Team Communication With Patient Actors: Findings From a Multisite Simulation Study

Siassakos, Dimitrios MSc, MRCOG, Cert Med Ed, DLSHTM; Bristowe, Katherine PhD; Hambly, Helen MSc; Angouri, Jo PhD; Crofts, Joanna F. MD, MRCOG; Winter, Catherine RM; Hunt, Linda P. PhD; Draycott, Timothy J. MD, MRCOG

Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare:
doi: 10.1097/SIH.0b013e31821687cf
Empirical Investigations

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.

Author Information

From the Southmead Hospital (D.S.), Westbury on Trym; North Academy (D.S.), University of Bristol; Department of Languages, Linguistics and Areal Studies (K.B.), University of the West of England (UWE); Speech and Language Research Unit (H.H.), Frenchay Hospital; Department of Languages, Linguistics and Areal Studies (J.A.), University of the West of England (UWE); Department of Clinical Sciences (J.F.C.), Faculty of Medicine and Dentistry, University of Bristol, Southmead Hospital, Westbury on Trym; NIHR Western Comprehensive Local Research Network (C.W.), Women's Health, Southmead Hospital, Westbury on Trym; Department of Clinical Sciences (L.P.H.), Faculty of Medicine and Dentistry, Institute of Child Life and Health, UBHT Education Centre; Chilterns (T.J.D.), Women's Health, Southmead Hospital, Westbury on Trym; and Health Innovation and Education Cluster (T.J.D.), University of Bristol, Bristol, UK.

All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare that: (1) JFC received funding from the Department of Health; DS, KB, JA and HH were funded from the North Bristol Small Grant Scheme for the submitted work (2) none of the other authors own stock, or hold stock options, in any obstetric emergency training company; (3) none of the authors' spouses, partners, or children have any financial relationships that may be relevant to the submitted work; and (4) TJD, CW and JFC are members of the steering committee of PROMPT, a UK-based charity running training courses. They have no financial interest from this association.

Reprints: Dimitrios Siassakos, Southmead Hospital, Westbury on Trym, Bristol BS10 5NB, UK (e-mail:

Article Outline

Patient satisfaction is an important outcome of health care but it can be neglected. Large reviews including the annual report by the Care Quality Commission reveal that poor staff-patient interaction is the single most common cause of patient complaints in many disciplines including maternity,1–4 as well as being a common reason for litigation.5

In maternity, in particular, good communication with the mother and her family has been identified as a key outcome measure.6–9 Unfortunately, a significant number of women complete their birthing experience dissatisfied, particularly if they experience an emergency.10 Systematic reviews have shown that post hoc debriefing is not beneficial and potentially harmful after traumatic medical events11 or birth.12 Perhaps, the best opportunity to prevent dissatisfaction is during the acute event. The factors associated with maternal dissatisfaction with normal or complicated birth have been studied. Communication with staff is a critical one, but physical outcomes, pain relief, and personal control are also important.13–16 Nevertheless, a study has shown that faced with concerns about their health or that of their baby, most women prefer safety and good communication with clinicians to autonomous choice.17

A simple questionnaire, the Patient Perception Scoring system, was created to capture these critical aspects of women's satisfaction with birth avoiding unwieldy survey instruments. Its validity has been established for both simulated emergencies with patient-actors18,19 and real-life births.20 It was shown that, while being simple, it can capture the critical elements of women's satisfaction with birth20 and is also sensitive to intervention.18,19 Although the positive effect of clinical training on this measure of patient satisfaction has been shown,18,19 there is a large variation and many teams and individual caregivers score poorly,20 even after training.18 Perhaps, targeted training could improve their communication skills.

The aim of this study was to determine the range of communication practices between staff and patients during a simulated acute event, an eclamptic seizure.

