The importance of communication in obstetrics has been frequently highlighted; the American Joint Commission of Accreditation of Healthcare Organizations implicated failure of communication as the most common root cause in cases of perinatal death or permanent disability.1 Similarly, in England and Wales the National Confidential Enquiries into Maternal Deaths and the Confidential Enquiries into Stillbirths and Deaths in Infancy have repeatedly highlighted the lack of communication and teamwork within the obstetric and midwifery teams as a leading root cause in maternal and perinatal deaths.2^–5

A patient cared for by an obstetrician with a high number of previous lawsuits is more likely to report that the obstetrician did not listen, was rude, and did not show them respect.67 A recent study investigating closed claims in obstetrics and gynaecology reported that in 14% of reviewed cases, communication problems had upset the patient or family. Communication had not affected the medical outcome but it had adversely affected patient satisfaction of care and provoked questioning of concern for their safety.8 In obstetrics, most procedures, and indeed crises, occur in conscious women, often accompanied by close family members. The multiprofessional team must therefore be able to simultaneously manage the emergency and attend to the needs of the woman and her birth partners.

Obstetric emergency and teamwork training have been repeatedly recommended in response to errors in obstetric care.1910 Training in simulation centres using computerised manikins has been proposed as an effective method of improving communication and teamwork.11 However, there is currently no evidence that this or any training improves clinical outcomes, or enhances patients’ perception of care. This study aimed to:

1. explore the effect of obstetric emergency training on patient-actor perception of communication, safety and respect during simulated obstetric emergencies;

2. investigate whether this perception of care was influenced by the method (local versus simulation centre) or content (clinical versus clinical and teamwork) of training.

METHODS

This study was part of a large randomised controlled trial—Simulation and Fire-drill Evaluation (SaFE)—commissioned by the Department of Health of England and Wales. The SaFE study used a 2×2 factorial design to evaluate simulation centre and local inhospital training, with and without additional teamwork training. In this article we investigate the effect of obstetric emergency training on patient-actor perception of their care.

Participants, midwives and doctors from six hospitals in the southwest of England were randomly recruited and subsequently randomised to one of four obstetric emergency training courses:

• 1-day clinical course conducted in their own hospital;

• 2-day clinical and teamwork course conducted in their own hospital;

• 1-day clinical course conducted at a central simulation centre;

• 2-day clinical and teamwork course conducted at a central simulation centre.

Details of the exclusion criteria, power calculation and recruitment (target 144 participants) have been previously published.12

All training regardless of the location (local hospital or simulation centre) or duration (1 or 2 days) contained the same clinical information. Clinical training drills at the simulation centre were conducted in a simulated clinical environment using computerised patient manikins. An observer as the patient in an adjacent room communicated with the treating clinical team via a microphone embedded within the manikin. Observations were generated by the computerised patient manikin in response to treatment. Clinical training drills in local hospitals were conducted in a delivery room with a patient-actor, who was scripted to communicate with the treating clinical team in a standard manner. The patient’s observations were given from a standardised list by the trainer when required.

Participants randomised to the 2-day training course received additional specific teamwork training on communication, roles and responsibilities, and situational awareness. We used lectures, video clips and activities to demonstrate each component of teamwork. Activities were non-clinical so as not to increase the clinical content of the 2-day course compared with the 1-day course.

All participants were assessed in their own hospital (regardless of whether they received local or simulation centre training) up to 3 weeks before and 3 weeks after training. Participants managed three standardised simulated obstetric emergency scenarios (eclampsia, postpartum haemorrhage (PPH) and shoulder dystocia) in a delivery room in their own local hospital. Two scenarios (eclampsia and PPH) were managed by a multiprofessional team (one junior and one senior doctor, two junior and two senior midwives) randomised to the same training intervention. These scenarios commenced with a standardised handover to a junior midwife, who could call for help from the rest of the team if required, and continued for 10 min. Shoulder dystocia was managed individually by all participants and lasted up to 5 min.

