Exploring the trainee experience during a combined technical and non-technical skills obstetric training session on a simulated labour ward: A rapid ethnographic study

Exploring the trainee experience during a combined technical and non-technical skills obstetric training session on a simulated labour ward: A rapid ethnographic study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring the trainee experience during a combined technical and non-technical skills obstetric training session on a simulated labour ward: A rapid ethnographic study Aditi Siddharth, Muspratt Tucker Nadia, Divya Nambiar, Ruth Houlden, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4735683/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Obstetric training requires competence in both technical and non-technical skills (TS and NTS). Traditionally the acquisition of these skills is dependent on experience more than formal teaching. Simulation training can be an opportunity to bridge this gap in a safe environment. This study explores the impact of merging TS and NTS simulation into a single session of an obstetric on call on a simulated labour ward. Methods: All obsetric specialist trainees year 1 and 2 (ST1-2) from the Thames Valley Deanery (n = 14) participated in a 40 minute simulated labour ward oncall,managing patients on the labour and antenatal wards and maternity assessment unit. The trainees were divided into two groups, each group participated in the simulation followed by a focus group discussion. This study used rapid ethnography with in-situ observation, audio recordings, field notes and focus group interviews. Data analysis used Kopta’s 3 phase theorical framework of technical skill learning- cognitive, integrative and autonomous. Results: Trainees learnt TS in all three Kopta’s phases during this simulation. The trainee’s familiarity with the TS determined the phase of learning they achieved. For less familiar tasks, trainees were in the cognitive phase. The integrative phase was seen when the TS was partially familiar and required them to perform it in conjunction with the appropriate NTS. There was autonomous TS and NTS integration with tasks they were skilled in. Conclusion: Integrating TS and NTS simulation optimised the learning opportunities within one training session. This model is adaptable to various skill levels and specialities, without increasing trainee, faculty, or resource burden. Further exploration can broaden applicability of this approach across other specialities. Obstetric simulation Technical skill simulation non-technical skill simulation surgical simulation ethnography Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Safe obstetric practice requires both technical and non-technical skills, usually performed synchronously ( 1 ). Obstetric technical skills (TS) include procedures such as caesarean section and episiotomy along with the knowledge to diagnose and manage a range of obstetric conditions (e.g., pre-eclampsia and intra-uterine growth retardation). Non-technical skills (NTS) are the cognitive and social skills that enhance patient safety and surgical excellence ( 2 – 5 ). There are 4 categories of NTS: situation awareness, decision making, leadership and communication/teamwork ( 4 , 5 ). The non technical skills for surgeons (NOTSS) tool was developed to assess NTS of surgeons and was adapted for a labour ward setting by the royal college of obstetricians and gynaecologists (RCOG) ( 6 ). An obstetrician deals with many emergencies on the labour ward where it is essential that they are able to perform TS whilst also practising NTS seamlessly to ensure safe and effective patient care ( 7 ). Traditionally TS were learnt in hospital settings with patients ,under supervision ( 8 ) in an apprenticeship model of training ( 9 ). More recently, TS can be learnt on simulation models ( 10 ). The apprenticeship model has changed to the competency-based training model in many surgical specialities including Obstetrics and Gynaecology, in part due to changes in working patterns, including implementation of the European Working Time Directive (EWTD) ( 2 , 11 – 13 ). There are ethical considerations in exposing patients to a small but finite risk of harm as novice doctors learnin real clinical settings ( 13 ). For a novice obstetric trainee, it is nerve-wracking to perform an unfamiliar TS whilst communicating with an awake patient, their family, and the staff on a labour ward (NTS). Simulation has been used to provide experiential learning opportunities for real time decision making in a safe learning environment. It has been shown to improve performance and patient safety ( 14 , 15 ). The recent global consensus statement on simulation based practice in healthcare recognises the benefits of simulation and advocates for the integration of low cost high impact simulation into regular training ( 16 ). Simulation is an effective tool for training; but it is inadequately used ( 18 ). Paucity of simulation facilities, faculty, and timeare all barriers to inadequate use of simulation ( 17 ). There are simulation courses to learn obstetric TS such as the RCOG’s Operative Birth Simulation Training (ROBuST) course, which is designed to teach trainees how to perform an instrumental delivery ( 18 ). There are also team-based simulation training courses e.g. the Practical Obstetric Multiprofessional training (PROMPT) course to practice NTS ( 19 – 21 ), which has been shown to improve team performance, practitioner confidence and patient outcomes ( 19 , 22 , 23 ). However, learning to integrate TS and NTS is still reliant on practising on the job ( 24 ). This study aimed to understand the training experience when performing TS and NTS simultaneously in a simulated obstetric on call. The choice of methodology: Rapid Ethnography Ethnographers study social interactions to understand the way people interact with their surroundings ( 25 ). Though originally used in anthropological research, modified versions of ethnography have been used in other disciplines e.g. healthcare, and education. Multiple data sources are obtained in an ethnographic study e.g. observations, interviews, and audio-visual documentary recordings. These data can be compared, and contrasted to give a rich and complex understanding of the research subject and allow for triangulation of findings to improve the reliability of the results ( 26 – 29 ). Ethnographic studies would previously take years to complete but the methodology has now been adapted to suit different contexts including traditional, rapid, critical, online and autoethnography ( 25 ). In this study, we have used rapid ethnography. The participant observer (Fig. 1 ) in an ethnographic study is the researcher, who takes an active role engaging with the participants, sometimes acting as an insider and at other times observing and analysing like an outsider to maintain objectivity, positioned somewhere between “participant as an observer” and “observer as a participant” (Fig. 1 ) ( 25 , 30 ). Data analysis was conducted in the context of Kopta’s three phase theory of TS skill learning: the cognitive phase, the integrative phase and the automation phase ( 8 , 31 , 32 ). Cognitive Phase: Trainees gather knowledge, plan, and practise each component of the TS. Feedback in this phase helps reinforce good behaviours. Integrative Phase: skills are practised in realistic contexts, integrating TS and NTS. Any errors with the integration of TS and NTS can be identified and worked on. Automation Phase: With deliberate practice, trainees progress to the automation phase ( 33 ). In this phase, performing the TS requires less cognitive load, allowing trainees to handle new and complex situations with greater ease. Positionality statement: The lead author is a senior Obstetrics and Gynaecology trainee with extensive experience in both TS and NTS simulations. The faculty members involved in this study also have extensive clinical and simulation experience, especially with the use of the NOTSS tool to assess NTS. This background informed the development of clinical scenarios within the simulation, to ensure the cases were suitable for ST1-2 trainees though the trainees were assuming more senior roles during the simulation. The case complexity was carefully chosen to ensure even the ST2 acting as the “consultant” in the simulation could carry out the appropriate tasks. The lead author’s clinical background positioned her as an insider within the simulation, enhancing her role as an observer-participant during the ethnographic data collection. The insider perspective enabled the opportunity to empathise with the trainees’ anxiety, body language and concerns and to appreciate the nuances of each clinical scenario. However, it was important to remain mindful of unconscious assumptions that might be made due to the lead author’s clinical background on the perception of trainees and their management of clinical scenarios during the simulation. Reflexive strategies were employed from the outset to put the participants at ease by discussing her role and reassuring the participants that the simulation was not designed to include any adverse outcomes. Methods This study was registered as a quality improvement project and received ethics exemption by the University of Oxford Clinical Trials and Research Governance (CTRG) team. Written consent was taken from all the participants. Prior to conducting this ethnographic study, we conducted a pilot simulation session in 2022 using the developed simulation material to finalise the script, the timings used in the simulation to cue events. The pilot session also helped us choose ethnography as the methodology for the study as it allowed for the recording of body language, facial expression, trainee movements during the simulation etc. The trainees who participated in the study: All 14 Thames Valley deanery specialist year 1 and 2 (ST1 and ST2) obstetric trainees attended the obstetric simulation training day in February 2023. This training day was a routine part of their mandatory regional training where they would have usually participated in a team simulation designed to practise non-technical skills (NTS). The 14 trainees were divided into two groups, with each group undergoing one iteration of a 40-minute simulation followed by a 30-minute focus group interview. The inclusion criteria for the participants were : Trainees with up to two years of experience in the speciality: This specific group of trainees were included in this study as it helped reduce variability in experience levels. Technical skill competence ( 34 ): The Royal College of Obstetricians and Gynaecologists training matrix has a set number of procedures that ST1 and ST2 trainees are expected to be exposed to and gain competence in. Compared to more advanced trainees, this cohort has a more consistent skill set across the group which reduced the potential for variability in the study for example, ST2 trainees can perform a straightforward non-rotational forceps delivery, a straightforward caesarean section, and an episiotomy repair. Exclusion criteria: Trainees more senior than ST2 or with more the two years of post-graduate experience in Obstetrics. Faculty included in the simulation: Two senior obstetric trainees and two obstetric consultants experienced with conducting TS and NTS obstetric simulation were the faculty in this study. The trainers peer reviewed the simulation script and materials, and the script and learning outcomes were prepared after a consensus agreement on the management of the various clinical scenarios in the simulation based on the the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines (Table 1 ). The faculty were familiar with RCOG adapted NOTSS tool and had experience using it ( 35 ). Each faculty member was responsible a zone in the simulation (the labour ward board, theatre/room 1, antenatal ward and the maternity assessment unit) with them playing the role of the staff members usually present in these areas (midwife coordinating labour ward, anaesthetist in theatre/midwife in the room, midwife in charge of antenatal ward, midwife in maternity assessment unit respectively). Adopting these roles allowed the faculty to prompt the trainees during the simulation and provide pertinent clinical information at various junctures during the simulation based on the predetermined simulation script. An example is provided in Fig. 2 (please refer to the supplementary materials for the simulation script). Table 1 The expected actions the trainees were required to perform during the simulation, including the technical skills (TS) and nontechnical skills (NTS). Simulation timeline Expected actions to be performed by the trainees Technical (TS)/ Non-technical skill (NTS) At handover 1. Team members introduce themselves 2. Receive handover of labour ward board from coordinator midwife 3. Establish if there are any patient concerns that require immediate attention Situational awareness (NTS) Communication and teamwork (NTS) Immediately after handover Consultant to discuss with members of the team: • Identify learning needs and goals of each member of the team • Prioritise workload (ward round, assessment of room 1, antenatal ward round, review of patients in maternity assessment unit) • Appropriately delegate workload to members of the team (ideal allocation would be- ST5 to assess patient in room 1, ST3 for antenatal ward round, one SHO to review patients in maternity assessment unit and consultant and second SHO for labour ward round). Situational awareness (NTS) Decision making (NTS) Communication and teamwork (NTS) Leadership (NTS) Assessment of room 1 and decision for instrumental birth ST5 • To introduce themselves to patient and midwife • To establish the history • To perform the relevant abdominal and vaginal examination and correctly identify the abdominal and vaginal examination findings • Communicate findings of delay in second stage and malposition of foetal head to patient and midwife • Counsel patient regarding options and recommendation