Journal: exam finished

Yesterday morning, between 9am and 12.30pm local time, I and around 90 other midwives (I think) sat the exam.

The discussion at the university online forum and the fb site Graduate Diploma of Midwifery has been focused on relief.  The analogy to a difficult labour has, understandably, been made. 

The exam consisted of 18 questions, randomly allocated by computer for each student from a bank of questions.  There were multiple choice; true/false; short answer; and 'discuss the statement' questions.  I would have liked more time to complete the work - I spent more time than I should have on the early questions.  There were questions on pharmacokinetics, the absorption, distribution, metabolism and excretion of a drug; the therapeutic range for a drug; the changes in pregnancy when a drug is used, and what happens to the developing fetus.  There were questions that brought up polypharmacy, drug-drug interactions, genetic variances in enzyme activity, and social attitudes towards medication use in pregnancy.
 
I have nothing to compare this exam with, as it's the first of its kind, but I felt it was a reasonable test of the knowledge that should have been acquired over the past 5 months. 

As I have journalled my student experience since July 18 I have sought to look at the course, and my personal response to the challenges that it presented me with, objectively.  I put these things into writing as much for my own record as anyone else's. 

On the positive side of the ledger I have enjoyed learning the basics of pharmacology, and the application of pharmacology to midwifery practice.  I have appreciated the challenge to work on concepts that did not come easily to my ageing brain.  Visualising the microscopic processes which project molecules of drugs through the blood stream, across cell walls, and to target tissue is fascinating.  Remembering and revising basic science that I studied more than 40 years ago, understanding the constant movement of ionic charge from particle to particle, considering the anatomic function of the various body organs - this has all been good.  I have enjoyed it.  My friend Julie who I play tennis with most Thursdays is a high school science teacher, and she helped me revise the science of water solubility.

The less than positive side of what I want to record here is the lack of teaching by the university.  One tutor responded to calls for help, and presented helpful tutorials using the online webinar facility of the university.  With the wisdom of hindsight, I would encourage the faculty to offer a revision course for any students who are not up to date with current undergraduate midwifery knowledge in basic pharmacology - this applies to most of those for whom the course has been offered.  I think a series of lectures in the first month or so, using the webinar, would assist those students who have not studied at university in the past decade.  I have spoken in person about this to the head of the faculty for this course.

The ability to prescribe is still a little way off.  There is a further topic in the Graduate Diploma of Midwifery, Diagnostics and Investigations, which I will undertake in the first semester of 2013.  After that I will be able to apply for endorsement as a midwife prescriber.

I am thankful to the Commonwealth of Australia for the scholarship assistance that I have received. 


Thankyou for your comments

Journal: Preparation for exam

This week I am trying to spend some good time in revision of the core concepts that I will need, not just to achieve a pass mark in the pharmacology topic, but to consolidate the learning.

One of the main criticisms that I and other students have had as we approach the end of the course is that there has been a lack of teaching of the basics of pharmacology.  We are reading text books and academic papers, and for me the words and concepts of the science are often a confused jumble.

To address this deficit I have been watching a set of  lectures on Youtube

One of the faculty tutors hosted a webinar on Tuesday evening, and went through the practice exam that had been provided.  I found this very helpful.  A couple of points that were identified, at which I might improve my performance in the exam are:

• understanding how points are awarded: a question that is worth 2 marks towards the total score requires the student to make 4 statements (ie .5 each) that are relevant to the question.
• In multiple choice or true/false questions, a student will be awarded marks for each correct statement, whether it applies to the correct answer, or making the argument as to why a statement is incorrect or false.
• Clinical questions, such as discuss a pregnant woman who has a headache and wonders if she can take paracetamol, require discussion of the pharmacology of the drug in pregnancy, as well as the basic midwifery investigations, such as check the blood pressure, and question the cause of the headache.
• Polypharmacy is defined as the concurrent use of 5 or more medicines, which can include prescriptions, over the counter, and complementary.  For example, a woman who is receiving one prescribed medicine, such as oral antibiotics (1) for a chest infection in late pregnancy, may also take an antacid (2) for heartburn, raspberry leaf herbal tea (3) to achieve good uterine tone, an iron supplement (4) for anaemia, and pyridoxine (5) to treat mild fluid retention.  These substances will likely pass easily across the placenta to the fetal compartment.  What are the possible drug interactions with this group of apparently innocuous medicines?

Your comments are welcome.

Journal: Prescribing portfolio ready for submission

Today I am finalising the prescribing portfolio, which is worth 10% of the marks for the topic.  
The finished document contains dated responses to questions posed by the writer of the course, and summaries of my learning and reflections through the course.