Back to Top | Article Outline



This is a cross-sectional analysis of data from a multisite randomized controlled trial of training for obstetric emergencies: Simulation and Fire-drill Evaluation (SaFE), commissioned by the Department of Health for England and Wales. The methodology was described in detail elsewhere.18,21 In brief, the SaFE study used a 2 × 2 factorial design to evaluate simulation center and local in-hospital training, with and without additional teamwork training. Participants, midwives, and doctors from six hospitals in the southwest of England were randomly recruited and subsequently randomized to one of four obstetric emergency training programs. This study is a secondary analysis limited to evaluations before the teams entered the training programmers, as the focus was on identifying aspects of teamwork and staff-patient interaction that varied significantly in prevailing practice and possibly rendered some teams better than others.

Back to Top | Article Outline

Participants were recruited from 2004 to 2005 from six secondary and tertiary maternity units. Members of staff were excluded if they had attended a nationally accredited obstetric emergencies course within 12 months, participated in a pilot study, or were on leave. For this study, the sample and sample size was pragmatic.

Back to Top | Article Outline

Participants were randomly selected from staff lists and then allocated to one of four simulation teams within their own unit, a total of 24. The individual teams were made up of staff from one unit and each team comprised of one senior doctor (more than 3 years experience), one junior doctor, two senior midwives (more than 5 years experience), and two junior midwives.

Back to Top | Article Outline

Teams were evaluated for their ability to manage simulated eclampsia with a standardized clinical scenario. The scenarios used three different patient-actors who followed a standardized script and instructions. They were conducted in a delivery room and videorecorded using four ceiling-mounted cameras connected to a digital recorder. A scripted handover of a standardized scenario was given to a junior midwife while the remainder of the group waited in an adjacent room. Patient-actors imitated a grand mal seizure for 1 minute. A member of the evaluation team, who read from a standardized script, provided further clinical information when appropriate (such as current blood pressure) by an intercom system. The simulation was stopped at 600 seconds (10 minutes) after the end of the initial handover.

The patient-actors had previously taken part in a special training day to standardize their acting performance and assessment. Immediately after each evaluation scenario, the patient-actor subjectively assessed the quality of staff-patient interaction using three 5-point Likert scales (strongly disagree = 1; disagree = 2; neither agree nor disagree = 3; agree = 4; strongly agree = 5): (a) Communication: “I felt well informed due to good communication,” (b) Respect: “I felt I was treated with respect at all times,” and (c) Safety: “I felt safe at all times.”

The teams were also assessed, with rating scales (1 worst, 5 best), for their generic team working (Skills, Behavior and Overall) using a reliable teamwork analytical tool developed and validated by Weller et al (Table 1).22 All the evaluations were undertaken by two trained external assessors (a doctor and a midwife), working independently, who viewed the digital video recordings in different sequences randomly generated by computer, blind to the site, the timing, and type of training. If there was a discordance, a third independent assessor (also a doctor) scored the team and average of the scores was used, rounded to the nearest integer.21

For this new study, a language and communication specialist also ranked the teams in respect of global assessment of teamwork after reviewing the recordings, blind to other scores. This was a subjective assessment. After familiarization with the recordings, the language and communication specialist initially independently divided teams into excellent (six teams—no problems), good (three teams—good teamwork, minor leadership issues), reasonable (six teams—several minor issues each, such as initiation then abandonment of tasks), and suboptimal (four teams—many minor issues and some major ones also, including lack of direction, shouting, aggressive behavior, and what appeared to be competition for the lead). The specialist then reviewed the video records again and ranked teams within each category from best to worst, creating a summary list of 19 teams that were ranked from 1 to 19 (best overall to worst overall).

For staff-patient interaction, in the absence of specific literature for acute medical events, the choice of variables was informed by the findings of multiprofessional focus groups with randomly chosen maternity staff from the same units: obstetricians, midwives, and health care assistants, facilitated by two social scientists. This development process added face and content validity. Subsequently, two further assessors, one clinician and one language and communication specialist, different to the ones who had determined generic teamwork scores for each team and blind to these teamwork scores, reviewed the videos together to assess staff-patient interaction using these variables that evolved from the focus group discussions. The final list of verbal and nonverbal interaction factors and the assessment criteria are described in Table 2.

