Clear and effective communication among and between obstetric and pediatric professionals participating in high-risk deliveries is crucial to providing safe medical care to women and their newborn infants. However, the Joint Commission on Accreditation of Healthcare Organizations reports that communication breakdown occurs in approximately 70% of sentinel events that result in either perinatal mortality or permanent disability.1 Furthermore, communication failures among health care providers or between providers and families can lead to perinatal adverse events and patient dissatisfaction, resulting in preventable litigation.2,3
Because patient care is interprofessional and often involves the expertise of multiple disciplines, national health care organizations have challenged institutions to standardize handoff communication4 and implement interdisciplinary team training through the use of simulation and debriefing.5–8 The medical and nursing literature on simulation-based training (SBT) demonstrates that SBT can improve learner confidence, patient care skills, team function, and patient outcomes.9–11 For obstetric and pediatric professionals who interface as specialized teams during high-risk deliveries to provide maternal, fetal, and newborn care, SBT may promote interdisciplinary collaboration, help establish potentially better practices in perinatal care, and ultimately lead to improved neonatal outcomes, as has been demonstrated in cases of brachial plexus injury or hypoxic ischemic encephalopathy.12–15
The literature in perinatology identifies sources of communication problems among obstetric and pediatric providers that include the unavailability of prenatal information, failure to express concerns or clearly define problems, and inadequate counseling of patients and families.1,16–18 Despite this, perinatal research investigating the effectiveness of SBT on improving team dynamics has mainly focused on the behavioral aspects of communication and teamwork (eg, closing the loop of communication, asserting one’s concerns, making recommendations, etc) rather than on improving the quality of maternal, fetal and newborn information shared between obstetric and pediatric providers and/or between providers and families. Furthermore, standardized communication tools (eg, Situation, Background, Assessment, Recommendation; Introduction, Patient, Assessment, Situation, Safety concerns; Background, Actions, Timing, Ownership, Next, etc)19 used across medicine are mainly designed for information sharing during the transfer of patient care from one caregiver to another and thus are not completely applicable in the delivery room where the purpose of information sharing between teams is to improve the coordination and simultaneous care of the mother and newborn. Although there are validated tools in obstetrics that aim to assess teamwork and communication behaviors,20,21 a tool to standardize delivery room communication has not been published.
In this article, the authors describe the development of a delivery room communication checklist and an innovative interdisciplinary SBT program to improve communication between obstetric and pediatric teams and between providers and families in the delivery room. The authors hypothesized that provider participation in SBT would improve information sharing during SBT and provider perception of communication during actual high-risk deliveries.
Study Approval, Setting, and Participants
This was a prospective, longitudinal, observational study that was approved by the institutional review board at the University of Rochester Medical Center, a tertiary medical center with a 60-bed level IV neonatal intensive care unit (NICU). During the study period (3 academic years, 2008–2011), a total of 228 medical and nursing providers from the obstetric and pediatric departments performed patient care during high-risk deliveries that required the presence of the pediatric team from the NICU. These providers were eligible for participation in the study and included attendings (community obstetricians, perinatologists, and neonatologists), fellows (maternal-fetal-medicine and neonatal-perinatal), house staff (obstetric, medicine-pediatric, and pediatric), pediatric hospitalists, neonatal nurse practitioners, and obstetric and neonatal nurses. Provider participation in SBT was a medical center and/or departmental expectation because it was part of a patient safety initiative to improve interdisciplinary communication and teamwork. Scheduled providers who were unable to participate were rescheduled or excused until the following year. Although providers were expected to participate in training, they were given an opportunity to decline participation in the research component that consisted of analysis of the videotaped simulations for team communication.
Needs Assessment and Program Development
Overview of Needs Assessment
Investigators (R.D., J.W.) conducted a systematic needs assessment22 to identify strengths and opportunities for improvement in communication and collaboration among obstetric and pediatric providers during high-risk deliveries (Fig. 1). Referencing different frameworks on communication and teamwork from the literature,23–26 they reviewed, took field notes, and discussed emerging themes on communication and teamwork behaviors from various sources including historical experience (from root cause analyses), provider commentaries (from debriefings after delivery room events and discussions at interdisciplinary conferences), and direct observation of provider performance (during actual deliveries and pilot simulations of deliveries). From the needs assessment, study faculty identified gaps in both interdisciplinary communication between obstetric and pediatric teams and communication between the pediatric team and families as areas of focus during training. They proceeded to develop an interdisciplinary SBT program and evaluation tools that included a survey and checklist on delivery room communication.