of rotational instrumental birth in theatre (called trial of instrumental birth) • Communicate with coordinator midwife and consultant regarding patient in room 1 • Consent patient for the procedure, including discussing management of risks and possible additional procedures e.g., caesarean section and episiotomy Decision making (NTS) Communication and teamwork (NTS) Performing the examination (TS) Knowledge of procedure and risks to counsel patient (TS) Labour ward round Consultant and SHO to perform a ward round with the coordinator midwife • Prioritise the patients on labour ward to decide the order of patient review • For each patient, identify if they are any immediate concerns, plan next steps for investigations and management • Include and communicate plans with coordinator midwife • Include the SHO in the discussions Situational awareness (NTS) Decision making (NTS) Communication and teamwork (NTS) Leadership (NTS) Knowledge of management of routine clinical situations on labour ward (TS) Antenatal ward round ST3 • To introduce themselves to the midwife on the antenatal ward • Identify any immediate concerns and prioritise patients to decide the order of review • Discuss each patient with the midwife, address concerns, discuss management • Manage the emergency- hyperstimulation (contracting more than 5 times in a 10-minute period) • Identify the patient causing concern, discuss immediate management with midwife • Discuss the unwell patient with the consultant and the coordinator midwife on labour ward to arrange for transfer of patient to labour ward Situational awareness (NTS) Decision making (NTS) Communication and teamwork (NTS) Knowledge of management of routine antenatal clinical situations (TS) Recognising the unwell patient (TS) Maternity assessment unit SHO • To discuss with the midwife and prioritise patients in order for review • Review patients and make suitable management plans • Identify the unwell patient with Acute Fatty Liver of Pregnancy (AFLP) • Escalate concerns about patient with AFLP to consultant and coordinator midwife and organise an urgent senior review • Arrange for transfer of patient with AFLP to labour ward and handover to the coordinator midwife on labour ward about patient Decision making (NTS) Communication and teamwork (NTS) Leadership (NTS) Knowledge of management of routine obstetric clinical situations (TS) Recognising the unwell patient (TS) In theatre for instrumental birth ST5 1. Communicate to the consultant that supervision is required in theatre for the required training e-portfolio evidence 2. Perform the WHO check using the WHO check list 3. Clean and drape 4. Catheterise 5. Confirm vaginal findings 6. Communicate with anaesthetist, midwife, and patient 7. Decide to proceed with rotational instrumental birth 8. Perform the rotation of foetal head between contractions 9. Apply forceps and perform forceps delivery using the correct technique 10. Perform an episiotomy at the time of crowning of the foetal head 11. Deliver the baby and handover to the midwife after delayed cord clamping 12. Manage the third stage of labour and deliver the placenta with controlled cord traction 13. Examine the perineum including rectal examination to identify any tears 14. Repair the episiotomy using the appropriate technique 15. Enquire about blood loss and manage appropriately 16. Perform a swab and instrument count with the theatre staff at the end of the procedure 17. Sign out of theatre at the end 18. Debrief patient and staff after procedure Situational awareness (NTS) Decision making (NTS) Communication and teamwork (NTS) Leadership (NTS) Performing a rotational instrumental delivery (TS) Repair of an episiotomy (TS) The simulation script included roles for the faculty in the simulation (e.g., the coordinator midwife, the anaesthetist, the midwife on antenatal ward etc), participant instructions, the timeline for the events unfolding in the simulation, and the various clinical scenarios the participants would need to tackle on the simulated labour ward, the antenatal ward, and the maternity assessment unit (Figs. 2 and 3 and the supplementary material). The pre-simulation brief was a 10-minute discussion with all the ST1-2 trainees familiarising them to the simulation setup (Fig. 4 ) and building a rapport with the faculty. The participant roles were assigned. Trainee roles in the simulation (Table 2 ) included consultant, specialist year 5 (ST5) registrar, specialist year 3 (ST3) registrar, 2 senior house officers (SHOs), patient and observer. Participant instructions contained information about their role (their experience, personality traits etc.) and specific training objectives (Fig. 3 and supplementary materials). Table 2 The trainees were assigned roles of varying seniority in the simulation. The complexity of the clinical scenarios in the simulation was carefully chosen to ensure suitability for an ST1 and 2 to manage even if they were acting outside their usual role. All names were changed to pseudonyms for anonymity. The table also shows the training grade they belonged to Role in the simulation Participants in group 1 Pseudonym, training grade Participants in group 2 Pseudonym, training grade Consultant (C) Mellie, ST2, Daisy, ST2 ST5 Joseph, ST2 Hana, ST2 ST3 Uma, ST2 Catherine, ST2 SHO 1 Gemma, ST1 Maya, ST1 SHO 2 Tina, ST1 Justina, ST1 Observer Andrew, ST2 Ada, ST2 Patient Fenella, ST1 Elle, ST1 The setting and simulation layout (Fig. 4 ): Two training rooms were set up using low fidelity simulation models. The large training room was organised into distinct zones, each serving a distinct purpose: the labour ward board, the operating theatre with a model of a pregnant abdomen for examinations and instrumental deliveries, and the maternity assessment unit. The antenatal ward was a small office space a short walk away from the main room, allowing for participants to realistically transition between different areas of care. Conducting the simulation: Each iteration of the simulation involved specific clinical scenarios that trainees had to navigate by performing actions based on NOTSS tool and guidelines for assisted vaginal birth and management of labour (see supplementary material for details). The TS in this simulation were the performing of a rotational instrumental delivery in theatre, conducting labour ward and antenatal ward rounds and managing patients in the maternity assessment unit. Trainees were required to apply the relevant knowledge and physical hand skills required to perform these tasks. Data collection techniques: The data sources included participant observation, research diaries from ethnographic researchers, faculty field diaries and focus group interviews. Participant observation: The 4 faculty members, two trainee observers and the ethnographic researcher all acted as participant observers. They maintained field diaries, noting body language (uncertainty, confidence, anxiety etc), observed actions, professionalism (technical skills, communication etc.), movements within the simulation setting, clinical decisions taken and the timing of the decisions. Focus group discussion: After each simulation session, the participants, faculty members and the ethnographic researcher gathered to discuss their experience. The conversations were enriched by the observations recorded which served as prompts. Documentary data: Audio recordings from the labour ward board, the antenatal ward, and the focus group interviews were transcribed for detailed analysis. Additionally, documentary data from the field diaries were reviewed. The ethnographic researcher also tracked trainee movements using hand-drawn diagrams. Data analysis: The data analysis was an iterative process with frequent discussions with the faculty members to ensure the interpretations of the data accurately reflected the simulation experience. We used deductive coding to thematically analyse the transcripts and field notes, guided by Kopta’s three phase theory of technical skill development: cognitive/perceptive, integration, and automation. Microsoft Word and NVivo software was used for data management. Maintaining rigour through triangulation: We maintained rigour in our study by data triangulation using multiple sources of data. The involvement of the faculty, trainee observers, trainees and the ethnographic researcher provided diverse perspectives, representing multiple viewpoints and offered a comprehensive understanding of the simulation experience. Results Participant characteristics All the ST1-2s in the Thames valley deanery attended the study day (14 in total, with 6 ST1s and 8 ST2s). The roles were allocated as indicated in Table 2 . The decisions made and actions performed by the trainees in each group during the simulation have been detailed in Table 3 and their movements were tracked and displayed using diagrams such as in Figs. 5 and 6 . Table 3 Decisions and actions of trainees during the simulation, with a comparison to the expected actions for Group 1 and Group 2 Event Actions expected Actions performed by Group 1 Actions performed by Group 2 At handover (Fig. 6 ) • Team members introduce themselves • Receive handover of labour ward board from coordinator midwife • Establish if there are any patient concerns that require immediate attention Yes, actions were performed Yes, actions were performed Immediately after handover Consultant to discuss with members of the team: • Identify learning needs and goals of each member of the team • Prioritise workload (ward round, assessment of room 1, antenatal ward round, review of patients in maternity assessment unit (MAU) • Appropriately delegate workload to members of the team (ideal allocation would be- ST5 to assess patient in room 1, ST3 for antenatal ward round, one SHO to review patients in maternity assessment unit and consultant and second SHO for labour ward round). Learning needs were not discussed Workload was prioritised a little later, after the ward round started but no patients were missed and no delays in assessment of room 1. MAU did need to pull the emergency buzzer to alert the team. The Antenatal midwife had to alert the team about patients needing a review before Uma was allocated to doing the ward round. The workload was appropriately delegated with the ST5 assessing room 1, ST3 for the antenatal ward round, consultant and SHO for labour ward round and one SHO to the MAU Learning needs were identified after it was brought up by Hana before she left for the antenatal ward. This prompted the discussion about training needs but did not result in a reshuffle of the assignment of tasks to align with the training needs. “Hana raises a question about training needs- body language is hesitant and awkward. Daisy’s body language indicates that they feel threatened by this challenge” (research diary) Workload was prioritised but with no participation or discussion from the team members. Team members were arbitrarily assigned tasks by consultant. The workload was not appropriately delegated- Hana was sent to the antenatal ward round, Catherine assessed room 1, Daisy, the consultant, performed the labour ward round and Justina was asked to assess a non-urgent patient on labour ward. Maya asked to go to MAU to review patients. Assessment of room 1 and decision for instrumental birth ST5 • To introduce themselves to patient and midwife • To establish the history • To perform the relevant abdominal and vaginal examination and correctly identify the abdominal and vaginal examination findings • Communicate findings of delay in second stage and malposition of foetal head to patient and midwife • Counsel patient regarding options and recommendation of rotational instrumental birth in theatre (called trial of instrumental birth) • Communicate with coordinator midwife and consultant regarding patient in room 1 • Consent patient for the procedure, including discussing management of risks and possible additional procedures like caesarean section and episiotomy Yes, all of these were carried out appropriately Examination, decision, counselling, and consent taken for procedure by one person, as expected Information given during the consent process was detailed and accurate, but this increased the anxiety of the patient listening to it. Demonstrated lack of nuance when communicating information to a patient (possibly due to never having done this before in real life) “Joseph has very inclusive body language, kneeling down, makes eye contact and uses hand gestures when explaining complications” (research diary) “Fenella, the patient looks a little anxious but maintains eye contact. Looks nervous when talking about future pregnancies” (research diary) Multiple people were involved in the review of Elle, the patient. First, Catherine reviewed this patient, examined and accurate determined the malposition. She accurately decided a trial of instrumental birth was required in theatre and counselled the patient about it. Catherine started the consent process by discussing the risks of the procedure and alternatives. She had some difficulty with this. She did not have the form signed by the patient. “Catherine is finding it difficult to use patient friendly language to talk. (maybe she has never done this before?).discussion on forceps sounds very robotic.” (research diary) Hana took over the consenting and performing the procedure in theatre. Since there was a change of person, she rediscussed the consent again (causing a delay in the procedure) before the patient signed it. Labour ward round (Fig. 7) Consultant and SHO to perform a ward round with the coordinator midwife • Prioritise the patients on labour ward to decide the order of patient review • For each patient, identify if they are any immediate concerns, plan next steps for investigations and management • Include and communicate plans with coordinator midwife • Include the SHO in the discussions Started with review of room 1. Once the history was noted, this was delegated appropriately to Joseph to continue with the review and examination. The labour ward