More to teamwork than knowledge, skill and attitude

Context specific realities and experiences of nurses and midwives in basic emergency obstetric and newborn care services in two district hospitals in Rwanda: a qualitative study

BACKGROUND

In low and middle-income countries, nurses and midwives are the frontline healthcare workers in obstetric care. Insights into experiences of these healthcare workers in managing obstetric emergencies are critical for improving the quality of care. This article presents such insights, from the nurses and midwives working in Rwandan district hospitals, who reflected on their experiences of managing the most common birth-related complications; postpartum hemorrhage (PPH) and newborn asphyxia. Rwanda has made remarkable progress in obstetric care. However, challenges remain in the provision of high-quality basic emergency obstetric and newborn care (BEmONC). This study is a qualitative part of a broader research project about implementation of an mLearning and mHealth decision support tool in BEmONC services in Rwanda.

METHODS

In this exploratory qualitative aspect of the research, four focus group discussions (FGDs) with 26 nurses and midwives from two district hospitals in Rwanda were conducted. Each FGD was made up of two parts. The first part focused on the participants' reflections on the research results (from the previous study), while the second part explored their experiences of delivering obstetric care services. The research results included: survey results reflecting their knowledge and skills of PPH management and of neonatal resuscitation (NR); and findings from a six-month record review of PPH management and NR outcomes, from the district hospitals under study. Data were analyzed using hybrid thematic analysis.

RESULTS

The analysis revealed three main themes: (1) reflections to the baseline research results, (2) self-reflection on the current practices, and (3) contextual factors influencing the delivery of BEmONC services. Nurses and midwives felt that the presented findings were a true reflection of the reality and offered diverse explanations for the results. The participants' narratives of lived experiences of providing BEmONC services are also presented.

CONCLUSION

The insights of nurses and midwives regarding the management of birth-related complications revealed multi-faceted factors that influence the quality of their obstetric care. Even though the study was focused on PPH management and NR, the resulting recommendations to improve quality of care could benefit the broader field of maternal and child health, particularly in low and middle-income countries.

Start here- principles of effective undergraduate training

Obstetric and gynaecology undergraduate training is an intense time for learners as they encounter various health conditions related to women's health and also learn about pregnancy care and birth. The experience is directed to familiarise students with basic clinical management of gynaecological conditions, also develop communication and related core examination and procedural skills. Similarly, midwifery training encompasses independent care of low-risk pregnant women and assist in care of high-risk pregnancy in partnership with obstetricians. Although its necessary to acquaint most learners with core clinical skills in obstetrics and gynaecology, learning opportunities on patients can be limited, due to the intrusive nature of women's health examination. Simulation Based Education (SBE) can facilitate learning hands-on clinical examination and procedural skills, using realistic part-task and high-fidelity simulators prior to approaching patients. This can apply to both medical and midwifery undergraduate training, further creating opportunities for professional interaction and shared learning space to facilitate interprofessional education. IPE has been shown to improve professional relationships in practicing clinicians. This learning pedagogy can be applied in the undergraduate setting as well, to decrease risk of conflict and appreciate roles of other interprofessional staff in future clinical practice. In this chapter we highlight some challenges faced by medical and midwifery undergraduates in their learning from a global perspective. We also describe some teaching and learning initiatives that can be applicable across various settings of obstetrics, gynaecology medical undergraduate and midwifery teaching with relevant case studies to facilitate new graduates preparedness for practice.

Patient safety culture in maternity units: a review

PURPOSE

The purpose of this paper is to summarize studies that have examined patient safety culture in maternity units and describe the different purposes, study designs and tools reported in these studies while highlighting gaps in the literature.

DESIGN/METHODOLOGY/APPROACH

Peer-reviewed studies, published in English during 1961-2016 across eight electronic databases, were subjected to a narrative literature review.

FINDINGS

Among 100 articles considered, 28 met the inclusion criteria. The main purposes for studying PSC were: assessing intervention effects on PSC (n=17), and assessing PSC level (n=7). Patient safety culture was mostly assessed quantitatively using validated questionnaires (n=23). The Safety Attitude Questionnaire was the most commonly used questionnaire (n=17). Interventions varied from a single action lasting five weeks to a more comprehensive four year package. The time between baseline and follow-up assessment varied from 6 to 24 months. No study reported measurement or intervention costs, and none incorporated the patient's voice in assessing PSC.

PRACTICAL IMPLICATIONS

Assessing PSC in maternity units is feasible using validated questionnaires. Interventions to enhance PSC have not been rigorously evaluated. Future studies should report PSC measurement costs, adopt more rigorous evaluation designs and find ways to incorporate the patient's voice.

ORIGINALITY/VALUE

This review summarized studies examining PSC in a highly important area and highlighted main limitations that future studies should consider.

Health professionals' views on maternity care for women with physical disabilities: a qualitative study

BACKGROUND

During pregnancy, childbirth and puerperium, women receive care from a range of health professionals, particularly midwives. To assess the current situation of maternity care for women with physical disabilities in Austria, this study investigated the perceptions and experiences of health professionals who have provided care for women with disabilities during pregnancy, childbirth and postpartum.

METHODS

The viewpoints of the participating health professionals were evaluated by means of semistructured interviews followed by an inductive qualitative content analysis of the interview transcripts, as proposed by Mayring.