Investigators sought a survey that would guide the development of learning objectives for the SBT program by identifying the providers’ impressions of strengths and weaknesses in communication and teamwork during high-risk deliveries. The survey would also serve as a program evaluation tool by tracking changes in provider perceptions on communication during deliveries with ongoing training. Investigators reviewed published surveys that explored attitudes on patient safety and hospital culture.27–29 They sought a survey that was specific to delivery room care, asked questions related to interdisciplinary and interprofessional team interactions and communication with families, and included open-ended questions to allow for comments. Because no individual survey satisfied the previously mentioned criteria, the investigators developed a new survey to meet specific programmatic needs.
During development, the survey underwent several iterations of review and revision, based on expert opinion and pilot testing. A 5-member interdisciplinary and interprofessional team of neonatologists, perinatologists, and perinatal safety nurse was selected because of their clinical expertise during high-risk deliveries and experience working with the institution’s risk management department. They assessed the survey for content validity and provided constructive feedback. The survey was subsequently piloted with a group of educational specialists and senior obstetric and pediatric providers and again with a group of junior providers (n = 10), to test for clarity of content and feasibility. The result was a 2-part survey on provider attitudes and perceptions about communication and collaboration during high-risk deliveries. The first part of the survey asked providers to rate their level of agreement with 18 statements on communication and teamwork (subset of survey statements are shown in Table 1), using a 5-point Likert scale (1 to 5; “strongly disagree” to “strongly agree”). The second part of the survey asked providers to comment on specific areas of communication strengths and weaknesses, within both their own team and the collaborating team and with the family.
The investigators constructed a 20-item delivery room checklist that consisted of vital handoff information, feedback communication, and communication behaviors (Table 2). These items were divided into 4 categories related to the specific groups of individuals exchanging information (between obstetric and pediatric teams as well as between the pediatric team and family) and to the timing of communication in relation to the delivery (before and during delivery as well as after delivery and stabilization of the newborn).
The checklist underwent development, iterative review and revisions with expert opinion, and pilot testing, as described in the literature.30,31 Investigators tested the checklist during high-risk deliveries (n = 5) and pilot simulations (n = 5) for relevance, clarity, and feasibility. Checklist items were revised in several phases before finalization. Specific sources of evidence for construct validity, per guidelines from the Standards for Educational and Psychological Testing,32 are presented in Table 3.1,17,26,30,32,33
Program Implementation and Evaluation
This was a prospective, longitudinal, observational study (Fig. 2). During the fall of each academic year, providers were surveyed on their experiences of delivery room communication during the previous year. Investigators either e-mailed or handed the surveys directly to participants. The surveys were returned either by intramural mail or in batched collections by program faculty to allow for anonymity.
SBT and Video Review With Checklist
Subsequently during the fall and winter months, providers participated in interdisciplinary SBT, which consisted of simulated deliveries followed by facilitated debriefings. During any given year, providers participated in a similar delivery room scenario. Scenarios were standardized to provide participating teams with the same maternal and fetal history, maternal and newborn presentation, and clinical course. The scenario changed annually. Each year, program faculty worked with the perinatal safety nurse and the institution’s risk management group to develop scenarios from learning opportunities identified as high priority (Tables A1–3). During year 1 (2008–2009) and year 3 (2010–2011), the scenarios were based on shoulder dystocia deliveries, with differences in maternal and newborn presentation. During year 2 (2009–2010), the scenario was based on an actual maternal resuscitation that had resulted in an emergency cesarean delivery in the labor and delivery unit.
Simulation-based training sessions were conducted at the Center for Obstetric and Gynecology Simulation using mother and infant mannequins (S575 Noelle and Newborn Hal, Gaumard Scientific, Miami, FL). Eligible providers were scheduled to participate in SBT as part of interprofessional teams comprised of 6 to 9 obstetric and 3 to 5 pediatric providers with various levels of experience.