board was reviewed, and patients prioritised and room 9 was reviewed next by Mellie (the consultant). Each patient was discussed with the coordinator midwife and appropriate plans were made as expected. All plans were communicated to the coordinator midwife on the ward round. Gemma attended the ward round but did not communicate much with the consultant and was not included in discussions. But she was aware of all the plans that were made as she, later in the simulation, had to speak to the Joseph (when the consultant went to MAU) to handover the board and patients to him to continue with the ward round. She knew all the plans and patients. “Mellie goes to MAU to see a patient. Gemma goes to speak to Joseph and brings him up to speed about labour ward board and what has been done so far with ward round with help of coordinator midwife. Joseph has assumed helicopter view.” (research diary). The patients were prioritised, and tasks delegated very early in the shift, soon after handover. Patient concerns were identified. Though, the responsibility of review was assigned to people with the correct level of skill but not done in the appropriate order which impacted the workflow on labour ward and resulted in a reshuffling of staff for tasks later. The patients on labour ward did get reviewed on the ward round and did have appropriate plans. The plans were communicated to the coordinator midwife. The SHO had been assigned a separate review but first joined the ward round. She was very involved with the ward round and reviewed the patient she was assigned towards the end, when the consultant was called to the operating theatre, and she was on her own and could independently review the postnatal patients. She asked for relevant investigations and made appropriate plans. Antenatal ward round ST3 • To introduce themselves to the midwife on the antenatal ward • Identify any immediate concerns and prioritise patients to decide the order of review • Discuss each patient with the midwife, address concerns, discuss management • Manage the emergency- hyperstimulation • Identify the concerning patient, discuss immediate management with midwife • Discuss the unwell patient with the consultant and the coordinator midwife on labour ward to arrange for transfer of patient to labour ward “Appeared calm and composed. Reassuring body language and communication with midwife” – observations from the research diary of the antenatal ward midwife about Uma. Uma introduced herself to the midwife, correctly identified the priority was managing the hyperstimulation and correctly advised to administer the terbutaline quickly. Other patients were managed in order of room number and appropriate management plans were made, picking up on cues given by the midwife to improve the decisions made. Planned to appropriately escalate and ask for senior advice when Uma was not sure of the guideline or management. Correctly identified the patient had pre-eclampsia and was unwell. Planned to speak to the consultant about delivery. Uma discussed the patient with the consultant before the consultant had to go to theatre and they decided they will make a definite plan once the consultant has finished in theatre. First Hana was asked to perform the antenatal ward round (an appropriate level of skill but not the expected allocation given the other tasks that required to be completed in the simulation). But due to this allocation, she was called away midway through the ward round to perform the task that was more appropriate for her level of seniority (the instrumental birth). No one else was immediately assigned to perform the ward round and the antenatal midwife had to ask for a person to review the patients. The only person available at that time in the simulation was Justina, who did not have the appropriate level of skill to perform this task but accepted anyway. “Though only ST1 in real life, no uncertainty in body language was observed in Justina. Responded well to change in scenario”- research diary of antenatal midwife The ward round was partly carried out by Hana, who made immediate plans for management for some of the patients. No ongoing plans or escalation of patients when she was unsure. Justina did correctly identify the high-risk patients though she failed to escalate to a more senior person on return to labour ward. Both Hana and Justina knew about the patient with pre-eclampsia. Hana only made immediate plans for monitoring and moved on with the ward round to the next patient without a plan to escalate, even though the abnormal blood tests were discussed. Even though this patient had been discussed with Hana, the antenatal midwife discussed her care again with Justina, who realised that the patient required senior input regarding a plan for delivery but did not escalate this to the consultant when she went back to labour ward. Maternity assessment unit (MAU) SHO • To discuss with the midwife and prioritise patients in order for review • Review patients and make suitable management plans • Identify the unwell patient with Acute Fatty Liver of Pregnancy (AFLP) • Escalate concerns about patient with AFLP to consultant and coordinator midwife and organise an urgent senior review • Arrange for transfer of patient with AFLP to labour ward and handover to the coordinator midwife on labour ward about patient No one was automatically assigned to the review of patients in MAU. The MAU midwife interrupted the labour ward round to ask for a doctor to review patients due to the workload on MAU. Instructions were given by the consultant to recheck the patient’s observations in 15 minutes, when the midwife had expressed concerns about a pregnant patient with a headache. This resulted in the use of the emergency buzzer a few minutes later to alert the on-call team. All the doctors on labour ward rushed to MAU, leaving labour ward attended. This was pointed out to the consultant, who then reassigned staff to perform various tasks. Mellie consultant and Tina SHO went to MAU to review patients there. All patients were reviewed on MAU and appropriate plans were made. The patient with AFLP was recognised as being very unwell though the consultant was not very clear on the diagnosis at first and needed prompting and help coming up with a plan. The management plan was discussed with the coordinator midwife and arrangements were made to transfer the patient to labour ward. Plans were made to contact the appropriate members of the multidisciplinary team (MDT) for support. Maya was asked to review patients on MAU by the consultant as soon as the handover was completed. Had an appropriate approach to patients- went through the list of patients, appropriately asked for relevant immediate investigations like CTGs to be completed by the midwife. Reviewed the patient with the abdominal pain and vomiting in person as appropriate. Enquired about blood test results- identified very low blood sugars and initiated immediate emergency protocol. Needed prompting to review the observations. Escalated appropriately with the use of emergency buzzer to alert the rest of the team. There was some confusion as to who would go to MAU at that point. Initially, the consultant wanted to go but realised she was required in theatre to supervise Hana performing the instrumental delivery and so Catherine went to MAU instead. Asked Maya to organise transfer of patient to labour ward by speaking to the midwife coordinator. Prompted to think about involving the MDT team and further management to stabilise the patient. Bloods were reviewed but diagnosis of AFLP was established with some prompting, and it was clear to the team that this patient was seriously unwell (noting the body language and tone of voice which demonstrated anxiety). Good SBAR communication with consultant to update her about patient. But no further follow-up of patient and confusion as they lost track of where the patient went to after telling the MAU midwife to transfer the patient. In theatre for instrumental birth ST5 • Communicate to the consultant that supervision is required in theatre for the required training e-portfolio evidence • Perform the WHO check using the WHO check list • Clean and drape • Catheterise • Confirm vaginal findings • Communicate with anaesthetist, midwife, and patient • Decide to proceed with rotational instrumental birth • Perform the rotation of foetal head between contractions • Apply forceps and perform forceps delivery using the correct technique • Perform an episiotomy at the time of crowning of the foetal head • Deliver the baby and handover to the midwife after delayed cord clamping • Manage the third stage of labour and deliver the placenta with controlled cord traction • Examine the perineum including rectal examination to identify any tears • Repair the episiotomy using the appropriate technique • Enquire about blood loss and manage appropriately • Perform a swab and instrument count with the theatre staff at the end of the procedure • Sign out of theatre at the end • Debrief patient and staff after procedure Joseph communicated his requirement for supervision very clearly before going to theatre to the consultant. There was good communication between the theatre team and Joseph though he delegated too many tasks to one person. Displayed moderate level of anxiety in his body language and forgot some basic steps like cleaning, draping and catheterisation that were performed after prompting by the midwife in theatre. He reflected in the focus group discussion about being too keen to perform the procedure that he forgot the basic steps. Performed the WHO check using the checklist as appropriate. Was able to confirm the vaginal findings and proceed with appropriate skill to rotate the baby and carry out the instrumental delivery, delivery the baby and manage the third stage of labour. Did communicate with the theatre team but did not ensure he had assistance should he need it (e.g., having the SHO in theatre). Body language changed and he became more confident after the baby was delivered. Management of third stage and repair of episiotomy were performed very confidently and maintained casual communication with the theatre team. Signed out after the procedure and debriefed the patient. Hana had communicated requirement for supervision to the consultant immediately after the handover. The consultant did come to theatre to supervise this procedure but repeatedly stepped out to labour ward. Hana appeared diffident, and this showed in the body language and communication with the theatre team and patient. The steps of the procedure including performing the WHO check was performed accurately. Body language became more confident after delivery of the baby. The consultant noticed this as well and was able to leave theatre to leave Hana to complete the third stage management and episiotomy repair. Due to the workload and being called away from theatre after repair of the episiotomy, the sign out and the debrief of the patient was very rushed. Cognitive phase of technical skill learning (Table 4 and 5 ): Table 4 Cognitive phase of learning noted during the antenatal ward round “.. I learnt that I didn’t know a huge amount.. There was a lady with severe preeclampsia that was getting worse and just trying to make plans about when you are going to deliver people is actually quite a tough call.. and unless you know what you are doing I guess” Uma ST3, discussed their experience of conducting an antenatal ward round for the first time (focus group interview) Uncertainty was present about certain situations that required further review of guidelines. Was calm and thinking things through. Observation about Uma ST3 by the antenatal midwife (research diary) Antenatal ward was neglected- SHO (Justina) was sent eventually after some time but forgot to catchup with the consultant about what was going on there. Observation by the antenatal midwife (focus group interviews) Antenatal midwife to Justina: “Did you feedback about the unwell patient on antenatal ward?” Justina: “ I went to Hana, but she was still in theatres and didn’t get a chance.” Antenatal ward midwife :”That’s something even Hana didn’t communicate back. So, there was a patient on the ward who was quite unwell. Two people took rounds, but that information wasn’t communicated down to the team….” Conversation between the antenatal ward midwife and Justina (focus group interviews) Table 5 Cognitive phase of learning noted during the process of taking the patient's consent before the instrumental delivery Catherine ST3 went to room 1. Found it difficult to use patient friendly language to talk. Maybe she has never done this before? Maintained good eye contact and used open hand gestures. Observation of the ethnographic researcher (research diary) Joseph ST5 consented the patient for the instrumental delivery. Displayed inclusive body language, kneeling down, making eye contact when explaining complications. The discussion about complications made the patient more and more anxious and this was not picked up by Joseph. It was like he was trying to remember the complications rather than having a conversation with a person. Observation of the ethnographic researcher (research diary) There were two junctures in the simulation when the trainees consistently experienced the cognitive phase of learning: During the discussion of the instrumental birth with the patient to take their consent for the procedure Performing the antenatal ward round They appeared unsure when performing these tasks as documented by the ethnographer and the faculty who had noted body language and facial expressions that were consistent with appearing nervous and anxious. The trainees admitted to their feelings of inadequacy in the focus group discussion when reflecting on these two tasks. When performing the antenatal ward round, information regarding a crucial patient was not discussed with the consultant, potentially compromising patient safety. The lapse in communication (an NTS) was due to a lack of knowledge required to manage obstetric conditions