Introduction
Human factors have been described as ‘the science of improving human performance and well-being by examining all the effectors of human performance’ (Moneypenny, 2017). There has been considerable work over the last two decades to examine how human factors theory can be adopted into clinical practice. Much of the current knowledge and opinions have been formed from key seminal papers published in the USA (Kohn et al., 2000) and the UK (Department of Health, 2000). An assurance that Human Factors are now high on the national agenda was confirmed by the recent commitment in the form of a concordat (NHS England) by key state holders such as the General Medical Council and NHS England.
Another definition of human factors by Professor Rhona Flin is ‘the cognitive, social, and personal resource skills that complement technical skills, and contribute to safe and efficient task performance’ (Flin et al., 2008), with key aspects including situational awareness, teamwork, leadership, followership, communication and decision-making. This is reiterated by The Clinical Human Factors Group definition of ‘enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings’ (Catchpole). It is important that these elements, or what are also referred to as Team Resource Management (or Crew Resource Management in the Airline Industry; Civil Aviation Authority, 2003), are exercised in the management of Obstetric Emergencies.
There has been research into human factors for anaesthetists (Fletcher et al., 2003), surgeons (Yule et al., 2006) and scrub practitioners (Mitchell and Flin, 2008), and much of this work can be directly translated to the busy labour ward setting, although as yet there is no validated system for measuring non-technical skills in obstetric teams. A lack of communication and teamwork was cited as a leading cause of substandard obstetric care by the National Confidential Enquiry into Maternal Deaths (Lewis and Drife, 2004). It has also been commented that poor teamwork and suboptimal communication contribute to increased maternal and neonatal morbidity and mortality, and bad patient experience (Cornthwaite et al., 2013).
This chapter will examine the team resource management aspects of teamwork and communication and explore the importance of cognitive aids in time-critical emergencies.
Team-Working
A recent national report has demonstrated a need to increase the effectiveness and efficiency of team-working when obstetric emergencies occur (Lewis, 2007). The prospective surveillance study in one teaching hospital by Forster et al. (2006) demonstrated that 5% of obstetric patients experienced an important ‘quality problem’. This was defined as an adverse event or a potential adverse event. When these were further reviewed, 87% were deemed potentially preventable and with systems issues such as teamwork being cited as causative (Forster et al., 2006). The term ‘teamwork’ itself has been used as a catchall to refer to a number of behavioural processes and emergent states (Valentine et al., 2015). Work has been undertaken by Salas, who defines a team as ‘a distinguishable set of two or more people who interact dynamically, interdependently, and adaptively towards a common and valued goal, who have each been assigned specific roles or functions to perform, and who have a limited life-span membership’ (Salas et al., 2004). Another definition by Katzenbach describes a team as ‘a small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they hold themselves mutually accountable’ (Katzenbach and Smith, 1993). These definitions hold strong for the busy team working on the labour ward and in the obstetric theatres.
It is important to realise that teamwork is more than just subordinates doing what their leader tells them to do. Teamwork is about maximising the mental and physical problem-solving capabilities of the group, such that the sum of these exceeds its parts (Pierre et al., 2011). It is not surprising that poor teamwork and leadership can lead to devastating, and potentially avoidable, physical, psychological and financial consequences (Cornthwaite et al., 2013). A report by the King’s Fund came to the conclusion that maternity teams required clarity about team objectives and roles and effective leadership and efficient communication (O’Neill, 2008). Black and Brocklehurst identified that the largest contributing factor to the death of babies was a delay in assembling the team and that further research related to effective team training for obstetric emergencies should be undertaken (Black and Brocklehurst, 2003). It is also thought that increased clinical exposure, learned systematic responses and a focus on teamwork could result in diminished stress and improved care (Schull et al., 2001). Observations from acute care medicine demonstrate that inadequate teamwork is one of the most common reasons for preventable error (Pierre et al., 2011).
Good teamwork is associated with improved productivity, innovation and job satisfaction (Katzenbach and Smith, 1993). It is also considered that teams who demonstrate similar mental models move quicker through the phases common to most crises. Ripley describes these as denial, deliberation and then deliberate action (Ripley, 2009). Good teamwork also relies on situational awareness, an academic definition being ‘the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future’ (Salas et al., 2004). To maintain good situational awareness, it is important the maternity staff are aware of the competencies and skills of their colleagues, the background to situations and verbalise loudly information for everyone to hear (Cornthwaite et al., 2013). A properly conducted handover is essential to ensuring good situational awareness. But equally, effective training to prepare all healthcare professionals in the maternity team to deal with high-stakes emergencies is essential for saving mothers and babies (Cornthwaite et al., 2013).