Back to Top | Article Outline

The participants were not aware of the nature of the simulation before it started. The patient-actors and all the members of the evaluation team were blind to any other recorded measure or outcome.

Back to Top | Article Outline
Statistical Methods

Because of the ordinal nature of the patient perception scores, we used nonparametric methods [Kendall's rank correlation coefficient (taub) and Mann-Whitney U tests], with appropriate corrections for ties, to study their relationships with teamwork and communication variables. Statistical significance was set at P < 0.05.

For descriptive purposes, we also calculated summary statistics for the better and worse teams for each aspect of patient perception (communication, safety, and respect). Better were teams that achieved a score of 4 or 5 for each aspect of patient perception, and worse were teams that achieved a score of 1 to 3.

Back to Top | Article Outline

Ethical approval was granted from a Regional Research Ethics Committee (Southwest Devon MREC 04/Q2103/68). Further approval to extend the analysis was granted from a local Research Ethics Committee (Southmead REC 09/H0102/40).

Back to Top | Article Outline


Although 24 teams had undergone evaluation, one simulation was not recorded because of a fault in the recording equipment, and four teams were incomplete (five members only) because of failure of individual attendance. For one more team, the patient perception scores were not recorded. To ensure team comparability, we report here on the remaining 18 teams whose 108 participants had complete audiovisual records and evaluation scores with no missing data. A flowchart has been published.21

Inter-rater agreement for the generic teamwork scores was moderate (kappa = 0.44). Scores by the two teamwork reviewers were identical for 27 of 47 assessments and only differed by more than 1 point on the Likert scale for two assessments in the global teamwork scale. There was significant correlation between the ranking of the teams by a language and communication specialist and the teamwork scores given by the two (or average of three where discordant) clinical assessors for overall teamwork (taub [approximate 95% confidence interval] −0.50 [−0.79 to 0.22], P = 0.008) and behavior (−0.54 [−0.75 to 0.32], P = 0.003). The correlation was not significant for skills (−0.36 [−0.72 to 0.01], P = 0.057).

There was large variation in staff-patient interaction practices, as well as in teamwork and patient perception scores. Some teams did not exchange a single word or interacted at all with the patient-actor during the simulation other than to perform a clinical task (Table 3).

There was significant correlation (Table 4) between patient-actor perception of communication and the number and duration (0.66 [0.52–0.79], P = 0.001 and 0.48 [0.24–0.73], P = 0.015, respectively) of communication episodes.

There was significant correlation between patient-actor perception of safety and the teamwork skills scores of the teams (0.47 [0.19–0.75], P = 0.030). The patient-actor perception of safety was better when the content of the communication episodes included (Mann-Whitney U test) possible cause(s) of the emergency (P = 0.045), the condition of their baby (P = 0.038), and the ultimate treatment (need to expedite delivery after the mother is stabilized) (P = 0.028).

Finally, patient-actor perception of respect was significantly correlated with the teamwork behavior scores of the teams (0.58 [0.35–0.81], P = 0.008), as well as the number and total duration of communication episodes (0.49 [0.20–0.78], P = 0.020 and 0.43 [0.05–0.81], P = 0.036). Respect scores were better when the content of the communication episodes with the patient (actor) included the condition of their baby (Mann-Whitney U test, P = 0.021).

There were no other statistically significant associations in this study, including a lack of association between patient perception scores and the selected nonverbal interaction variables (number and duration of episodes of nonclinical contact with the patient-actor).

Table 5 shows summary statistics for the better and worse teams for each aspect of the patient perception.

Back to Top | Article Outline


In this study of frontline staff from a large UK region, there was significant variation in communication with patient-actors during a simulated medical emergency, with some teams not exchanging a single word and others striving to interact. The more the teams interacted with the patient-actors, verbally or nonverbally, the better the perception by patient-actors.