RESULTS

Four main categories emerged from the inductive content analysis: (i) structural conditions and accessibility, (ii) interprofessional teamwork and cooperation, (iii) action competence, and (iv) diversity-sensitive attitudes. According to the participating health professionals, the structural conditions were frequently not suitable for providing targeted group-oriented care services. Additionally, a shortage of time and staff resources also limited the necessary flexibility of treatment measures in the care of mothers with physical disabilities. The importance of interprofessional teamwork for providing adequate care was highlighted. The health professionals regarded interprofessionalism as an instrument of quality assurance and team meetings as an elementary component of high-quality care. On the other hand, the interviewees perceived a lack of action competence that was attributed to a low number of cases and a corresponding lack of experience and routine. Regarding diversity-sensitive attitudes, it became apparent that the topic of mothers with physical disabilities in care posed challenges to health professionals that influenced their natural handling of the interactions.

CONCLUSION

The awareness of one's own attitudes towards diversity, in the perinatal context in particular, influences professional security and sovereignty as well as the quality of care of women with disabilities. There is a need for optimization in the support and care of women with physical disabilities during pregnancy, childbirth and puerperium.

The importance of non-technical performance for teams managing postpartum haemorrhage: video review of 99 obstetric teams

OBJECTIVE

Little is known about how teams' non-technical performance influences clinical performance in obstetric emergencies such as postpartum haemorrhage.

DESIGN

Video review - observational study.

SETTING

A university hospital (5000 deliveries) and a regional hospital (2000 deliveries) in Denmark.

POPULATION

Obstetric teams managing real-life postpartum haemorrhage.

METHODS

We systematically assessed 99 video recordings of obstetric teams managing real-life major postpartum haemorrhage. Exposure was the non-technical score (AOTP); outcomes were the clinical performance score (TeamOBS) and the delayed transfer to the operating theatre (defined as blood loss >1500 ml in the delivery room).

RESULTS

Teams with an excellent non-technical score performed significantly better than teams with a poor non-technical score: 83.7 versus 0.3% chance of a high clinical performance score (P < 0.001), 0.2 versus 80% risk of a low clinical performance score (P < 0.001), and 3.5 versus 31.7% risk of delayed transfer to the operating theatre (P = 0.008). The results remained robust when adjusting for potential confounders such as bleeding velocity, aetiology, time of day, team size, and hospital. The specific non-technical skills associated with high clinical performance were vigilance, role assignment, problem-solving, management of disruptive behavior, and leadership. Communication with the patient and closing the loop were of minor importance. All performance assessments showed good reliability: the intraclass correlation was 0.97 (95% CI 0.96-0.98) for the non-technical score and 0.84 (95% CI 0.76-0.89) for the clinical performance score.

CONCLUSION

Video review offers a new method and new perspectives for research in obstetric teams to identify how teams become effective and safe; the skills identified in this study can be included in future obstetric training programmes.

TWEETABLE ABSTRACT

Non-technical performance is important for teams managing postpartum haemorrhage; video review of 99 obstetric teams.

Assessment of quality of care among in-patients with postpartum haemorrhage and severe pre-eclampsia at st. Francis hospital nsambya: a criteria-based audit

BACKGROUND

The maternal mortality ratio of Uganda is still high and the leading causes of maternal mortality are postpartum haemorrhage (PPH), severe pre-eclampsia and eclampsia. Criteria-based audit (CBA) is a way of improving quality of care that has not been commonly used in low income countries. This study aimed at finding out the quality of care provided to patients with these conditions and to find out if the implementation of recommendations from the audit cycle resulted in improvement in quality of care.

METHODS

This study was a CBA following a time series study design. It was done in St. Francis Hospital Nsambya and it involved assessment of adherence to standards of care for PPH, severe pre-eclampsia and eclampsia. An initial audit was done for 3 consecutive months, then findings were presented to health workers and recommendations made; we implemented the recommendations in a subsequent month and this comprised three interventions namely continuing medical education (CME), drills and displaying guidelines; a re-audit was done in the proceeding 3 consecutive months and analysis compared adherence rates of the initial audit with those of the re-audit.

RESULTS

Pearson Chi-Square test revealed that the adherence rates of 7 out of 10 standards of care for severe pre-eclampsia/eclampsia were statistically significantly higher in the re-audit than in the initial audit; also, the adherence rates of 3 out of 4 standards of care for PPH were statistically significantly higher in the re-audit than in the initial audit.

CONCLUSION

The giving of feedback on quality of care and the implementation of recommendations made during the CBA including CME, drills and displaying guidelines was associated with improvements in the quality of care for patients with PPH, severe pre-eclampsia and eclampsia.

Neonatal outcomes after introduction of a national intrapartum fetal surveillance education program: a retrospective cohort study

OBJECTIVE

To determine the impact of a multidisciplinary fetal surveillance education program (FSEP) on term neonatal outcomes.

METHODS

A retrospective cohort study of term neonatal outcomes before (1998-2004) and after (2005-2010) introduction of a FSEP. Clinical data was collected for all term infants admitted to a neonatal intensive care unit (NICU) in Australia between 1998 and 2010. Infants with congenital abnormalities were excluded. Neonatal mortality and severe neonatal morbidity (admission to a NICU, respiratory support, hypoxic encephalopathy) were compared before and after the FSEP was introduced. The rates of operative delivery during this time were assessed.

