Table 5

Examples and key findings of the analysis of the simulations

Example of data analysisKey finding
Errors and corrections on charts
Completed charts were evaluated against the scenarios and video recordings to identify errors and corrections when using the prototype chart during the simulations
Across prototype care at the five sites:
  • 13 errors in recorded observations

    • 7 in fetal or maternal heart rate recordings, with likely minimal or no impact on safety of care

    • 6 in action diagram actions, with potentially significant impact on safety of care

  • 10 corrections, defined as cases where the original incorrect mark/value was changed to the correct value

    • 5 in fetal or maternal heart recordings

    • 4 in action diagram actions

    • 1 in gestation period

Safety of prototype care vs usual care
Video analysis of triggers during the simulation (eg, vaginal bleeding, pathological cardiotocography) leading to the required actions for safe care
When using the draft prototypes, triggers during the simulation consistently led to the required actions for safe care as prescribed in the prototype action diagram (eg, transfer to obstetric-led centre, expediting birth). These actions were generally also undertaken in the usual care simulations.
Reference to prototype chart during team member exchanges
Video analysis of verbal and visual reference to the prototype chart in identified exchanges between team members, and qualitative analysis of focus group discussions and ethnographic notes
The prototype chart was verbally and visually referenced in 84% of 50 identified exchanges between team members during high-risk scenarios, but was referenced in only 33% of 18 identified exchanges during low-risk scenarios. The focus groups suggested this may have been a function of the relative simplicity of the low-risk scenarios, which required relatively few events to recall and explain during the team member exchange. Ethnographers and participants noted that referring to prototype chart enabled more rapid transfer of information and understanding of the clinical situation:
‘The obstetrician actually got the picture of this woman very quickly, as to what was happening because she hadn’t been in the room at all during the first part of the simulation, so she was coming into the room as she possibly might be in a real-life situation.’
Team communication and decision-making
Qualitative analysis of focus group discussions, focusing on usability of the prototype for improving team communication and decision-making
Ethnographers and participants noted that the visual flow of recorded observations and associated triggers in the action diagram improved team communication and decision-making:
‘I did find it was easier to escalate. […] It was more of an agreed decision there, like we were all in agreement with what the plan was, rather than just being like, different doctors make different plans.’
Communication with those in labour and their partners
Qualitative analysis of ethnographic notes and focus group discussions, focusing on quality and quantity of communication with service user actors
The ethnographic observations indicated tendencies for midwives to focus more on the paperwork than on communicating with those in labour—both in the usual care setting as well as when using the prototype tools. Participants suggested in the focus groups that the simulation situation contributed to this, and that the effect would diminish with familiarity and training with the chart, but also that enhanced chart design might further encourage optimal communication with those in labour.
Suggested areas of improvement
Qualitative analysis of focus group discussions, synthesising suggestions of participants for improving the prototype
One potential area of improvement was the integration of the separate draft prototypes (one for low-risk settings with use of intermittent auscultation, and one for high-risk settings with use of cardiotocography) into a single prototype. Perceived advantages were facilitation of tracking of risk factors across settings, and reduction of error risk when transcribing from one chart to the other:
‘Actually, we do look after people who start off on intermittent auscultation and then rupture the membranes with meconium and then have to go on a CTG [cardiotocography].’
‘I like that idea, having them both on the same piece of paper but just really, really clearly demarked, this is the intermittent auscultation.’