2014. Vol.5, No.1, 36-45
Published Online January 2014 in SciRes (http://www.scirp.org/journal/ce) http://dx.doi.org/10.4236/ce.2014.51008
Health Quality Improvement Using Instructional Communication
and Teamwork Videos: An Outcome Study
Neil Cowie1, Angela Bowen2, Susan Kuling3, Kalyani Premkumar1,
Mark Burbridge1, Jo celyne Martel1
1College of Mediicne, University of Saskatchewan, Saskatoon, Canada
2College of Nursing, University of Saskatchewan, Saskatoon, Canada
3Saskatoon Health Region, Saskatoon, Canada
Received December 15th, 2013; revised January 15th, 2014; accepted January 22nd, 2014
Copyright © 2014 Neil Cowie et al . This is an open access article distributed under the Creative Commons At-
tribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
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Many factors contribute to errors that occur during emergency Cesarean birth under general anesthesia.
The Joint Commission of Accreditation of Health Care Organizations (JACO) reports that 70% of sentinel
events in obstetric practice are attributable to errors in communication and teamwork. Our objective was
to develop a video training module to address these deficiencies, and measure its effectiveness. A web-
based learning resource was created using professionally made videos that depicted effective and non-ef-
fective communication/teamwork techniques in an obstetrical event. This resource could be accessed by a
facilitator of small group sessions or by self directed learners. Obstetrical nurses watched this learning
resource and were then debriefed by a facilitator to highlight examples of how human factors contribute
to the evolution of adverse events. The knowledge and skills, as well as, perceptions of their own beha-
viors and of other health professionals in the team, were evaluated pre- and post intervention. The per-
formance of a subgroup of participants in a high-fidelity simulation of an emergency Cesarean birth was
assessed to measure the outcome of intervention. Ninety-five obstetrical nurses were given the pre-inter-
vention questionnaires, and 52 completed the post-intervention questionnaires one year later. Participants
had significantly higher scores post-intervention (M = 0.78, SD = 0.09) as compared to pre-intervention
(M = 0.73, SD = 0.12; t(53) = −3.07, p <0.003, d = .47). Following intervention, participants were more
conscious of the behaviors of those they worked with (t(51) = −4.99, p < 0.001, d = −0.66). Ten months
after intervention, nurses indicated that they were able to identify challenges in teamwork and communi-
cation in their practice, and were more willing to speak up and be more assertive, and use strategies of
conflict resolution and communication that they had learned. There was an improvement in performance
of a sub-group of participant when assessed using a simulation scenario. The video web-based learning
resource used in small group sessions effectively improved performance of obstetrical nurses as evaluated
using questionnaires and high fidelity simulation. Future work will determine if the web-based version
will be as effective in orienting new staff to the challenges of working in acute care obstetrical practice.
Keywords: Simulation; Video Training; Nursing Education; Anesthesiologists; Obstetrics; Emergency
Cesarean Birth; Communication; Teamwork; Human Factors; Health Quality Improvement;
Web-Based Training; Acute Care
Effective teamwork is a crucial defense against the evolution
of adverse events in rapidly evolving critical clinical situations;
this is never truer than in the labour and birth unit (Mann et al.
2006); when lack of communication or cooperation, it can have
devastating effects on both mother and baby.
Regional anesthesia (spinal and epidural) is recommended
over general anesthesia for elective and all but the most urgent
Cesarean birth as it reduces the likelihood of failed endotra-
cheal intubation with resulting life-threatening complications
(Practice Guidelines for Obstetric Anesthesia, 2007; Cyna,
2007; Bloom et al., 2005). Emergency Caesarean birth under
primary gener al anesthesia is therefore a rare occurrence, (Tsen,
1998) and is often preceded by a life-threatening obstetrical
event. Because of the paucity of exposure to such critical events,
and because obstetrical teams seldom have the opportunity to
practice and develop confidence together, patient safety is in
peril every time a pregnant woman comes to the operating room
for an emergency Cesarean birth.
Undoubtedly, healthcare professionals are well trained in
technical aspects of their profession. Unfortunately, creation of
a team of experts does not ensure that the team will work coo-
peratively towards a common goal of avoiding errors and main-
taining health of the patient (Burke, 2004). To use an airline
N. COWIE ET AL.
analogy, the modern jet aircraft “is too much airplane for one
man to fly” (Stout, 1999). Interdisciplinary team failures that
result in medical errors occurring because of the complexities
of managing a sick patient, whic h require attention by more
than one team member, are not appreciated by a leader who is
operating solo (Burk, 2004). A well-functioning team effec-
tively communicates, anticipates, shares their mental model,
identifies and corrects errors in patient care that may lead to
adverse events (Burke, 2004). In an effort to train practitioners
to work more effectively in obstetrical teams, medical educa-
tors have adapted the lessons learned in aviation’s cockpit re-
source management (Helmreich, 1999) into high-fidelity medi-
cal simulations (Draycott, 2006; Morgan, 2007; Blum 2005).