independently as well as unfamiliarity with the TS required to perform a ward round independently, which requires both TS and NTS. These findings were observed by the faculty as well as the participants in both groups showing their learning was in the cognitive phase of skill development, where the trainee was not entirely confident in the knowledge-based decisions they were making and could not effectively integrate it with the NTS required in performing the ward round. Integrative phase of technical skill learning (Table 6 and 7 ): Table 6 Integrative phase of learning noted during the performance of the instrumental delivery in theatre Joseph ST5 is the clear leader in charge of the procedure in theatre. Displayed body language that showed medium level of stress (probably appropriate considering this is a rotational delivery). In theatre, a relaxed atmosphere, friendly attitude was maintained. Observation made in research diary of the ethnographic researcher during the performance of the instrumental delivery for group 2 Hana ST5 appeared diffident, and this showed in the body language and communication with the theatre team and patient. The steps of the procedure was performed accurately. Observation made in research diary of the ethnographic researcher during the performance of the instrumental delivery for group 2 “If it had been in a room, I would have been able to kind of trick myself. But because it was so different, in theatre..” Hana ST5 when asked to reflect on her experience performing an instrumental delivery in a theatre which she has never done in real life before. Table 7 Integrative phase of learning noted during the performance of the labour ward round Mellie Consultant: “ Examine her and just check that she is on the correct antibiotics, fluids and septic screen results.” Coordinator midwife: “Ok. She is just looking a bit unwell, she is warm to touch, her uterus is quite tender, and it’s a little bit big, below the umbilicus” Mellie Consultant: “Ok, so let’s continue with the IV (intravenous) antibiotics to cover for endometritis, and make sure she has some fluids, and chase the septic screen results.” Conversation between the consultant from group 1 and coordinator midwife during the labour ward round (transcript). Daisy Consultant: “We have done the ward round for the three patients.” Catherine ST3: “I’ve examined the lady in room 1 and she is doing really well. The foetal head is 0/5th palpable in the abdomen. But she is LOP (left occipito-posterior) at + 1/spines. She has a good working epidural and I’ll speak to her about the process, but I think she’ll need a trial in theatre.” Daisy Consultant: “I agree with that. Are you happy with the CTG (cardiotocography)?” Catherine ST3: “She has some variable decelerations when she is pushing.” Daisy Consultant: “In that case it’s still reasonable when it’s a compensated CTG to go for a swift category two trial. In which case, would you be able to liaise with Hana ST5. Why don’t we go find her together and it’s something she would like to do and then why don’t you join us for the round?” Conversation Daisy Consultant and Catherine ST3 regarding the findings after the examination of a patient in room 1. The trainees were familiar with performing a straightforward instrumental birth on a part task simulator, having practised this TS during the RoBUST simulation course. However, they had never performed a rotational instrumental birth in theatre before. During the simulation, the trainees entered the integrative phase of skill learning when they performed the rotational instrumental delivery in theatre. At this level of training, whilst the trainee would have assisted in a rotational instrumental birth in theatre, they would never have had the opportunity to perform it independently. In this simulation, it was evident that the trainees were able to practise their instrumental delivery skills in the integrative phase in the context of a theatre setting. Another instance of integration of TS and NTS was seen with the management of the patients on labour ward and the labour ward round from the very start of the simulation. Once the coordinator midwife discussed the patients on the labour ward board, the team had to use a combination of knowledge and NTS such as delegation, leadership, and prioritisation to ensure the appropriate management plans were initiated (Table 7 ). Transition from integrative to autonomous phase (Table 8 ): Table 8 Transition from the integrative and the autonomous phase occurred in the operating theatre Daisy Consultant : “I think I find I am willing to trust my colleagues to do their job and delegate… I saw Hana ST5 do the trial and I let her deal with whatever tears and postpartum haemorrhage. I felt comfortable with that...” Reflection of Daisy Consultant about task delegation in theatre (focus group discussion) The body language visibly relaxes, Joseph ST5 smiles at patient, is chattier... Consultant leaves the operating theatre. Observations of the ethnographic researcher about the change in body language of Joseph ST5 immediately after the delivery of the baby The thematic analysis of the data revealed a distinct phase which marked the transition from the integrative to the autonomous phase. This is evidenced within the events that occurred in the operating theatre where the baby was handed over to the midwife, the placenta was delivered and the perineum was evaluated for suturing, immediately after the baby was delivered, in both the groups. Autonomous phase of skill learning (Table 9 and 10 ): Table 9 Autonomous phase of skill learning seen during the repair of the episiotomy after delivery of the baby In theatre, Joseph ST5 became confident once he started to suture the perineum, making casual conversation with the team and patient. Observations of the ethnographic researcher of the body language of the Joseph ST5 during the episiotomy repair. “ … when you started suturing, you looked super confident doing that. Because you knew how to do it very well. I could see that switch between having to think through every step you were doing to when you can actually relax and enjoy it…” Discussion between the ethnographic researcher and Joseph ST5 (focus group discussion) I did feel like that as well suddenly it was like I can relax now Reflection made by Joseph ST5 about the relief he felt when he was repairing the episiotomy “During the suturing, would say someone might be very happy sitting and suturing and you do have to be present in the moment and maybe you have some awareness of what’s going on outside, but you have to be present in the suturing at that time.” Statement by the observer from group 2 during the focus group discussion about the relationship between performing the technical skill of suturing that is familiar with the situational awareness required when in theatre and on call on labour ward Table 10 Autonomous phase of skill learning seen during the diagnosis of the unwell patient in MAU In MAU, Mellie consultant was unsure of diagnosis of AFLP (Acute fatty liver of pregnancy) but correctly identified that patient was very sick… Observation of ethnographic researcher (field diary) Catherine ST3: “She is 36 weeks, and she has had epigastric pain. She has got raised liver enzymes and low platelets. So, we’re thinking she has acute fatty liver of pregnancy. Her GCS (Glasgow Coma Scale) score is a little bit low so I’m about to call the anaesthetist, but we have managed to stabilise her and send off some bloods. We’re hoping to bring her around to the observation area to stabilise her before delivery.” Conversation between the Catherine ST3 and the coordinator midwife In this simulation, the skill for which the participants consistently entered the automatization phase was during the episiotomy repair, in theatre after the forceps delivery. By ST2 in the obstetric training programme, most trainees would be comfortable repairing a straightforward episiotomy and would have been performing this skill independently both in simulation and in real life. The level of comfort with performing the repair is demonstrated during the simulation from the following statements recorded through observations and in the transcript (Table 9 ). Another instance where automatisation was noted was the recognition of the unwell patient in the maternity assessment unit. ST1-2s are very familiar with the working of the maternity assessment unit (MAU) and are often left to manage the patients there on their own under indirect supervision. This real-world experience is evident during the simulation, where the junior most members of the team in both groups were assigned to see patients in MAU and in both groups the acutely unwell patient was recognised and escalated appropriately. Changed behaviour after participating in a combined technical and non-technical skill simulation (Table 11 ): Table 11 Changed behaviour at work after one session of technical-nontechnical skill combined simulation “I think it’s been nice to do a trial run as a team and have that knowledge that you are not going to be all by yourself on delivery suite. That there should always be someone who is going to support you. So, it takes the pressure off.” Reflection by Mellie consultant during the focus group interview “I guess that conversation we just had about mental rehearsal but reemphasising that. If you had asked me this morning what is an important thing to do before we go into theatre, I would have hopefully said mentally rehearse everything, but I still didn’t do it. And so, re-emphasising that.” Reflection by Joseph ST5 about the benefit of practicing the steps of the procedure in simulation and mentally rehearsing it in real life “…I think where it was a board round it felt more realistic as we do that all the time anyway…Whereas other moments like pretending to go in and see a patient or theatre felt a lot more artificial but still valuable.” Mellie consultant reflecting on the value of participating in this simulation “I felt that as it went on it felt more real. But that might have been because I just relaxed more. And then you sort of go with it.” Uma ST3 who felt it became easier to suspend disbelief and participate in the simulation as it progressed In the focus group discussion, the trainees were asked if the experience they had would help prepare them to perform their jobs better, including managing a labour ward and performing a delivery in theatre. Both groups felt that whilst there was some dissonance between reality and the simulation in terms of realism, it had helped them formulate a mental model they could rely on when using these skills in real life. Two of the participants in group 2 found it difficult to suspend disbelief but felt it was a beneficial feeling as it helped them not to panic when taking on more responsibility than they would have been comfortable with in real life (Table 12 ). Table 12 Reflections of trainees who found it difficult to suspend disbelief in the simulation but had a beneficial experience “I thought because it doesn’t feel a 100% real it was a good thing cause otherwise you would be so panicked and stressed that you wouldn’t be able to explore.. like in a real-life situation if someone asked you to go and do an antenatal ward round.. I would be like aaahhhh.. I can try and, but I wouldn’t be making any decisions but here I felt like I was able to just push myself and see cause nothing bad is going to happen and no one is going to die.so that’s kind of a good thing. yea I definitely felt that.. a part of it is to have a plan in your mind if you have to do it again, you have already done it before… like now I’ll know what my first step is..” Justyna SHO who was asked to perform an antenatal ward round, which they had never done in real life “I think I felt more comfortable doing things in simulation than I would in real because I felt like I could take my time and discuss things and be more like.. but with a patient I think I would be more uncertain to make my decision.” Catherine ST3, talking about the benefit of participating in this simulation Discussion Previous studies in obstetrics have demonstrated the efficacy of using simulation to learn TS and practise NTS ( 36 – 39 ). This study aligns with the findings from the wider literature and makes a case for combining TS and NTS into one simulation session to enhance the training experience. Participants’ experiences suggested that the integration of the two modalities of simulation training, TS and NTS, helped them practise both TS and NTS in a more realistic simulation setting by integrating the two as would be expected in real clinical practice. Guided by Kopta’s theory of learning technical skills, our study underscores the importance of providing trainees the opportunity to practise in integrated simulations alongside TS and NTS only simulations during their training years ( 32 ). The use of rapid ethnography as a methodology to study simulation is relatively recent ( 26 , 40 ). Unlike other methodologies, including quantitative and qualitative, rapid ethnography allowed us to capture the training experience from multiple view points simultaneously, in real time, as the simulation played out. Rapid ethnography lends itself to be used for observing and interpreting behaviour and experiences in a wide range educational settings, both real and simulated. Nuances including facial expression and body language, which otherwise would not be accounted for, was recorded during the ethnographic study. This study was a deviation from the traditional approach to simulation in obstetrics, where the focus is on either TS development or team training for NTS ( 41 , 42 ). With the limited time trainees have for educational activities including simulation within their training programmes, innovative solutions are required to maximise the learning opportunities from each session ( 43 ). Previous solutions explored in the literature include the development of simulation curricula that integrate TS and NTS training, practising TS and NTS in a simulated