Virtual Intrauterine Device Placement Training Improves Clinician Comfort

Comprehensive contraceptive care includes offering a range of Food and Drug Administration (FDA)-approved methods to patients.1 However, many primary care clinicians and reproductive health specialists lack the knowledge and technical skills to offer intrauterine devices (IUDs) to eligible patients.2–6 Misconceptions about IUD safety and appropriateness for specific patient populations (ie, adolescents, nulliparous patients) leave many untrained clinicians ill equipped to offer them.3,4,7–10 Training that addresses IUD knowledge gaps and technical skills can increase patient access,11,12 especially in rural communities.5,13

Training in IUD procedures is typically conducted in person. However, other viable options are needed, as in-person training logistics are difficult for rural clinicians14,15 and provider training must continue during public health emergencies. The use of simulations in procedural training and health care education prioritizes patient safety and can mitigate demands on training hours.16,17

Few evaluations of virtual options for clinician IUD training have been conducted. A Canadian study with family medicine residents found that satisfaction, procedural knowledge, and observed skills performance were comparable when the didactic and demonstration portions of an IUD insertion training were delivered via video versus a live session; both groups practiced insertion using pelvic models.18 Our objective was to evaluate an interactive live virtual IUD training for practicing clinicians by assessing satisfaction and impact on self-rated comfort with IUD procedure skills.

The Long-Acting Reversible Contraceptive (LARC) Mentoring Program (LMP) at the University of New Mexico (UNM) Health Sciences Center has used in-person instruction to train clinicians to provide comprehensive reproductive counseling and to insert and remove IUD and implant devices since 2016, with the goal of increasing statewide access to a range of contraceptive methods.

Starting in spring 2020, the response to the COVID-19 pandemic precluded most in-person training. In response, the LMP team developed and implemented an innovative virtual, hands-on IUD practicum in collaboration with the Beyond the Pill (BtP) program from the University of California, San Francisco.19 The virtual practicum has on-going utility in New Mexico, a geographically large, predominantly rural state.20

Prior to the virtual training, attendees were mailed a pelvic model, contraceptive device demonstration kits, IUD insertion and removal instruments, and a phone camera tripod to support visualization of the model cervix and uterus. Attendees received a 2-hour, one-on-one or small group training with an experienced reproductive health provider via Zoom. The number of trainees per session was limited to allow trainers to more effectively guide participants through hands-on procedures over Zoom. The trainer delivered a 45-minute didactic presentation reviewing IUD eligibility, counseling, placement, and removal and performed an IUD procedure demonstration using a pelvic model. The trainer then provided individualized guidance while trainees practiced loading, placing, and removing all FDA-approved hormonal and copper IUDs. After the training, the pelvic model and instruments were mailed back to UNM using a prepaid label.

Trainees were recruited directly by LMP via professional society listservs, clinic outreach, and at reproductive training events in a rolling manner from January 2021-June 2021. Thirty-four New Mexico clinicians (all clinicians who expressed interest) were trained during 29 sessions during that time frame.

The evaluation protocol was deemed exempt by the UNM Human Research Protections Office (#16-434). The project team used anonymous surveys administered pretraining and immediately posttraining to collect information on provider demographic and clinical characteristics, to assess learner satisfaction, and to evaluate changes in self-rated comfort level with IUD procedures. Comfort level was rated using Likert scales. Surveys were adapted from measures developed by Dodge, et al21 and reviewed for face and content validity by LMP and BtP team members. Thirty-two trainees completed both the pre- and postsurveys.

We collected and managed data using REDCap software.22 We conducted analyses in SPSS Statistics (Version 27, IBM, Armonk, NY). Descriptive statistics are presented as median and interquartile range or number and percentage. We used Wilcoxon signed-rank sum tests to evaluate pre-to-post training changes, overall and stratified by previous IUD experience (yes or no) or provider status (practicing or in training). Significance is reported at the P≤.05 level.

Participating clinicians included nurse practitioners and midwives (48%), physician assistants (28%), physicians (17%), and clinicians in training (7%, Table 1). About one-third (37%) had previous experience placing IUDs.

Overall, elements of training delivery were highly rated, with potential room for improvement in the model and tripod setup instructions (Table 2). Half of participants said they would choose virtual over in-person training options in the future, and 100% said that they would recommend the training to a colleague. In addition, 100% of learners reported it was easy to ask the instructor questions and that their questions were adequately answered. Open-ended comments mentioned that the virtual training format simplified logistics (eg, easier scheduling, no travel time).

Participants reported statistically significant increases in comfort level with all aspects of IUD placement and removal (P≤.010, Table 3). The biggest increases in comfort pre-to-post training were reported for uterine sounding (on a scale of 1-7, pre: median 2, interquartile range [IQR] [1, 3]; post: 6 [4, 6]) and inserting and deploying IUDs (pre: 1 [1, 4]; post: 5 [5,6]). Results were consistent regardless of provider status or previous IUD experience.

Evidence generated by this model project demonstrates potential for interactive, virtual IUD skills training for clinicians. Overall, participants rated the virtual practicum highly and felt that it improved their comfort with IUD procedures, with half indicating that they would actually choose a virtual over in-person training option in the future, citing easier logistics. There are opportunities to improve the training instructions.

Similar to the video IUD module findings of Garcia-Rodriguez and Donnon,18 clinicians in this study were satisfied with an interactive live virtual IUD skills training model. Future evaluation of this model should compare outcomes for virtual versus in-person training and include objective assessment of clinician competence. In addition, outcomes for one on one versus small group training options should be compared and cost effectiveness evaluated.

Limitations of this evaluation include a small sample size and loss to follow-up (n=2). Clinicians with strong interest in online training options may have disproportionately participated, and most trainees were white women, limiting generalizability. We assessed comfort immediately posttraining, and provider perceptions may change as they apply skills in clinical practice. Social desirability bias may have influenced survey responses.