Medical simulation is structured so that the performance of an
interdisciplinary team in an artificial, but realistic scenario, can
be observed and recorded (Gaba, 1993). Debriefing following
the event serves as a powerful learning strategy that teams can
use to improve future performance (Gaba, 1993).
Health care has created tremendous improvements in quality
of life, productivity, and longevity with a significant reduction
in perinatal morbidity and mortality (McGlynn, 2003; Shaw,
1990; Saugstad, 2011). To Err is Human, a landmark publica-
tion in 1999, by the Institute of Medicine in the United States
describes two studies that measured adverse events during hos-
pital admissions in New York, Colorado, and Utah. Adverse
events were attributed to medical errors, 58% of the time in
New York (2.9% of hospitalizations) and 53% in Colorado and
Utah (3.7% of hospitalizations). When extrapolated across the
United States, medical errors would account for 33.6 million
hospital admissions in 1997, and 44,000 to 98,000 preventable
deaths annually (Kohn, 1999). A similar scope of adverse
events was reported in a review of hospital admissions in Can-
ada. Of 2.5 million admissions in 2000, about 185,000 (7.5%)
are associated with an unexpected adverse event, and 1.8%
resulted in death (Baker, 2004). Of all adverse events, close to
70,000 (2.8%) of these were potentially preventable (Baker,
In the United Kingdom the Confidential Enquiries into Ma-
ternal and Child Health drew attention to substandard care that
resulted in maternal and neonatal deaths: 36% to 67% of ma-
ternal deaths resulted from substandard care from 2000-2002).
The Joint Commission (Bloom, 2005), the American College of
Obstetricians and Gynecologists (Joint Commission sentinel
event alert #30, 2004), and the Institute of Medicine (Kohn,
1999) acknowledged that teamwork and communication were
necessary components of a safe patient environment. The Joint
Commission reported that failures in teamwork and communi-
cation were among the leading causes of adverse obstetric
events, and account for over 70% of sentinel events (Bloom,
An example of how training obstetrical personnel in commu-
nication and teamwork led to safer patient care was demon-
strated by Beth Israel Deaconess Medical Center in Boston
(Mann, 2006). They initiated team training as a quality im-
provement project. Using an adverse outcome index, patient
safety improved by 47% in high-risk premature births. Mal-
practice claims decreased by 50%, which prompted the insurer
to reduce malpractice premiums by 10% for physicians who
participated in teamwork training (Mann, 2006).
Factors Contributing to Adverse Patient Outcomes
Events leadi ng to fetal dist ress an d emerge nt Cesare an birth a re
usually unexpected, but always lead to rapid assembly of a team
usually including physicians, nurses, allied health care providers
and trainee s, in what ofte n appea rs to be a cha otic frenzy of acti v-
ity with team members unfamiliar with each other and their spe-
cific roles. Staff who work in critical care environments may be
technically competent, but individual performance is not enough
to guarantee patient safety (Burke, 2004). A number of factors
might provi de the “perfect s torm” for an adve rse obstetri cal event
to occur include, local obstetrical anesthesia best-practice guide-
lines favouring regional anesthesia, the rarity of emergent Cesa-
rean births under general anesthesia, lack of team rehearsal, no
role clarity or team expectations, as well as the time-pressure to
deliver a heal thy baby before hy poxia results in irreversible b rain
For obstetrical nur ses, lack of practice and experience assisting
with those ra re instances req uiring general a nesthesia in the preg-
nant patient, can be anxiety-provokin g. Additionally, the practice
of rotating non-obstetrical anesthesiologists through obstetrical
call, as they would on any other surgical service, leads to a lack of
familiarity with the skills of the nur ses, and a lack of familiarity of
the nurses with anesthesiologist’s expectations at a time when
team member s must wor k together in a time press ured, acute care
Apart from the se, a number of ot her factors contr ibuting to ad-
verse patient outcomes have been identified in literature. These
include situational awareness, communication, leadership, shared
mental model, hierarchy, mutual support, conflict resolution and
distraction, published as the evidence-based team training pro-
gram “Team STEPPS™” (King, 2008).