September and October were very busy months for me, with a full caseload.  I have not been able to devote all the time I would have liked to, to the course.  Babies have been born, and I have been privileged to accompany a small number of women in their birthing journeys.  In this brief time I have shared great joy, and great sorrow.

I started this course without much idea of how to navigate an online learning situation.  As I now prepare for the exam in a month's time, worth 50% of the mark, I am seeking to consolidate the new knowledge that I have accessed in the past few months.  I expect to do well in the exam, and I am satisfied that I will have met my personal learning objectives at the conclusion of the course.

Personal Learning objectives:

30 July 2012

• To critically review my knowledge of the medicines which I currently use as a midwife
• To develop a useful body of knowledge about the prescription of medicines which will become part of a midwife’s formulary
• To explore and reflect on published scientific work that is relevant to pregnancy, birth, and breastfeeding.
• To undertake the course of study that will meet my undertaking to the NMBA, to successfully complete "an accredited and approved program of study determined by the Board to develop midwives' skills and knowledge in prescribing"

These objectives are within the topic’s stated learning objectives

Some of the issues I have reflected upon and explored have already been mentioned in this blog.  In summary, here are a few highlights: 

Journal of a new student: I have learned a lot about working within an online learning site, and I can now work my way through MIMS online.  This is a big achievement.  I do not yet feel 'fluent' in a virtual library - I just get lost!

Writing prescriptions: I will need to continue to work on the knowledge and skill of prescribing.  The small number of medicines is OK.  I think there are many aspects of the various formularies that still need to be ironed out.  The Victorian law is in the process of being amended to allow midwives to prescribe.

The two Case Studies in which we explored the prescribing of Metoclopramide for nausea in pregnancy, and Benzylpenicillin for Group B Streptococcus (GBS) colonisation of the genital tract, provided good opportunities for learning and critical thinking.  Where I exceeded the word limit, and needed to remove some of what I wrote, I brought it across to this blog, such as in Case Study 2.  Blogs have no word limit!  

A significant piece of work that this study brought me to is the pharmacology of uterotonics.  I am not surprised that the study of pharmacology has confirmed my desire to work in harmony with wonderful natural processes in pregnancy, birth, and nurture of the infant. 

This study has given me information which confirms my commitment to protecting, promoting and supporting unmedicated, physiological birth, except in clinical situations where there is a valid reason to intervene.  The benefit of synthetic oxytocic treatment in preventing excessive blood loss after birth is undeniable.  My reluctance to use these drugs routinely rather than as indicated is related to the majority of women for whom the treatment is not required, and who are thereby exposed to unnecessary medication with attendant risks.

I am also concerned about the extent of possible adverse effects in newborn babies, particularly any sick babies who may need to receive drug treatments, and who may experience adverse drug reactions to syntometrine in mother's milk.  

A question on collaboration has given students the opportunity to engage in the maternity reform process that requires a collaborative arrangement as the starting point for women to receive Medicare rebate for a midwife's services.  It looks like this:
$$=carrot; collaboration=stick 

Collaboration is actually not onerous; it's basic to midwifery practice.  The problem with collaboration as the Australian government requires is that it's one-way collaboration, which is an oxymoron.  'co' + 'labor' requires at least 2 parties to participate.


As I look back on (most of) the pharmacology course, it's worth stepping into the assessor role, asking questions about how the course met my learning needs, and how it could be improved.

I am conscious of a great deal of new knowledge that is foundational to an understanding of pharmacology.  The course lacked systematic teaching of that basic body of knowledge.  I believe this could be corrected by offering weekly lectures for the first month or so, using the webinar function of the interactive online learning site.  Although the course is post graduate, most students have not studied undergraduate contemporary pharmacology courses, and even those who have would do well to refresh their minds. 

A further step is the application of that knowledge to effective midwifery practice.  This is a challenging topic, and could be used for debate between midwives working in various settings.  

Are midwives who have achieved the endorsement as 'prescribers' likely to take a liberal attitude towards medicines, and prescribe excessively, like a kid with a new toy? 



Thankyou for your comments

Journal: back to pharmacology

The last two weeks were the mid-term break for the university, and I was happy to take a break from study.  However, it wasn't a restful time for me, as several babies needed to make their entry into this world of ours, and they all needed me to be on the job through the night.  The early postnatal days are very demanding for the new mother, even after an uncomplicated birth, and the midwife needs to stay focused as we watch and support and at times guide.

We are now in Week 9 of the pharmacology course.  The focus is on writing prescriptions, and working on the second case study.

Today I have listened to the recording of an online tutorial of a session that one of the tutors has put up for students to access.  This is the first 'live' opportunity that any of the students have had to interact with the faculty.  Unfortunately it was attended by only 3 students, who were able to put questions and discussion.

