There are reports dating back to 2006 relating to multidisciplinary team working and the associated consequences for women and babies on the labour ward (Healthcare Commission, 2006; Kirkup, 2015; 2022; Royal College of Obstetricians and Gynaecologists, 2017; Care Quality Commission, 2021; Ockenden, 2022). Despite this, there has been minimal examination of the role of the labour ward co-ordinator (Bunford and Hamilton 2019). For the duration of their shift, the labour ward co-ordinator is the focal point for all activity and communication in the multidisciplinary team, having a profound influence on team working and clinical decision making. The labour ward co-ordinator's role is key to the effective functioning of the labour ward and the safety of women and babies (Mackintosh et al, 2009; Abbott et al, 2012; Bunford and Hamilton, 2019).
Research on the labour ward co-ordinator role is restricted to one self-reporting study of five labour ward co-ordinators in New Zealand, who define their role as being at the hub of activity and having the ability to solve problems; these responsibilities become increasingly challenging as labour ward activity increases (Fergusson et al, 2010). Observational studies of labour ward multidisciplinary team working acknowledge the impact of team situational awareness on the delivery of safe intrapartum care (Abbott et al, 2012; Health Care Safety Investigation board (HSIB), 2020a). The labour ward co-ordinator is deemed to be a key role as a conduit for information exchange and support for staff with decision making (Lankshear et al, 2005; Berridge et al, 2010). However no studies identify how effective labour ward co-ordinators operate.
There has been extensive research into student midwives’ and midwives’ perceptions of the attributes of a good midwife delivering direct clinical care (Byrom and Downe, 2010; Fergusson et al, 2010; Nicholls et al, 2011; Hallsdorottir and Karlsdottir, 2011; Carolan, 2013; Borrelli et al, 2016; Feijen-de-Jong et al, 2017). Exploration of multidisciplinary team perspectives of midwives as work colleagues on the labour ward in non-labour ward co-ordinator roles is limited to two Australian studies. Reiger and Lane (2009) and Hastie and Fahy (2009) suggested that obstetricians and midwives identify different qualities that they valued in midwives as work colleagues. Midwives valued midwifery colleagues who were flexible, approachable and did not panic when complex situations arose. These midwives supported their colleagues with the physical workload and aspired to a profession grounded in normal birth. Obstetricians valued and respected midwives who recognised complications and made timely referrals to the medical team. In addition, some obstetricians felt that midwives’ desire to protect normality in childbirth might create a fragmented multidisciplinary team (Hastie and Fahy, 2009). This perception is echoed in maternity enquires in the UK (Kirkup 2015; 2022).
It could be argued that the labour ward co-ordinator role, predominately focusing on managing people and information, requires a different skillset to the midwife, providing one-to-one care. Kay (2010) and Hewitt et al (2019) suggested that clinical managers in the community setting require a balance between management and leadership skills to manage a team. While there will be transferable skills between community and labour ward management, the labour ward co-ordinator needs knowledge of many more midwives’ and doctors’ abilities and skills than community teams of 6—8 midwives (NHS England, 2016).
The aims of this study were to explore skills and attributes considered to be essential by the multidisciplinary team in an excellent and effective labour ward co-ordinator, and provide differentiation between co-ordinators deemed to be good or ineffective (Table 1). Perceptions of how labour ward co-ordinators positively or negatively influence running of shifts and potential outcomes for women and babies were explored. The research data were informed by thematic analysis and logic modelling of labour ward co-ordinator job descriptions (n=15), which identified three key aspects that trusts expected the labour ward co-ordinator role to fulfil: co-ordination of staff and activity, leadership of the multidisciplinary team, and staff development (Bunford and Hamilton, 2019).