All evaluation scenarios used a patient-actor (an experienced midwife) who followed a standardised script and instructions during each emergency. Immediately after each evaluation scenario, the patient-actor subjectively assessed the quality of their care in relation to communication, safety and respect using three five-point Likert scales (strongly disagree = 1; disagree = 2; neither agree nor disagree = 3; agree = 4; strongly agree = 5):

• Communication: “I felt well informed due to good communication”

• Respect: “I felt I was treated with respect at all times”

• Safety: “I felt safe at all times”

All members of the evaluation team, including the patient-actor, were blinded to the participants’ training intervention. However, due to the timings of the evaluations, it was not possible for patient-actors to be blinded to whether the evaluation was before or after training. Patient-actors took part in a “patient-actor training day” to standardise scenarios and assessment and were not involved in any of the training interventions. After the evaluation scenarios, no feedback was given to participants on clinical management or interaction with the patient-actor. Post-training assessment was undertaken within 3 weeks of training. Clinical scenarios and patient-actors were unchanged from those used in the pretraining assessments; however, the scenarios were conducted in a different order.

Wilcoxon matched-pairs ranks test was used to look at overall change with training. Mann–Whitney U tests were used to look at the effects of the locality of training and teamwork training on post-training scores. Stata version 8 was used for statistical analysis.

RESULTS

At the start of the study, 975 staff were working in the maternity departments in the six participating hospitals, of whom 912 were eligible for inclusion. We approached 240 staff, and 158 gave consent to participate in the study. Of these, 18 subsequently withdrew from the study before the first evaluation. The target to recruit 144 staff was not achieved. Two junior doctors and one senior doctor could not be recruited due to clinical commitments and one midwife withdrew on the morning of the assessment due to illness; therefore 140 staff participated in the study.

Of the 140 participants, 136 attended training and 132 completed the post-training assessment (fig 1), a dropout rate of 8/140 (5.7%), all due to illness. Pretraining 140 individual shoulder dystocia scenarios, and 24 team PPH and 24 eclampsia scenarios (20 teams of 6 participants, 4 teams of 5 participants) were conducted. Post-training 132 individual shoulder dystocia scenarios and 24 team PPH and 24 eclampsia scenarios (14 teams of 6, 8 teams of 5 and 2 teams of 4 participants) were conducted. Patient-actor perception scores were inadvertently not awarded in 1/24 PPH, 1/24 eclampsia and 1/140 shoulder dystocia pretraining scenarios. Patient-actor perception scores were awarded in all post-training scenarios.

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Figure 1 Scenarios awarded a patient-actor perception score (PPS). *PPS not awarded in 1 out of 34 completed shoulder (Sh) dystocia scenarios; **PPS not awarded in 1 out of six eclampsia and postpartum haemorrhage (PPH) scenarios.

Three patient-actors were used for the 96 team scenarios; four patient-actors were used in the 272 individual shoulder dystocia scenarios. The same patient-actor was used to evaluate the same participants both before and after training in 16/24 (67%) PPH, 16/24 (67%) eclampsia and 91/132 (69%) shoulder dystocia scenarios.

Following training there was a significant increase in every aspect of the patient-actors’ perception of their care, regardless of whether they were cared for by a multiprofessional team (PPH and eclampsia) or by an individual (shoulder dystocia) (see table 1 for p values).

During simulated PPH, safety and communication scores were significantly higher when the patient-actor was cared for by teams trained locally with a patient-actor compared with teams trained at the simulation centre using a computerised patient manikin (safety p = 0.048, communication p = 0.035), with a non-significant trend towards a higher scores for respect too (p = 0.077). In the eclampsia scenarios there was also a non-significant trend towards better perception of communication in teams trained with patient-actors than teams trained using manikins (p = 0.071).

The patient-actor perception scores for participants who had received the additional teamwork training and those who were randomised to clinical training alone did not differ significantly (table 2).

DISCUSSION

Patient-actor perception of care can be improved by training. All multiprofessional obstetric emergency training, whether conducted in local hospitals using patient-actors or at a simulation centre using computerised patient manikins, improved the patient-actors’ perception of their care during simulated crises. Moreover, training with patient-actors may offer some advantages, particularly with perceptions of safety and communication.