It was perhaps not surprising that the number and total duration of communication episodes was significantly associated with the patient-actors' perceptions. It is very likely that the ethnic, racial, and social background of the patient makes a difference with regard to both the content and delivery of information in such context. However, a systematic review of the factors affecting maternal satisfaction indicated that the behavior of the caregivers and their relationship with the patient was a far more powerful determinant of satisfaction than any clinical or demographic factor measured in the included studies.23 A systematic review of satisfaction with emergency departments also concluded that, while age and race of the patient influenced satisfaction in some studies, the key intervention to improve satisfaction with emergency care would be to improve the interaction skills of staff and the amount of information they provide to patients.24

Although previous studies have shown that training with patient-actors per se improves the communication skills of both clinical staff18 and undergraduate students,19 this study goes further to indicate that, for acute emergencies, three or four specific sentences might make the difference between adequate and inadequate amount of information. Such a modification in practice could easily be incorporated into obstetric emergency training to improve the communication of information between the medical practitioners and the patient.

There was no significant association in this study between patient perceptions and the number or duration of nonverbal interaction episodes, despite the qualitative observation that some members of staff strived to maintain physical contact with the patient-actor for her reassurance, often having to stretch their arms to reach for catheters and other equipment while in contact. The observation of these behaviors possibly indicates that there was immersion of these participants in the simulation. However, the lack of significant association between these nonverbal episodes and patient-actor perceptions in this study might have been influenced by the design of the simulation scenario or the power of the study. There is a need for further research into the significance of nonverbal interaction, possibly with interviews with staff and real patients.

Furthermore, this study also underlined the importance of good teamwork not only for better physical25,26 but also for better psychologic patient outcome. The critical role of teamwork is in agreement with the top priorities set by the World Health Organization27 and offers extra support to the call for research into better team training in obstetrics28,29 or any profession where teams may face acute events.30

The use of simulated data in this study might be perceived as a constraint. However, in view of the paucity of relevant evidence, the findings are useful to understand the prevailing practices of acute teams and inform further research with real patients. Another limitation of this study was that the sample size was selected for the original SaFE randomized trial and was not based on a power calculation specific to this study; this might be relevant to findings without statistical significance. Further work is needed, including the study of real patients. However, it should be acknowledged that the feasibility of large-scale recruitment of pregnant women to studies of video-recorded real-life acute events, including catastrophic obstetric emergencies, might be questionable.

Moreover, this study was limited to maternity units in a high-income country. In other settings, different factors might be more relevant; for example, continuous support in labor was strongly associated with maternal satisfaction in 11 countries in a Cochrane Systematic Review of 16 randomized trials.31 According to the World Health Organization, better communication and consideration of human factors are a top safety priority in “developed” and “transitional” countries, but even in “developing” ones, better maternity care and staff training are two of the top five research priorities.27

The main strength of this study was the use of tools with face and construct validity for simulated and real-life obstetric emergencies.18–21,26,32 There was no reliance on self-assessments by the participants, which are unreliable and inaccurate, particularly for transferable skills and behaviors.33–37 Randomization and masking reduced the risk of bias, and the involvement of clinicians, social scientists, and patient-actors added external validity to the assessments by increasing the number of perspectives that were covered.

Even though some studies and systematic reviews have addressed satisfaction with admissions to emergency departments,24,38 or childbirth,23 the content of communication in the context of a very acute event has not been studied before. This study revealed that many teams did not communicate simple, but possibly crucial, items of information to the patient-actor. If this finding reflects accurately communication practices with real patients, it clearly indicates a need for specific training to address such deficiencies in communication.

Studies with real patients could explore these issues further, for example by videorecording actual team communication behaviors in emergencies to triangulate the evidence with the findings in simulation. Interviews with patients could also cast light on the importance of communication behaviors and the impact they have on patient experience. The findings from this study, together with evidence from future research, could also inform multiprofessional team training with patient-actors,29 teaching frontline teams how to communicate with patients and with each other39 in the heat of emergencies. Such training should start from undergraduate level19,40 and continue into postgraduate professional development,29 involving as many professions as realistically possible.29,41 Ideally, individuals should train with colleagues from their clinical setting, using scenarios they are likely to encounter, the facilities available, and realistic and cost-effective tools.29 This method of training may be more likely to have an impact on what they do for real patients.