theatre setting, courses like the Advanced Trauma Life Support (ATLS), and the introduction of crisis resource management for anesthetists ( 44 – 48 ). Our work expands on the existing literature by increasing the complexity of the activities trainees had to perform within one simulation, including managing a labour ward board, performing a procedure in theatre etc. The findings suggest that we can use each simulation training opportunity to enhance the skills beyond a single skillset, whilst increasing the fidelity of the simulation by making it feel more real. The findings of this study demonstrate the possibility of practicing TS in all three phases of learning (as per Kopta’s theory), though it is best used to practice TS in the integrative and automation phases. A combined simulation as described in this study does not allow the time and instruction needed to learn a new TS in the cognitive phase. The cognitive phase of TS learning is best practised, as demonstrated in numerous studies, using part task simulation ( 49 – 51 ). The scope to use combined TS and NTS simulation goes beyond ST1-2 training. The model we have described is easily modified to varying levels of difficulty depending on the seniority of the trainees by changing the clinical scenarios presented within the simulation. The TS within the simulation can also be modified, based on the learning objectives and the trainees’ level of experience. This type of simulation could be used to support those returning to training after a career break (after maternity leave, research break, illness, etc.) as one session can be used to deliver multiple training opportunities. The study findings highlighted the importance of the design of the simulation which must be tailored to the experience level of the group participating, with a few tasks they are very comfortable performing and some tasks where they are pushing the boundary of their skill and experience. For example, for trainees in this study who were confident with episiotomy repair, it was easy to perform that task at an autonomous level. Similarly, unfamiliar tasks could only be performed at the cognitive phase. For the integrative phase, trainees are required to have some prior knowledge and had previously practised on a simulation model (e.g. an instrumental delivery on a model during the RoBUST course) or in real life before it could be performed with integration with the NTS. The level of difficulty (to get the trainees to practise integration of skills) should be slightly higher than their current level of training but cannot be vastly more difficult without it compromising the phase of skill learning they achieve in the simulation. Finally, beyond of the context of obstetrics, similar simulation programmes could be organised in any surgical speciality. The recent global consensus statement on simulation based practice in healthcare emphasises the importance of TS and NTS training that should be delivered to all healthcare professionals though current training does not meet this need ( 16 ). Our study describes a valuable technique that can be employed with relatively no increase in resource burden. Study Limitations This study reports the experience of one group of trainees of similar skill set at one point in time. This may impact the generalisability of the findings to beyond the context in which the study was conducted. The faculty members involved in the development of the simulation materials and the conduct of the simulation are experienced with both the speciality and with delivering simulation training. This potential bias may have influenced their views of the data collected. We have minimised the influence of these biases by involving two of the authors in data analysis, who have education and simulation backgrounds but no obstetric knowledge. Obstetrics and gynaecology trainees are familiar with using simulation for technical and non-technical skills training separately. This may not be the case with all surgical specialities and therefore more participant preparation may be required prior to the commencement of the simulation to acclimatise them to the simulation setting. Another limitation is the lack of multidisciplinary team representation within this iteration of the simulation. The roles of coordinator midwife, antenatal ward midwife and maternity assessment unit midwife could have been played by midwifery staff with simulation experience. Conclusion Combining TS and NTS simulation into a single training session enhanced trainee learning with no increase of trainee or trainer burden. We recommend the use of combined TS and NTS simulation in a large variety of contexts- various surgical specialities and to support return to training, as it can be easily modified to suit a variety of learning objectives. The model of simulation presented in this study could be a valuable resource in the current context of healthcare post pandemic with several training deficits, a workforce with low morale and a recognition that long-term workforce planning should include simulation based education as a modality to enhance development opportunities for all healthcare professionals. Abbreviations ATLS Advanced Trauma Life Support CTRG Clinical Trials and Research Governance EWTD European Working Time Directive NOTSS Non Technical Skills for Surgeons NTS Non Technical Skills PROMPT PRactical Obstetric Multi- Professional Training RCOG Royal College of Obstetricians and Gynaecologists ROBuST RCOG Operative Birth Simulation Training SHO Senior House Officer ST1 Specialist Trainee Year 1 ST2 Specialist Trainee Year 2 ST3 Specialist Trainee Year 3 ST5 Specialist Trainee Year 5 TS Technical Skill Declarations The authors declare that they have no competing or conflict of interests. No funding was received for this project. Human ethics and consent to participate This work received Ethics exemption from Clinical Trials and Research Governance (University of Oxford) and was registered as a quality improvement project. All participants provided written consent for participating, audio recording and publication/ presentation of the work. Clinical trial number Not applicable Author Contribution A.S.: Concept development, Design of study and simulation material, data collection, data analysis, manuscript writing, manuscript editingN.M.T. and D.M.: Development of simulation material and faculty in the simulation during the study R.H., D.A., H.H.: Project supervisor, manuscript editingAll authors reviewed the manuscript. Acknowledgement Miss Flora Wong and Miss Sarah Louise Smyth alongside two of the co-authors to participate as faculty in the simulation. References Johannsson H, Ayida G, Sadler C. Faking it? Simulation in the training of obstetricians and gynaecologists. Current Opinion in Obstetrics and Gynecology. 2005;17(6):557–61. Jones O, Reid W. The development of a new speciality training programme in obstetrics and gynaecology in the UK. Best Practice & Research Clinical Obstetrics & Gynaecology. 2010;24(6):685–701. Flin R, O'Connor P. Safety at the sharp end: a guide to non-technical skills: CRC Press; 2017. 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Applying objective metrics to neurosurgical skill development with simulation and spaced repetition learning. Journal of Neurosurgery. 2023;139(4):1092–100. Ryaan E-A, Bozso SJ, Kang JJ, Fialka NM, Adams C, Nagendran J. Teaching heart valve surgery techniques using simulators: a systematic review. Canadian Journal of Surgery. 2023;66(2):E139. Mannella P, Malacarne E, Giannini A, Russo E, Caretto M, Papini F, et al. Simulation as tool for evaluating and improving technical skills in laparoscopic gynecological surgery. BMC surgery. 2019;19:1–9. Additional Declarations No competing interests reported. Supplementary Files Ethnographystudysupplementarymaterials.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4735683","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":337550574,"identity":"a9f77a68-5474-4a8a-9d06-3d144f123063","order_by":0,"name":"Aditi Siddharth","email":"data:image/png;base64,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","orcid":"","institution":"University of Oxford","correspondingAuthor":true,"prefix":"","firstName":"Aditi","middleName":"","lastName":"Siddharth","suffix":""},{"id":337550575,"identity":"28c68b36-aa16-4414-ac6c-9aefcd85c6d6","order_by":1,"name":"Muspratt Tucker Nadia","email":"","orcid":"","institution":"Stoke Mandeville Hospital","correspondingAuthor":false,"prefix":"","firstName":"Muspratt","middleName":"Tucker","lastName":"Nadia","suffix":""},{"id":337550580,"identity":"54cbaef6-532c-43c7-b593-6cad9a991a39","order_by":2,"name":"Divya Nambiar","email":"","orcid":"","institution":"Stoke Mandeville Hospital","correspondingAuthor":false,"prefix":"","firstName":"Divya","middleName":"","lastName":"Nambiar","suffix":""},{"id":337550591,"identity":"d053ebce-0d51-4349-9471-63d7155dfb6f","order_by":3,"name":"Ruth Houlden","email":"","orcid":"","institution":"Oxford University Hospitals NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Ruth","middleName":"","lastName":"Houlden","suffix":""},{"id":337550599,"identity":"4d59d987-eefc-418b-b6fe-600ea56c71ba","order_by":4,"name":"Debbie Aitken","email":"","orcid":"","institution":"University of Oxford","correspondingAuthor":false,"prefix":"","firstName":"Debbie","middleName":"","lastName":"Aitken","suffix":""},{"id":337550608,"identity":"ba8e601f-750c-4cf3-83b8-2036ed31543f","order_by":5,"name":"Helen Higham","email":"","orcid":"","institution":"University of Oxford","correspondingAuthor":false,"prefix":"","firstName":"Helen","middleName":"","lastName":"Higham","suffix":""}],"badges":[],"createdAt":"2024-07-13 15:10:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4735683/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4735683/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63271733,"identity":"e144cf9a-468e-467a-8cd7-ce6e586f6ec1","added_by":"auto","created_at":"2024-08-26 11:28:26","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":27590,"visible":true,"origin":"","legend":"\u003cp\u003eGold's typology of participation by the researcher in a study. In a study that uses ethnographic methodology, the researcher acts as either the ‘participant as an observer’ or the ‘ observer as participant.\u003c/p\u003e","description":"","filename":"Figure1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4735683/v1/d7d15b57d7874b54fc5885ea.jpeg"},{"id":63272958,"identity":"5f417b5b-13b0-4dcf-98cf-e8a00de362e4","added_by":"auto","created_at":"2024-08-26 11:36:26","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":765906,"visible":true,"origin":"","legend":"\u003cp\u003eInstructions to the faculty member acting as the coordinator midwife in the simulation.\u003c/p\u003e","description":"","filename":"Figure2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4735683/v1/ead9fdf186fd9a25ed36b5cb.jpeg"},{"id":63271734,"identity":"374ad0f9-0442-4e29-9061-a130d78b36a8","added_by":"auto","created_at":"2024-08-26 11:28:26","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":96143,"visible":true,"origin":"","legend":"\u003cp\u003eParticipant instruction for the trainee playing the ST5 registrar in the simulation. There were similar role specific instructions for each participant role. Out of programme research (OOPR) refers to the trainee pausing their clinical training to participate in research.\u003c/p\u003e","description":"","filename":"Figure3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4735683/v1/8cf0b43aeea3468b623ad717.jpeg"},{"id":63271738,"identity":"8e42d8ec-cb70-4085-b1cd-9c863b0e999a","added_by":"auto","created_at":"2024-08-26 11:28:26","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":341147,"visible":true,"origin":"","legend":"\u003cp\u003eLayout of the main simulation training room.\u003c/p\u003e","description":"","filename":"Figure4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4735683/v1/c1a2b70c9b821f4198c3f768.jpeg"},{"id":63271736,"identity":"81d0ee4a-9e2e-48ae-8a4e-1d9a92a0153b","added_by":"auto","created_at":"2024-08-26 11:28:26","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":570037,"visible":true,"origin":"","legend":"\u003cp\u003eOrientation of the participants in group 1 and faculty at the start of the simulation.\u003c/p\u003e","description":"","filename":"Figure5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4735683/v1/46ab503ef3540f5ddcc3235f.jpeg"},{"id":63271740,"identity":"7de887fd-7b3f-4127-9ce3-a3c175885c86","added_by":"auto","created_at":"2024-08-26 11:28:27","extension":"jpeg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":647263,"visible":true,"origin":"","legend":"\u003cp\u003eMovement of the participants during the simulation from group 1, 16 minutes after the simulation had started. The Antenatal ward round was being conducted by Uma in another room. Room 1 had been assessed by Joseph and decision had been made for trial of instrumental delivery in theatre. Joseph had returned to the labour ward board to catch up with Gemma and the coordinator midwife regarding the plans made for the other patients on labour ward on the ward round.\u003c/p\u003e","description":"","filename":"Figure6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4735683/v1/3296535589cb079175d23467.jpeg"},{"id":84551763,"identity":"28c46b04-6e69-42b9-908c-2934afec16eb","added_by":"auto","created_at":"2025-06-13 10:32:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3865085,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4735683/v1/3fcc3c02-d891-4334-8e59-8200dcc33b37.pdf"},{"id":63272957,"identity":"55eac2db-fe7f-45c6-9a21-d6fa1160658f","added_by":"auto","created_at":"2024-08-26 11:36:26","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":46146,"visible":true,"origin":"","legend":"","description":"","filename":"Ethnographystudysupplementarymaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-4735683/v1/8cc3c5476b214ff6e710bcd4.