The tutor gave information about the course expectations for the assignments.  I found the tutor's comments useful - would have preferred having this prior to submission of the first case study. The tutor stressed the importance of referencing scholarly articles, and going into depth about the pharmacology of the medications that are being discussed. This is the field that I would like more teaching on. I have read the articles, but find there is a lot of new knowledge to acquire, and I think it's a good learning strategy to hear and discuss a topic as well as to read about it.

For example, when considering the pharmacology of metoclopramide, used to treat nausea, we need to discuss the general pharmacokinetic and pharmacodynamic actions of the drug, together with the changes that occur as a result of pregnancy.  In addition to the physiological changes in a pregnant woman's digestive system, metoclopramide has an effect on the dopamine receptors in the GI tract, inhibiting some receptors, and activating cholinergic effects leading to increased motility of the GI tract, in addition to the effect of metoclopramide on the central nervous system.  Reference to scholarly papers is needed for each point made.

Much of this language is new to me, and to the midwifery profession as I know it.  I recognise the importance of a strong foundation when establishing a new body of knowledge.  I have written to the tutor requesting more opportunities for live teaching as well as discussion, so that I can hear as well as read and discuss these aspects of the course. 


Thankyou for your comments

journal: week 3

It's more than a week since my last entry into this little e-journal.

Today I have spent 4+ hours of focused time on the pharma topic, reading published papers and text, and working on Activity 1 of Module 2.


It's a cold day, and although the heater is on, and I am warmly dressed, my hands and feet are cold.  I thought about going for a walk.  I went outside to check my leafless Bonsai trees, and put a little water on a few of them, and some ferns that were looking dry.  Then it started raining, so I didn't go for that walk.

I feel pleased with myself for having got on with the study.  The course information tells me that it requires 18 hours study per week, which is 3X6 or 2X9, and that's just not going to happen.  So I tell myself I just have to work smarter, not longer.

I do enjoy getting my mind around a subject.  It's often difficult to find blocks of time in my world.  The phone rings, a woman thinks she might be in early labour, so we talk for a while.  Then I need to think ahead - do I need to be ready to re-schedule any consultations?  Is my equipment ready?  ...  Perhaps it's time for a cup of coffee.  The phone rings again.  Emails come in.  Let's not even think about FB!  [and, you might wonder how I have time to write a blog?] 


Activity 1 of Module 2, Pharmacology and Pharmacokinetics, is an exercise in which we look in some depth at the pharmacokinetics and pharmacodynamics of two medications. I have chosen Metoclopramide (Maxolon, an anti-emetic) and Enoxaparin (Clexane, a form of Heparin). 

Maxolon is a medicine that I might use if a woman is vomiting in labour.
Clexane is sometimes prescribed for pregnant women who have clotting disorders, or who have had recurrent early fetal loss.  One of my current clients is on Clexane, so it's a good opportunity for me to learn more about it.

Having put down the good side, here's a bit of the other side of the coin.

I am feeling very isolated and unsure as I work in this virtual classroom. I haven’t done online university study previously. I am wondering when we will have the opportunity for tutorials, and how that works. I am finding the discussion channels via the university's system and facebook inadequate and frustrating. There are 95 students enrolled, and it seems that the course was set up for a much smaller group. Many of the students seem to be in current employment, with a hope/plan for private practice in the future.

I am particularly concerned that I get it right, because other colleagues look to me for guidance.  It could easily be a case of the blind leading the blind.

Thankyou for your comments

journal - ready to start

There has been an air of excitement this past week in the topic forum on FLO (Flinders Learning Online) as people introduce themselves and prepare for this course to start on Monday.

Someone wants to set up a facebook study group - isn't that an oxymoron?  For me, study needs to be focused, and fb is one big series of distractions, thoughts popping up all over the place like rabbits in a paddock.

My evolution has not taken me yet to the paperless office.  I prefer to have important stuff in my hand, on paper.  My office is set up with a good printer, and the best I can do in saving trees is to print double sided.


Paper copies
I need paper copies - should I say 'hard' copies?

I have copied the study plan module for week 1, and *of course* printed it out.

The 'assumed knowledge' and 'learning objectives'  are pretty much what I expected.

Students are told we need to set aside 18 hours per week for work on the course.

Time
That's 18 hours of reasonable brain activity time, preferably before lunch for me, which would be 3 hours a day, 6 days a week.  That's 18 hours fitting into a midwifery practice, in which babies often choose to be born in the early morning, as the new day gets started.  The weary old midwife often returns home mid-morning, with another episode of her life-long learning quest bubbling up in her mind!

