British Journal Of Midwifery - How delivery suite co-ordinators create situational awareness in the multidisciplinary team

Teamwork has been highlighted as a vital component for ensuring patient safety and positive patient outcomes in a range of healthcare settings (Firth-Cozens, 2001; Leonard et al, 2004). In maternity care, the particular focus for teamwork has been the delivery suite. Failures in this team have consistently been identified as a contributing factor to poor maternal and neonatal outcomes (Lewis et al, 2004; Healthcare Commission, 2004; Commission for Healthcare Audit and Inspection, 2006; Lewis, 2007; Royal College of Anaesthetists et al, 2007; O'Neill, 2008; Kirkup, 2015; Knight et al, 2015; 2016; Manktelow et al, 2015; 2016).

Historically, poor neonatal outcomes have been linked with deprivation and maternal ethnicity (Lewis, 2007). However, once adjustments have been made for these demographic factors, the variation in stillbirth rates is as high as 20% between maternity units (National Maternity and Perinatal Audit (NMPA) project team, 2017). This would suggest that other human factors are affecting outcomes. For example, there could be variations in the clinical care provided by the multidisciplinary team on the delivery suites (NMPA project team, 2017). This is supported by the findings from investigations into units with higher than expected incidences of maternal and neonatal deaths, which have cited poor communication, leadership and working relationships between multidisciplinary team members as direct causative factors in poor maternal and neonatal outcomes, possibly accounting for the variations seen between units (Healthcare Commission, 2004; Commission for Healthcare Audit and Inspection, 2006; Kirkup, 2015).

In the delivery suite multidisciplinary team, midwives are the largest professional group and spend the most time with women who are giving birth. It would therefore seem important that this staff group demonstrates strong clinical leadership within the team. However, unlike nursing, which acknowledges the importance of leadership at ward/clinical level (Pembrey, 1980; Ogier, 1982; Department of Health, 1999; 2000; 2009; Royal College of Nursing (RCN), 2009; Pegram et al, 2014), the focus for midwifery leadership has been restricted to higher management posts, Heads of Midwifery and delivery suite managers (Department of Health, 2000; 2007; Royal College of Anaesthetists et al, 2007; Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010; Bannon et al, 2017). Indeed all the maternity policies dating back to the 1990s have omitted the delivery suite leadership role in the context of intrapartum care provision, thereby failing to recognise delivery suite co-ordination as fundamental to a cohesive multidisciplinary team (Department of Health, 1993; 1999; 2000; 2004; 2007; Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010). The importance of the role of delivery suite co-ordinator as a clinical leader was last referenced by the Maternity Services Advisory Committee (1984).

‘Better Births fails to acknowledge the importance of the day-to-day management and leadership on delivery suite. This leadership has an impact on the early detection of deterioration in maternal and fetal wellbeing, thus preventing emergency situations, an area widely acknowledged in medical and surgical nursing as critical to instigating prompt interventions to avoid emergency scenarios’

The strategic direction for maternity services in England, Better Births (National Maternity Review, 2016), advocates the breaking down of barriers between midwives and obstetricians to improve multidisciplinary team relationships. This followed the Morecombe Bay review, which was highly critical of ‘dysfunctional’ multidisciplinary team working (Kirkup, 2015). A strategy to improve multidisciplinary team working put forward in the Better Births report (National Maternity Review, 2016) was for the multidisciplinary team to train together. This recommendation originated from studies evaluating the Practical Obstetric Multi-Professional Training (PROMPT), a simulated emergency skills drills course (Draycott, 2013). These studies consistently found an improvement in the communication and cohesive multidisciplinary team working, which improved team performances in simulated emergency situations (Siassakos et al, 2010; Bristowe et al, 2012) and highlighted the benefits of incorporating simulation and human factors into multidisciplinary team training.

Although joined-up multidisciplinary teamwork is essential in emergencies (Bristowe et al, 2012; Cornthwaite et al, 2013), Better Births fails to acknowledge the importance of the day-to-day management and leadership on delivery suite. This leadership has an impact on the early detection of deterioration in maternal and fetal wellbeing, thus preventing emergency situations (National Maternity Review, 2016), an area widely acknowledged in medical and surgical nursing as critical to instigating prompt interventions to avoid emergency scenarios (Luettel et al, 2007).

National reports have identified the consultant obstetrician and delivery suite ward manager as holding responsibility for the management of delivery suite. Delivery suite managers predominately work from 9 am to 5 pm, and only units with more than 6000 deliveries per year will have 24-hour consultant cover (Royal College of Anaesthetists et al, 2007; O'Neill, 2008). Responsibility for providing 24-hour leadership and co-ordination of the multidisciplinary team therefore falls to delivery suite co-ordinators.

