Care professionals are required to be skilled experts in their own discipline as well as effective team players.

Chapter 1

General introduction

Care professionals are required to be skilled experts in their own discipline as well as effective team players.

Medical teams, especially in the dynamic domains of healthcare, work under conditions that change frequently, have changing team membership, often work together for a short period of time and have to integrate different professional cultures.

In addition, professional responsibility and accountability for some or all aspects of care can be transferred to another care professional or team during handovers. This is even more complicated when care professionals work at different locations, for example in primary care practices and hospitals. These conditions challenge effective teamwork and its features, like positive communication patterns, low levels of conflict and high levels of coordination, cooperation and collaboration.

Although medical care is delivered by multiple team members, for a long time effective teamwork used to be assumed and formal training and assessment has been largely absent.

In 1999, the publication of To Err is Human by the Institute of Medicine (IOM) contributed to a change in this perception. This report highlighted the fact that delivery of care is not error free. The authors concluded that a significant amount of deaths and adverse events are caused by medical and human error. One of the recommendations was the need for enhanced teamwork in healthcare.

This remains an important research topic as the use of teams in health care continues to grow due to increasing complexity of health care delivery and adoptions of integrated care models.

This thesis focuses on an intervention to improve aspects of teamwork in maternity care in the Netherlands.

This setting is an example of care provided by dynamic interprofessional teams, integrating primary care as well as hospital-based care. The purpose of this thesis is to examine interprofessional collaboration and the effectiveness of team training aimed to improve collaboration and communication during patient referral situations. This chapter outlines the organization of maternity care in the Netherlands, the contextual setting that gave rise to the study described in this thesis, rationale for improvement efforts and a brief description of the intervention. At the end of this chapter, the research questions are formulated and an overview of the chapters in this thesis is presented.

MATERNITY CARE IN THE NETHERLANDS

In the Netherlands, maternity care is provided by different professionals working at three levels of care;

primary, secondary and tertiary care. Independent primary-care midwives take care of women with low risks

of pathology. If pregnancy and childbirth remain without complications, women can choose to give childbirth

at home or in a hospital, both under supervision of their own primary-care midwife. Primary-care midwives

refer women to a secondary or tertiary care hospital if risks of adverse fetal or maternal outcomes are high or if

complications arise during pregnancy or childbirth. In the hospital, obstetricians take over responsibility and

care, in collaboration with nurses, hospital-based midwives (also called clinical midwives) and pediatricians

to provide the appropriate level of care. More specialized care for complex and acute cases is provided in

academic hospitals, representing the third echelon.

Risk selection, based on a standard list of indications

to consult or refer women to another echelon, forms the basis of this maternity care system.

A consequence of this system is a high referral rate between care settings.

To illustrate, 86.8% (N=146 727) of all pregnant women were cared for by primary-care midwives in the early stage of pregnancy in 2016.

At the onset of childbirth, 51.5% (N=86 822) of all women were cared for by primary-care midwives. Of those women, 36 250 women (41.8%) were referred to a hospital and gave childbirth under supervision of an obstetrician.

The number of referrals during childbirth has increased steadily over the past years. The increase in referral rates is mainly a results of a rise in indications during the first stage of labour, such as lack of progress, meconium-stained amniotic fluid and request for pain relief.

These intrapartum referrals are high- risk situations for patient safety and require optimal communication and collaboration between obstetrical team members.

INTERPROFESSIONAL COLLABORATION IN MATERNITY CARE

Teams are often defined as ‘a collection of individuals who are interdependent in their tasks, who share responsibility for outcomes, who see themselves and who are seen by others as an intact social entity embedded in one or more larger (social) systems’.

Interprofessional collaboration is an essential part of teamwork, which requires a cohesive practice between professionals from different disciplines.

Mainly, in maternity care in the Netherlands collaboration is centered within Local Obstetrical Collaborations (LOCs).

An LOC refers to a specific regional area: an obstetric department in a hospital (secondary or tertiary) and the surrounding primary-care midwifery practices. An important barrier for interprofessional collaboration can be differences between professional cultures.

In the Netherlands, midwives and obstetricians are known to have different views on pregnancy and childbirth. They have their own areas of expertise as a result of differences in education, responsibilities and patient populations. These differences can sometimes negatively affect collaboration by hampered mutual trust and understanding, lack of shared-decision making and conflict.