RESULTS

There were 3 512 596 live term births between 1998 and 2010. The intrapartum hypoxic death rate at term decreased from 2.02 to 1.07 per 10 000 total births. More neonates were admitted to NICU after 2005 (10.6 versus 14.6 per 10 000 live births), however fewer babies admitted to the neonatal unit had Apgar scores < 5 at five minutes (55.1-45.5%, RR 0.82, 95% CI 0.7-0.87); and rates of hypoxic ischemic encephalopathy fell from 36% to 30% (RR 0.83, 95% CI 0.76-0.90). There was no increase in rates of emergency in labour caesarean sections (11.7% pre versus 11.1% post, RR 0.95, 95% CI 0.95-0.96).

CONCLUSIONS

Introduction of a national FSEP was associated with increased neonatal admissions but a reduction in intrapartum hypoxia, without increasing emergency caesarean section rates.

Integrating teamwork, clinician occupational well-being and patient safety - development of a conceptual framework based on a systematic review

BACKGROUND

There is growing evidence that teamwork in hospitals is related to both patient outcomes and clinician occupational well-being. Furthermore, clinician well-being is associated with patient safety. Despite considerable research activity, few studies include all three concepts, and their interrelations have not yet been investigated systematically. To advance our understanding of these potentially complex interrelations we propose an integrative framework taking into account current evidence and research gaps identified in a systematic review.

METHODS

We conducted a literature search in six major databases (Medline, PsycArticles, PsycInfo, Psyndex, ScienceDirect, and Web of Knowledge). Inclusion criteria were: peer reviewed papers published between January 2000 and June 2015 investigating a statistical relationship between at least two of the three concepts; teamwork, patient safety, and clinician occupational well-being in hospital settings, including practicing nurses and physicians. We assessed methodological quality using a standardized rating system and qualitatively appraised and extracted relevant data, such as instruments, analyses and outcomes.

RESULTS

The 98 studies included in this review were highly diverse regarding quality, methodology and outcomes. We found support for the existence of independent associations between teamwork, clinician occupational well-being and patient safety. However, we identified several conceptual and methodological limitations. The main barrier to advancing our understanding of the causal relationships between teamwork, clinician well-being and patient safety is the lack of an integrative, theory-based, and methodologically thorough approach investigating the three concepts simultaneously and longitudinally. Based on psychological theory and our findings, we developed an integrative framework that addresses these limitations and proposes mechanisms by which these concepts might be linked.

CONCLUSION

Knowledge about the mechanisms underlying the relationships between these concepts helps to identify avenues for future research, aimed at benefiting clinicians and patients by using the synergies between teamwork, clinician occupational well-being and patient safety.

Perimortem caesarean deliveries

Although cardiac arrest in pregnancy is rare, it is important that all individuals involved in the acute care of pregnant women are suitably trained, because the outcome for both mother and fetus can be affected by the management of the arrest. Perimortem caesarean delivery was first described in 715 BC. Initially the procedure was performed principally for religious or political reasons. Although the potential for fetal survival was proposed, it was rarely successful, probably because the delivery was delayed until maternal death was established. However, in recent decades, case reports have suggested improved maternal as well as fetal survival if perimortem caesarean section was performed rapidly once maternal arrest has occurred. While evidence for this is largely based on case reports, the physiological advantages including removing inferior caval obstruction, and hence improving venous return to the heart, reducing oxygen requirement and improving chest compliance appear compelling. Factors that reduce errors and minimise the delay in performance of caesarean delivery are discussed, in particular the importance of training, organizational factors within a hospital and the use of prompts during an arrest. While evidence is limited, it is probable that both maternal and fetal survival are improved with early delivery by perimortem caesarean delivery. More importantly, no evidence was found from case report reviews that either maternal or fetal survival was worsened. Perimortem caesarean delivery therefore remains a key consideration in the management of maternal arrest from the mid second trimester.

Trauma teams and time to early management during in situ trauma team training

OBJECTIVES

To investigate the association between the time taken to make a decision to go to surgery and gender, ethnicity, years in profession, experience of trauma team training, experience of structured trauma courses and trauma in the trauma team, as well as use of closed-loop communication and leadership styles during trauma team training.

DESIGN

In situ trauma team training. The patient simulator was preprogrammed to represent a severely injured patient (injury severity score: 25) suffering from hypovolemia due to external trauma.

SETTING

An emergency room in an urban Scandinavian level one trauma centre.

PARTICIPANTS

A total of 96 participants were divided into 16 trauma teams. Each team consisted of six team members: one surgeon/emergency physician (designated team leader), one anaesthesiologist, one registered nurse anaesthetist, one registered nurse from the emergency department, one enrolled nurse from the emergency department and one enrolled nurse from the operating theatre.

PRIMARY OUTCOME

HRs with CIs (95% CI) for the time taken to make a decision to go to surgery was computed from a Cox proportional hazards model.

RESULTS

Three variables remained significant in the final model. Closed-loop communication initiated by the team leader increased the chance of a decision to go to surgery (HR: 3.88; CI 1.02 to 14.69). Only 8 of the 16 teams made the decision to go to surgery within the timeframe of the trauma team training. Conversely, call-outs and closed-loop communication initiated by the team members significantly decreased the chance of a decision to go to surgery, (HR: 0.82; CI 0.71 to 0.96, and HR: 0.23; CI 0.08 to 0.71, respectively).

CONCLUSIONS

Closed-loop communication initiated by the leader appears to be beneficial for teamwork. In contrast, a high number of call-outs and closed-loop communication initiated by team members might lead to a communication overload.