Computerised patient manikins were primarily designed for anaesthesia training, containing mathematical models of physiological and pharmacological responses to drug treatment,13 but their use has now expanded into obstetric training.14 Technology allows inanimate manikins to “speak” (via a trainer in an adjacent room using a remote microphone linked to speakers embedded within the manikin) to the treating team.12 However, training with such manikins did not seem to improve patient-actor perception of communication and safety as much as training using patient-actors, perhaps because of missing non-verbal cues, which are a vital component of communication.15

Manikin-based training may over-focus on the task and lose sight of the global needs of the patient, whereas training with patient-actors alone may mean technical skills cannot be performed. Integration of patient-actors and part-task trainers allows both technical and non-technical skills to be practised, and has been successfully used for obstetric training, and in other areas, e.g. urinary catheterisation, endoscopy and suturing.16 “Patient-focused simulation” aims to combine technical expertise with sensitivity to patient needs throughout clinical procedures and seems to be particularly appropriate for obstetric care, where the majority of procedures are performed on a conscious mother. It has been argued that patient-focused simulation provides an improved level of realism and links to actual practice, compared with training using manikins alone.1718

In the present study, an additional day of teamwork training did not improve the patient-actors’ perception of their care more than clinical training alone. Our teamwork training focused on the principles of crew resource management from the airline industry.19 Much emphasis has been directed towards improving clinical care through teamwork training, stressing the importance of effective communication between members of the multiprofessional team.20 However, unlike the airline industry, medical emergencies focus around a patient. Communication was a principal component of our teamwork training but concentrated on communication within the multiprofessional team and did not highlight communication with the patient and her “birth partners” during emergencies. This may explain why our team training did not influence the patient-actors’ perception of their care.

This is the first randomised controlled trial of multiprofessional obstetric emergency training which has measured patient-actor perception of care. By conducting the evaluation scenarios in a normal delivery room in each participating hospital, we aimed to increase the environmental fidelity of the simulations, making the scenarios as realistic as possible.21 However, simulation is limited and it cannot accurately mimic all aspects of real life. An actual patient’s perception of their care during an obstetric emergency, when she may be unwell, in pain and concerned about her baby, will be different from a patient-actor’s perception during a simulated crisis. It is therefore not possible to be certain whether our results would translate to the patient’s perception during genuine emergencies.

Scoring systems have previously been described measuring patient-actor perception or satisfaction during simulated medical scenarios.22^–24 However, they were not translatable to this study, as they were developed to assess non-acute patient–staff interaction—for example, catheterisation,23 suturing23 or outpatient consultations2425—rather than emergency situations. Calculation of the inter–patient-actor agreement and intra–patient-actor agreement of patient-actor perception scores was not possible; each scenario could only contain one patient-actor and was managed in a unique manner. We aimed to reduce the effect of inter–patient-actor variability by using the same patient-actor to evaluate the simulated emergencies before and after training whenever possible, and this was achieved in over two-thirds of evaluations. Difficulties standardising patient-actor assessments have been acknowledged elsewhere, with the proposed solution of using actors with knowledge of the scenario they role play.17 The patient-actors in our study were experienced midwives and were different from those used during training. However, it was not possible to blind patient-actors to whether participants were being evaluated before or after training, and this may have led to bias in comparing pretraining and post-training performance. Nevertheless, patient-actors were blind to the training intervention and therefore comparison of post-training performance by training is acceptable.

The improvement in patient-actor perception of care following training may simply be a reflection of participants’ increased comfort at managing simulated emergencies by repeated exposure to simulated emergencies, rather than their training per se. A control group, left untrained, would have answered this question. Further studies could be performed to answer this. However, even if improved patient-actor perception of care was a result of repeated simulations, rather than training, this finding is still important and highlights the benefit of practising managing obstetric emergencies through simulation.

This study does not address whether there is any difference in clinical management between those who were trained locally on low-fidelity manikins compared with those trained at a simulation centre on high-fidelity manikins. Clearly improved patient perception of care should not be achieved at the expense of worsened maternal and fetal outcome. Further work is underway to examine the clinical outcomes of all the simulated emergencies conducted during the SaFE study.12 However, this present study highlights an important message for training: patient-actor perception of care can be improved with training. Patient communication may be best taught using experienced patient-actors, integrated with part-task trainers where appropriate, rather than computerised “speaking” manikins. Finally, the importance of communicating with the patient, as well as within the multiprofessional team, must be emphasised during teamwork training.