Various reports have advocated the use of interdisciplinary team training to improve communication and coordination within care teams. Although training programs for individuals occur, if the care team is responsible for most clinical errors, then team training might be more effective. Kirkpatrick’s theoretical model for evaluation of training has 4 potential levels to be evaluated, with the bottom 2 levels indicating the trainee’s personal reaction to the training and the trainee’s improvement in knowledge. Level 3 measures the conversion of learned skills and behavior into clinical practice. Level 4 measures the effect of training on measurable clinical outcomes. No randomized controlled trials have evaluated the effectiveness of team training in obstetric emergencies with simulation methods using Kirkpatrick’s third- or fourth-level model. This cluster, multicenter, randomized controlled trial was designed to evaluate the effectiveness of team training in a medical simulation center based on the hypothesis that such obstetric team training can improve team performance and increase use of essential clinical skills.
Eligible units were hospital-based obstetric departments in all teaching and nonteaching hospitals in the Netherlands with at least 1000 deliveries annually. Units were randomly allocated to the intervention or control group for teaching and nonteaching hospitals. The obstetric units in the intervention group received a 1-day team training course in a medical simulation center. Eighty percent and 20% of the training time was devoted to crew resource management and medical technical skills, respectively, for the 74 teams. Training was delivered by a gynecologist and a communication expert. The birthing simulators were used in 6 obstetric emergency scenarios: fetal distress including cardiotocographic analysis, shoulder dystocia, postpartum hemorrhage, umbilical cord prolapse, eclampsia, and resuscitation of a pregnant woman. Every scenario started with a briefing via an introductory video involving actors. Then the team moved to the simulation delivery room where they managed the simulated patient. All 15-minute scenarios were videotaped. After completing each scenario, the team had a 30-minute debriefing session. Feedback on teamwork concentrated on communication, leadership, decision making, and situational awareness. More than 6 months after completing the training courses, unannounced in situ clinical simulations with 2 scenarios, shoulder dystocia and amniotic fluid embolism, were conducted at all units for the intervention and control groups. In the scenario on shoulder dystocia, the simulation continued until the baby was delivered in the all-fours position. If the all-fours maneuver was not applied, the baby was delivered anyway. The second scenario on amniotic fluid embolism required resuscitation of the mother. The simulation was halted after the baby was delivered by a perimortem cesarean delivery or when the medical team did not make progress in managing the scenario. Both scenarios lasted a maximum of 10 minutes. The Clinical Teamwork Scale (CTS) was used to assess team performance and consists of 15 items in domains of communication, decision making, role responsibility, situational awareness/ resource management, and patient-friendliness. To assess whether medical team training can lead to the acquisition of medical technical skills, the prespecified, recommended but unfamiliar obstetric procedure was used in each obstetric emergency (ie, the all-fours position and perimortem cesarean delivery). Data management and analyses were performed using SPSS.
The study included 12 obstetric departments in each group. The training and nontraining groups were comparable in relation to the number of teaching hospitals in each group, the total and mean number of deliveries per year, and staffing levels. The in situ simulations were performed at a mean interval of 8.27 months after randomization (8.43 ± 1.62 and 8.12 ± 1.36 months for the intervention and control groups, respectively; P = 0.6). The total median CTS score of all items was 7.5 in the training group and 6.0 in the nontraining group, a significant difference (P = 0.01). The CTS results for the training and nontraining groups differed significantly for communication (P = 0.008) and decision making (P = 0.01). The differences in the other domains of the CTS did not differ significantly. The required obstetric procedures were performed in 19 of the 23 in situ simulation recordings (83%) in the trained units compared with 10 (46%) of the 22 recordings in the untrained units (P = 0.009). Nine trained and 4 nontrained teams used the all-fours maneuver (P = 0.08). Ten trained and 6 nontrained teams performed a perimortem cesarean delivery (P = 0.193).
Significant improvements in team performance and increases in the use of new medical technical skills were apparent 8 months after the team training. Although team training has been implemented in a wide range of medical disciplines, good-quality evidence was lacking for the effect of team training on Kirkpatrick’s level 3 and level 4 outcomes. These results contribute evidence for improvement in outcomes at level 3 of Kirkpatrick’s model. Further research should focus on the evaluation of the effect of training on measurable clinical outcomes, that is, Kirkpatrick’s level 4.