Situational awareness is a perception of what is happening
now, what the actual events mean and being aware of the direc-
tion to which the situation could evolve (Endsley, 1995). Situa-
tional awareness often depends on the previous experience of
the health care provider (pattern recognition), and, as such, can
vary considerably amongst team members with dire conse-
quences for the patient (King, 2008; Klein, 2006; Kozlowski,
Team communication can be enhanced by use of concise,
structured techniques such as SBAR-R (Situation, Background,
Assessme nt, Recom mendati on and Response) (King, 2008; The
Joint Commission, 2012; Institute for Healthcare Improve-
ment.Web and action: using SBAR to improve communication,
2006; St Pierre, 2008). When using SBAR-R, the listener is
first alerted to the importance of the conversation, which directs
the listener to the critical nature of the problem. The sender
then specifies the situation, background, and a suggested course
of action, followed by a request for clarification of when the
receiver will able to attend in person. Team members close the
loop in communication, to ensure that the meaning of the mes-
sage is understood, and demand feedback when a task is com-
The leader takes charge of assignment of tasks, prioritization,
re-evaluation, problem solving, and wise use of resources. Lis-
N. COWIE ET AL.
tening, communicating back to the team, and maintaining an
open environment where team members can report their con-
cerns are the key attributes demonstrated by an effective leader
(St Pierre, 2008).
Shared Mental Model
A common reason for misunderstanding occurs when team
members fail to accurately share the mental model of what they
perceive the situation to be. Misunderstanding can occur when
one team member’s mental model and related plans for man-
agement differ from those of the leader and other team mem-
bers. Contributing factor s such as a lack of a ssertiveness in com-
munication and the hierarchical nature of medical teams inter-
fere with sharing one’s mental model (King, 2008; St Pierre,
An effective team needs some hierarchy-where the leader di-
rects the actions of the team. Junior members of the team may
interpret the hierarchy as a barrier to speak up with important
information, perhaps assuming the leader already knows what
they know or fear of being criticized if their information con-
tradicts what other team members perceive as correct (King,
2008; St Pierre, 2008).
Mutual support protects team members from becoming
overwhelmed or overloaded with tasks. Prioritization might
already have been implemented by the leader, but there may
also be physical limitations (e.g., chest compressions during a
cardiac arrest) where a team member becomes fatigued or
overloaded with tasks. Subsequently, another team member
should step forward, acknowledge the situation, and offer their
support or assign another team member to assist. In a similar
way, cross-monitoring by each team member of each other’s
performance will pick up and correct unsafe management be-
fore a critical incident occurs (King, 2008; St Pierre, 2008).
Lack of information or ineffective communication is a com-
mon reason for conflict which can lead to divisiveness within a
team. Tools such as DESC (Describing the problem concretely,
describing the Emotional impact the problem has on the Sender,
suggesting solutions and describing Consequences (King, 2008)
and CUS (describing Concern, stating the event makes the
sender feel Uncomfortable, or describing the patient Safety
issue) are powerful methods to resolve conflict without con-
frontation (King, 2008). The two-challenge rule (taught in avia-
tion’s crew resource management) enables two team members
to challenge a potentially unsafe act by a third member of the
team (King, 2008). If acknowledged, but still unsuccessful,
such a confrontation empowers the flight crew to take over the
controls of the aircraft, or in the example of health care provid-
ers to directly intervene or recruit a more senior colleague to
Distraction (too much focus on something else resulting in
neglect of the current situation), and errors of fixation: this and
only this (new information contrary to the present diagnosis is
disregarded or not sought), everything but this, (continuing to
order more tests without ever making a diagnosis) everything is
OK (this event cannot be happening) have often been impli-
cated in adverse events in both aviation and medicine (Hel-
mreich, 1999). This is of equal importance to all team members,
who, must not only be vigilant for breaches of care, but must
assert their mental model (King, 2008).
Existing Team Training Prog rams
The World Health Organization (WHO) launched its “Safe
Surgery Saves Lives” program in 2009 (Haynes, 2009). Intrin-
sic to this program are paradigms of communication and team-
work. In 2008, the Canadian Patient Safety Institute (Frank,
2008) developed six competencies that act as a framework for
education in undergraduate, postgraduate and continuing pro-
fessional development i.e., contribute to a culture of patient
safety, work in teams for patient safety, communicate effec-
tively for patient safety, manage safety risks, optimize human
and environmental factors, recognize, respond to and disclose
adverse events (Frank, 2008). In an attempt to address shortfalls
in training of inter-professional teams, the American Healthcare
Quality and Research (AHRQ) and the American Department
of Defense developed and published Team STEPPS™ (King,
2008), that has been adopted by high risk organizations such as
aviation, the military, healthcare, and the nuclear industry. This
program consolidated teaching of human factors important to
leadership, communication and teamwork into a portable, mul-
Medical simulation is another effective strategy used for
team training. Medical Simulation grew out of an innovative,
quality improvement program in aviation known as Crew Re-
source Management (Helmreich, 1999) that has been utilized
for decades to train airline pilots, in technical skills to avert
dangerous events, and in non technical skills to improve lea-
dership, communication and teamwork (Gaba, 1993). In medi-
cal simulation, a medical case is recreated in a laboratory using
a mannequin, with vital signs, and actors using appropriate
dialogue (Gaba, 1993). Such simulations make it easier for
students to suspend disbelief, and for the scenario to “come to
life”. Following the experiential session, students participate in
a debriefing where sense is made of the clinical events. The
increased level of activation experienced in the lab translates to
improved receptivity to alternative coping skills presented dur-
ing the debriefing (circumplex model of emotion) (Feldman,
1999). Students are better able to change behavior if they first
understand why they performed in a certain way.