For example, the three mothers in my caseload who gave birth over an eight-day span this month have been the focus of my life/practice.  When I am with woman everything else is forgotten - placed in another part of my brain, and retrieved when needed (or completely forgotten). 

 
18 hours is a lot of time!  I wonder if it includes all the time I know I will need to simply learn how to do the online process for this particular course?

For example, I have been trying to access the e-readings for the first week's study, using the library process provided. Here's one e-reading listed in the notes:

McKenna, L & McIntyre, M 2006, ‘What over the counter preparations are pregnant women taking? A literature review’, Journal of Advanced Nursing, vol. 56, no. 6, pp. 636-645. 

Perhaps I am expecting something that is unreasonable!  I would like to click the title and be given a .pdf file of that paper.  But that doesn't happen.  After jumping through several hoops I am given a bit of information about the paper - not the paper itself!  I have spent a considerable amount of time and still don't have what I want.  Although I have spent time I have learnt nothing about pharmacology for midwives, and I don't think I am any the wiser about what I should have done.

Oh well, I hope that by the end of this course I will be able to navigate a university library system.  In the meantime, I'll hope some other student who works out how to get the .pdf will take pity on me and send it to me.

e-speak
I am constantly amused by the language of the online sphere.  Today I have

• followed the "breadcrumb trail"
• set up a "pebble pad"
• found ways of "docking a block"
• watched a tutorial on using and making a "wiki"
• and worked out what "toggle" means in the online context

In conclusion, 
I will be happy if, through this course, I can consolidate a good body of knowledge about drugs in pregnancy, birth and breastfeeding, so that the women and babies in my care are in good hands.  It is possible that I may never prescribe most of the items on the PBS formulary for midwives.  The one class of drugs I want, oxytocics, are not listed, so that's a hurdle for the future.

I do not want to learn everything about electronic storage and retrieval systems; I don't want to become more of a granny-geek than I already am; I don't really care about the electronic culture of universities. 

Thankyou for your comments

journal of a new student

The text book: Pharmacology for Health Professionals 2011

This month I am beginning university studies at Flinders (SA), in order to undertake

"an accredited and approved program of study determined by the Board to develop midwives' skills and knowledge in prescribing"

This is a requirement for midwives who have notation on the Register as eligible for Medicare.  It is a new extension of practice for Australian midwives, as I noted in a previous post.

The topic is within a Graduate Certificate of Midwifery; will be by distance education, and is to be completed part time in one semester.  The text book, Pharmacology for Health Professionals, Bryant and Knights, 3rd edition 2011 (pictured) is a weighty tome that appears, on first glance, to be well presented and comprehensive.

I plan to make entries to this journal each week, for my own record as well as for readers who are interested. I would like to record an overview of this journey - not a step by step process. I hope to be honest and objective, not sugar-coating, and not bad-mouthing any aspect of the experience.  There will be times when I expect I will find it difficult to set aside time for focused study.  I won't be the only one experiencing this.  Any midwife who has a caseload has a high degree of unpredictability in life, when we must put the women and babies in our care first. 

I have not been enrolled in a university course since the late 1960s, and I have pretty well forgotten the details of that year! I completed hospital-based nursing studies (Royal Brisbane) in 1972, and hospital-based midwifery (Women's, Melbourne) in 1973.  I studied for, and passed exams for the International Board Certified Lactation Consultant certification on several occasions in more recent decades.  (Oh, I also studied Chinese painting, but that doesn't give me any prior learning credit!)  My other university experience is that I am a casual lecturer, tutor and marker in midwifery at Deakin University.

As I embark on this journey I wonder if my ageing mind will be a problem.  It's not that the knowledge is new learning - it will be good to review current evidence, and to check my 'knowledge' against what the course topic expects.

My style of learning is to take note of anything that varies from my current body of knowledge.  I think of it as a flashing red light, and I use this system in all areas of life.  When I listen to a lecture, or a sermon in Church, or a documentary, or read something, most is unremarkable, because it's what I expect.  But if something different comes up, I take note.  In a sense it's an editorial skill, but in stead of looking at the spelling and sentence construction, you look at the thought content and the conclusions.

When I go into my Flinders Learning Online site, and type in my password, I find topic information, and a forum to which all students of that topic are automatically connected (oh, the wonderful web and electronic databases!). There are 90 students enrolled at present.  Some have written introducing themselves; some have added a picture of themselves ...

There is an email site to which the course posts direct communication, and through which students can contact the faculty.  There are probably other aspects that I haven't found yet - you don't know what you don't know!

Enough for now.  As someone said, "Watch this space".




Thankyou for your comments