In recent years, these issues have been publicly discussed by the Ministry of Health and Welfare as well as the professional societies of both midwives and obstetricians.

Towards close(r) collaboration

Improving interprofessional collaboration was triggered by recommendations in a report called A good start, initiated by the Dutch Ministry of Health and Welfare in 2009.

This joint report by the Dutch society of midwives (KNOV) and Dutch society of gynaecologists (NVOG) was written when European comparisons showed that maternity care in the Netherlands was performing suboptimal. Building on the same level of scientific knowledge, other Western European countries with comparable demographics had lower perinatal mortality rates.

Explanations for these adverse outcomes have been put forward at different levels, including the organization of care. For example, the increasing number of patient referrals had led to fragmented and service-oriented care. Findings were supported by a scientific report with a comprehensive analysis of national perinatal data, an overview of knowledge gaps and a proposition for a research agenda.

Both reports underlined the need for organizational improvement towards an integrated maternity care

system.

An integrated maternity care system is aimed at patient centered care, enabling continuity of

care and close interprofessional collaboration.

Therefore, one of the measures to improve perinatal and

EFFORTS TO IMPROVE INTERPROFESSIONAL COLLABORATION

Crew Resource Management

A well-known method to support interprofessional collaboration is Crew Resource Management (CRM) training. Four decades ago, deficiencies in teamwork were found to be important contributing factors in major accidents in aviation. As a result, specialized training programmes were developed, such as CRM, in an effort to improve critical safety behaviours.

CRM team training focuses on team performance, performance limiters and team coordination to promote safety and enhance efficiency.

In 1999, the IOM advocated the adoption of this aviation’s approach to safety and error management in healthcare.

Over the years, CRM training has been applied in various health care settings, including intensive care units, acute care settings and maternity care.

A central concept of CRM is situational awareness. This is defined as ‘a person’s perception of the elements in the environment within a volume of space and time, the comprehension of their meaning and the projection of their status in the near future’. In other words, appropriate awareness of the situation around you.

In essence, this involves continuously monitoring what is happening in the task environment in order to understand what is going on and what might happen in the next minutes or hours.

For example, during referrals is it important that all relevant patient- and context information is transferred to another care professional to optimize situational awareness and to enable adequate response to change. Situational awareness can be diminished by fatigue and stress and affected by interruptions and distractions.

Managing fatigue, coping with stress, leadership, decision-making and teamwork aspects are other central factors of CRM team training.

Evaluation – Kirkpatrick levels

Many studies and reviews have focused on the effectiveness of CRM in healthcare. In general, a distinction is made between classroom based- and simulation based CRM team training. Classroom-based team training uses lectures, discussions and role plays whereas simulation includes a technique or device that presents a simulated patient and allows realistic interaction.

The training evaluation model of Kirkpatrick is often applied and recommended to study the effectiveness of CRM.

This model describes four levels of outcomes from an intervention: (1) Reaction—to what degree are participants satisfied with the training? (2) Learning—to what degree do participants acquire the intended knowledge, skills and attitudes?

(3) Behaviour—to what degree do participants apply what they learnt during training? (4) Results—to what

degree do targeted outcomes improve as a result of the training? It is important to measure the effects of a

complex intervention at different levels because this allows triangulation and increased understanding of the

impact on care professionals, teams, the organization and on patient outcomes.

Until 2013, findings showed that CRM team training has had positive effects on participants’ reactions and attitudes towards teamwork and safety. However, results for the impact on behavioural changes were mixed and information was lacking on effects on patient outcomes.

In many reviews, the quality of study designs has been questioned as well as the comparability of measures to assess the impact of the intervention on different levels. For example, several studies used only pre–post measurements, included a short follow- up period and restricted their intervention to one department or setting.

In a Cochrane review it was concluded that ‘more rigorous, cluster randomized studies, with an explicit focus on interprofessional collaboration and its measurement, are needed to provide better evidence of the impact of practice-based interprofessional collaboration intervention on professional practice and healthcare outcomes’.

Clearly, a need remained for studies measuring the impact of CRM team training involving multiple measures, including patient outcomes.

SBAR(R)

In studies on the impact of CRM team training, it is important to consider implementation strategies and ways to sustain effects. CRM team training is not a ‘one-time fix’ and requires ongoing attention, evaluation and feedback.

