do is to ask maybe do a little focus group with women and ask them what they think about those two simulators and whether it would be helpful for them to see the effects of alcohol and to hear the effects of drug withdrawal. Someone who's worked in neonatal intensive care and I've worked with babies who was drawing which is quite dramatic for both women and carer to see and experience those kind of effects. So it needs to be, I think we need to talk to women before we think about a video because I'm also thinking about a short video in relation to using the dolls to demonstrate the effects. Absolutely, so the idea of the video is to sort of provide some screens that can go out either on anti-antial clinics or GP surgeries and in that respect, educate pregnant women or even the public. So we're kind of like, it's all very novel at the moment but we're thinking of developing a digital educational resource that can be accessed by the public and hopefully educate them about charatogens and then about fetal alcohol and drug affected syndrome. It should be very effective. Okay, our second question. The student indicated that the simulators could be useful at the booking appointment. Have we done that once? Louise was having covered. Yeah, more or less than the Mona. We've done them all. I wanted to respond to Shelly Harris-Studart talking with women before pregnancy. I would agree with that entirely. Pre-conceptual care is really important and as we were thinking about taking these simulators into school and talking to six-form young men and young women about the effects of charatogens. So I think it does need to be before pregnancy. Many women who are pregnant often don't know that they're pregnant and are still drinking or taking drugs or whatever it is. So there's so much to do with these simulators. Absolutely, and I'm just answering a question somebody put forward about looking at Indian use of beetle nut. In fact, I've got my MSc student who's doing a scoping review on that and I'm planning to go out to Pakistan if I get the funding for it. I've got connections with the Pakistani Midwifery Network and they are really interested in training their midwives around fetal alcohol and especially the drug-affected doll to look at the impact of charatogens such as beetle nut and smokeless tobacco used from Parn on the baby. There hasn't been much research carried out on the fetal outcomes. So all I can say is watch this space and if you're interested, email me. Yeah, put the slide up with our... Who's got the slide up with our deep nose on it? Okay, there you go. You have our addresses here. If you wish to contact us, we'd love to hear from you. If you have any ideas of any ways of collaborating and research collaboration will be fantastic. So do you want to ask us any questions? Our pleasure, Carol. I'd like to ask a question to both of you or a comment, actually it's not a question, it's a comment on somebody has just said something like women in Nigeria will not accept publicly that they consume alcohol. I don't know whether you'd want to make a comment about that. I think obviously, okay, so what happens at the booking appointment then in Nigeria then? Do they have to admit it then? Hello? Carol? Hello? Hello, so I was saying that at the booking appointment, do they not have to admit alcohol consumption then? It's a comment I have seen from somebody by the name Moff Anita who says that women in Nigeria will not accept publicly that they consume alcohol. I don't know whether Anita would like to say something about it or maybe she would probably want to stop to you offline after this. Yeah, I mean, women don't have to admit to anything that they feel they're going to be censored by the healthcare professional. So it's better to have a relationship with these women before you start asking invasive questions. In the UK, you have to ask at the booking appointment whether a woman consumes alcohol, whether she admits to that is entirely individual perspective. So not all women will say yes or not all women will own up to it. So we just have to build up relationships with women so that they trust us and are able to confide in us if they are abusing particular substances. Yes, absolutely. I'm responding to Oluwukira's comment about the idea of cultural taboos. Obviously the same in Pakistan and India and Bangladesh. Obviously drinking alcohol, women are not supposed to do that or even smoking cigarettes. But yet what they're not understanding is that the impact of smokeless tobacco is just as dangerous to the baby and their own health in terms of sudden death in drones or prenatal stillbirth and all that sort of thing. There's all sorts of problems that occur even from battle from passive smoking, doing research around passive smoking and the impact on the baby as well. So I think Louise's point is correct. You have to really do build that rapport up with the lady in front of you. But here in the UK, booking appointment, normally the questionnaire you go through where you hope that for the sake of the child, the baby, and for the better health outcomes that the woman admits to smoking or drinking. So, yes, I agree culturally. It can be quite difficult. I believe we have to close the session now. Is that correct? I think we can now wrap up. Thank you very much, Louisa and Humaira. We really appreciate that. Very, very interesting and part provoking presentation. We appreciate so much. Thank you for the opportunity. Thank you so much. We really appreciate it. It's been really interesting to answer your questions and to present our research. Thank you for the opportunity.