In our institution, 10 - 12 of the 4000 births each year require
primary general anesthesia to facilitate emergency surgery.
Because of the rarity of emergency Cesarean birth under gener-
al anesthesia (GA), nursing staff found it difficult to maintain
skills and confidence in assisting anesthesiologists with emer-
gency induction. Since high fidelity simulation has been effect-
tive in other centres to facilitate team training in obstetrical care,
it would have been logical for our centre to adopt this pathway.
However, using such simulation to train all members of the
obstetrical team in our hospital is not feasible because of li-
mited physical resources, personnel, and financial support. In
order to reach the greatest number of staff and trainees, we
undertook to create a high quality video re-enactment of an
N. COWIE ET AL.
obstetrical event, and debrief participants as if they had partici-
pated in an actual simulated event.
The purpose of this study was to:
a. Develop a web-based educational resource describing nurs-
ing technical skills, teamwork and communication in a situ-
ation requiring Cesarean birth under GA, and
b. Evaluate the outcome of training obstetrical nurses using
the developed resource.
A professional film company was hired to create videos to de-
pict two scenarios that portrayed the evolution of fetal distress and
antepartum bleeding followed by an emergent Cesarean birth under
general anesthesia. The first scenario used ineffective communica-
tion and teamwork techniques, and the other demonstrated more
effective ones. Each of the two videos was 13 minutes long. A
summary of c ompetencies highlighted in t he videos are shown in
Videos were housed in a web-based interface along with links
to library articles, other videos and pertinent web-based refer
ence materials, that could be used for self-direc ted or facil itate d
small group learning, described in web page (Premkumar, 2013).
The nursing staff were trained during the designated educa-
tional days allocated by hospital administration. During a 2-hour
interactive workshop, participants watched the less-effective
communication video. The first author (NC) ran video clips of
the events that best demonstrated the skills and engaged the
participants in discussion about human factors that adversely
affect teamwork and communication. The second video about
effective communication was run, and discussion highlighted
reasons why the outcome was different using more effective
techniques of communication and teamwork in the same scena-
rio. All nurses were given the opportunity to review the self
directed portion of the web-based resource after completion of
Six months prior to the intervention, all obstetrical nursing
staff (n = 95) were administered a questionnaire, which con-
sisted of 14 items that reflected knowledge of the various re-
sponsibilities of nurses (e.g., circulating, scrub, and anesthesia
Competencies demonstrated in video clips.
Competency Definition Example Demonstrated in Vide o Clip
Situational Awareness Conscious o bs ervation of one’s own environment and
recognition of changing condition of the patient
In the face of no neonatal t eam, failed intubation, ongoing
hemorrhage, in the C/S un der GA, the anesthesiologist replies to
the circulating nurse he doesn’t need any help
SBAR-R Structured communication about a critical situation
hat involves clear specification of
S: The patient has abdominal pain, ble eding and fetal
B: The pat i ent is a VBAC, had a functioning e pidural
A: The pati ent might be rupturing her uterus
R: We need the obstetrician to assess for a stat C/S
R: When can I expect you?
Communication Communication to a specific person that is acknowledged by
the receiver and then affirmed by the sender
The anest hesiologist s ays “make sure she’s tilted” , “give her
some Oxygen”, without indi cating anyone in partic ul ar to
perform the task. The tasks never get done.
Leadership Assignment of tasks, prioritization, problem sol ving,
acknowledge and listen to concerns of the team
The obstetrician repeatedly asks when she can cut, because the
anesthesiologist never gave specific ins
tructions like “don’t make
the incision until I say the word cut”
Shared Mental Model Teams ability to articulate a common understanding of the
problem and plan
The birthing room nurse uses “call out” to alert the team that her
patient has fetal decelerations, is bleeding and needs the
obstetrici an to come now.
Overcom e Hierarchy
Every te am member, no matter how junior, should be assertive
enough to bring forward new information that may challenge
the team’s situational awareness
The junior birthing room
nurse does n ot persist in c onvincing the
resident about seriousness of her patient’s situation, because she
assumed the experienced resident already knew the situation,
wasn’t conc erned, so why should she be concerned.