Each SBT session lasted 90 minutes. Providers were briefed on the learning objectives and oriented to the simulation facility and mannequins. After this orientation, obstetric and pediatric teams participated in the simulated delivery. Each simulation started with an obstetric nurse triaging the laboring woman. Remaining providers participated in the simulation as their assistance was sought. A standardized actor portrayed the laboring woman’s voice, and another acted as a family member. If participating teams deviated from the overall goals of the simulated scenario, the actors provided prescripted cues to help redirect teams. Simulations were videotaped to allow for enhanced learning among participating providers during facilitated debriefings and for later review by the study team.
Facilitated debriefings were conducted by a core group of 3 facilitators who completed nationally recognized simulation instructor courses. Debriefings occurred immediately after the simulations. The obstetric and pediatric teams separately discussed communication and teamwork within their respective teams, and then, both teams and the actors portraying the family members joined to discuss communication between teams and with the family. Facilitators blended the plus-delta and defusing, discovering and deepening models of debriefing during discussions, so there was an opportunity for participants to express their experiences and emotions from the simulation experience, reflect as a group by identifying examples of effective communication and opportunities for improvement, and conclude by stating how they will translate ideas discussed during the debriefing to patient care.34,35 Discussions during team debriefings were mainly directed by participating providers. On occasion, facilitators would redirect discussions to ensure that participants talked about team communication. The specific contents of the checklist were not shared with providers.
After all SBT sessions from each year were completed, the study team used the spring and summer months for program evaluation and preparation of the SBT curriculum for the following academic year. During this time, 2 to 4 members of the study team reviewed each video of the simulated deliveries using the checklist.
All data analyses were conducted with SAS version 9.2 (SAS Institute Inc, Cary, NC). Significance was accepted at P < 0.05. Survey ratings and checklist scores were either reported as medians with the interquartile range (IQR) or as means (SD). Provider characteristics such as position, years of experience, and past participation in SBT were summarized by study year and compared among the years using the χ2 or Mantel-Haenszel test, as appropriate.
Cronbach α was used to test for internal consistency of the survey for each year and across years 1 to 3. Two-way analysis of covariance was performed to test the effects of study year and provider team on Likert scale ratings on communication between teams and communication with the family, after controlling for years of provider experience and past participation in SBT. The interaction between study year and provider team was also investigated. Pairwise comparisons among the study years were also performed, but because these were considered to be a post hoc analysis, no multiple testing justifications were made. Written survey comments by providers were analyzed using the principles of grounded theory.36 Investigators independently reviewed all comments and abstracted key themes. After reviewing the first 20 surveys, they compared, discussed, and reached consensus on identified themes and then proceeded to repeat the review process for the rest of the surveys in batches of 20. Comments were either categorized into preexisting themes or placed into new thematic categories. This process continued until all comments were categorized. The frequency of responses by theme was tallied.
The interrater reliability of checklist scores from years 1, 2, and 3 among 4, 3, and 2 independent raters, respectively, was calculated using the intraclass correlation coefficient and reported with 95% confidence intervals. The overall interrater reliability for all 3 years was also calculated. Checklist scores were compared using the Wilcoxon rank sum and Kruskal-Wallis tests.
Each year, 70% to 86% of eligible providers completed the survey on communication during actual high-risk deliveries. Reliability analysis for the survey on communication during deliveries revealed good internal consistency with Cronbach α coefficients of 0.80, 0.85, 0.81, and 0.82 for years 1, 2, 3, and all 3 years, respectively. Table 4 provides the characteristics of survey respondents. The relative proportion of medical and nursing providers by position remained similar. However, preliminary analysis showed that years of provider experience and past participation in SBT increased with time during the study period (P = 0.01). After controlling for these covariates using analysis of covariance, survey results revealed that providers from both the obstetric and pediatric teams perceived significant improvements in communication between teams over time (P < 0.005 and P < 0.0001, respectively; Fig. 3A and Table 1, statements 1–6). In addition, obstetric providers rated pediatric communication with families higher over time, with a significant difference between years 1 and 3 (P < 0.05; Fig. 3B and Table 1, statement 7). In contrast, pediatric providers rated communication with families consistently high across the study period (Fig. 3B).