Myths and realities of training in obstetric emergencies

Training for intrapartum emergencies is a promising strategy to reduce preventable harm during birth; however, not all training is clinically effective. Many myths have developed around such training. These principally derive from misinformed beliefs that all training must be effective, cheap, independent of context and sustainable. The current evidence base for effective training supports local, unit-based and multi-professional training, with appropriate mannequins, and practice-based tools to support the best care. Training programmes based on these principles are associated with improved clinical outcomes, but we need to understand how and why that is, and also why some training is associated with no improvements, or even deterioration in outcomes. Effective training is not cheap, but it can be cost-effective. Insurers have the fiscal power to incentivise training, but they should demand the evidence of clinical effect; aspiration and proxies alone should no longer be sufficient for funding, in any resource setting.

Teamwork assessment in internal medicine: a systematic review of validity evidence and outcomes

OBJECTIVE

Valid teamwork assessment is imperative to determine physician competency and optimize patient outcomes. We systematically reviewed published instruments assessing teamwork in undergraduate, graduate, and continuing medical education in general internal medicine and all medical subspecialties.

DATA SOURCES

We searched MEDLINE, MEDLINE In-process, CINAHL and PsycINFO from January 1979 through October 2012, references of included articles, and abstracts from four professional meetings. Two content experts were queried for additional studies.

STUDY ELIGIBILITY

Included studies described quantitative tools measuring teamwork among medical students, residents, fellows, and practicing physicians on single or multi-professional (interprofessional) teams.

STUDY APPRAISAL AND SYNTHESIS METHODS

Instrument validity and study quality were extracted using established frameworks with existing validity evidence. Two authors independently abstracted 30 % of articles and agreement was calculated.

RESULTS

Of 12,922 citations, 178 articles describing 73 unique teamwork assessment tools met inclusion criteria. Interrater agreement was intraclass correlation coefficient 0.73 (95 % CI 0.63-0.81). Studies involved practicing physicians (142, 80 %), residents/fellows (70, 39 %), and medical students (11, 6 %). The majority (152, 85 %) assessed interprofessional teams. Studies were conducted in inpatient (77, 43 %), outpatient (42, 24 %), simulation (37, 21 %), and classroom (13, 7 %) settings. Validity evidence for the 73 tools included content (54, 74 %), internal structure (51, 70 %), relationships to other variables (25, 34 %), and response process (12, 16 %). Attitudes and opinions were the most frequently assessed outcomes. Relationships between teamwork scores and patient outcomes were directly examined for 13 (18 %) of tools. Scores from the Safety Attitudes Questionnaire and Team Climate Inventory have substantial validity evidence and have been associated with improved patient outcomes.

LIMITATIONS

Review is limited to quantitative assessments of teamwork in internal medicine.

CONCLUSIONS

There is strong validity evidence for several published tools assessing teamwork in internal medicine. However, few teamwork assessments have been directly linked to patient outcomes.

Impact of introducing practical obstetric multi-professional training (PROMPT) into maternity units in Victoria, Australia

OBJECTIVE

To assess the introduction of Practical Obstetric Multi-professional Training (PROMPT) into maternity units and evaluate effects on organisational culture and perinatal outcomes.

DESIGN

A retrospective cohort study.

SETTING

Maternity units in eight public hospitals in metropolitan and regional Victoria, Australia.

POPULATION

Staff in eight maternity units and a total of 43,408 babies born between July 2008 and December 2011.

METHODS

Representatives from eight Victorian hospitals underwent a single day of training (Train the Trainer), to conduct PROMPT. Organisational culture was compared before and after PROMPT. Clinical outcomes were evaluated before, during and after PROMPT.

MAIN OUTCOME MEASURES

The number of courses run and the proportion of staff trained were determined. Organisational culture was measured using the Safety Attitude Questionnaire. Clinical measures included Apgar scores at 1 and 5 minutes (Apgar 1 and Apgar 5), cord lactate, blood loss and length of baby's stay in hospital.

RESULTS

Seven of the eight hospitals conducted PROMPT. Overall about 50% of staff were trained in each year of the study. Significant increases were found in Safety Attitude Questionnaire scores representing domains of teamwork (Hedges' g 0.27, 95% confidence interval [95% CI] 0.13-0.41), safety (Hedges' g 0.28, 95% CI 0.15-0.42) and perception of management (Hedges' g 0.17, 95% CI 0.04-0.31). There were significant improvements in Apgar 1 (OR 0.84, 95% CI 0.77-0.91), cord lactates (odds ratio 0.92, 95% CI 0.85-0.99) and average length of baby's stay in hospital (Hedges' g 0.03, 95% CI 0.01-0.05) during or after training, but no change in Apgar 5 scores or proportion of cases with high blood loss.

CONCLUSION

PROMPT can be introduced using the Train the Trainer model. Improvements in organisational culture and some clinical measures were observed following PROMPT.

Suboptimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the 'migration three delays' model

BACKGROUND

Several European countries report differences in risk of maternal mortality between immigrants from low- and middle-income countries and host country women. The present study identified suboptimal factors related to care-seeking, accessibility, and quality of care for maternal deaths that occurred in Sweden from 1988-2010.

METHODS

A subset of maternal death records (n = 75) among foreign-born women from low- and middle-income countries and Swedish-born women were audited using structured implicit review. One case of foreign-born maternal death was matched with two native born Swedish cases of maternal death. An assessment protocol was developed that applied both the 'migration three delays' framework and a modified version of the Confidential Enquiry from the United Kingdom. The main outcomes were major and minor suboptimal factors associated with maternal death in this high-income, low-maternal mortality context.

