Team Communication and Collaboration: Debriefing after Acute Obstetric Clinical Events

Intro/Background

In 1999 The Institute of Medicine released To Err is Human and healthcare institutions and organizations began developing processes to improve patient safety.  Creating a culture of safety begins with effective teamwork and communication. Root cause analyses of poor obstetrical outcomes have linked poor organizational culture and communication to perinatal death and injury. Formation of effective teams has become a priority in healthcare and debriefing after acute clinical events is a highly regarded tool for team building that has been shown to have a positive impact on teamwork.

Highly reliable industries such as aviation and the military developed debriefing to improve team performance and safety. Pioneers of debriefing use in medicine taught and encouraged debriefings for simulation and real patient care events. Debriefing after simulation scenarios has become the gold standard and sufficient literature exists on this topic. However, only a few studies have revealed the outcomes of debriefing real-time events.

Prior researchers have studied the effects of debriefing using checklists and facilitated feedback with residents in an ICU setting and reported that the debriefing process was helpful and resident performance had improved. Researchers have also studied team learning in the adoption of minimally invasive cardiac surgery, and debriefings were seen as one of the key success factors of the surgical team because they yielded the fastest learning curve and best clinical outcomes. Debriefings were also studied in the Labor and Delivery setting and those results revealed that team debriefing after obstetric hemorrhages resulted in a 33% decrease in massive transfusions and a 78% decrease in unplanned hysterectomies.

Although there is limited literature on the topic of real patient care debriefings, available evidence suggests that debriefings have the potential to improve collaboration, communication and patient safety. The site of this research study is a large, safety-net academic facility which average approximately 350 deliveries a month. Of those deliveries, 50% are considered high-risk deliveries (trial of labor after cesarean section, hypertensive disorder of pregnancy, diabetes, placenta previa, etc). Furthermore, the facility serves as the primary teaching institution for Obstetricians, OB Anesthesiologists, Neonatolgists, Medical Students and Nursing Students. The practice environment includes Emergency Room residents, Family Practice residents, Neonatology fellows, Maternal-Fetal Medicine fellows and Certified Nurse Midwives. Because Individuals can often learn better as active participants responsible for their own learning, engaging in debriefings provides opportunities for these professionals to develop the ability to critically analyze their performance retrospectively.

The purpose of the IRB approved study was to examine the effects of debriefing after acute obstetrical events on the safety attitude of the health care workers. Safety attitude is a ‘snapshot’ of the safety culture from the perception of the frontline healthcare worker. Safety attitude includes the following dimensions: teamwork climate, safety climate, job satisfaction, perceptions of management, stress recognition and working conditions.

Methods

Setting/Participants

The longitudinal study took place over 13 months. Participation in the study was voluntary; all staff within the clinical areas that either influence or are influenced by the working environment were invited to participate. Inclusion criteria included working in the labor and delivery unit for at least one month. Potential participants included: registered nurses, unlicensed staff, respiratory therapists, OB/GYN faculty and residents, Maternal Fetal Medicine faculty and fellows, Anesthesia faculty and residents and Neonatology/Pediatric faculty and residents. There were no exclusion criteria based on age, race, ethnicity or gender.

Prior to designing the study, the Chief of Obstetrics, OB-Anesthesia and Neonatology were included on discussions and agreed to the plan to implement team debriefings to promote teamwork and a culture of safety. Prior to IRB approval, the study received approval from the Senior Nurse Executive Council.

Research Design

A descriptive, correlation design was chosen for this study. At the onset of the study, the safety attitude of participants was measured and then the intervention of inter-professional team debriefing was implemented. The safety attitude of the participants was measured again at six months and one year after the intervention was implemented. Safety attitude was assessed using a validated tool, the Safety Attitudes Questionnaire – Labor and Delivery (SAQ- L&D). The SAQ-L&D has 57 items and demographic information; the six constructs measured by the SAQ – L&D include: teamwork climate, safety climate, job satisfaction, perceptions of management, stress recognition and working conditions.

Reliability of the Safety Attitude Questionnaire has been reported in literature as robust, with a p value of 0.90; the internal reliability of the SAQ-L&D version is adequate with a p value of 0.78. To maximize response rates, the instrument was distributed to all potential participants electronically. The study consent was on the first page of the electronic survey and to begin the survey, each participant “agreed” to participate in the study. The electronic survey included instructions that participants could decline to answer any, or all, questions. The notice also

provided a statement to assure participants that responses were anonymous, as results are reported in aggregate.

Procedure

Debrief training occurred in October 2013 and was based on the teamSTEPPS philosophy. The training objectives included:

1. Identify appropriate situations for obstetric debriefings.

2. Identify who participates in debriefing.

3. Discuss the debrief “checklist”.

4. Demonstrate debriefing as a facilitator (simulation)

5. Demonstrate documenting the debriefing record.

The debrief facilitators include 14 Registered Nurses; members of nursing leadership and nurse clinician bedside leaders.

Upon IRB approval, potential participants were recruited via an introductory e-mail beginning November 1, 2013 (T1), May 1, 2014 (T2) and November 15, 2014 (T3). The introductory e-mail and all subsequent communication to participants was sent from the Administrative Director, Research & Sponsored Programs to remove the risk of coercion to participate as the PI and co-investigators have leadership roles with the potential participants.

Beginning November 15th, team debriefings occurred after acute obstetrical events, including but not limited to: shoulder dystocia, hemorrhage, cord prolapse, acute placenta abruptio, emergent (stat) cesarean section, breach vaginal delivery, maternal respiratory or circulatory collapse and neonatal code. Information regarding team debriefing was disseminated to all staff that work in Labor and Delivery through their supervisor.

Debriefing takes approximately 5-10 minutes and is conducted as closely as possible to the time of the critical event. The debrief facilitator documented the debriefing on the “debrief checklist”; the PI collected lists and tracked the events. In situations of high patient census and/or high patient acuity, available staff attended the debriefing. As a reminder and to encourage active participation, posters with the debriefing process were placed in high traffic areas.

Results

Responses were received from 51/258 of health care workers in T1 (19 % response rate), 86/258 in T2 (33 % response rate) and 39/258 in T3 (15 % response rate). Mean scores were compared by ANOVA and percent-positive scores by chi-square. Overall, factor scores were moderate to high across all factors (range across administrations: 43.4–74.9 mean scores, 25-85 percent positive). Mean and percent-positive scores did not differ significantly across the three administrations. The dimensional positive scores were found to be average to high on T1 and T2 administrations, T3 dimensional positive scores were found to be low to average. The lowest positive scoring dimension on all three administrations was “stress recognition” (28%). The dimensions of “job satisfaction” and “teamwork climate” generated the highest percent positive scores (60%).

Conclusion

The perception of the safety culture of healthcare workers that participated in this study did not change significantly over time after implementation of inter-professional debriefings. However, the research intervention of inter-professional team debriefing did lead to actionable initiatives. Once such initiative was developing and implementing an obstetric emergency response team with a goal to improve communication and teamwork during an obstetrical emergency.

Effective teamwork is a necessity for safe care in high-risk settings such as Labor and Delivery where transition to an emergency is quick. Utilizing debriefings can help structure communication and increase inter-professional team predictability. Consistent use of debriefings is one way to embed desired professional behaviors and improve safety culture for all members of the team. Also, debriefings can provide a method for all team members to have a voice in reliable delivery of safe patient care.