Supporting patient safety: Examining communication within delivery suite teams through contrasting approaches to research observation
Introduction
This paper reports aspects of an in-depth, longitudinal mixed methods study of four delivery suites (DS) over a two-year period, during which interprofessional simulation-based training for senior staff was introduced. The structure of the overall project and an overview of the multifaceted findings, including mothers’ views, can be found in the project’s final report (Freeth et al., 2008). The present paper will examine aspects of communication within the DS environments that are pertinent to maintaining safety, and will present insights gained from interrogating complementary datasets generated through contrasting forms of observation. The findings will be grouped into four themes (communication underpinning collaboration, effects of workload pressures, interprofessional communication and architectural influences).
Effective communication is central to quality health care (Audit Commission, 1993). Communication failures contribute to preventable errors and adverse care outcomes (Leonard et al., 2004). Within the domain of obstetrics and gynaecology, failure to communicate effectively is the most common cause of medical errors (White et al., 2005). These failures are usually caused by a disruption in the flow of critical patient-relevant information between or among caregivers, and thus an error in judgment or in the decision-making process occurs (Collins, 2008).
The Department of Health (e.g. Department of Health, 1993), the Royal Colleges (e.g. Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 1995) and others (e.g. O’Neill, 2008) have recognised the importance of communication for promoting quality and safety in maternity care, and have been involved in initiatives to raise standards. ‘Towards Better Births’ highlights the importance of good communication for woman-centred care (Healthcare Commission, 2008a). Multidisciplinary working and communication are vital for successful outcomes (Department of Health, 2007).
Difficulties in relaying and interpreting information across interprofessional boundaries have been documented extensively (National Patient Safety Agency, 2007, O'Neill, 2008). Several reports detail inter- and intra-professional rivalries in maternity care (between obstetric consultants, obstetric consultants and midwives, obstetricians and gynaecologists) (Commission for Health Improvement, 2003, Healthcare Commission (HCC), 2004, Healthcare Commission, 2006). Occupational and hierarchical boundaries contribute to care management problems with delayed recognition and poor response to clinical deterioration (National Patient Safety Agency, 2007, Healthcare Commission, 2008b). Conclusions drawn from ‘Confidential Enquiries into Maternal Deaths’ show that inadequate vigilance and/or poor responses to problems affected outcomes in 50% of direct maternal deaths; the main factors were poor communication and teamwork (Lewis, 2001, Lewis, 2004). Communication barriers and a lack of collaborative working between health professionals contribute to patient safety risks (Rowe et al., 2001, Rowe et al., 2002).
Team situation awareness (TSA) (Cooke et al., 2001) is a precursor to safe decision-making and performance (Endsley, 2000). This shared awareness acts as the safety net that mitigates the impact of an individuals’ attention narrowing (Burke et al., 2004) due to fixation, overload or distraction. Effective teams hold higher levels of TSA than low-performing teams (Leonard et al., 2004). Elsewhere (Mackintosh et al., 2009), the authors described configurations of processes, roles and artefacts through which the DS teams in this study communicated to establish TSA to inform their decisions and actions. This paper considers other aspects of communication in the DS and the structures that contribute to these.
Section snippets
Research sites
The research sites were purposively selected to provide variation in size, location, local demographics, footfall, client acuity, care model (midwifery-led or consultant-led) and resources. All sites served relatively deprived populations with significant social support needs. Two sites were in the north of England and two in London, labelled Milltown, Romantown, Eastborough and Westborough. Eastborough and Westborough were very busy (5000 and 6000 births per annum). They had high staff
Findings
Analysed through the lens of improving safety in DS care, the observations drew attention to different facets of communication. TSA has been discussed elsewhere (Mackintosh et al., 2009) and four further facets will be described in this paper: communication underpinning collaboration, effects of workload pressures, interprofessional communication, and architectural influences. Examples have been selected from the sites that most clearly illuminated each theme, although data from all sites
Methodological strengths and limitations
To date, patient safety research and interventions focusing on communication have been commonly conducted in operating theatres or intensive care, and have sought to promote more standardised communication (e.g. Catchpole et al., 2007, Lingard et al., 2008, de Vries et al., 2009, Haynes et al., 2009, Association of periOperative Registered Nurses, 2010). Most work in these environments can be observed from a single vantage point and involves relatively stable multidisciplinary teams (Hewett et
Conclusions
Recently, Ovretveit (2009) called for further research to aid understanding of problems and solutions in communication and co-ordination in the ‘in-betweens’ – between professionals and between shifts, professions, units and services.
Within safety discourse, care pathways and trajectories are often depicted as linear and temporal constructions. Communication is also perceived as the transmission of concise, salient information, with little acknowledgement of socio cultural meanings. However,
Acknowledgements
The authors wish to thank the staff of the four participating delivery suites. The study was funded by the UK National Patient Safety Agency, and ethical approval was granted by the South West NHS Multi-Centre Research Ethics Committee.
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