However, achieving these objectives is particularly difficult for the delivery suite co-ordinator because of the fluidity of team membership, with each shift comprising different team members. This makes developing personal working relationships through mutual trust and group cohesiveness more complex to achieve within the shift timescale (O'Neill, 2008).

Supporting individual practitioners and fostering positive multidisciplinary teamwork is challenging. Historically, midwives and doctors have been influenced by competing ideologies: midwives trained to follow a holistic model of care that views childbirth as a normal process, and doctors trained with a medical model that views childbirth as normal in retrospect (Donnison, 1988; Kitzinger et al, 1990; Hastie and Fahy, 2011). An inability of the delivery suite co-ordinator to encourage compromise, often between multiple health professionals, has been shown to fragment multidisciplinary team decision-making, which, at its most dysfunctional, results in maternal and neonatal morbidity and mortality (Berridge et al, 2010; Kirkup, 2015).

There is a lack of literature on the leadership role that delivery suite co-ordinators play in multidisciplinary teamwork. Ethnographic studies suggest that the delivery suite co-ordinator is critical to team situational awareness, acting as a conduit for information exchange from formal ward rounds and instigating impromptu handovers as workload and clinical complexities change (Lankshear et al, 2005; Mackintosh et al, 2009). Co-ordinators are required to understand staff and their capabilities; who needs closer support and supervision; and whether a junior, registrar or consultant member of staff is the most appropriate to involve in clinical care (Lankshear et al, 2005). Delivery suite co-ordinators' opinions of the role can be found in one study from New Zealand (Fergusson et al, 2010). The delivery suite co-ordinators articulated the personal qualities that they believed were required for the role, but did not acknowledge the personal impact of the role on the individual multidisciplinary team (Fergusson et al, 2010). Transferability of the findings to the UK multidisciplinary team and the delivery suite co-ordinator role is limited, as in the New Zealand model for maternity care, staff dynamics and power relationship are fundamentally different (Grigg and Tracy, 2013).

Although these studies provide a useful insight into the role of the delivery suite co-ordinator in multidisciplinary team group dynamics, the impact of the delivery suite co-ordinator on teamwork is still poorly understood.

Aim

Despite the lack of UK-based research evidence to define and underpin the role, delivery suite co-ordinator posts continue to be advertised. This suggests that there is some knowledge or understanding in the NHS as to what the post-holder is required to do. As such, this rich source of information could be used to develop a deeper understanding of the post. This study therefore aimed to analyse job descriptions to gain an understanding of organisations' expectations of the delivery suite co-ordinator role. To the authors' knowledge, this is the first study to use job descriptions in this way.

Study design

A qualitative documentary analysis was adopted. This approach involved finding, selecting, appraising and synthesising data found in documents and was chosen as it offers a robust framework and a systematic procedure for reviewing and evaluating the job descriptions (Bowen, 2009). This was a desk-based study of publicly available documents and data were anonymised.

Data collection

A purposive sampling approach (Glaser and Strauss, 1967) was used to identify job descriptions from a freely available website where NHS jobs are advertised. The website was searched weekly between April 2017 and October 2017 using the search terms ‘delivery suite/labour ward co-ordinator’. All job descriptions that met the inclusion criteria (Table 1) were included.

Table 1. Inclusion and exclusion criteria

Inclusion criteria	Exclusion criteria	Rationale
Consultant-led units (with/without alongside midwifery-led units)	Stand-alone midwifery-led units	In stand-alone units, the post-holder co-ordinates midwives only as opposed to the multidisciplinary team
Co-ordinator of a shift	Delivery suite managers	Delivery suite managers co-ordinate the delivery suite unit in its entirety as opposed to the clinical co-ordination of a shift
Delivery suite/labour ward	Ante/postnatal ward co-ordinator/community team co-ordinator	The co-ordination role of the multidisciplinary team on delivery suite is more intensive than the ward and community

The delivery suite co-ordinator job descriptions incorporated the roles and responsibilities for both the short-term leadership and management of the shift, and longer-term staff management. For the purpose of this study, the analysis focused on the expectations of the delivery suite co-ordinator for the short-term leadership and management of a shift.

Data analysis

Each job description was analysed using a modified five-step thematic analysis (Rapley, 2016) (Table 2).