Mutual Support Support to each team member should be f reely offered and
freely sought when overload is recog ni zed throug h s ituational
The circulating nurse recognizes that there are more tasks to be
done than team members available, s o when she phones for drugs
and blood, s he asks the receiver to come to the OR because
she ”needs another pair of hands”
Conflict Resolution What is said is heard is understood. Use of SBARR, CUS and
DESC, a nd t wo challenge rule
The birthing room nurse and the charge nurse both try to
convince t he resident unsuccessfully about the ser i ousness of the
problem. The two-
challenge rule would have empowe red them to
seek help directly from the obstetrician.
Avoid Distr action Fixation: this and only this, any t hing but this, everythin g i s ok
Fixate on one thing, fail to receive new information
Birthing room nurse fail s t o l isten to the f ather’s histor y about his
wife’s sore throat following previous GA for C/S, because it
happens at the same time as the fetal heart rate drops
N. COWIE ET AL.
assist nurse) and responsibilities of anesthesiologist in emer-
gency Cesare an de liveries.
They were also asked about knowledge of specific tasks,
which health care professionals are responsible for performing
(application of ECG leads and BP cuff, pre-oxygenation, appli-
cation of cricoid pressure, application of BURP (Backward,
Upward, Right sided Pressure on the larynx to bring the glottis
into view during intubation).
Eleven items questioned knowledge about the steps in diffi-
cult airway management and the location of the difficult int u ba-
tion cart, and understanding of the difficult airway algorithm. A
further 15 items reflected interactions with the anesthesiologist
such as: anesthesiologist knows who is assisting with induction,
who determines prioritization, feelings of reluctance to speak up,
ability to deliver information, role clarity, resource management,
and recruitment of help.
We also asked participants the length of time they practiced
as a registered nurse, an obstetrical nurse, whether they worked
in the Obstetrical operating room, and whether they had expe-
rience with Cesarean birth under general anesthesia.
An identical post-intervention questionnaire was administered
immediately following the training sessi ons . Long term outcome
of training was measured by written survey about lessons
learned distributed to all participants approximately 10 months
after training. Questions asked are listed in Table 2.
Of 95 original participants, 52 co mpleted both the pre and post
intervention questionnaires (see Figure 1). Volunteers who
participated in simulated cases in the sim lab came from the 52
who had completed both questionnaires. Sampling adjustments
due to attrition of participants who began the study, but did not
complete the training or the post questionnaire is described in
In order to study more in-depth the changes in communication
and teamwork immediately after the intervention, eight partici-
pants were recruited and divided into two teams of four nurses
Pre and post comparisons of items reflecting personal behavior.
M SD Post
M SD Statistical Information
I always tell the Anesthesiologist “I am the anesthesia assist” if I am 3.35 2.02 3.17 2.16 t(47) = 0.56, p = 0.575, d = 0.09
I always know how to organize and relay i nf ormation effectively during a stat
Cesarean birth 3.78 1.74 3.68 1.45 t(49) = 0.32, p = 0.748, d = 0.06
When I am speaking to a doctor or another nurse, I am not always
sure if they understood what I have said (Reverse Coded) 3.71 1.98 4.37 2.09 t(51) = −10.99, p = 0.053, d = −0.32
I understand my role as an anesthesia assist nurse during induction
of general anesthesia 3.12 2.11 2.94 2.08 t(49) = 0.52, p = 0.608, d = 0.09
I do not speak up during a crisis situation because I do not think others in the room
would listen to what I have to say (Reverse Coded) 3.38 1.97 3.64 2.15 t(49) = −0.78, p = 0.439, d = −0.13
I do not feel comfortable enough to speak up during a crisis situation because I am
afraid of wha t the doctor wo ul d say back to me (Reverse Coded) 3.14 1.95 3.75 2.24 t(50) = −10.49, p = 0.142, d = −0.29
I know how to recruit other st aff to assist during an emergency 2.67 1.75 2.62 1.62 t(51) = 0.22, p = 0.824, d = 0.03
I understand my role w hen the anesthesiologist asks me to assist after inducti on is
completed during emergency surgery 3.52 1.85 3.44 2.12 t(49) = 0.26, p = 0.800, d = 0.04
I always know who the nursing t eam leader i s during an emergency
Cesarean birth after 1700 hours 3.53 1.87 3.65 2.25 t(48) = −0.34, p = 0.737, d = −0.06