RESULTS

Major and minor suboptimal factors were associated with a majority of maternal deaths and significantly more often to foreign-born women (p = 0.01). The main delays to care-seeking were non-compliance among foreign-born women and communication barriers, such as incongruent language and suboptimal interpreter system or usage. Inadequate care occurred more often among the foreign-born (p = 0.04), whereas delays in consultation/referral and miscommunication between health care providers where equally common between the two groups.

CONCLUSIONS

Suboptimal care factors, major and minor, were present in more than 2/3 of maternal deaths in this high-income setting. Those related to migration were associated to miscommunication, lack of professional interpreters, and limited knowledge about rare diseases and pregnancy complications. Increased insight into a migration perspective is advocated for maternity clinicians who provide care to foreign-born women.

Optimization of competency in obstetrical emergencies: a role for simulation training

PURPOSE

In obstetrical emergency situations, optimal management requires the immediate coordinated actions of a multi-disciplinary and multi-professional team. This study investigated the influence of simulation training on four specific skills: self-confidence, handling of emergency situation, knowledge of algorithms and team communication.

METHODS

Clinical algorithms were first presented to the participants. Training for six emergency situations (shoulder dystocia, postpartum haemorrhage, pre-eclampsia, maternal basic life support, neonatal resuscitation and operative vaginal birth) was performed using high- and low-fidelity simulation mannequins. General impression of the simulation training and the four above-mentioned skills were evaluated anonymously through a self-assessment questionnaire with a five-point Likert scale immediately after the training and 3 months later.

RESULTS

From November 2010 to March 2012, 168 participants, distributed over six one-day courses, took part in the training. 156 participants returned the questionnaire directly after the course (92.9 %). The questionnaire return rate after 3 months was 36.3 %. The participants gave higher Likert scale answers for the questions on the four specific skills after 3 months compared to immediately after the course. The improvement was statistically significant (p ≤ 0.05) except for the question regarding team communication.

CONCLUSION

Implementation of simulation training strengthens the professional competency.

The case for an electronic fetal heart rate monitoring credentialing examination

The Perinatal Quality Foundation has created an examination containing both knowledge-based and judgment questions relating to the interpretation of electronic fetal heart rate monitoring for credentialing all medical and nursing personnel working on a labor and delivery floor. A description of the examination and the rationale for its use throughout the United States is presented.

Helping mothers survive bleeding after birth: an evaluation of simulation-based training in a low-resource setting

OBJECTIVE

To evaluate "Helping Mothers Survive Bleeding After Birth" (HMS BAB) simulation-based training in a low-resource setting.

DESIGN

Educational intervention study.

SETTING

Rural referral hospital in Northern Tanzania.

POPULATION

Clinicians, nurse-midwives, medical attendants, and ambulance drivers involved in maternity care.

METHODS

In March 2012, health care workers were trained in HMS BAB, a half-day simulation-based training, using a train-the-trainer model. The training focused on basic delivery care, active management of third stage of labor, and treatment of postpartum hemorrhage, including bimanual uterine compression.

MAIN OUTCOME MEASURES

Evaluation questionnaires provided information on course perception. Knowledge, skills, and confidence of facilitators and learners were tested before and after training.

RESULTS

Four master trainers trained eight local facilitators, who subsequently trained 89 learners. After training, all facilitators passed the knowledge test, but pass rates for the skills test were low (29% pass rate for basic delivery and 0% pass rate for management of postpartum hemorrhage). Evaluation revealed that HMS BAB training was considered acceptable and feasible, although more time should be allocated for training, and teaching materials should be translated into the local language. Knowledge, skills, and confidence of learners increased significantly immediately after training. However, overall pass rates for skills tests of learners after training were low (3% pass rate for basic delivery and management of postpartum hemorrhage).

CONCLUSIONS

The HMS BAB simulation-based training has potential to contribute to education of health care providers. We recommend a full day of training and validation of the facilitators to improve the training.

Simulation: improving patient outcomes

Effective training has been shown to improve perinatal care and outcome, decrease litigation claims and reduce midwifery sick leave. To be effective, training should be incentivised, in a realistic context, and delivered to inter-professional teams similar to those delivering actual care. Teamwork training is a useful addition, but it should be based on the characteristics of effective teamwork as derived from the study of frontline teams. Implementation of simulation and teamwork training is challenging, with constraints on staff time, facilities and finances. Local adoption and adaptation of effective programmes can help keep costs down, and make them locally relevant whilst maintaining effectiveness. Training programmes need to evolve continually in line with new evidence. To do this, it is vital to monitor outcomes and robustly evaluate programmes for their impact on patient care and outcome, not just on participants.

Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies

Poor teamwork results in preventable morbidity and mortality for mothers and babies. Suboptimal communication and lack of leadership cost not only lives but also money that is diverted from clinical care to insurance and litigation. Avoidable harm is usually not the result of staff failing their duty of care, it is the result of poor training failing hard-worked staff. A few simple teamwork and leadership behaviours can make a huge difference to outcome and experience for women and their companions, yet they are often missing from maternity care. Recent research has identified the problems and solutions, including the best way to train maternity teams to make a palpable difference. We describe simple yet evidence-based methods to improve teams and leaders.

Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting

A culture of safety is a growing movement in obstetrical healthcare quality and management. Patient-centered and safe care is a primary priority for all healthcare workers, with communication and teamwork central to achieving optimal maternal health outcomes. A mandatory educational program was developed and implemented by physicians and nurses to sustain awareness and compliance to current protocols within a large university-based hospital. A didactic portion reviewing shoulder dystocia, operative vaginal delivery, obstetric hemorrhage, and fetal monitoring escalation was combined with a simulation session. The simulation was a fetal bradycardia activating the decision to perform an operative vaginal delivery complicated by a shoulder dystocia. More than 370 members of the healthcare team participated including obstetricians, midwives, the anesthesia team, and nurses. Success of the program was measured by an evaluation tool and comparing results from a prior safety questionnaire. Ninety-seven percent rated the program as excellent, and the response to a question on perception of overall grade on patient safety measured by the Agency for Healthcare Research and Quality safety survey demonstrated a significant improvement in the score (P = .003) following the program.

Management of pregnancy-related emergencies: what do Polish anesthesiologists know?

BACKGROUND

Emergencies can occur at any time during pregnancy. In addition to obstetricians and midwives, anesthesiologists should also be familiar with pregnancy-related emergencies. The aim of this study was to assess the basic and advanced knowledge regarding the management of pregnancy-related emergencies of anesthesiologists.

METHODS

An anonymous questionnaire was distributed to anesthesiologists at two conferences (S1, n = 87; S2, n = 35), and to other groups comprising doctors during specialization (DS, n = 28) and postgraduate doctors (PD, n = 130). Ultimately, 280 doctors were included in the survey. The first part of the questionnaire collected demographics, and a second one evaluated both their basic and advanced knowledge by taxonomy.

RESULTS

Basic knowledge regarding the management of pregnancy-related emergencies of the tested group was poorer compared with advanced knowledge. The DS group had better basic management skills than anesthesiology specialists and the PD group. Significantly worse results of the tested group were obtained on the questions about maneuvers for choking pregnant women and time to cesarean section during cardiopulmonary resuscitation. The specialists and the DS group had results on advanced level questions better than the PD group.

CONCLUSIONS

Older specialists in anesthesiology did not know how to properly manage pregnancy-related emergencies at the basic level; however, anesthesiologists were familiar with advanced management. No relationship between recalling and using such knowledge in difficult situations was observed. The teaching process of acute obstetric emergencies must be improved through implementation of compulsory nationwide courses and verification of knowledge every few years.

Teamwork for clinical emergencies: interprofessional focus group analysis and triangulation with simulation

Our purpose was to investigate health care professionals' beliefs about effective teamwork in medical emergencies based on their experiences. We used framework analysis of interprofessional focus groups in four secondary and tertiary maternity units. The participants were randomly selected senior and junior doctors, senior and junior midwives, and health care assistants, in five groups of 5 to 7 participants each. We found that optimal teamwork was perceived to be dependent on good leadership and availability of experienced staff. The participants described a good leader as one who verbally declares being the leader, communicates clear objectives, and allocates critical tasks, including communication with patients or their family, to suitable individual members. We triangulated the results with evidence from simulation to identify convergent findings and issues requiring further research. The findings will inform the development of teaching programs for medical teams who manage emergencies to improve patient safety and experience.

Contemporary issues in the training of UK health and social care professionals--Looking after people with a learning disability

The health and social care of people labelled with 'learning disability' has historically been a disputed territory for those individuals working within the nursing and allied health professions. In recent times this situation has seen public debate as instances of poor care and avoidable deaths have received a high profile in the popular and professional presses. Here we report on a local initiative where students can study for a joint honours award which allows them to practise as a generic social worker and a learning disability nurse. We believe that the inter-professional perspective improves their ability to manage the increasingly complex aspects of health and social care that this client group demands. Furthermore, we suggest that if a similar model were to be applied at a foundation module level to the training of ALL health and social care professionals, then the results would be a win/win situation for all parties. This would also go some way to meeting the recommendations of Sir Jonathan Michael's report, Health Care for All (DH, 2008).

Transferring responsibility and accountability in maternity care: clinicians defining their boundaries of practice in relation to clinical handover

OBJECTIVE

This exploratory study reports on maternity clinicians' perceptions of transfer of their responsibility and accountability for patients in relation to clinical handover with particular focus transfers of care in birth suite.

DESIGN

A qualitative study of semistructured interviews and focus groups of maternity clinicians was undertaken in 2007. De-indentified data were transcribed and coded using the constant comparative method. Multiple themes emerged but only those related to responsibility and accountability are reported in this paper.

SETTING

One tertiary Australian maternity hospital.

PARTICIPANTS

Maternity care midwives, nurses (neonatal, mental health, bed managers) and doctors (obstetric, neontatology, anaesthetics, internal medicine, psychiatry).

PRIMARY OUTCOME MEASURES

Primary outcome measures were the perceptions of clinicians of maternity clinical handover.

RESULTS

The majority of participants did not automatically connect maternity handover with the transfer of responsibility and accountability. Once introduced to this concept, they agreed that it was one of the roles of clinical handover. They spoke of complete transfer, shared and ongoing responsibility and accountability. When clinicians had direct involvement or extensive clinical knowledge of the patient, blurring of transition of responsibility and accountability sometimes occurred. A lack of 'ownership' of a patient and their problems were seen to result in confusion about who was to address the clinical issues of the patient. Personal choice of ongoing responsibility and accountability past the handover communication were described. This enabled the off-going person to rectify an inadequate handover or assist in an emergency when duty clinicians were unavailable.