Table 2. Thematic analysis process

1. Familiarisation with the dataset (job descriptions)

2. Generation of initial codes

3. Search for themes collating similar codes (similar sentences to other job descriptions) into potential themes/categories

4. Review of themes, checking if themes work in relation to the datasets and checking for examples that do not fit

5. Refinement of themes and links between them, key areas of responsibility identified and used as headings

The descriptive sentences/bullet points from the first job description were read and transcribed verbatim. Initial analysis of these sentences led to the development of three overarching themes. Further analysis was conducted to refine the overarching themes and a number of related sub-themes emerged. This iterative process of code generation and allocation to the themes and sub-themes was applied to each job description in the sample.

Where descriptive sentences from the second and subsequent job descriptions were similar, sentences were numerically logged for frequency, then merged into one code. This process was followed as each job description became available on the website until all the job descriptions had been analysed. In total, 240 descriptive sentences/bullet points from the job descriptions were extracted, coded and allocated to themes and sub-themes.

This decision to ‘count’ or quantify qualitative data was influenced by Silverman (1985:140) who argued that ‘simple counting techniques can offer a means to survey the whole corpus of data ordinarily lost in intensive, qualitative research’. This highlighted the most commonly used sub-themes generated from the job descriptions. This was important, as it enabled a hierarchy of most-used through to least-used to be identified, and assumptions drawn about their importance to the role to be made.

The findings from the thematic analysis were then used to develop a logic model (Wilder Research, 2009; Adamson and Prion, 2016; Community Tool Box, 2017) to assist with a more in-depth understanding.

Requirements from the personal specification were not included in the analysis, as the aim of the study was to understand the expectations of the role as opposed to the skills and experience required.

Findings

A total of 15 job descriptions were included in the study and originated from maternity units delivering between 2500 to 6000+ babies per year.

Analysis of the job descriptions generated 3 themes (Table 3): the co-ordination role, leadership of the multidisciplinary team, and staff development. The findings tables (Tables 4 and 5) include illustrative descriptive sentences/bullet points from the job descriptions for each sub-theme.

Table 3. Analysis of job descriptions: themes and sub-themes

Themes	Sub-themes
Co-ordination role (n=125)	Co-ordination of the unit (n=42)
	Staff management (n=61): Short term (n=30) Long term (n= 31)
	Safety management (n=22)
Leadership and support of the multidisciplinary team (n=86)	Conduit for information (n=41)
	Communication with the multidisciplinary team (n=29)
	Communication women and families (n=16)
Staff development (n=29)	Personnel and staff development (n=29)

Table 4. Co-ordination role

Sub-themes	Examples of statements from the job descriptions
Co-ordination of the unit	Co-ordinating with an awareness of activity on the unit and midwife-led unit Maintains information board Co-ordination of women's care through handover from outgoing shift to incoming shift Co-ordinates admissions and discharges, bed shortages implements diversion policy Liaison with the obstetric, anaesthetic, theatre teams and neonatal unit
Staff management (shift specific)	Deal with unpredictable high levels of activity Ensure adequate staffing levels for the shift Effective management of staff and resources on a shift by shift basis
Safety management (shift specific)	Minimise risk and report incidents

Table 5. Leadership and support of the multidisciplinary team

Sub-themes	Examples of statements from the job descriptions
Co-ordination of the unit	Update communications board Ensure effective communication between the multidisciplinary team Deciding whether to alert medical team to situations outside the remit of the midwife's role Works with other co-ordinators
Communication with the multidisciplinary team	Co-ordinates the multidisciplinary team for the duration of the shift Promotes team working challenging poor behaviours and attitudes Create an environment central to decision-making
Communication women and families	Ensure effective communication between relatives and visitors

Co-ordination role

This theme was underpinned by the highest number of descriptive sentences extracted from the job descriptions (125 of the 240 descriptive sentences). This might lead to assumptions about its perceived importance for hospitals; clearly ‘co-ordination’ is the main focus of the role. The job descriptions described co-ordination as taking a ‘helicopter view’ of activity, both on the delivery suite and units that share co-dependencies with the delivery suite. Understanding how to perform this activity was identified as fundamental to staff management on the shift, and encompassed the allocation and redeployment of staff to accommodate the varying levels of activity and clinical dependencies on the unit.

The ability to co-ordinate the shift was underpinned by three sub-themes: co-ordination of the unit, staff management and safety management (Table 4). Co-ordination of the unit related to the post-holder's responsibilities for the shift, in contrast to staff management, which included organising people on a shift-by-shift basis, longer-term recruitment and sickness management. The delivery suite co-ordinator's responsibilities for safety management involved risk assessment and reporting of incidents on a shift-by-shift basis, and the longer-term initiatives of reviewing incidents and general equipment maintenance.