Total 3.34 1.15 3.49 1.20 t(51) = −0.87, p = 0.387, d = −0.13
N. COWIE ET AL.
each to participate in high fidelity simulation of events leading
up to Cesarean birth under general anesthesia. Two additional
scenarios were developed. The first depicted the onset of an
eclamptic seizure during insertion spinal anesthetic for Cesa-
rean birth for non-reassuring fetal heart tracing, necessitating
emergency cesarean birth under GA. The anesthesiologist was
inattentive. The second was a twin birth, where what was
thought to be twin A’s tight nuchal cord, is clamped and cut,
but following delivery of twin A it was determined that twin
B’s cord had been cut leading to an urgent Cesarean birth to
deliver twin B. The anesthesiologist in this scenario was also
Nurses were oriented to the simulation centre. They were
told that they would be part of a nursing team that would man-
age an obstetrical patient who required an urgent Cesarean birth.
Team 1 enacted the first simulation Scenario over 15 minutes,
and was immediately given the training session. Following
intervention, team 1 then enacted the second Scenario over 15
minutes. Team 2 enacted the same two scenarios and training
on a different day. Both scenarios were debriefed for each team
by faculty from the simulation centre. Teams 1 and 2 watched
their own performance in a video replay, created by B-Line
Medical Simcapture (B-line Medical Sim capture). The record-
ings were coded and delivered to four raters who scored the
sessions using a Global Assessment of Obstetrical Team Per-
formance (Tregunno, 2009, Morgan, 2011) (GAOTP). The
raters reviewed a video of each simulation and independently
rated it on whether various items pertaining to communication,
teamwork, and situational awareness were met. In those situa-
tions where there was marked variation between the raters, the
videos were replayed, and the raters came to a consensus on
scores. Ethics approval was obtained from the University Re-
search Ethics Board and the local Health Region Ethics Board.
All participants signed a written consent for the study.
Descriptives were performed. Items about knowledge were
coded as 1 for correct response and an incorrect response re-
ceived a score of 0. Then, the means for all items pertaining to
roles and other knowledge were calculated so that a mean score
of 1.00 would indicate 100% accuracy in answering questions
and .00 would indicate all questions were answered incorrectly.
Items about the perceptions of behaviour were answered on a
Likert scale of 1 (Strongly agree) to 9 (Strongly disagree),
where lower scores reflected more positive behaviours. Of
these items, nine questions reflected personal behaviours and
six questions reflected the behavior of others. All analyses were
done using SPSS (Becker, 2000).
Paired-samples t-tests were conducted to compare the res-
ponses given by nurses before and after the training session.
Effect sizes (Cohen’s d) were calculated, where 0.2 is consi-
dered small, 0.5 is medium, and 0.8 is large. Descriptive statis-
tics were calculated for the nurse follow-up survey. Descriptive
statistics and t-tests were conducted using the SPSS Statistics
19 program. Effect sizes were calculated using an online calcu-
lator (Becker, 2000).
Of the 52 nurses who completed both surveys, the majority
(64.8%) had been a nurse for more than 15 years. Thirty-five
percent of nurses had been an obstetrical nurse for greater than
15 years while 31.5% had been an obstetrical nurse for less than
five years. The majority (83.3%) currently worked in the obste-
trical OR. As well, most participants (77.8%) had assisted with a
Cesarean birth under general anesthesia.
During the six month period between administration of the
pre-questionnaire and the intervention, 52 remained out of the
original 95 nurses to undergo intervention and complete the
post-questionnaire. Discrepancies in numbers were due to high
staff turnover and leaves. In view of the ongoing turnover of
nursing staff and in an effort to promote ongoing personal de-
velopment, the participants were all given access to the web-
based resources as self-directed learners after the study.
Knowledge of Roles
Nurses who attended the intervention answered significantly
more questions correctly on the post intervention questionnaire
(M = 0.95, SD = 0.05) than before (M = 0.85, SD = 0.09; t(53)
= −8.19, p < 0.01, d = 1.38). This difference yielded a large
Other Knowledge (Airway Related)
Nurses attending the intervention session correctly answered
signifi ca nt ly more items a fte r the se ssi on (M = 0.78, SD = 0.09)
than before (M = 0.73, SD = 0.12; t(53) = -3.07, p < 0.003, d =
0.47). This difference yielded a medium effect size.
Perceptions of Behaviour
With regard to the nine questions that reflected personal be-
haviours Cronbach’s α = 0.75 for pre, α = 0.73 for post and for
the six questions that reflected the behaviour of others Cron-
bach’s α = 0.65 for pre, α = 0.71 after the intervenion. No sta-
tistically significant differences were found when comparing
the responses on items pertaining only to personal behaviours
and perceptions. However, there were significantly higher res-
ponses after completing the training session (M = 4.53, SD =
1.17) than before (M = 3.73, SD = 1.27) about the behaviour of
others, indicating that they were more critical of the behaviours
of those they worked with (t(51) = −4.99, p < 0.001, d = −0.66).