Moreover, team training seems most effective when implemented with other methods to improve non-technical skills. Each approach should have value in its own right, but must also complement the other. A growing number of studies show promising results of CRM programmes focusing on the implementation of checklists for structured communication. This seems an effective strategy, as the training provides a broad rationale for teamwork and general competencies while the tools provide scaffolding, support and reminders for using teamwork skills on the job.

The SBAR (Situation, Background, Assessment, Recommendation) tool for structured communication is

the most applied and recommended approach to improve communication.

SBAR provides a common

and predictable structure for an accurate information exchange in a brief and concise way.

Moreover, a

Read-back is a relevant addition to this structure. This enables the receiver of information to ‘read-back’ the

information to the sender to obtain verification as well as provides an opportunity to correct any mistakes or

ambiguities.

This tool can be used to improve communication between care professionals and enhance

situational awareness during patient referrals.

AIM AND RESEARCH QUESTIONS

The chapters in this thesis are divided into three parts. The objective of this thesis was to study

interprofessional collaboration in maternity care and the effectiveness of CRM training aimed to improve interprofessional collaboration through implementation of the SBAR(R) tool for structured communication during patient referrals. This was examined in the LOCoMOTive (Local Obstetrical Collaboration Onsite Teamtraining effectiveness) study. The LOCoMOTive study has been conducted in the north-western region of the Netherlands. In this region, maternity care is provided by LOCs. In 2013, the LOCs in this region started a collaborative perinatal network to improve perinatal and maternal outcomes by means of innovation and research projects.

The LOCoMOTive study was one of the research projects assigned to the Regional Perinatal Network. In total, five regional LOCs participated in the LOCoMOTive study from 2013 to 2016.

We incorporated Kirkpatrick’s model to study interprofessional collaboration and to evaluate effects of the intervention on care professional level and patient level.

Part 1: Provides a detailed description of the study protocol of the LOCoMOTive study

Part 2: Studies interprofessional collaboration in maternity care and the effects of the intervention on care professional level

Research questions:

• What are discrepancies in the perception of interprofessional collaboration in interdisciplinary teams consisting of obstetricians, nurses and midwives?

• What are discrepancies in decision-making regarding intrapartum referrals between midwives and obstetricians?

• To what extent do care professionals use the SBAR(R) tool for structured communication after CRM team training?

Part 3: Studies interprofessional collaboration during intrapartum referrals and the effects of the intervention on patient level

Research questions:

• What is the relation between perceived continuity of care and overall experience with

childbirth for women who were referred during childbirth and women who were not referred during childbirth?

• What is the effect of CRM team training aimed at implementing the SBAR(R) tool for structured

communication on adverse patient outcomes?

OUTLINE OF THIS THESIS

The purpose of Chapter 2 is to describe the study protocol of the LOCoMOTive study. This chapter provides a detailed description of the intervention and an overview of the outcome measures related to interprofessional collaboration and the evaluation model of Kirkpatrick. We included measures on care professional level (Chapters 3, 4 and 5) as well as patient level (Chapters 6 and 7).

Prior to the CRM team training sessions, we studied perceptions of interprofessional collaboration as well the decision making process of obstetrical care professionals. In a cross-sectional study, described in Chapter 3, we aimed to understand how different care professionals in an obstetrical team assessed interprofessional collaboration. In addition, we aimed to gain insight into similarities and differences between midwives and obstetricians in their decision making process. We used a factorial survey involving the assessment of a prolonged first stage of labour and the decision to refer a woman to a clinical setting in the Netherlands, presented in Chapter 4. In Chapter 5 we evaluated the intervention on care professional level. In this chapter we explored to what extent care professionals use the SBAR(R) tool for structured communication after CRM team training.

Measures on patient level involved both patient experiences as well as adverse patient outcomes. During the entire study period, we collected data on patient experiences with childbirth using a questionnaire.

In Chapter 6 we investigated the relationship between continuity of care and overall patient experiences with childbirth, for women who were referred during childbirth and women who were not referred during childbirth. Finally, a composite measure has been used to study the effect of the intervention over three study period, before, during and after the intervention. The results of the intervention on adverse patient outcomes are presented in Chapter 7.

In Chapter 8 the main findings are summarized and discussed. In addition, methodological considerations are

discussed and implication for practice and future research are proposed.

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