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the trainee experience during a combined technical and non-technical skills obstetric training session on a simulated labour ward: A rapid ethnographic study","fulltext":[{"header":"Background","content":"\u003cp\u003eSafe obstetric practice requires both technical and non-technical skills, usually performed synchronously (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Obstetric technical skills (TS) include procedures such as caesarean section and episiotomy along with the knowledge to diagnose and manage a range of obstetric conditions (e.g., pre-eclampsia and intra-uterine growth retardation). Non-technical skills (NTS) are the cognitive and social skills that enhance patient safety and surgical excellence (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). There are 4 categories of NTS: situation awareness, decision making, leadership and communication/teamwork (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The non technical skills for surgeons (NOTSS) tool was developed to assess NTS of surgeons and was adapted for a labour ward setting by the royal college of obstetricians and gynaecologists (RCOG) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). An obstetrician deals with many emergencies on the labour ward where it is essential that they are able to perform TS whilst also practising NTS seamlessly to ensure safe and effective patient care (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTraditionally TS were learnt in hospital settings with patients ,under supervision (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) in an apprenticeship model of training (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). More recently, TS can be learnt on simulation models (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The apprenticeship model has changed to the competency-based training model in many surgical specialities including Obstetrics and Gynaecology, in part due to changes in working patterns, including implementation of the European Working Time Directive (EWTD) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). There are ethical considerations in exposing patients to a small but finite risk of harm as novice doctors learnin real clinical settings (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). For a novice obstetric trainee, it is nerve-wracking to perform an unfamiliar TS whilst communicating with an awake patient, their family, and the staff on a labour ward (NTS). Simulation has been used to provide experiential learning opportunities for real time decision making in a safe learning environment. It has been shown to improve performance and patient safety (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The recent global consensus statement on simulation based practice in healthcare recognises the benefits of simulation and advocates for the integration of low cost high impact simulation into regular training (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Simulation is an effective tool for training; but it is inadequately used (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Paucity of simulation facilities, faculty, and timeare all barriers to inadequate use of simulation (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere are simulation courses to learn obstetric TS such as the RCOG\u0026rsquo;s Operative Birth Simulation Training (ROBuST) course, which is designed to teach trainees how to perform an instrumental delivery (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). There are also team-based simulation training courses e.g. the Practical Obstetric Multiprofessional training (PROMPT) course to practice NTS (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), which has been shown to improve team performance, practitioner confidence and patient outcomes (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). However, learning to integrate TS and NTS is still reliant on practising on the job (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study aimed to understand the training experience when performing TS and NTS simultaneously in a simulated obstetric on call.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eThe choice of methodology: Rapid Ethnography\u003c/h2\u003e \u003cp\u003eEthnographers study social interactions to understand the way people interact with their surroundings (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Though originally used in anthropological research, modified versions of ethnography have been used in other disciplines e.g. healthcare, and education. Multiple data sources are obtained in an ethnographic study e.g. observations, interviews, and audio-visual documentary recordings. These data can be compared, and contrasted to give a rich and complex understanding of the research subject and allow for triangulation of findings to improve the reliability of the results (\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Ethnographic studies would previously take years to complete but the methodology has now been adapted to suit different contexts including traditional, rapid, critical, online and autoethnography (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In this study, we have used rapid ethnography. The participant observer (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) in an ethnographic study is the researcher, who takes an active role engaging with the participants, sometimes acting as an insider and at other times observing and analysing like an outsider to maintain objectivity, positioned somewhere between \u0026ldquo;participant as an observer\u0026rdquo; and \u0026ldquo;observer as a participant\u0026rdquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eData analysis was conducted in the context of Kopta\u0026rsquo;s three phase theory of TS skill learning: the cognitive phase, the integrative phase and the automation phase (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eCognitive Phase: Trainees gather knowledge, plan, and practise each component of the TS. Feedback in this phase helps reinforce good behaviours.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIntegrative Phase: skills are practised in realistic contexts, integrating TS and NTS. Any errors with the integration of TS and NTS can be identified and worked on.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAutomation Phase: With deliberate practice, trainees progress to the automation phase (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In this phase, performing the TS requires less cognitive load, allowing trainees to handle new and complex situations with greater ease.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePositionality statement:\u003c/h2\u003e \u003cp\u003eThe lead author is a senior Obstetrics and Gynaecology trainee with extensive experience in both TS and NTS simulations. The faculty members involved in this study also have extensive clinical and simulation experience, especially with the use of the NOTSS tool to assess NTS. This background informed the development of clinical scenarios within the simulation, to ensure the cases were suitable for ST1-2 trainees though the trainees were assuming more senior roles during the simulation. The case complexity was carefully chosen to ensure even the ST2 acting as the \u0026ldquo;consultant\u0026rdquo; in the simulation could carry out the appropriate tasks. The lead author\u0026rsquo;s clinical background positioned her as an insider within the simulation, enhancing her role as an observer-participant during the ethnographic data collection. The insider perspective enabled the opportunity to empathise with the trainees\u0026rsquo; anxiety, body language and concerns and to appreciate the nuances of each clinical scenario. However, it was important to remain mindful of unconscious assumptions that might be made due to the lead author\u0026rsquo;s clinical background on the perception of trainees and their management of clinical scenarios during the simulation. Reflexive strategies were employed from the outset to put the participants at ease by discussing her role and reassuring the participants that the simulation was not designed to include any adverse outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003e This study was registered as a quality improvement project and received ethics exemption by the University of Oxford Clinical Trials and Research Governance (CTRG) team. Written consent was taken from all the participants. Prior to conducting this ethnographic study, we conducted a pilot simulation session in 2022 using the developed simulation material to finalise the script, the timings used in the simulation to cue events. The pilot session also helped us choose ethnography as the methodology for the study as it allowed for the recording of body language, facial expression, trainee movements during the simulation etc.\u003c/p\u003e \u003cp\u003eThe trainees who participated in the study:\u003c/p\u003e \u003cp\u003eAll 14 Thames Valley deanery specialist year 1 and 2 (ST1 and ST2) obstetric trainees attended the obstetric simulation training day in February 2023. This training day was a routine part of their mandatory regional training where they would have usually participated in a team simulation designed to practise non-technical skills (NTS). The 14 trainees were divided into two groups, with each group undergoing one iteration of a 40-minute simulation followed by a 30-minute focus group interview.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe inclusion criteria for the participants were\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTrainees with up to two years of experience in the speciality: This specific group of trainees were included in this study as it helped reduce variability in experience levels.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTechnical skill competence (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e): The Royal College of Obstetricians and Gynaecologists training matrix has a set number of procedures that ST1 and ST2 trainees are expected to be exposed to and gain competence in. Compared to more advanced trainees, this cohort has a more consistent skill set across the group which reduced the potential for variability in the study for example, ST2 trainees can perform a straightforward non-rotational forceps delivery, a straightforward caesarean section, and an episiotomy repair.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eExclusion criteria:\u003c/h2\u003e \u003cp\u003eTrainees more senior than ST2 or with more the two years of post-graduate experience in Obstetrics.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eFaculty included in the simulation:\u003c/h2\u003e \u003cp\u003eTwo senior obstetric trainees and two obstetric consultants experienced with conducting TS and NTS obstetric simulation were the faculty in this study. The trainers peer reviewed the simulation script and materials, and the script and learning outcomes were prepared after a consensus agreement on the management of the various clinical scenarios in the simulation based on the the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The faculty were familiar with RCOG adapted NOTSS tool and had experience using it (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Each faculty member was responsible a zone in the simulation (the labour ward board, theatre/room 1, antenatal ward and the maternity assessment unit) with them playing the role of the staff members usually present in these areas (midwife coordinating labour ward, anaesthetist in theatre/midwife in the room, midwife in charge of antenatal ward, midwife in maternity assessment unit respectively). Adopting these roles allowed the faculty to prompt the trainees during the simulation and provide pertinent clinical information at various junctures during the simulation based on the predetermined simulation script. An example is provided in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e (please refer to the supplementary materials for the simulation script).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe expected actions the trainees were required to perform during the simulation, including the technical skills (TS) and nontechnical skills (NTS).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSimulation timeline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpected actions to be performed by the trainees\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTechnical (TS)/ Non-technical skill (NTS)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt handover\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. Team members introduce themselves\u003c/p\u003e \u003cp\u003e2. Receive handover of labour ward board from coordinator midwife\u003c/p\u003e \u003cp\u003e3. Establish if there are any patient concerns that require immediate attention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSituational awareness (NTS)\u003c/p\u003e \u003cp\u003eCommunication and teamwork (NTS)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmediately after handover\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant to discuss with members of the team:\u003c/p\u003e \u003cp\u003e\u0026bull; Identify learning needs and goals of each member of the team\u003c/p\u003e \u003cp\u003e\u0026bull; Prioritise workload (ward round, assessment of room 1, antenatal ward round, review of patients in maternity assessment unit)\u003c/p\u003e \u003cp\u003e\u0026bull; Appropriately delegate workload to members of the team (ideal allocation would be- ST5 to assess patient in room 1, ST3 for antenatal ward round, one SHO to review patients in maternity assessment unit and consultant and second SHO for labour ward round).