In pre intervention responses there was reluctance to speak
up (M 3.85 sd 2.05), nursing input was not heeded (M 3.30 sd
1.99), evidence of a good working environment between nurs-
ing, anesthesia and obstetrics (M 3.76, sd 1.51). See Table 3.
Follow-Up Questi onnaire
Ten months after the intervention, the nurses were asked to
complete a follow-up questionnaire to determine if they were
still able to apply the lessons learned to their practice. Four-
teen nurses completed the questionnaire, 54% indicated that
they now better understood how breakdown in communication
and teamwork might lead to compromised patient safety. See
Raters used the GAOTP score for each of the videos of si-
mulation. To test for reliability of raters, an intracl ass correlation
coefficient was calculated. A high inter-rater reliability was
N. COWIE ET AL.
Pre and post comparisons of items reflecting the behavior of the team.
M SD Statistical Information
The nursing team always receives clear direction from the
anesthes iologist 3.43 1.69 4.31 1.68 t(50) = −3.35, p < 0.002, d = −0.52
The nursing team leader understands the role of each team
member in the room during the Cesarean birth 3.04 1.61 3.61 1.69 t(48) = −2.22, p = 0.031, d = −0.35
After a stressful critical event, debriefing occurs with all
involved staff 4.78 2.44 6.49 2.34 t(50) = −5.12, p < 0.001, d = −0.71
The health care provider who speaks to the anesthesiologist
to alert them of an impeding stat Cesarean Birth is always
familiar with the patient and the reason for the emergency 4.06 2.09 5.04 1.97 t(50) = −2.99, p = 0.004, d = −0.48
A good working environment exists between nurses,
obstetricians, and anesthesiologists during stat Cesarean
births under general anesthesia 3.82 1.59 4.14 1.50 t(49) = −1.16, p = 0.252, d = −0.21
The nursing team leader understands her role during a stat
Cesarean birth under general anesthesia 3.08 1.57 3.51 1.50 t(48) = −1.62, p = 0.111, d = −0.28
Total 3.73 1.26 4.53 1.17 t(51) = −4.99, p < 0.001, d = −0.66
Knowledge and team competencies in practice after 10 months.
Competencies % Implemented
It is OK for me to be more assertive if it means safer patient care 100
It is OK for me to speak up if I am aware of any threat to patient safety 100
Situational awareness and anticipation can improve patient safety 91
Using names and making eye contact i s a good way to ensure that a task is actually done 91
It is OK for m e to call for help on behalf of physicians if I think there is a threat to patient safety 82
Conflict can be resolved by emphasi zing how the situation is affecting you
(I am concerned, I am uncomfortable, This is a patient safety issue) 82
Closing the loop bette r i nforms the leader that a t ask is completed or an order is understood 73
Knowing ahead of time what the steps the anesthesiologist mi ght us e during a fa i l ed intubation i mproves pat i ent safety 73
SBARR is a technique use ful in delivering organized information 64
Effectively sharing your mental model can improve patient safety 55
Knowing how best to apply cricoid pressure improves patient safety 55
Knowing how best to apply BURP improves patient safety 45
confirmed by a calculated Intraclass Correlation Coefficient of
Pre- and post scores for both teams reviewed in video from
simulations were low which suggested the teams did not perform
very well. Although not statistically significant, the trend
showed that there was improved performance following the
training. This was the first simulation experience the teams had
encountered, and the teams found it difficult to react as they
might have during a real clinical encounter. Teams found it
unbelievable that an anesthesiologist would behave in such an
inattentive fashion that would make it necessary for nurses to
intervene on behalf of the anesthesiologist. Participants indi-
cated that they enjoyed the experience, and requested that more
opportunities be offered for simulation. They expressed that
they gained a great deal of insight into their performance during
the debriefing by watching videos of themselves.
Personal communication from participants suggest that the
video depicting ineffective communication evoked unpleasant
emotions similar to those they had experienced when a similar
event had happened to them in the past. We feel that even
though they had not engaged in a simulated clinical event, that
the emotional activation achieved by viewing this video placed
them in a receptive learning state such that they were ready to
listen to, and adopt, communication and teamwork strategies
presented during the debriefing.