CONCLUSIONS

There is a clear lack of consensus about the transition of responsibility and accountability-this should be explicit at the handover. It is important that on each shift and new workplace environment clinicians agree upon primary role definitions, responsibilities and accountabilities for patients. To provide system resilience, secondary responsibilities may be allocated as required.

Medical simulation for professional development--science and practice

From the earliest days of medical practice, when surgeons used cadavers to explore the possibilities of surgical intervention, simulation has been employed to advance the practice of health care. In the last 10 years, technological advances have allowed for a wider availability and greater realism of simulation, and this has encouraged a great expansion in its use. Simulation aims to create a virtuous cycle of professional development to improve patient outcomes. Although it seems eminently logical to believe that simulation will result in better outcomes, there is a need to test these new training interventions rigorously to be sure of their worth and to understand any limitations. The purpose of this BJOG supplement is to examine in depth several paradigms of medical simulation within maternity care and gynaecology, in different settings, looking at what can be achieved and how. In this opening review, we look at the potential use of medical simulation in broad terms and describe the types of evidence that can be employed to support its use.

Sustaining simulation training programmes--experience from maternity care

There is little scientific evidence to support the majority of simulation-based maternity training programmes, but some characteristics appear to be associated with sustainability. Among these are a clear institutional-level commitment to the course, strong leadership in course organisation, a curriculum relevant to clinical practice, a nonthreatening learning environment, the establishment of multiprofessional training and the use of simulators appropriate to the learning objectives. There is still some debate on whether simulation-based sessions should be carried out in dedicated training time outside normal working hours or in ad-hoc drills that are run during clinical sessions, whether they should be located in clinical areas, simulation centres, or both, and whether or not they should include standardised generic teamwork training sessions. In this review, we discuss the main characteristics that appear to make a simulation-based training programme a sustainable initiative.

Impact of resuscitation system errors on survival from in-hospital cardiac arrest

BACKGROUND

An estimated 350,000-750,000 adult, in-hospital cardiac arrest (IHCA) events occur annually in the United States. The impact of resuscitation system errors on survival during IHCA resuscitation has not been evaluated. The purpose of this paper was to evaluate the impact of resuscitation system errors on survival to hospital discharge after IHCA.

METHODS AND RESULTS

We evaluated subjective and objective errors in 118,387 consecutive, adult, index IHCA cases entered into the Get with the Guidelines National Registry of Cardiopulmonary Resuscitation database from January 1, 2000 through August 26, 2008. Cox regression analysis was used to determine the relationship between reported resuscitation system errors and other important clinical variables and the hazard ratio for death prior to hospital discharge. Of the 108,636 patients whose initial IHCA rhythm was recorded, resuscitation system errors were committed in 9,894/24,467 (40.4%) of those with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) and in 22,599/84,169 (26.8%) of those with non-VF/pVT. The most frequent system errors related to delay in medication administration (>5 min time from event recognition to first dose of a vasoconstrictor), defibrillation, airway management, and chest compression performance errors. The presence of documented resuscitation system errors on an IHCA event was associated with decreased rates of return of spontaneous circulation, survival to 24h, and survival to hospital discharge. The relative risk of death prior to hospital discharge based on hazard ratio analysis was 9.9% (95% CI 7.8, 12.0) more likely for patients whose initial documented rhythm was non-VF/pVT when resuscitation system errors were reported compared to when no errors were reported. It was 34.2% (95% CI 29.5, 39.1) more likely for those with VF/pVT.

CONCLUSIONS

The presence of resuscitation system errors that are evident from review of the resuscitation record is associated with decreased survival from IHCA in adults. Hospitals should target the training of first responders and code team personnel to emphasize the importance of early defibrillation, early use of vasoconstrictor medication, and compliance with ACLS protocols.

Safety culture in the maternity units: a census survey using the Safety Attitudes Questionnaire

Background

Patient safety has been a priority for many societies and health care systems in the last decades. Identification of preventable risks and aversion of potentially unsafe situations and fatal complications in maternity units is life saving. The explicit need to focus on quality of care underpins the aim of the study to initially evaluate the safety culture and teamwork climate in the public Maternity Units of the 5 Regional Hospitals in Cyprus as measured by a validated safety attitudes tool.

Methods

Data were collected from 140 midwives working in the public sector all over Cyprus by the Greek Version of the Safety Attitudes Questionnaire-Labor version.

Results

One hundred and six (75.71%) registered midwives completed the questionnaire fully. The median of total work experience as a registered midwife was 3 years (IQR: 2-18.25); whereas the median of total working experience in the nursing and maternity units was 5 years (IQR: 2-21.75). Experienced midwives rated the following domains higher: team work, safety climate, job satisfaction and working conditions as opposed to the midwives with less experience. Additionally those with a longer working life in the current maternity units rated these domains higher: safety climate, job satisfaction and working conditions as opposed to the less experienced midwives.

Conclusions

The high mean total score on team work and safety climate in the more experienced group of midwives is a predominant finding for the maternity units of Cyprus. In Cyprus where facilities are small in size and midwives know each other, share more responsibility towards patient safety. It could be suggested that younger midwives need more support and teamwork practice to enhance the safety and teamwork climate towards self-confidence.