Challenging hierarchy among the team is also important in high-stakes emergency situations. Recent work has shown that ‘speaking up’ or the ability to effectively challenge erroneous decisions is essential to preventing harm and that despite significant multifactorial barriers, systematic training in effective ‘speaking up’ could improve the confidence and ability of juniors to challenge erroneous decisions (Beament and Mercer, 2016). In the field of aviation, United Airlines uses the acronym ‘CUS’, which stands for ‘I’m concerned’, ‘I’m uncomfortable’, and ‘this is unsafe or I’m scared’. Staff, regardless of their hierarchical status, are encouraged to use this acronym to challenge senior members of staff (Leonard, 2004).
Communication
Previous work by Gawande and colleagues (2003) cited communication failures as being responsible for 43% of errors in three large teaching hospitals in the USA. Specific to obstetric practice, one review of closed obstetric malpractice claims concluded that 31% of adverse events were attributable to communication problems (White et al., 2005). In time-critical situations, it is important that there is a team leader who has the ability to impart any critical information without the potential for misinterpretation or misunderstanding, irrespective of the situation or the professional diversity of the surrounding team. Effective communication is reliant on good ‘crowd control’ so that excessive noise levels are kept low. During rapidly changing situations such as an obstetric emergency, continuous communication is vital and this can be facilitated by a team brief followed by regular situational updates (or SIT-REPS). Effective communication establishes and maintains a shared mental model for the team. This falls short when handovers are inadequate and the shared mental model is no longer ‘shared’. Landro has referred to this as ‘the Bermuda Triangle of health care’ (Landro, 2006). Communication is essential, not only between the team leader and the team, but also in the reverse direction so that the multidisciplinary team can feedback important information such as physiology changes and drugs administered.
Elements of effective communication rely on clarity, ‘keeping it clear’, brevity, ‘keeping it brief’, empathy, ‘how will it feel to receive this?’ and ensuring there is a feedback loop. Effective communication is reliant on the following.
Addressing statements or messages to a specific person to avoid pronouncing them into thin air. This ensures that the correct person knows that they have been asked to perform a task and there is no ambiguity among other team members. This directed communication and closed-loop communication is particularly important when rapid response is critical. Directed communication involves specifying who is intended to receive an order or communication, usually by using a hand signal or saying the person’s name (Guise and Segel, 2008).
Closing the communication loop. An example of this would be asking a team member to repeat the instructions back to the team leader so that the instructions have been understood.
Fostering an atmosphere of open information exchange among all team members. If this is adopted then everyone will be listened to regardless of job description or status. This culture empowers all team members to speak out to communicate to the team leader to prevent an error. Barriers to challenging and the importance of barriers to challenging have recently been reviewed (Beament and Mercer, 2016). These have included poor intraoperative communication between seniors and juniors (Belyansky et al., 2011) and poor communication skills in general (Kobayashi et al., 2006; Okuyama et al., 2014).
Continuous re-evaluation. Periodic updating ensures that situation awareness is maintained as information is collected, summarised and shared among the team members.
Effective communication is further facilitated by a team brief and this also facilitates shared mental models and situational awareness. If time permits then this is led by the nominated team leader. This process involves the following.
Introduction of all team members by name and role. This not only allows the use of first names during a scenario but also ensures that peripheral members of the team such as medical or nursing students can be identified and employed if necessary. The team leader is also aware of the competencies and skills of individual team members.
Briefing of the team as to what is expected to happen. This may not be possible in an obstetric emergency, but in a trauma team situation there is often up to 10 minutes to allow a discussion of the likely events based on the team leader’s mental model. This also allows a discussion of any potential problems and a highlighting of potential solutions.
Tasks are then allocated and agreed.
During a critical emergency on the obstetric ward it will also be very important that there is effective communication with external agencies in the hospital. This will include the transfusion laboratory, critical care and the operating theatres. Additional team members may also be summoned, such as consultants and senior midwives, to ensure senior robust decisions are made in a timely manner. Often a runner will be nominated to facilitate the delivery of blood products and nominated individuals will communicate with the laboratory via the telephone. This ensures that there are direct lines of communication.
