الفهرس 
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Abstract
High fidelity simulation refreshing courses and training program based on the evidence based practice should be provided for maternity nurses to improve their knowledge and practice regarding PPH and other emergencies. Improve the quality of obstetric emergency care through interdisciplinary simulation training program on a regular basis for health care workers at different levels on life saving skills, as well as equipping the health facilities with the necessary equipment, medical supplies, and drugs. Recommendations for further studies: Explore the effect of high fidelity simulation based training program on problems encountered during the maternity cycle such as pregnancy induced hypertension and other critical patient care. Replication of the same study at various nursing faculties to introduce the concept of high fidelity simulation and investigate its importance for nursing students. Childbirth is a life-changing event for most women and families all over the world. Sometimes it is associated with great risks, and disability; PPH is one of the most dangerous causes of maternal deaths. It usually occurs within the first four hours of giving birth as a result of problems during the third stage of labor. Previous studies have suggested that many deaths associated with PPH could be prevented with prompt recognition and more timely adequate treatment. Therefore, training of health professionals including nursing staff and students to prevent and manage PPH is a fundamental principle of risk management. Maternity nursing students are the future maternity nurses who will assume this responsibility. Nursing education mandates the use of clinical stimulation and facilities to assure that learners have adequate knowledge and skills of clinical background required for transition from student to professional practitioner. However, nursing students are unable to acquire high quality experiences because of the difficulties in reaching cases at real health care settings. Simulation of the actual clinical emergency situation including PPH can be a kind of solution to enhance student nurses’ abilities needed for safe and effective women care. Therefore the aim of the present study was to determine the effect of high fidelity simulation based training program on nursing students’ performance, selfefficacy and confidence regarding prevention of PPH. To fulfill the study aim: Setting: The study was conducted at two settings; (1) Clinical obstetric laboratory skills for academic third year at Faculty of Nursing, Tanta University, which contains a high fidelity birthing simulator (SimMom), equipment and symbols, (2) Labor unit of obstetric department at Tanta University Hospital where the students’ basic obstetrical routine clinical training course was conducted. Subjects: A cluster random sample of 60 nursing students who fulfilled the following inclusive criteria were included in the study. Those students had training through summer training course at August 2019 as well as the period of first semester 2019. Male or/female students, third academic year nursing students (Obstetric and gynecological nursing semester) Faculty of Nursing, Tanta University and willing to participate in the study. They were divided into two equal groups; (1) Study group: consisted of 30 students who received both theoretical part through powerpoint presentation by the researcher in addition to the students’ basic obstetrical routine clinical training course as well as simulation based training program about prevention of PPH using high fidelity birthing simulator “SimMom”. (2) Control group: consisted of the other 30 students who received both theoretical part through powerpoint presentation by the researcher as well as the students’ basic obstetrical routine clinical training course about prevention of PPH. Tools of data collection: to achieve the aim of the study the following tools were used: Tool (I): A structured interview schedule; comprised of two main parts as follows: Part I: Socio demographic characteristics of nursing students as age, sex, residence, and previous simulation training program participation. Part II: Students’ knowledge regarding PPH; It included 20 questions related to the following items; definition, causes, risk factors, signs & symptoms, classification, complications, nursing management and evidence based guidelines for prevention and treatment of PPH. Tool (II): Students’ clinical performance observational checklist: it included data related to prevention and management of atonic PPH. It was contained two parts as following: Part I: Prevention of atonic PPH during intra-natal period (3rd stage of labor) that included active management of the third stage of labor (administration of uterotonic drug, controlled cord traction, and uterine massage); empty urinary bladder and also avoidance of prolonged labor. In addition, proper bearing down; proper timing for episiotomy; applying perineal support as well as avoidance of fundal pressure; and finally exploration and examination of the birth canal, placenta and membranes. Part II: Prevention and management of atonic PPH during immediate postnatal period (4th stage of labor): a. Prevention of atonic PPH that comprised of careful and close observation in the fourth stage of labor; fundal examination and bladder assessment; in addition, routine use of ecbolics after delivery; as well as early breast feeding. b. Management of PPH (Primary PPH) that included the estimation of the amount of blood loss; assessment of general condition of the parturient woman; good communication and call for help; resuscitation and drug administration in PPH. In addition, the initial measures to stop or control bleeding (external bimanual uterine massage, internal bimanual uterine compression, and abdominal aortic compression), health education for the woman on self-care as well as evaluation and