Table 1. Definition of terms
| Term | Explanation within context of findings | |
|---|---|---|
| Excellent labour ward co-ordinator | Effective | Participants viewed as having exceptional attributes which made them ‘stand out’ from the others |
| Good | Participants viewed as having attributes which had a positive effect on the shift | |
| Ineffective | Participants viewed as having had attributes which had a negative effect on the shift |
Methods
This study, using a constructive grounded theory design, was conducted at a maternity unit in the north of England with an annual birth rate of approximately 5000 births. Facilities included a co-located and rural midwifery-led unit, a tertiary neonatal unit and associated in utero transfers. The head of midwifery, labour ward manager and lead obstetrician from the unit participated in the study design, interview schedule, consent procedure, sampling and formation of the inclusion/exclusion criteria.
Sampling
Purposeful and theoretical sampling informed recruitment. Purposeful sampling ensured all staff groups from the multidisciplinary team, midwives, obstetricians, maternity care assistants and ward clerks were included in the sample (Table 2). In-keeping with constructive grounded theory methodology, theoretical sampling informed the final sample size and data saturation (Charmaz, 1995; 2014). The final sample size was 21.
Table 2. Number of staff interviewed
| Staff group | n | Staff code | Order of interviews |
|---|---|---|---|
| Consultants | 4 | C | C1 |
| Registrars (years 4-7 in obstetric training) | 3 | R | R2 |
| Senior house officers (years 1-3 in obstetric training) | 3 | SHO | SHO3 |
| Midwives (band 6) | 4 | M6 | M62 |
| Midwives (band 5) | 4 | M5 | M54 |
| Maternity care assistant | 2 | MCA | MCA2 |
| Ward clerk | 1 | WC | WC1 |
Inclusion/exclusion criteria and recruitment
All doctors and midwives who had worked for a minimum of 6 months on a labour ward in two or more maternity units, in their current role, were eligible to participate. A period of 6 months ensured exposure to labour ward co-ordinators, enabling individuals to construct their sense of the reality of the labour ward co-ordinators by being in the labour ward environment (Lincoln et al, 2018). Participants’ experiences of more than one maternity unit mitigated against the narrow social context and influence of unit culture on the richness of data collection through introspective views.
Obstetrician's responses were grouped according to experience, ST1-3 (senior house officers), ST4-7 (registrars) and consultants, and band 5 and 6 midwives were included to reflect a diversity of experience (Table 2). To avoid selection bias, the head of midwifery, labour ward manager and clinical director acted as gatekeepers inviting eligible staff to participate via email. Registration of interest and invitation to interview was direct via the researcher, to protect participant anonymity.
Data collection
Data were collected using semi-structured interviews with open-ended questions. The initial interview question invited the participants to reflect on shifts that had gone well and the attributes of the labour ward co-ordinators leading the shift. Further exploratory questions, in line with the constructive grounded theory approach, were dependant on the participant's response The exact question used was ‘could you think of times when you have been on shifts where things have gone really well and could you think about the labour ward co-ordinators’ attributes that have contributed to those shifts?’. This question was piloted on two midwives prior to the interviews.
In total, 21 individuals, from a diversity of ethnic backgrounds and with a variety of length of service, were interviewed. Interviews were recorded and transcribed verbatim by the researcher. In-keeping with constructive grounded theory, subsequent interview questions were adapted to focus on the emerging themes, and data saturation informed the final sample size. Charmaz (2014) defined data saturation as theoretical completeness, where the collection of rich and sufficient data has resulted in no new categories or theoretical insight being discovered.
Data analysis
Data collection and analysis were conducted simultaneously using constant comparison of the emerging data (Charmaz, 2000; 2014) (Figure 1). Data were analysed using both NVivo and traditional pen and paper (Maher et al, 2018), and analysis was conducted according to the constructivist module of grounded theory advocated by Charmaz (2014). The relationship between the emerging categories identified three main themes (Table 3). Reflexivity was maintained through memo writing and reflective diary accounts, adding rigour and transparency to the analysis and theory generation process (Charmaz, 1995; Lempert, 2017). Peer review at each stage of the analysis and findings maintained accountability.
