SBAR – clarify the situation and background, then make an assessment and a recommendation loudly for everyone to hear; including patient and companions who can then be informed in the same simple step even without communication directed specifically at them at that point (if not enough staff)
Closed-loop communication – use closed-loop communication to allocate critical tasks to team members, including communication with the patient and companions (if enough staff); follow simple algorithms that determine the order and/or importance of tasks
Avoid distraction – it might be useful to focus on leadership and avoid performing tasks that can be done by other members of the team. This allows the leader to take a step back and maintain a broader, ‘helicopter’ view.
Situational Awareness
Situational awareness is defined as ‘the perception of the elements in the environment, the comprehension of the meaning, and the projection of their status in the near future’. More simply, it refers to knowing what is going on, and is frequently found to be deficient in simulation [29–31] or by observation of labour wards [32]. It is a concept that was first defined in aviation, and it has been consistently difficult to define and measure in obstetrics [33–35], where situations are often complex. However, focus groups have identified three teachable components: find out the clinical situation; find out the team abilities; and keep aware of patient and companion needs for communication and information.
Shared Mental Methods
This concept refers to having a shared objective and a plan of work to achieve it. Shared mental models emerge through the interactions of team members. However, in healthcare, teams are often created there and then for an emergency, and individuals may never have worked within the same team, or even met before. Clear and early verbalization of the situation or diagnosis (for example, saying ‘this is eclampsia’) can help focus team members, improve performance and keep patients and their companions informed [28]. Certain teamwork behaviours can be taught, as shown in Table 30.3.
| 1 | Find out clinical situation (and maintain regular update). |
| 2 | Know or find out what the team members can do for the emergency at hand. |
| 3 | Declare or allocate leadership verbally based on relevant experience of emergency at hand. |
| 4 | Use closed-loop communication for allocation of critical tasks. |
| 5 | Keep patients and companions informed. |
| 6 | Team leader should focus on leadership to ensure effective teamwork unless the task is simple or there is no one else who can do it. |
Teamwork Training: Why Bother?
Acquisition of Knowledge and Skills
As discussed, the SaFE study demonstrated a definitive and sustained improvement in both knowledge and skills following training [21]. Another study revealed that clinical performance for drills requiring multi-professional team effort (postpartum haemorrhage, eclampsia) was poorer than that for drills focusing on skills of the individual accoucheur (breech vaginal delivery, shoulder dystocia) prior to training. Team-based simulation training improved performance in subsequent drills, even when scenarios were changed [2].
Satisfaction of Learners
Evidence shows that clinicians enjoy obstetric emergency training [36]. Multi-professional team training using simulation not only improves knowledge and clinical management of obstetric emergencies, but also confers confidence and enhances communication skills [37].
Change in Attitude
A study using a validated tool (Sexton safety attitude and climate questionnaire) to assess staff attitudes in a maternity unit showed that the introduction of team training enhances teamwork climate and promotes a positive safety culture [38].
Clinical Behaviours
Behavioural changes are difficult to assess, with most evaluation tools relying extensively on self-reporting and subjective assessments by observers [39].
However, clinical and social science methods have been used to describe specific teachable behaviours of effective teams and leaders [24,40]. Better teams are likely to vocalize the nature of the emergency earlier, use closed-loop communication to allocate critical tasks and use more structured handovers.
Patient and Organizational Outcomes
Obstetric emergency training can improve knowledge, skills, satisfaction and team behaviours, but do these changes translate into better outcomes for patients and healthcare organizations?
Patient Safety
A retrospective observational study demonstrated improved perinatal outcomes in a large UK maternity unit after the introduction of ‘in-house’ obstetric emergency training: low Apgar scores (<7 at five minutes) and moderate, severe or total hypoxic-ischaemic encephalopathy were all reduced by about 50% [41], and brachial plexus injuries by 70% [42].
Notably, the units that demonstrated improved outcomes all made use of department-level incentives to train and ‘in-house’ training programmes were attended by 100% of staff.
Patient Satisfaction
Obstetric lawsuits repeatedly cite deficient interpersonal skills and communication problems, which adversely affect patients’ and relatives’ satisfaction and raise concerns about their safety [43].
Training in obstetric emergencies can improve these communication shortages and subsequent patient satisfaction, and reduce litigation [44].
Teams trained ‘in-house’ with patient-actors demonstrate significantly higher safety and communication scores compared with teams trained at simulation centres using computerized patient mannequins. Accordingly, obstetric training should be designed to closely imitate the demands of a real-life labour ward in order to enhance psychological fidelity [45].
Simulation studies have shown significant improvements in patient-actors’ perception of care following training [46]. Furthermore, patient-actor perception was better when the leader had a directive style of communication, which included certain items of information such as condition of the baby, cause of the emergency and aims of treatment [40].
Teamwork Training: How Should We Organize It?
Lessons for Training
A good clinical outcome should be the decisive factor for the success of a team. Our understanding regarding characteristics of effective teams and how best to organize team training has been enhanced through the study of teams in simulation, in conjunction with inter-professional focus group analysis [25]. In this multi-centre study, team performance during simulation was assessed by measuring the time to administer an essential drug (magnesium for eclampsia), which is a clinically relevant surrogate of team performance and safety [49]. Front line staff participating in focus groups recounted real-life emergencies and enriched our knowledge further. Participants identified a need for teamwork training, which incorporates several methods suited to different learning styles and levels of seniority.