documentation of all procedures. Tool (III): Self-efficacy Scale: This tool was used to assess students’ sense of perceived self-efficacy in the training program regarding prevention of PPH. Tool (IV): Modified self-confidence measurement scale: This tool was used to measure how confident students feel about their skills when they participate in the training program regarding prevention of PPH. The main findings of the current study can be summarized as follows: Students’ socio-demographic characteristics: It is found that half (50%) of the students in the study group and slightly less than one third (30%) in the control group were 20 years old, while nearly two fifth (36.7%) of the students in the study group were 21 years old. Three quarters (75%) of studied students (both groups) were females. Also, slightly more than one half (53.3%) and more than two thirds (66.7%) respectively of students among both the study and control groups were from rural areas. Students’ knowledge regarding PPH: The finding of the present study revealed that the mean total score of students’ knowledge regarding PPH was approximately the same in both groups before the intervention with no statistical significant difference (P = 0.393). While, there was significant enhancement of students’ mean total score of knowledge regarding PPH immediately and one month after implementation of the training program, but the enhancement was higher among the study group than the control group with statistical significant difference between them (P = 0.0001*and P = 0.0001* respectively). Students’ clinical performance regarding prevention and management of atonic PPH: The finding of the present study revealed that the mean total score of students’ clinical performance regarding prevention and management of atonic PPH was approximately similar in both groups before the intervention with no statistical significant difference (P = 0.427). While, there was significant enhancement of the mean total score of students’ clinical performance regarding most of the studied items for prevention and management of atonic PPH immediately and one month after implementation training program among the study group more than the control group with statistical significant difference (P = 0.0001*). Students’ self-efficacy regarding prevention and management of atonic PPH: The findings of the current study donated that almost all (100%) students among both the study and control group had negative perception of self-efficacy regarding prevention and management of atonic PPH before implementation of the training program. On the other hand, the majority (83.3% and 90.0% respectively) of study group immediately and one month after implementation of the training program had positive perception of self-efficacy with highly significant change (P =0.0001*) compared to (0.0%, and 3.3% respectively) among control group with no significant difference (P =0.364). Students’ self-confidence regarding prevention and management of atonic PPH: The findings of the current study reported that almost all (100%) students among both study and control group were approximately not confident about their skills regarding prevention and management of PPH before implementation of the training program. On the other hand, the majority (80.0% and 96.7% respectively) of the study group revealed good level of self-confidence immediately and one month after implementation of the training program with highly significant change (P =0.0001*) compared to (3.3%, and 10.0% respectively) among control group with no significant difference (P = 0.160). Conclusion: Based on the findings of the present study, it can be concluded that:- Obviously, before implementation of the training program, there were lack of students’ knowledge, clinical performance, self-confidence, as well as selfefficacy regarding prevention and management of PPH. While it is found that immediately and one month after implementation of the training program of high fidelity simulation, there were significant improvement of students’ (study group) knowledge, clinical performance, self-confidence, as well as self-efficacy regarding prevention and management of PPH. By this respect, it is widely evident that, the use of simulation in teaching is important for improvement of the three domains of learning; knowledge, skills, and attitude of nursing students. Thus the research hypothesis has been met. Recommendations: Based on the findings of the present study, the following recommendations are suggested:- Recommendations for basic nursing education: Incorporation of high fidelity simulation programs in basic nursing educational curriculum as well as continuing education at the Faculties of Nursing, Technical and Health Nursing Institutes, as well as Nursing Schools as an important step in curriculum development especially for training on emergencies. The use of the high fidelity simulation-based learning in combination with the traditional teaching methods for more enhancement of the students’ selfefficacy and self-confidence, knowledge as well as skills acquisition level for prevention, early detection, and rapid effective nursing response for management of PPH and other critical patient care. Recommendations for hospital, and maternal and child health centres’ administration: High fidelity simulation refreshing courses and training program based on the evidence based practice should be provided for maternity nurses to improve their knowledge and practice regarding PPH and other emergencies. Recommendations for further studies: Further studies are needed in this field to assess: Explore the effect of high fidelity simulation based training program on problems encountered during the maternity cycle such as pregnancy induced hypertension and other critical patient care. Replication of the same study at various nursing faculties to introduce the concept of high fidelity simulation and investigate its importance for nursing students.