The providers’ written comments on surveys during the study period revealed 10 major categorical and 57 subcategorical themes related to team communication and collaboration. The most common major themes were (1) the need for improved obstetric-to-pediatric handoff communication on maternal and fetal status before delivery, (2) the need for improved pediatric-to-obstetric feedback on infant status after stabilization, and (3) barriers preventing effective team-to-team communication (36%, 36%, and 14% of 663 comments, respectively). Samples of providers’ comments are shown in Table 5.
There was excellent interrater reliability when the reviewers used the checklist to independently assess team communication during SBT. The intraclass correlation coefficients and 95% confidence intervals for each year and all 3 years were as follows: year 1, 0.88 (0.85–0.95); year 2, 0.96 (0.91–0.98); year 3, 0.96 (0.89–0.99); and all 3 years, 0.95 (0.91–0.97).
Each year, 56% to 69% of eligible providers participated in both SBT and the study (Fig. 2 and Table 6). The composition of SBT teams was similar during over the 3-year study period with 2 exceptions during year 3. Neonatal nurse practitioners were not able to participate owing to scheduling conflicts, whereas the participation of neonatologists increased after the introduction of an incentive to use SBT to reduce malpractice premiums. The overall proportion of eligible providers who participated in 2 or more SBT sessions increased over time, from 31% during year 2 to 55% during year 3 (Table 6).
Analysis of checklist scores on team communication during SBT included review of 47 of a total of 48 sessions. One SBT session during year 1 was excluded from the analysis because it was inadvertently not videotaped. Of a total possible score of 20, median checklist scores on communication during SBT improved incrementally from year 1 to 3 (year 1: median, 6; IQR, 4; year 2: median, 8; IQR, 4; year 3: median, 11; IQR, 6; P < 0.001) (Fig. 4). Communication that showed the most improvement was (1) information exchanged between the obstetric and pediatric teams when the pediatric team arrived at the delivery and (2) communication by the pediatric team with the family after newborn stabilization (Table 2). In each of the study years, participating teams showed variability in their coverage of checklist items, with teams performing 25% to 80% of items.
The investigators developed an innovative SBT program to train interprofessional providers on effective interdisciplinary team communication and to provide facilitated debriefings to discuss the specific types of information that should be communicated during deliveries. The authors also provided validity evidence for a 20-item checklist on delivery room communication and demonstrated, using the checklist to assess annual simulated high-risk deliveries, an increase during a 3-year period in sharing of vital information between obstetric and pediatric teams as well as between providers and families.
Although various educational methods, including SBT, have been used to teach handoffs, only a limited number of studies demonstrate the efficacy of these educational interventions.37 Our results show that the incremental increase in checklist scores between years 2 and 3 was greater than that seen between years 1 and 2. The overall proportion of eligible providers who had previously participated in at least 1 previous SBT session increased from 31% in year 2 to 55% in year 3 (Table 6). These participants may have role-modeled “best practices” in communication behaviors and information sharing to novice learners, resulting in more effective learning. The greater improvement in communication attributable to the learning of previous participants may be an educational analogy to the medical phenomenon of “herd immunity”38; the learned knowledge and experience of a significant portion of the teams may elevate the overall function and communication practices of the whole team, although novice learners may not have participated in previous training.
Although overall team communication improved after annual sessions of SBT were implemented, the range of checklist scores during any given year demonstrated variability in communication from team to team (Fig. 4). The literature on SBT shows that debriefing contributes profoundly to learning during SBT.10,39,40 Participating providers learn through self-discovery and realization by discussing communication elements that they feel are important to team functioning, barriers to effective communication, and strategies to improve current communication practices. However, the quality of learning during debriefings is dependent on the facilitator’s experience and skills, as well as the breadth and depth of discussion by participating providers.41,42 Although facilitators used a similar approach and guided debriefings to ensure that team communication was discussed, they remained cognizant of the need to balance provider and facilitator contribution. The level of participation by providers and the specific communication points that they talked about influenced the richness of discussions. This factor may have affected learning during some of the debriefings and thus contributed to differences in future performances by teams. The variability noted in team communication may be reduced by adopting a more directive facilitation approach to debriefings.