Table 3. Emerging themes and categories from focused coding
| Category | Situational awareness | Supporting staff with decision making | Approachable |
|---|---|---|---|
| 1 | Ability to make quick decisions | ||
| 2 | Knowledge | ||
| 3 | Helicopter view | ||
| 4 | Organised and in control | ||
| 5 | Personality to challenge | ||
| 6 | Proactively leads | ||
| 7 | Supportive and approachable | ||
| 8 | Team player | ||
| 9 | Sharing of information | ||
Ethical considerations
Verbal and written consent was gained pre interview and supported by a participant information leaflet. The research study documents were approved by the Health Research Authority (reference: IRAS 246685), university's ethics committee (reference: 209/17) and hospital's research and development department. All ethical review processes were underpinned by the World Medical Association (2013) declaration of good practice.
Results
The theory developed from the research findings identified an effective labour ward co-ordinator requires three distinct attributes: keeping abreast of events through situational awareness, supporting staff with decision making, and being approachable, which requires the ability to oscillate between a number of leadership styles.
Situational awareness
All participants related to labour ward co-ordinators who were in control because they were situationally aware, having a ‘helicopter view’ of the labour ward that provided structure and organisation. This enabled staff to plan and carry out their work with a sense of pride, as a team, to the best of their ability, which required engaging, transformational, transactional and adaptive leadership styles.
‘Helicopter view … Looking at the whole picture. Just having that overall view of the unit, I think is to me what makes a good team leader’. M6-3
The thing that I find frustrating is if the midwife [labour ward co-ordinator] doesn't have control of the situation, that ‘helicopter view’, then you feel the whole responsibility rests on your shoulders as the registrar if you're on nights and there is no consultant’. R3
Effective labour ward co-ordinators maintained situational awareness by proactively collecting and personally updating the communications board.
‘She's so strict about what goes on that board, and she gets cross if someone has not updated her and there is information that has not gone via her’. R2
Strategies used included visiting midwives and women in delivery rooms and maintaining knowledge about women's status on the antenatal units. Excellent labour ward co-ordinators avoided becoming involved in deliveries, while ensuring the right personnel were in attendance.
‘Yes, again it's just about being organised, they go round and speak to each person in turn “where are we at? What are we doing?” That type of thing, huddles, are great, just because we could have chance to take 5 minutes altogether to find out where we're all at’. MCA-2
When activity and the associated information streams increased, effective labour ward co-ordinators recognised the limits of their own comprehension, instigating impromptu huddles at the communications board to maintain team situational awareness and articulating priorities, facilitating a shared understanding.
‘Then also it's been crazily busy, having like many huddles. Getting everybody in to say “right, where are we at? Okay, so we can move this person, we cannot move that person". So making a plan, so everybody is aware of what's going on’. M5-4
Labour ward co-ordinators who were identified as being excellent used the information on the communication board to pre-empt potential problems and planned accordingly.
‘So it is about their ability to look at something and go “well at the minute, we are all fine but I suspect that in 1 or 2 hours, we might not be fine so what can we do"’. C3
‘I do think some team leaders “forward think” situations more to pre-empt what the board [information and communication] could look like in for example, 1 hours’ time. So, I do think it goes back to that forward planning really’. M5-2
Supporting staff with decision making
Effective labour ward co-ordinators adopted a personalised approach to supporting staff with decision making, requiring situational and compassionate leadership styles. For staff with less experience with intrapartum care, they offered support and advice, involving staff in decision making as a learning opportunity and screening concerns prior to escalation to the medical staff.
‘Being involved, that is the most satisfying thing… So, I'm involved in the decision-making process or I have been told why the decision has been made’. S3
For more experienced staff, labour ward co-ordinators acted as a sounding board. This group of staff had the capability to make autonomous decisions but valued bouncing their ideas off the labour ward co-ordinator. This was particularly important for registrars and consultants.
‘So I guess there are some co-ordinators where I feel they come to me and just expect and put everything on me to fix stuff which is fine, but I would say it's best when we are almost like equals and we are bouncing ideas between ourselves. And sometimes there is no right or wrong answer, it's not clearcut, and if you're in the middle of the night, the consultant is asleep in bed, you want to have someone you can bounce ideas off’. R1
Supporting staff with decision making was not limited to one-to-one conversations. Effective labour ward co-ordinators understood the human factors of fatigue, hydration and nutrition on staffs’ cognitive processing and its impact on staffs ability to make decisions, proactively ensuring staff had breaks.