Leadership of the multidisciplinary team

The theme of leadership and support of the multidisciplinary team was underpinned by the next highest number of descriptive sentences (86 of the 240 descriptive sentences). Again, this highlighted the importance of the role, particularly in gathering and communicating information from a number of sources and escalating care to the most appropriate member of the multidisciplinary team (Table 5). This theme was underpinned by three subthemes: the delivery suite co-ordinator's role as a conduit for information, communicating with the multidisciplinary team, and communicating with the women and their families.

Logic modelling

Although the analysis of the job descriptions illuminated the roles, responsibilities and expectations of delivery suite co-ordinators, other important questions such as the impact of the elements of this role needed to be explored. This level of understanding—the ‘so what?’ question—was important if the findings from the study were to be useful for clinicians and managers in informing the development of future job descriptions. The challenge was to identify a framework that could bring the required level of understanding to the findings and illuminate the expected outcomes; logic modelling met this requirement.

Logic models present a simplified picture of the connections between resource inputs, activities and the resulting outcomes of programmes or NHS services (North of England Commissioning Support (NECS), 2016). They can be used for a range of purposes, including mapping and planning the resources needed to produce specific outcomes, or identifying the expected outcome if specific resources and inputs are used. This latter approach was adopted in this study.

Logic models are underpinned by theories of change and therefore depict assumed or conjectured causal connections (ie the reasoning as to how a programme works) (NECS, 2016). In this study, the logic model therefore presented a conjectured picture of the relationship between:

The inputs of the delivery suite co-ordinator role as identified from the thematic analysis of the job descriptions

The activities undertaken by delivery suite co-ordinators as depicted in the descriptive sentences extracted from the job descriptions

The conjectured outcome if the role operates successfully, which was informed by the literature and the authors' clinical knowledge.

At the heart of the logic model (Figure 1) are the ‘activities’ undertaken by delivery suite co-ordinators during a shift (as identified from the descriptive sentences contained in the job descriptions). These activities had already been grouped into two themes after the earlier thematic analysis: co-ordination of the unit, and leadership and support of the multidisciplinary team. The logic model comprises nine outcomes that are expected to arise if these activities occur. It shows that many of the relationships between activities and outcomes are simple and trigger only one outcome.

However, the use of logic modelling has highlighted a locus of complexity in that six of the nine activities triggered the same outcome: ‘situational awareness of changes in clinical status, activity and capacity of staff/beds’. Relating this finding back to the thematic analysis presented in Tables 3, 4 and 5, it is clear that the co-ordinator is expected to use a number of information-gathering strategies to build the overall picture that enables them to become situationally aware.

Figure 2 highlights the importance of these six activities in underpinning situational awareness. In nature, the hexagon depicts a stable and strong structure; if one of the sides is weak the whole structure becomes weak. Likewise, situational awareness can only be a stable feature of the delivery suite if the co-ordinator has all the information, which contributes to the ‘helicopter view’ of what is happening on the unit.

Figure 2. Summary of activities undertaken by the delivery suite co-ordinator to encourage situational awareness.

If executed effectively by the delivery suite co-ordinator, situational awareness should ensure that there are no delays in communicating the ‘whole picture’ to the staff. This enables the multidisciplinary team to make joint decisions in context, allowing the right professionals to plan and provide timely care. This is the foundation of safe care (Berridge et al, 2010).

Discussion

The key finding of the logic modelling was the central role of the delivery suite co-ordinator in using resources and information to be situationally aware, which they achieved by gathering, managing and communicating information to and from the multidisciplinary team. This situational awareness is then shared with the multidisciplinary team to enable joint decision-making, planning and the provision of timely clinical care.

Situational awareness

Although the activities required to generate situational awareness were explicit in the job descriptions, the term ‘situational awareness’ was more abstract, hidden in the wording of the job descriptions and not specifically named. This contrasts with the more explicit operational management responsibilities of short- and long-term staff management and clinical governance.

Abbott et al (2012) suggested situational awareness was fundamental to a positive safety culture, which can be achieved only through good communication, workload management and group cohesion. If achieved, this leads to a common understanding of the clinical environment and events by the right multidisciplinary team members, which mitigates against poor decision-making and substandard care (Edozien, 2015). The consequences of poor decision making are reiterated in the Each Baby Counts report (Royal College of Obstetricians and Gynaecologists (RCOG), 2017), which cites loss of situational awareness by the clinical team as a causative factor in 44% of the poor outcomes reviewed.

Wright et al (2004) suggested that situational awareness operated at 3 levels: the ability of the individual to perceive elements of their environment; comprehension of the situation; and the ability to project into the future situation (the highest level of situational awareness). On the delivery suite, this would equate to pre-empting potential changes to clinical care and activity so that corrective action can be taken to prevent clinical emergencies and/or capacity issues (Luettel, 2007).