In conclusion, patient dissatisfaction is a poor outcome for health care; it is certainly significant and possibly preventable. This study is the first to show specific teamwork and communication practices that varied among frontline teams; improving these practices could increase patient satisfaction with the immediate management of acute events and optimize patient experience. These findings could inform specific training to reduce patient harm, complaints, and litigation, as well as further research.

Back to Top | Article Outline


1. Hickson GB, Clayton EW, Entman SS, et al. Obstetricians' prior malpractice experience and patients' satisfaction with care. JAMA 1994;272:1583–1587.
2. Healthcare Commission. Spotlight on complaints: a report on second-stage complaints about the NHS in England. London: Healthcare Commission; 2009.
3. White AA, Pichert JW, Bledsoe SH, Irwin C, Entman SS. Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol 2005;105:1031–1038.
4. Taylor DM, Wolfe RS, Cameron PA. Analysis of complaints lodged by patients attending Victorian hospitals, 1997–2001. Med J Aust 2004;181:31–35.
5. Neale G. Clinical analysis of 100 medicolegal cases. BMJ 1993;307:1483–1487.
6. Cherouny P, Federico FA, Haraden C, et al. Idealized Design of Perinatal Care. IHI Innovation Series White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2005.
7. Royal College of Obstetricians and Gynaecologists. Maternity Dashboard: Clinical Performance and Governance Score Card (Good Practice Guideline No. 7). London: RCOG Press; 2008.
8. Draycott T, Sibanda T, Laxton C, Winter C, Mahmood T, Fox R. Quality improvement demands quality measurement. BJOG 2010;117:1571–1574.
9. Department of Health. The NHS Outcomes Framework 2011/12; 2010.
10. Waldenstrom U, Hildingsson I, Rubertsson C, Radestad I. A negative birth experience: prevalence and risk factors in a national sample. Birth 2004;31:17–27.
11. Roberts N, Kitchiner NJ, Kenardy J, Bisson JI. Multiple session early psychological interventions for the prevention of post-traumatic stress disorder. Cochrane Database Syst Rev 2009:CD006869.
12. Rowan C, Bick D, Bastos MH. Postnatal debriefing interventions to prevent maternal mental health problems after birth: exploring the gap between the evidence and UK policy and practice. Worldviews Evid Based Nurs 2007;4:97–105.
13. Murphy DJ, Pope C, Frost J, Liebling RE. Women's views on the impact of operative delivery in the second stage of labour: qualitative interview study. BMJ 2003;327:1132–1136.
14. Uotila JT, Taurio K, Salmelin R, Kirkinen P. Traumatic experience with vacuum extraction—influence of personal preparation, physiology, and treatment during labor. J Perinat Med 2005;33:373–378.
15. Goodman P, Mackey MC, Tavakoli AS. Factors related to childbirth satisfaction. J Adv Nurs 2004;46:212–219.
16. Waldenstrom U, Rudman A, Hildingsson I. Intrapartum and postpartum care in Sweden: women's opinions and risk factors for not being satisfied. Acta Obstet Gynecol Scand 2006;85:551–560.
17. Kingdon C, Neilson J, Singleton V, et al. Choice and birth method: mixed-method study of caesarean delivery for maternal request. BJOG 2009;116:886–895.
18. Crofts JF, Bartlett C, Ellis D, et al. Patient-actor perception of care: a comparison of obstetric emergency training using manikins and patient-actors. Qual Saf Health Care 2008;17:20–24.
19. Siassakos D, Draycott T, O'Brien K, Kenyon C, Bartlett C, Fox R. Exploratory randomized controlled trial of hybrid obstetric simulation training for undergraduate students. Simul Healthc 2010;5:193–198.
20. Siassakos D, Clark J, Sibanda T, et al. A simple tool to measure patient perceptions of operative birth. BJOG 2009;116:1755–1761.