‘It's also about making sure the staff had something to eat and drink because when it's really crazy, people don't eat and drink, and you see them [midwives] slowly getting… faint…getting unwell…too warm’. MCA-1
‘One particular team leader talks a lot about human factors, I cannot think of the term, but there's this window that happens between 3 and 5 in the morning. Regardless of how busy it is, she will go round and make sure, “have you had something to eat? Have you had something to drink? Can I relieve you?” Because some team leaders will say you have got to have your break, but they won't physically support you to do that’. M6-4
The excellent labour ward co-ordinators understood that non-visible staff were most prone to loss of situational awareness, as a result of emotional fatigue, and used strategies such as allocating a relief midwife to cover their colleagues, ensuring a physical break from an intense situation. This was in stark contrast to the feeling of vulnerability expressed by midwives working with ineffective labour ward co-ordinators, who were unable to make connections between the effect of lack of nutrition on cognitive function and decision making.
Approachable
All participants made reference to the importance of the labour ward co-ordinator being approachable, requiring a high level of emotional intelligence. Individuals wanted to feel comfortable and safe in asking questions to support their decision making.
‘Good ones you can ask the silliest of things to and they will say “yes will get that sorted", it's just being able to talk to them, for them to listen to you’. M5-4
Doctors in particular valued the challenge and debate from the labour ward co-ordinator about plans of care as equal partners.
‘Personalities that…like to keep the peace, tend to agree with what you're saying…Whereas a team leader who will challenge a consultant is a very good thing’. C2
‘They might think they know when certain things are indicated, but it might be different to what we
think. So I think it's about respecting each other and be able to have a conversation, it is a critical part of it’. R3
This was in contrast to ineffective labour ward co-ordinators, who adopted a more aggressive communication style. Their personality was to assert themselves as ‘the boss’. This lack of emotional intelligence led to a lack of psychological safety and an unpleasant working environment, creating politics where midwives consulted with other members of the multidisciplinary team for advice and bypassed the unapproachable labour ward co-ordinator to avoid the unpleasantness of potentially difficult conversations.
‘Sometimes I find the midwives bypass a co-ordinator and come straight to me, which is frustrating for me because I feel if you'd asked them [the co-ordinator], they'd probably been able to tell you what to do, that's maybe because they don't have a good relationship with the coordinator’. R1
‘There are certain team leaders that I would always go to someone else first’. M5-4
‘I think I might be inclined to speak to the obstetric team directly in favour of some team leaders’. M6-4
Discussion
The findings of the present study outline the attributes of an excellent labour ward co-ordinator in a theoretical module (Figure 2), diagrammatically developed using a triangle to represent the safety of staff, women and babies.
The labour ward co-ordinator having situational awareness is essential for this awareness in the team as a whole and joint decision making (Edozien, 2015). Endsley (1995) defines situational awareness as operating at three levels, perception, comprehension and projection (Table 4).
Table 4. Levels of situational awareness
| Level | Explanation |
|---|---|
| 1 | Perception: The individual's ability to recognise the relevant information, environmental data, or elements of data |
| 2 | Comprehension: The cognitive ability to process and synthesise information to create a holistic picture |
| 3 | Projection: The ability to use the holistic view to forward project events, to create a mental model into the future |
Source: Endsley (1995)
The labour ward co-ordinator plays a key role in decision making at level 2 of situational awareness, both in supporting individual staff with decisions about clinical care and in how they influence multidisciplinary team decision making through facilitation of team situational awareness. Ineffective decision making is widely acknowledged as a major influence on intrapartum care (Bristowe et al, 2012; Cornthwaite et al, 2015; Royal College of Obstetricians and Gynaecologists, 2017; HSIB, 2020a; Liberati et al, 2020). However, correct decision making by the labour ward co-ordinator can only be made if the correct information is available at level 1. This information sharing is dependent on the approachability of the coordinator.