Another method to reduce variability of team performance may be to standardize communication by sharing the contents of the checklist with providers and implementing the checklist by participants during SBT and actual practice. As seen with other areas of medicine, checklists can be very powerful in improving communication, reducing patient complications, and improving care.43–46 Although there are no known perinatal studies that examine the effect of delivery room communication breakdown on neonatal outcomes, studies have shown that handoffs in other disciplines of medicine, including handoffs during presurgical briefings between anesthesiologists and surgeons, have been associated with near misses or adverse outcomes.23,47–49 Hence, an interdisciplinary SBT program on delivery room communication may be an effective strategy to mitigate or prevent delivery room complications.
In addition to improved team communication during SBT sessions, survey data revealed significant improvements in provider perception of communication practices during actual high-risk deliveries (Fig. 3). Likert scale ratings of communication increased during the 3-year study period. This finding suggests that providers may be applying knowledge learned from SBT to patient care. Greater provider satisfaction associated with improved collaboration in delivery room care may be achieved by standardizing communication during deliveries, as seen in a previous study that implemented presurgical huddles or briefings by surgeons and anesthesiologists.50 In addition, comments written by providers give insight into communication barriers and areas for improvement (Table 5). Some identified problems may be systems-based issues that can be targeted for quality improvement (eg, identifying a consistent obstetric provider to share maternal and fetal history with the pediatric team at deliveries). On the other hand, other identified areas for improvement (eg, reminding pediatric providers to consistently give timely feedback to both the obstetric team and to families) can be targeted as specific learning objectives and reinforced during SBT and in clinical practice to improve interdepartmental relations and family-centered patient care.
Limitations of our study are primarily methodological. Because the SBT program was evaluated annually to provide the opportunity to make modifications to the curriculum for the following year, faculty who reviewed the videos using the checklist were not blinded to the timing of simulations. To mitigate the potential of a measurement bias, at least 2 reviewers rated each video independently.
Another limitation is that interpretation of changes in checklist scores and survey results across years was complicated by the participation of different combinations of providers in SBT each year. The variability in the skills of providers who constituted each team being trained was reduced because teams in each year were composed of a similar mixture of junior and more experienced providers. Educationally, inclusion of previously trained providers in years 2 and 3 was probably beneficial. From the research perspective, the results would have been more pure if providers could have been randomized to either a group who received SBT or to a control group. However, this separation of groups would have been untenable during the study period, and intergroup contamination would have been unavoidable.
Checklist scores on communication during SBT sessions may not accurately reflect provider practice during actual high-risk deliveries because SBT does not completely replicate patient care experiences. However, simulation scenarios were designed to challenge providers and place stress on their communication skills. Hence, deficiencies in communication noted during simulations may reflect areas of communication that are also likely to break down during deliveries, when unpredicted events occur. Using the checklist to evaluate communication during actual deliveries will help clarify whether specific communication patterns observed during SBT are similar to those that occur during deliveries.
The checklist may prove in the future to be a useful tool to help providers recall types of information that are important to communicate during deliveries, but the tool itself cannot assess for accuracy of information communicated between providers in clinical practice. Moreover, the items on the checklist were not weighted according to their relative importance, as perceived by providers and families, or assessed for their potential impact on patient care. These options can be further explored in a future study to strengthen the checklist as a team assessment tool.
A final limitation is that our observed improvement in communication during the study period may not be entirely due to SBT; concurrent initiatives may also have contributed. In particular, interdisciplinary debriefings after actual acute patient events began during this period. However, participation in the debriefing component of SBT may have accustomed providers to the critical review of events during high-stress delivery room care, thus making the actual debriefing sessions better accepted and more productive.
Interdisciplinary SBT may be an effective experiential learning strategy to improve communication between obstetric and pediatric teams as well as between providers and family members during simulated high-risk deliveries. Although this study was conducted in a tertiary academic institution, effective communication during deliveries in any institution may mitigate patient complications and improve neonatal outcomes. In such training and in actual patient care, standardized delivery room communication using a checklist of critical items has the potential to reduce variability in communication and help promote safer medical and family-centered patient care. The potential impact of using the checklist developed in this study in the clinical care setting needs further evaluation.
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Keywords:© 2013 Society for Simulation in Healthcare
Checklist; Communication; Delivery room; Handoff; Patient safety; Simulation; Team training