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSituational awareness (NTS)\u003c/p\u003e \u003cp\u003eDecision making (NTS)\u003c/p\u003e \u003cp\u003eCommunication and teamwork (NTS)\u003c/p\u003e \u003cp\u003eLeadership (NTS)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssessment of room 1 and decision for instrumental birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eST5\u003c/p\u003e \u003cp\u003e\u0026bull; To introduce themselves to patient and midwife\u003c/p\u003e \u003cp\u003e\u0026bull; To establish the history\u003c/p\u003e \u003cp\u003e\u0026bull; To perform the relevant abdominal and vaginal examination and correctly identify the abdominal and vaginal examination findings\u003c/p\u003e \u003cp\u003e\u0026bull; Communicate findings of delay in second stage and malposition of foetal head to patient and midwife\u003c/p\u003e \u003cp\u003e\u0026bull; Counsel patient regarding options and recommendation of rotational instrumental birth in theatre (called trial of instrumental birth)\u003c/p\u003e \u003cp\u003e\u0026bull; Communicate with coordinator midwife and consultant regarding patient in room 1\u003c/p\u003e \u003cp\u003e\u0026bull; Consent patient for the procedure, including discussing management of risks and possible additional procedures e.g., caesarean section and episiotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDecision making (NTS)\u003c/p\u003e \u003cp\u003eCommunication and teamwork (NTS)\u003c/p\u003e \u003cp\u003ePerforming the examination (TS)\u003c/p\u003e \u003cp\u003eKnowledge of procedure and risks to counsel patient (TS)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLabour ward round\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant and SHO to perform a ward round with the coordinator midwife\u003c/p\u003e \u003cp\u003e\u0026bull; Prioritise the patients on labour ward to decide the order of patient review\u003c/p\u003e \u003cp\u003e\u0026bull; For each patient, identify if they are any immediate concerns, plan next steps for investigations and management\u003c/p\u003e \u003cp\u003e\u0026bull; Include and communicate plans with coordinator midwife\u003c/p\u003e \u003cp\u003e\u0026bull; Include the SHO in the discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSituational awareness (NTS)\u003c/p\u003e \u003cp\u003eDecision making (NTS)\u003c/p\u003e \u003cp\u003eCommunication and teamwork (NTS)\u003c/p\u003e \u003cp\u003eLeadership (NTS)\u003c/p\u003e \u003cp\u003eKnowledge of management of routine clinical situations on labour ward (TS)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntenatal ward round\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eST3\u003c/p\u003e \u003cp\u003e\u0026bull; To introduce themselves to the midwife on the antenatal ward\u003c/p\u003e \u003cp\u003e\u0026bull; Identify any immediate concerns and prioritise patients to decide the order of review\u003c/p\u003e \u003cp\u003e\u0026bull; Discuss each patient with the midwife, address concerns, discuss management\u003c/p\u003e \u003cp\u003e\u0026bull; Manage the emergency- hyperstimulation (contracting more than 5 times in a 10-minute period)\u003c/p\u003e \u003cp\u003e\u0026bull; Identify the patient causing concern, discuss immediate management with midwife\u003c/p\u003e \u003cp\u003e\u0026bull; Discuss the unwell patient with the consultant and the coordinator midwife on labour ward to arrange for transfer of patient to labour ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSituational awareness (NTS)\u003c/p\u003e \u003cp\u003eDecision making (NTS)\u003c/p\u003e \u003cp\u003eCommunication and teamwork (NTS)\u003c/p\u003e \u003cp\u003eKnowledge of management of routine antenatal clinical situations (TS)\u003c/p\u003e \u003cp\u003eRecognising the unwell patient (TS)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternity assessment unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHO\u003c/p\u003e \u003cp\u003e\u0026bull; To discuss with the midwife and prioritise patients in order for review\u003c/p\u003e \u003cp\u003e\u0026bull; Review patients and make suitable management plans\u003c/p\u003e \u003cp\u003e\u0026bull; Identify the unwell patient with Acute Fatty Liver of Pregnancy (AFLP)\u003c/p\u003e \u003cp\u003e\u0026bull; Escalate concerns about patient with AFLP to consultant and coordinator midwife and organise an urgent senior review\u003c/p\u003e \u003cp\u003e\u0026bull; Arrange for transfer of patient with AFLP to labour ward and handover to the coordinator midwife on labour ward about patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDecision making (NTS)\u003c/p\u003e \u003cp\u003eCommunication and teamwork (NTS)\u003c/p\u003e \u003cp\u003eLeadership (NTS)\u003c/p\u003e \u003cp\u003eKnowledge of management of routine obstetric clinical situations (TS)\u003c/p\u003e \u003cp\u003eRecognising the unwell patient (TS)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn theatre for instrumental birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eST5\u003c/p\u003e \u003cp\u003e1. Communicate to the consultant that supervision is required in theatre for the required training e-portfolio evidence\u003c/p\u003e \u003cp\u003e2. Perform the WHO check using the WHO check list\u003c/p\u003e \u003cp\u003e3. Clean and drape\u003c/p\u003e \u003cp\u003e4. Catheterise\u003c/p\u003e \u003cp\u003e5. Confirm vaginal findings\u003c/p\u003e \u003cp\u003e6. Communicate with anaesthetist, midwife, and patient\u003c/p\u003e \u003cp\u003e7. Decide to proceed with rotational instrumental birth\u003c/p\u003e \u003cp\u003e8. Perform the rotation of foetal head between contractions\u003c/p\u003e \u003cp\u003e9. Apply forceps and perform forceps delivery using the correct technique\u003c/p\u003e \u003cp\u003e10. Perform an episiotomy at the time of crowning of the foetal head\u003c/p\u003e \u003cp\u003e11. Deliver the baby and handover to the midwife after delayed cord clamping\u003c/p\u003e \u003cp\u003e12. Manage the third stage of labour and deliver the placenta with controlled cord traction\u003c/p\u003e \u003cp\u003e13. Examine the perineum including rectal examination to identify any tears\u003c/p\u003e \u003cp\u003e14. Repair the episiotomy using the appropriate technique\u003c/p\u003e \u003cp\u003e15. Enquire about blood loss and manage appropriately\u003c/p\u003e \u003cp\u003e16. Perform a swab and instrument count with the theatre staff at the end of the procedure\u003c/p\u003e \u003cp\u003e17. Sign out of theatre at the end\u003c/p\u003e \u003cp\u003e18. Debrief patient and staff after procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSituational awareness (NTS)\u003c/p\u003e \u003cp\u003eDecision making (NTS)\u003c/p\u003e \u003cp\u003eCommunication and teamwork (NTS)\u003c/p\u003e \u003cp\u003eLeadership (NTS)\u003c/p\u003e \u003cp\u003ePerforming a rotational instrumental delivery (TS)\u003c/p\u003e \u003cp\u003eRepair of an episiotomy (TS)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe simulation script included roles for the faculty in the simulation (e.g., the coordinator midwife, the anaesthetist, the midwife on antenatal ward etc), participant instructions, the timeline for the events unfolding in the simulation, and the various clinical scenarios the participants would need to tackle on the simulated labour ward, the antenatal ward, and the maternity assessment unit (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and the supplementary material).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe pre-simulation brief was a 10-minute discussion with all the ST1-2 trainees familiarising them to the simulation setup (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) and building a rapport with the faculty. The participant roles were assigned. Trainee roles in the simulation (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) included consultant, specialist year 5 (ST5) registrar, specialist year 3 (ST3) registrar, 2 senior house officers (SHOs), patient and observer. Participant instructions contained information about their role (their experience, personality traits etc.) and specific training objectives (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and supplementary materials).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe trainees were assigned roles of varying seniority in the simulation. The complexity of the clinical scenarios in the simulation was carefully chosen to ensure suitability for an ST1 and 2 to manage even if they were acting outside their usual role. All names were changed to pseudonyms for anonymity. The table also shows the training grade they belonged to\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRole in the simulation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipants in group 1\u003c/p\u003e \u003cp\u003ePseudonym, training grade\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants in group 2\u003c/p\u003e \u003cp\u003ePseudonym, training grade\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsultant (C)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMellie, ST2,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDaisy, ST2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eST5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJoseph, ST2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHana, ST2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eST3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUma, ST2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCatherine, ST2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSHO 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGemma, ST1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaya, ST1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSHO 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTina, ST1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eJustina, ST1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObserver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAndrew, ST2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAda, ST2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFenella, ST1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eElle, ST1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eThe setting and simulation layout (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e):\u003c/h2\u003e \u003cp\u003eTwo training rooms were set up using low fidelity simulation models. The large training room was organised into distinct zones, each serving a distinct purpose: the labour ward board, the operating theatre with a model of a pregnant abdomen for examinations and instrumental deliveries, and the maternity assessment unit. The antenatal ward was a small office space a short walk away from the main room, allowing for participants to realistically transition between different areas of care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eConducting the simulation:\u003c/h2\u003e \u003cp\u003e Each iteration of the simulation involved specific clinical scenarios that trainees had to navigate by performing actions based on NOTSS tool and guidelines for assisted vaginal birth and management of labour (see supplementary material for details). The TS in this simulation were the performing of a rotational instrumental delivery in theatre, conducting labour ward and antenatal ward rounds and managing patients in the maternity assessment unit. Trainees were required to apply the relevant knowledge and physical hand skills required to perform these tasks.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData collection techniques:\u003c/h2\u003e \u003cp\u003eThe data sources included participant observation, research diaries from ethnographic researchers, faculty field diaries and focus group interviews.\u003c/p\u003e \u003cp\u003e\u003col style=\"list-style-type:lower-alpha;\"\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eParticipant observation: The 4 faculty members, two trainee observers and the ethnographic researcher all acted as participant observers. They maintained field diaries, noting body language (uncertainty, confidence, anxiety etc), observed actions, professionalism (technical skills, communication etc.), movements within the simulation setting, clinical decisions taken and the timing of the decisions.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e Focus group discussion: After each simulation session, the participants, faculty members and the ethnographic researcher gathered to discuss their experience. The conversations were enriched by the observations recorded which served as prompts.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDocumentary data: Audio recordings from the labour ward board, the antenatal ward, and the focus group interviews were transcribed for detailed analysis. Additionally, documentary data from the field diaries were reviewed. The ethnographic researcher also tracked trainee movements using hand-drawn diagrams.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData analysis:\u003c/h2\u003e \u003cp\u003eThe data analysis was an iterative process with frequent discussions with the faculty members to ensure the interpretations of the data accurately reflected the simulation experience. We used deductive coding to thematically analyse the transcripts and field notes, guided by Kopta\u0026rsquo;s three phase theory of technical skill development: cognitive/perceptive, integration, and automation. Microsoft Word and NVivo software was used for data management.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMaintaining rigour through triangulation:\u003c/h2\u003e \u003cp\u003eWe maintained rigour in our study by data triangulation using multiple sources of data. The involvement of the faculty, trainee observers, trainees and the ethnographic researcher provided diverse perspectives, representing multiple viewpoints and offered a comprehensive understanding of the simulation experience.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eAll the ST1-2s in the Thames valley deanery attended the study day (14 in total, with 6 ST1s and 8 ST2s). The roles were allocated as indicated in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The decisions made and actions performed by the trainees in each group during the simulation have been detailed in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and their movements were tracked and displayed using diagrams such as in Figs.