In the commercial sector, the effects of incivility by a line manager on staff stress levels, job satisfaction and an individual's choice as to whom they approach to share and/or seek advice is widely acknowledged (Leiter et al, 2011; Porath et al, 2015). Civility and psychological safety and their impact on information exchange between the multidisciplinary team is now beginning to gain traction in maternity services (Kirkup, 2022; Ockenden, 2022).
Since the 1990s, the aviation industry have focused their analysis of errors on level 1, an individual's inability to perceive and collate all the information to support accurate decision making, accounting for 70% of all errors (Jones and Endsley, 1996; Endsley, 2000). The NHS focuses its analysis of poor decision making on level 2, the comprehension of information (HSIB, 2020b). However, labour ward co-ordinators can only be aware of information at level 1, to inform multidisciplinary team decision making at level 2, if they are deemed approachable by the staff for this information exchange process to occur.
All staff groups differentiated excellent and effective labour ward co-ordinators as operating at level 3, having the ability to forward project by creating a mental model of the future state, taking appropriate evasive action to avoid potential consequences, which denotes the expert in their field (Endsley, 2000; Fore and Sculli, 2013; HSIB, 2020a, b). This installed total confidence in the multidisciplinary team by their ability to project into the future, proactively forward planning to mitigate against potential problems.
Clinical leadership and its impact on outcomes and care of labouring women is widely acknowledged (Kirkup, 2015, 2022; Care Quality Commission, 2021; Ockenden, 2022). Published studies on midwifery clinical leadership are limited to the community setting and midwives providing direct care; these studies suggest emotional intelligence and transformational styles of leadership predominate among good midwives (Bryom and Downe, 2010; Hewitt et al, 2019). The findings from the present study suggest that a wider range of styles are required by the labour ward co-ordinator with a high level of emotional intelligence (Goleman et al, 2002; Bar-on, 2010), and the ability to oscillate between situational, servant, engaging, transformational, transactional, adaptive and compassionate leadership (Bass and Avolio, 1994; Alimo-Metcalfe et al, 2008; Hersey et al, 2008; Van Dierendonck, 2011)
Labour ward co-ordinators require a different skillset for managing staff and information compared to midwives providing one-to-one clinical care. Recommendations from the Ockenden (2022) report and 3-year plan (NHS England, 2023) highlight the need for all labour ward co-ordinators to attend a course specifically designed to meet these needs. The present study suggests that emotional intelligence is key to leadership on the labour ward and feedback completed by the multidisciplinary team could be invaluable to labour ward co-ordinators as part of their performance and development review, to develop their self and social awareness.
Recommendations
Further research is required to understand the impact of the labour ward co-ordinator on team working. Currently, career progression for excellent labour ward co-ordinators is limited to management roles, taking them and their skills away from the labour ward environment. Consideration should be given to developing consultant labour ward co-ordinator roles to support the development of current co-ordinators and nurturing midwives aspiring to become labour ward co-ordinators. The ‘helicopter view’ is key to the labour ward coordinator role; therefore, the supernumerary status needs to be protected to facilitate situational awareness.
Conclusion
Labour ward co-ordinators play a significant role in the organisation of labour ward and how the multidisciplinary team functions. The theoretical module presented represents the attributes required for an effective labour ward co-ordinator. Underdevelopment of any of the three aspects render the role ineffective, directly impacting on team situational awareness, decision making, staff support, the working environment, job satisfaction and ability of the multidisciplinary team to deliver safe care to women.
Key points
- Labour ward co-ordinators play a key role in multidisciplinary team functioning, which has a direct impact on safety.
- The three key attributes of an effective labour ward co-ordinator are situational awareness, supporting staff with decision making and approachability.
- All levels of situational awareness need to be addressed if the helicopter view of labour ward is to be achieved.
- The ability to pre-empt and forward plan differentiates an excellent from an effective labour ward co-ordinator.
CPD reflective questions
- As a labour ward co-ordinator, how do you positively influence the shifts you co-ordinate?
- As a midwife working on a labour ward, how do you support the labour ward co-ordinator to be situationally aware?
- As an individual, do you consider how your emotional intelligence impacts others?