Team communication with patient actors: findings from a multisite simulation study

INTRODUCTION

Patient satisfaction is an important healthcare outcome and communication with clinical staff is an important determinant. Simulation could identify problems and inform corrective action to improve patient experience.

METHODS

One hundred eight randomly selected maternity professionals in 18 teams were videoed managing a patient-actor with a simulated emergency. The trained patient-actor assessed the quality of staff-patient interaction. Clinicians scored teams for their teamwork skills and behaviors.

RESULTS

There was significant variation in staff-patient interaction, with some teams not having exchanged a single word and others striving to interact with the patient-actor in the heat of the emergency. There was significant correlation between patient-actor perceptions of communication, respect, and safety and individual and team behaviors: number, duration, and content of communication episodes, as well as generic teamwork skills and teamwork behaviors. The patient-actor perception of safety was better when the content of the communication episodes with them included certain items of information, but most teams failed to communicate these to the patient-actor.

CONCLUSION

Some aspects of staff-patient interaction and teamwork during management of a simulated emergency varied significantly and were often inadequate in this study, indicating a need for better training of individuals and teams.

Clinical efficiency in a simulated emergency and relationship to team behaviours: a multisite cross-sectional study

OBJECTIVE

To identify specific aspects of teamworking associated with greater clinical efficiency in simulated obstetric emergencies.

DESIGN

Cross-sectional secondary analysis of video recordings from the Simulation & Fire-drill Evaluation (SaFE) randomised controlled trial.

SETTING

Six secondary and tertiary maternity units.

SAMPLE

A total of 114 randomly selected healthcare professionals, in 19 teams of six members.

METHODS

Two independent assessors, a clinician and a language communication specialist identified specific teamwork behaviours using a grid derived from the safety literature.

MAIN OUTCOME MEASURES

Relationship between teamwork behaviours and the time to administration of magnesium sulfate, a validated measure of clinical efficiency, was calculated.

RESULTS

More efficient teams were likely to (1) have stated (recognised and verbally declared) the emergency (eclampsia) earlier (Kendall's rank correlation coefficient τ(b) = -0.53, 95% CI from -0.74 to -0.32, P=0.004); and (2) have managed the critical task using closed-loop communication (task clearly and loudly delegated, accepted, executed and completion acknowledged) (τ(b) = 0.46, 95% CI 0.17-0.74, P=0.022). Teams that administered magnesium sulfate within the allocated time (10 minutes) had significantly fewer exits from the labour room compared with teams who did not: a median of three (IQR 2-5) versus six exits (IQR 5-6) (P=0.03, Mann-Whitney U-test).

CONCLUSIONS

Using administration of an essential drug as a valid surrogate of team efficiency and patient outcome after a simulated emergency, we found that more efficient teams were more likely to exhibit certain team behaviours relating to better handover and task allocation.

SIMULATION TRAINING FOR OBSTETRIC PROCEDURES AND EMERGENCIES

The World Health Organisation (WHO) has estimated that 1500 women die every day from preventable complications of pregnancy and childbirth. While barriers to accessing healthcare are undoubtedly multi-factorial, studies have repeatedly shown that providing skilled healthcare workers can result in untold benefits for women and babies in developing countries. The phenomenon of preventable maternal and fetal morbidity and mortality is not limited to the developing world. The Confidential Enquiries into Maternal Deaths (CEMD) and Stillbirths and Infant Deaths (CESDI) in the UK have repeatedly identified substandard care as a major contributor to maternal and neonatal mortality. In 2008 The King's Fund publishedSafe Births: Everybody's business,an independent enquiry into the safety of maternity services in England. This recommended that simulation-based training to assess clinical, communication and team skills should be available to all maternity staff, and that training should form a core activity. Many hospitals in the UK have been running in-house courses for staff for over a decade with measurable improvements in neonatal outcomes. The value of these training schemes is recognised and rewarded through reduced insurance premiums for participating hospital trusts as part of clinical negligence schemes. Gaining competence in managing obstetric emergencies presents particular challenges for trainees. Most emergencies are, thankfully, uncommon but some constitute life-threatening events where management naturally falls to the most experienced available clinician. The skills required are often particular to emergencies and therefore novel to trainees. Utilising emergencies as training opportunities is further complicated by the presence of a conscious patient.

The management of a simulated emergency: better teamwork, better performance

OBJECTIVES

To determine whether team performance in a simulated emergency is related to generic teamwork skills and behaviours.

METHODS

Design - Cross-sectional analysis of data from the Simulation and Fire-drill Evaluation (SaFE) randomised controlled trial. Setting - Six secondary and tertiary Maternity Units in Southwest England. Participants - 140 healthcare professionals, in 24 teams. Assessment - Blinded analysis of recorded simulations. Main outcome measures - Correlation of team performance (efficiency conducting key clinical actions, including the administration of an essential drug, magnesium), and generic teamwork scores (using a validated tool that assesses skills and behaviours, by Weller et al.).

RESULTS

There was significant positive correlation between clinical efficiency and teamwork scores across all three dimensions; skills (Kendall's tau(b)=0.54, p<0.001), behaviours (tau(b)=0.41, p=0.001), and overall score (tau(b)=0.51, p<0.001). Better teams administered the essential drug 2½min more quickly (Mann-Whitney U, p<0.001).

CONCLUSIONS

The clinical conduct of a simulated emergency was strongly linked to generic measures of teamwork. Further studies are needed to elucidate which aspects of team working are critical for team performance, to better inform training programs for multi-professional team working.