21. Ellis D, Crofts JF, Hunt LP, Read M, Fox R, James M. Hospital, simulation center, and teamwork training for eclampsia management: a randomized controlled trial. Obstet Gynecol 2008;111:723–731.
22. Weller JM, Bloch M, Young S, et al. Evaluation of high fidelity patient simulator in assessment of performance of anaesthetists. Br J Anaesth 2003;90:43–47.
23. Hodnett ED. Pain and women's satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol 2002;186:S160–S172.
24. Taylor C, Benger JR. Patient satisfaction in emergency medicine. Emerg Med J 2004;21:528–532.
25. Siassakos D, Draycott TJ, Crofts JF, Hunt LP, Winter C, Fox R. More to teamwork than knowledge, skill and attitude. BJOG 2010;117:1262–1269.
26. Siassakos D, Fox R, Crofts JF, Hunt LP, Winter C, Draycott TJ. The management of a simulated emergency: better teamwork, better performance. Resuscitation 2011;82:203–206.
27. Bates DW, Larizgoitia I, Prasopa-Plaizier N, Jha AK; Research Priority Setting Working Group of the WHO World Alliance for Patient Safety. Global priorities for patient safety research. BMJ 2009;338:1242–1243.
28. Merien AE, van de Ven J, Mol BW, Houterman S, Oei SG. Multidisciplinary team training in a simulation setting for acute obstetric emergencies: a systematic review. Obstet Gynecol 2010;115:1021–1031.
29. Siassakos D, Crofts JF, Winter C, Weiner CP, Draycott TJ. The active components of effective training in obstetric emergencies. BJOG 2009;116:1028–1032.
30. Salas E, Wilson KA, Burke CS, Wightman DC. Does crew resource management training work? An update, an extension, and some critical needs. Hum Factors 2006;48:392–412.
31. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2007:CD003766.
32. Strachan B, Crofts J, James M, et al. Proof of Principle Study of the Effect of Individual and Team Drill on the Ability of Labour Ward Staff to Manage Acute Obstetric Emergencies. Edgbaston, Birmingham: PSRP, Department of Health, Public Health, Epidemiology & Biostatistics, University of Birmingham; 2008.
33. Weller JM, Robinson BJ, Jolly B, et al. Psychometric characteristics of simulation-based assessment in anaesthesia and accuracy of self-assessed scores. Anaesthesia 2005;60:245–250.
34. Shapiro MJ, Gardner R, Godwin SA, et al. Defining team performance for simulation-based training: methodology, metrics, and opportunities for emergency medicine. Acad Emerg Med 2008;15:1088–1097.
35. Paige JT, Aaron DL, Yang T, et al. Implementation of a preoperative briefing protocol improves accuracy of teamwork assessment in the operating room. Am Surg 2008;74:817–823.
36. Moorthy K, Munz Y, Adams S, Pandey V, Darzi A; Imperial College—St. Mary's Hospital Simulation Group. Self-assessment of performance among surgical trainees during simulated procedures in a simulated operating theater. Am J Surg 2006;192:114–118.
37. Morgan PJ, Pittini R, Regehr G, Marrs C, Haley MF. Evaluating teamwork in a simulated obstetric environment. Anesthesiology 2007;106:907–915.
38. Gordon J, Sheppard LA, Anaf S. The patient experience in the emergency department: a systematic synthesis of qualitative research. Int Emerg Nurs 2010;18:80–88.
39. Siassakos D, Bristowe K, Draycott T, et al. Clinical efficiency in a simulated emergency—association with team behaviours: cross-sectional observational study. BJOG 2011;118:596–607.
40. Siassakos D, Timmons C, Hogg F, Epee M, Marshall L, Draycott T. Evaluation of a strategy to improve undergraduate experience in obstetrics and gynaecology. Med Educ 2009;43:669–673.
41. Siassakos D, Fox R, Hunt L, et al. Attitudes toward safety and teamwork in a maternity unit with embedded team training. Am J Med Qual 2011;26:132–137.

Team training; Teamwork; Patient satisfaction; Medical education; Communication skills; Obstetric; Standardized patient

© 2011 Society for Simulation in Healthcare