There continues to be evidence of poor inter-professional working in maternity. Training together in realistic settings, via attendance at local skills and drills training, can improve this and provide an opportunity for team bonding. ‘In-house’ training allows new staff to familiarize themselves with their specific role and environment in emergencies, while maintaining competence for permanent staff. This helps to prepare teams on the ‘shop-floor’ to rapidly come together as a team and manage any emergency.
Accordingly, the UK NHS Litigation Authority mandate annual multidisciplinary skills drills through its Clinical Negligence Scheme for Trust (CNST) standards [48]. Despite this, in 2003 only 51% of UK centres surveyed were conducting such training. Common causes for not undertaking skills drills were concerns about the impact on service provision and a perception of the training process as threatening or stressful [50].
The following highlights ways to alleviate such fears and maximize the benefit from drills.
Organizing Effective Skills and Drills Training
Course Planning and Administration
The course programme should be finalized by a local training team who can allocate individual modules to specific trainers, who can then practise scenarios prior to running the courses so as to identify any problems.
A practice midwife can be invaluable in administering the course. All presentations, handouts and equipment may be stored centrally, and it is useful if trainers are familiar with each other’s workstations and lectures, so that both trainers and workstations are interchangeable when necessary. The programme should ideally change annually to maintain interest. Course manuals should be sent out to all participants prior to the course.
To ensure that staff are released to attend the training day, several dates may be arranged well in advance. A database should be kept of all attendees for clinical negligence scheme assessments. Appraisals of consultants and trainee doctors, and supervision schemes for midwives, should identify non-attendees and a mandatory session can be arranged at the end of the year. Certificates of attendance should be provided and logbooks of training can be signed to increase motivation.
Access
Locally organized emergency training days should be available to both hospital and community staff. In view of the increasing numbers of births outside consultant-led units, it is important to advertise and actively promote in the community [18].
Location
The emergency drills are best undertaken in a delivery room or another clinical area, as it provides the highest environmental fidelity. A suitable seminar room nearby should be used for lectures.
Delivery rooms may not always be available for use, but training in the true clinical environment enables local protocols and procedures to be tested and, if necessary, revised, thereby improving the system and creating a sense of general ownership.
The workload can be reduced in advance, for example by limiting the number of elective caesarean sections. It may be best to leave the decision of which rooms will be used for each drill until the latest possible time, and remain flexible.
Scenarios
The scenarios should be simple and outline the immediate emergency action required. The participation in role-play is a new experience for many healthcare professionals and this is often the first obstacle to be encountered. Given time, participants overcome their initial embarrassment and appreciate the opportunity to actively take part in the scenario as part of ‘the team’.
It can be helpful to conduct a drill briefing prior to the first drill, in which the actions the participants are required to undertake can be highlighted. This can then be reinforced between drills if necessary. During each scenario, it works well to take one member of the team into the room first for a handover, while the rest of the team waits outside. Individuals then get an opportunity to practise their handover skills when other team members enter the room.
Facilitation
Between six and ten ‘in-house’ trainers should be enlisted to facilitate the day. Participants should feel welcome and relaxed, and encouraged to participate in the planning and evaluation of their learning. This is vital to the success of drills.
Patient-Actors
Drills tend to be more successful if the setting is as near to reality as possible [44]. Obstetric emergencies are unique in that there is significant audience participation; good communication with both the woman and their family or friends is essential.
Using a patient-actor, or integrating a patient-actor with a mannequin, is cheap, easy and effective [18]. It can also increase the realism of the situation, enhance communication between team members and women, and lead to improvement in communication scores as assessed by patient-actors [44]. Hence, it can be useful for the patient-actors to give the team feedback after each drill.
A member of staff with experience of the emergencies portrayed can make an excellent patient. Alternatively, using a healthcare assistant as the patient-actor may be advantageous in giving them an insight into their role as part of the multi-professional team when attending obstetric emergencies.
Equipment
The correct equipment must be available. If mannequins are used, a pregnant abdomen, bra and female wig add realism to the simulated scenario. In the PROMPT (PRactical Obstetric Multi-Professional Training) course, props are used to increase the realism of the scenarios: blood-stained incontinence sheets, trousers that bleed, a pregnant uterus, life-size copy of O Rhesus negative blood bags, a perineum with a prolapsed cord [18].
The level of fidelity of simulations is not as important as designing the drills to suit task demands in real life, and in many cases low-technology props may be as effective as more sophisticated equipment.
Pictorial guidelines can be used to facilitate visual estimation of blood loss [51], otherwise underestimation might occur in as many as 95% of obstetric haemorrhage cases [2].
Record Keeping
A ‘made-up’ set of patient notes and partogram can be used at the handover in the delivery room as an aide-memoir of the patient’s history, and also to document the care given during the scenario.
Structured documentation proforma can be developed and used for both training and real-life emergencies. The team should allocate the role of scribe to one person during the drill. If necessary this can be prompted by the trainer. Documentation, including completion of clinical incident forms, should be discussed following the drill.
Objectives, Feedback and Assessment
Workshops should remain focused, and outcome-based training can achieve this. At the beginning of training sessions, the learning objectives or the most common challenges should be identified. It may be useful to discuss difficulties and omissions identified from past learners, and aim to avoid the same mistakes. Specific checklists can help structure observation of clinical actions, and provide a useful starting point in the discussion and evaluation of management of the scenario [18].
Appropriate feedback to learners is as important as objectives. Learning is about having an experience, reviewing it, concluding and planning the future. Consequently, drills need to incorporate both practical and reflective elements through constructive feedback that is directly linked to the outcome-based objectives. Pendleton’s rules are useful but several other feedback models exist (Table 30.4).