Analysis of the questionnaires showed, that knowledge and
skills significantly improved post intervention. Nurses’ know-
N. COWIE ET AL.
ledge of the roles of the members of the team also improved
following training. Nurses were more critical of the behaviour
of both of themselves and of other team members, following
the training. This might indicate that the training video intro-
duced concepts that challenged pre-existing attitudes. Nurses
had no prior training in human factors, team training, or com-
munication skills on the labour and birth unit pertaining to ob-
stetrical situations. The videos enabled participants to discover
concrete consequences of ineffective communication and team-
The follow-up survey of lessons learned, done 10 months af-
ter the training, showed that respondents were able to: identify
that challenges in teamwork and communication did exist in
their practice, that they were more willing to speak up and be
more assertive, use strategies of conflict resolution, and com-
munication (closing the loop). Narrative responses reinforced
data collected in the questionnaire. We were encouraged, that
there was sufficient retention of the concepts given during the
training session for the respondents to be positive in their res-
ponses as late as 10 months post-intervention.
Under powering the section of the study pertaining to simu-
lation meant that any results comparing pre and post training
would not have statistical significance. Still, low global scores
did indicate reluctance to participate for various reasons. Per-
formance in a simulation environment improves with practice.
Since this was the first encounter, participants may not have
understood our expectations. Interestingly, their disbelief that
an anesthesiologist could behave in such an inattentive fashion
may have prevented them from intervening on behalf of the
That nurses enjoyed the experience, gained insight into their
own performance during crisis management, and requested
more educational experiences of this kind, motivates us to seek
funding for ongoing educational initiatives.
The behavioural portion of the questionnaire demonstrated
reluctance of nursing staff to speak up or feel that their input
was heeded. These concerns have been reported by investiga-
tors using the Safety Attitudes Questionnaire te amwork climate
scale (Sexton, 2006; Miller, 2008) in obstetrical practice.
To our knowledge, this study is the first to test the principle
of using professionally made, full-length video re-enactments
of an obstetrical event in place of hands on simulation expe-
rience to improve team performance. Our experience in doing
this study demonstrated the magnitude of nursing turnover over
one year, and the substantial difficulty nurse educators would
have to keep their staff current on any topic has impact on de-
veloping team skills. Further, limited time for educational
events further curtails the opportunity for nurses to acquire
team skills. Having a web-based educational module on com-
munication and teamwork available, gives nurse educators an
opportunity to present consistent training to new employees.
The training module was found to make nurses more critical
of the performance of anesthesiologists during emergency Ce-
sarean birth under GA. Reluctance of obstetrical nursing staff to
speak up or feel that their input was heeded by physicians is
paralleled by reports from other tertiary care obstetrical centres
Although we now have results from small group workshops
using the teaching resource, we still do not have results on how
effective self directed learning might be, using the web-based
resource. Our expectation that is that the live performance of
the group facilitator and the recorded, on-line debriefer com-
menting on the video clips, is comparable. This will be eluci-
dated in a future study.
Limitations in This Study
Small numbers of respondents who were trained and who
submitted pre and post surveys, made interpretation of the re-
sults difficult, even though the results were statistically signifi-
cant. Since only 55% (n = 52) participants completed both pre
and post intervention questionnaires, the remainder represented
staff who left the unit permanently or who had gone on leave
before the intervention.
Work by Morgan et al. (Morgan, 2011), using the GAOTP
determined that a minimum of eight evaluators were required to
achieve a significantly reliable score. Because of our small
simulation centre, we had limited faculty who could be evalua-
tors. Our decision to use consensus on scoring increased in-
ter-rater reliability above what it would have been had we not
used consensus scoring. Pre and post scores for both teams were
low which suggested the teams did not perform very well. This
was the first simulation experience the teams had encountered,
and the teams found it difficult to react as th ey might have during
a real clinical encounter. Underpowering of the section of the
study pertaining to simulation was primarily because of insuffi-
cient funding to bring nurses in after hours to do simulation.
Applications of the Learning Resource
We have successfully used the training resource to deliver
local, national and international workshops that improve under-
standing of the importance of human factors in acute care teams.
We are working towards making the web-based learning re-
source available to other tertiary care obstetrical centres. It has
already been implemented locally in the undergraduate nursing
education program, and we hope soon to incorporate it into the
undergraduate medical education program. For students who
have had no simulation experience, these videos are valuable as
“trigger” videos to encourage discussion of human factors prior
to attending their first simulation experience. A disk containing
the training module is published at MedEdPortal of the Ameri-
can Association of Medical Colleges so that other training in-
stitutions will have an opportunity to use it and make sugges-
tions on how to improve it (Cowie et al., 2012).
The video-based learning resource appears to be valuable in
improving knowledge and skills as well as heightening aware-
ness of human factors that can hinder optimal team perfor-
mance. Because of constant turnover of members of the obste-
trical nursing staff over time, orientation of new members and
continuing personal development of existing members, and us-
ing the web-based learning resource, may provide an opportu-
nity to keep the topics current, and impress upon members, the
importance human factors that play in influencing optimal team-
work and communication.
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