To maintain effective communication, it is vital that there is an awareness of distractions that could occur during a critical emergency. These are often caused by increased noise and the team leader has the job of maintaining ‘crowd control’. It is well known that substantial extraneous noise and movement occur in the obstetric theatre environment and this is thought to create both auditory and physical distraction (Jenkins et al., 2014). A ‘sterile cockpit’ has been described in the airline industry during key moments in emergency care (Broom et al., 2011). An example of this is the intubation of a patient during a rapid sequence induction of anaesthesia. This requires that the noise level is kept to an absolute minimum by having only the required team members present and minimal noise. Another form of ‘crowd control’ practised, if noise levels inhibit communication, is for any member of the team to ASK for a pause (A, ask for a pause; S, share the mental model; K, keep communication closed loop) (Monks and Maclennan, 2016).
Communication Tools
SBAR
The communication tool SBAR is made up of the acronym Situation, Background, Assessment and Recommendation (Haig et al., 2006). It provides a structure to a conversation where one individual is communicating information to another in a time-critical situation. This is particularly useful for conversations on the telephone.
AT-MIST
Another communication tool that is widely used by the trauma team during handover is AT-MIST. This refers to Age, Time of Injury, Mechanism of injury, Injuries sustained, Signs and symptoms and Treatment given. It must also be noted that asking the wrong questions can also ‘get the wrong answer’. For example, during surgery, the Surgeon asking ‘how are you doing’ could lead to a reply from the Anaesthetist such as ‘obs are stable’ or ‘we are keeping up’. A similar question from the Anaesthetist could lead to a response from the Surgeon such as ‘things are a little tricky now’. Both these answers convey little information as the Anaesthetist might indeed be ‘keeping up’ by transfusing 400 ml/minute via a Belmont Rapid Infuser and the stable observations might be a systolic blood pressure of 70 mmHg. Equally, ‘things are a little tricky’ conveys no meaningful information either. In an attempt to counteract this poor communication, the Defence Medical Services have suggested a ‘Trauma WHO Checklist’ (Arul et al., 2015) with a situational update (Sit-Rep) using the mnemonic STACK (Table 8.1).
Table 8.1 The STACK mnemonic used for situational updates by the UK Defence Medical Services.
| S | Systolic BP |
| T | Temperature |
| A | Acidosis |
| C | Coagulation |
| K | Kit (including blood products used) |
GAMES
To facilitate effective handover to the neonatal team, when called to a delivery in an emergency, the GAMES mnemonic can be used. Gestation, Antenatal history, Maternal problems/medications, Examination findings (CTG, scalp pH, meconium, risk factors for sepsis) and Suggested actions (Maclennan et al., 2017).
Communication and Checklists
The ideal properties of cognitive aids used during anaesthetic emergencies are that they must be derived from best practice, they should be appropriate, familiar and in a format that has been used in practice and training and leads to coordinated team activity (Marshall, 2013). There is good evidence to support the impact of checklists in improving the quality of healthcare professional’s handovers of care in addition to their adherence to recognised standards of care during perioperative crisis situations (Tan and Helsten, 2013; Petrovic et al., 2012). One such checklist is The World Health Organization (WHO) surgical safety checklist that was introduced in 2009 (Haynes et al., 2009; The World Health Organization; World Alliance for Patient Safety, 2008). The primary aim of this intervention was to eliminate ‘never events’.1 This process involves a team brief and then has a series of questions to include confirmations of key aspects of the operation, any patient-specific factors and any unusual steps in the process. The WHO Checklist has recently been reported to reduce hospital mortality (Van Klei et al., 2012), and although this checklist is important, it wasn’t designed to be used in a rapidly changing situation such as a massive postpartum haemorrhage, nor was it intended to be religiously adopted in a time-critical situation such as a category one caesarean section. In terms of trauma management and the WHO Checklist, a discussion paper published in 2012 sought to improve and streamline communication during the damage control resuscitation (Arul et al., 2012) and there are many similarities with acute obstetric emergencies. The Trauma WHO (Arul et al., 2015) is described in Table 8.2 with four key stages: Command Huddle, Snap Brief, Sit-Reps and Debrief.
Table 8.2 The Trauma WHO.
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