Situation awareness therefore could be likened to a jigsaw puzzle. If the collective pieces of the puzzle (clinical information) are not shared, it is impossible to see the whole picture.

Construction of the clinical jigsaw

This study raises the question of how the delivery suite co-ordinator ensures that they collect all the pieces of the clinical jigsaw. Mackintosh et al (2009) studied team communication on the delivery suite and identified the communication board to be fundamental to the summary of all clinical information, facilitating team situational awareness and decision-making. The researchers identified that the delivery suite co-ordinator was the main conduit for this information, which was gathered through formal ward rounds, handovers and impromptu, informal discussions with multidisciplinary team members. All this information was then used to update the communication board.

This gathering of information from members of the multidisciplinary team is particularly challenging for delivery suite co-ordinators who work in a fluid team of autonomous practitioners with differing perspectives on the need to share clinical information. Hunter (2004) found that senior midwives took the overview of information from the organisational perspective but junior midwives focused on the women in their care. Lankshear et al (2005) observed that delivery suite co-ordinators frequently made excuses to go into the delivery rooms to elicit the clinical information necessary for the overview of activity. It is therefore imperative that the delivery suite co-ordinator develops a trusting relationship with the multidisciplinary team members, and that this relationship is supportive as opposed to oppressive, if key clinical information is to be shared within the team (Bedwell et al, 2015).

Transition from clinical midwife to leadership

The transition from clinical midwife to delivery suite co-ordinator is based on the assumption that the skills required to provide clinical care are readily transferable. The UK literature on what makes a ‘good’ clinical midwife is limited to studies informing curriculum development (Pope et al, 1998; Nicholls and Webb, 2006; Nicholls et al, 2011) and a small-scale study of midwives providing care across the range of ante-, intra-and postnatal care (Byrom and Downe, 2010). The attributes identified focused on technical knowledge and competence, empathy and advocacy to support women in decision-making about their care. They also related to midwives providing one-to-one clinical care, skills that fundamentally differed to the co-ordination of staff and planning for changes in the clinical status of multiple women (Abbot et al, 2012).

Despite the different skills required for the delivery suite co-ordinator role, anecdotal evidence suggests that less than 50% of delivery suite co-ordinators received formal training for the transition from clinical to co-ordinator role.

Implicitly, an element of this transition process should include human factors training. Although the connections between human factors training and improvements in obstetric outcomes is yet to be fully evaluated in the delivery suite environment (Monks and Maclennan, 2016; RCOG, 2017), it provides an excellent opportunity for raising situational awareness and is consequently gaining traction in a number of Trusts.

Strengths and limitations of the study

This is the first study to gain an insight into the role of the delivery suite co-ordinator by developing a logic model from the thematic content analysis of job descriptions.

Although the themes identified were remarkably consistent, this might suggest that units use each other's job descriptions as a template for their own. The job description analysis represented a range of units in size and geography, but were limited to 15 job descriptions; therefore, the findings cannot be generalised to every delivery suite co-ordinator's role. However, the coding framework and logic modelling from the study has provided a template that could be used for a larger and more generalisable study.

Conclusion

Analysis of job descriptions suggests that Trusts implicitly understand the importance of situational awareness in safe decision-making and the vital role that delivery suite co-ordinators play in leading situational awareness. However, this important role has been overlooked in all the strategic maternity documents.

Midwives making the transition to become delivery suite co-ordinators require skills in leadership and management of staff and complex information—a different skill set to clinical midwifery. If newly appointed co-ordinators are to successfully make this transition, investment in training and succession planning is required to ensure that they are equipped to lead the multidisciplinary team in the provision of safe care.

Key points

Job descriptions are a source of tacit knowledge regarding the role of delivery suite co-ordinators

Findings from this study highlight the vital role played by the delivery suite co-ordinator in creating a safe clinical environment by fostering situational awareness across the multidisciplinary team

Delivery suite co-ordinators require additional skills to those required by clinical midwives, including well-developed leadership skills and an ability to take a ‘helicopter view’ of activity, both on the delivery suite and units that share co-dependencies with the delivery suite

Delivery suite co-ordinators would benefit from support and training to transition from clinical to delivery suite co-ordinator

CPD reflective questions

What is situational awareness and why is it important on delivery suite?

How does the delivery suite co-ordinator encourage situational awareness in the multidisciplinary team?

Have the findings of this study influenced or changed your views of the delivery suite co-ordinator role? If so, how and why?

How do you view the role of the delivery suite co-ordinator and why is the role important to midwives working on the delivery suite?