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDecisions and actions of trainees during the simulation, with a comparison to the expected actions for Group 1 and Group 2\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActions expected\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eActions performed by Group 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eActions performed by Group 2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt handover\u003c/p\u003e \u003cp\u003e(Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Team members introduce themselves\u003c/p\u003e \u003cp\u003e\u0026bull; Receive handover of labour ward board from coordinator midwife\u003c/p\u003e \u003cp\u003e\u0026bull; Establish if there are any patient concerns that require immediate attention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes, actions were performed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes, actions were performed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmediately after handover\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant to discuss with members of the team:\u003c/p\u003e \u003cp\u003e\u0026bull; Identify learning needs and goals of each member of the team\u003c/p\u003e \u003cp\u003e\u0026bull; Prioritise workload (ward round, assessment of room 1, antenatal ward round, review of patients in maternity assessment unit (MAU)\u003c/p\u003e \u003cp\u003e\u0026bull; Appropriately delegate workload to members of the team (ideal allocation would be- ST5 to assess patient in room 1, ST3 for antenatal ward round, one SHO to review patients in maternity assessment unit and consultant and second SHO for labour ward round).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLearning needs were not discussed\u003c/p\u003e \u003cp\u003eWorkload was prioritised a little later, after the ward round started but no patients were missed and no delays in assessment of room 1. MAU did need to pull the emergency buzzer to alert the team. The Antenatal midwife had to alert the team about patients needing a review before Uma was allocated to doing the ward round.\u003c/p\u003e \u003cp\u003eThe workload was appropriately delegated with the ST5 assessing room 1, ST3 for the antenatal ward round, consultant and SHO for labour ward round and one SHO to the MAU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLearning needs were identified after it was brought up by Hana before she left for the antenatal ward. This prompted the discussion about training needs but did not result in a reshuffle of the assignment of tasks to align with the training needs.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Hana raises a question about training needs- body language is hesitant and awkward. Daisy\u0026rsquo;s body language indicates that they feel threatened by this challenge\u0026rdquo; (research diary)\u003c/p\u003e \u003cp\u003eWorkload was prioritised but with no participation or discussion from the team members. Team members were arbitrarily assigned tasks by consultant.\u003c/p\u003e \u003cp\u003eThe workload was not appropriately delegated- Hana was sent to the antenatal ward round, Catherine assessed room 1, Daisy, the consultant, performed the labour ward round and Justina was asked to assess a non-urgent patient on labour ward. Maya asked to go to MAU to review patients.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssessment of room 1 and decision for instrumental birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eST5\u003c/p\u003e \u003cp\u003e\u0026bull; To introduce themselves to patient and midwife\u003c/p\u003e \u003cp\u003e\u0026bull; To establish the history\u003c/p\u003e \u003cp\u003e\u0026bull; To perform the relevant abdominal and vaginal examination and correctly identify the abdominal and vaginal examination findings\u003c/p\u003e \u003cp\u003e\u0026bull; Communicate findings of delay in second stage and malposition of foetal head to patient and midwife\u003c/p\u003e \u003cp\u003e\u0026bull; Counsel patient regarding options and recommendation of rotational instrumental birth in theatre (called trial of instrumental birth)\u003c/p\u003e \u003cp\u003e\u0026bull; Communicate with coordinator midwife and consultant regarding patient in room 1\u003c/p\u003e \u003cp\u003e\u0026bull; Consent patient for the procedure, including discussing management of risks and possible additional procedures like caesarean section and episiotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes, all of these were carried out appropriately\u003c/p\u003e \u003cp\u003eExamination, decision, counselling, and consent taken for procedure by one person, as expected\u003c/p\u003e \u003cp\u003eInformation given during the consent process was detailed and accurate, but this increased the anxiety of the patient listening to it. Demonstrated lack of nuance when communicating information to a patient (possibly due to never having done this before in real life)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Joseph has very inclusive body language, kneeling down, makes eye contact and uses hand gestures when explaining complications\u0026rdquo; (research diary)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Fenella, the patient looks a little anxious but maintains eye contact. Looks nervous when talking about future pregnancies\u0026rdquo; (research diary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultiple people were involved in the review of Elle, the patient. First, Catherine reviewed this patient, examined and accurate determined the malposition. She accurately decided a trial of instrumental birth was required in theatre and counselled the patient about it. Catherine started the consent process by discussing the risks of the procedure and alternatives. She had some difficulty with this. She did not have the form signed by the patient.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Catherine is finding it difficult to use patient friendly language to talk. (maybe she has never done this before?).discussion on forceps sounds very robotic.\u0026rdquo; (research diary)\u003c/p\u003e \u003cp\u003eHana took over the consenting and performing the procedure in theatre. Since there was a change of person, she rediscussed the consent again (causing a delay in the procedure) before the patient signed it.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLabour ward round\u003c/p\u003e \u003cp\u003e(Fig.\u0026nbsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant and SHO to perform a ward round with the coordinator midwife\u003c/p\u003e \u003cp\u003e\u0026bull; Prioritise the patients on labour ward to decide the order of patient review\u003c/p\u003e \u003cp\u003e\u0026bull; For each patient, identify if they are any immediate concerns, plan next steps for investigations and management\u003c/p\u003e \u003cp\u003e\u0026bull; Include and communicate plans with coordinator midwife\u003c/p\u003e \u003cp\u003e\u0026bull; Include the SHO in the discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStarted with review of room 1. Once the history was noted, this was delegated appropriately to Joseph to continue with the review and examination. The labour ward board was reviewed, and patients prioritised and room 9 was reviewed next by Mellie (the consultant).\u003c/p\u003e \u003cp\u003eEach patient was discussed with the coordinator midwife and appropriate plans were made as expected.\u003c/p\u003e \u003cp\u003eAll plans were communicated to the coordinator midwife on the ward round.\u003c/p\u003e \u003cp\u003eGemma attended the ward round but did not communicate much with the consultant and was not included in discussions. But she was aware of all the plans that were made as she, later in the simulation, had to speak to the Joseph (when the consultant went to MAU) to handover the board and patients to him to continue with the ward round. She knew all the plans and patients.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Mellie goes to MAU to see a patient.\u003c/p\u003e \u003cp\u003eGemma goes to speak to Joseph and brings him up to speed about labour ward board and what has been done so far with ward round with help of coordinator midwife.\u003c/p\u003e \u003cp\u003eJoseph has assumed helicopter view.\u0026rdquo; (research diary).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe patients were prioritised, and tasks delegated very early in the shift, soon after handover. Patient concerns were identified. Though, the responsibility of review was assigned to people with the correct level of skill but not done in the appropriate order which impacted the workflow on labour ward and resulted in a reshuffling of staff for tasks later.\u003c/p\u003e \u003cp\u003eThe patients on labour ward did get reviewed on the ward round and did have appropriate plans.\u003c/p\u003e \u003cp\u003eThe plans were communicated to the coordinator midwife.\u003c/p\u003e \u003cp\u003eThe SHO had been assigned a separate review but first joined the ward round. She was very involved with the ward round and reviewed the patient she was assigned towards the end, when the consultant was called to the operating theatre, and she was on her own and could independently review the postnatal patients. She asked for relevant investigations and made appropriate plans.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntenatal ward round\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eST3\u003c/p\u003e \u003cp\u003e\u0026bull; To introduce themselves to the midwife on the antenatal ward\u003c/p\u003e \u003cp\u003e\u0026bull; Identify any immediate concerns and prioritise patients to decide the order of review\u003c/p\u003e \u003cp\u003e\u0026bull; Discuss each patient with the midwife, address concerns, discuss management\u003c/p\u003e \u003cp\u003e\u0026bull; Manage the emergency- hyperstimulation\u003c/p\u003e \u003cp\u003e\u0026bull; Identify the concerning patient, discuss immediate management with midwife\u003c/p\u003e \u003cp\u003e\u0026bull; Discuss the unwell patient with the consultant and the coordinator midwife on labour ward to arrange for transfer of patient to labour ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Appeared calm and composed. Reassuring body language and communication with midwife\u0026rdquo; \u0026ndash; observations from the research diary of the antenatal ward midwife about Uma.\u003c/p\u003e \u003cp\u003eUma introduced herself to the midwife, correctly identified the priority was managing the hyperstimulation and correctly advised to administer the terbutaline quickly.\u003c/p\u003e \u003cp\u003eOther patients were managed in order of room number and appropriate management plans were made, picking up on cues given by the midwife to improve the decisions made.\u003c/p\u003e \u003cp\u003ePlanned to appropriately escalate and ask for senior advice when Uma was not sure of the guideline or management.\u003c/p\u003e \u003cp\u003eCorrectly identified the patient had pre-eclampsia and was unwell. Planned to speak to the consultant about delivery. Uma discussed the patient with the consultant before the consultant had to go to theatre and they decided they will make a definite plan once the consultant has finished in theatre.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst Hana was asked to perform the antenatal ward round (an appropriate level of skill but not the expected allocation given the other tasks that required to be completed in the simulation). But due to this allocation, she was called away midway through the ward round to perform the task that was more appropriate for her level of seniority (the instrumental birth). No one else was immediately assigned to perform the ward round and the antenatal midwife had to ask for a person to review the patients. The only person available at that time in the simulation was Justina, who did not have the appropriate level of skill to perform this task but accepted anyway.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Though only ST1 in real life, no uncertainty in body language was observed in Justina. Responded well to change in scenario\u0026rdquo;- research diary of antenatal midwife\u003c/p\u003e \u003cp\u003eThe ward round was partly carried out by Hana, who made immediate plans for management for some of the patients. No ongoing plans or escalation of patients when she was unsure. Justina did correctly identify the high-risk patients though she failed to escalate to a more senior person on return to labour ward.\u003c/p\u003e \u003cp\u003eBoth Hana and Justina knew about the patient with pre-eclampsia. Hana only made immediate plans for monitoring and moved on with the ward round to the next patient without a plan to escalate, even though the abnormal blood tests were discussed. Even though this patient had been discussed with Hana, the antenatal midwife discussed her care again with Justina, who realised that the patient required senior input regarding a plan for delivery but did not escalate this to the consultant when she went back to labour ward.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternity assessment unit (MAU)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSHO\u003c/p\u003e \u003cp\u003e\u0026bull; To discuss with the midwife and prioritise patients in order for review\u003c/p\u003e \u003cp\u003e\u0026bull; Review patients and make suitable management plans\u003c/p\u003e \u003cp\u003e\u0026bull; Identify the unwell patient with Acute Fatty Liver of Pregnancy (AFLP)\u003c/p\u003e \u003cp\u003e\u0026bull; Escalate concerns about patient with AFLP to consultant and coordinator midwife and organise an urgent senior review\u003c/p\u003e \u003cp\u003e\u0026bull; Arrange for transfer of patient with AFLP to labour ward and handover to the coordinator midwife on labour ward about patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo one was automatically assigned to the review of patients in MAU. The MAU midwife interrupted the labour ward round to ask for a doctor to review patients due to the workload on MAU. Instructions were given by the consultant to recheck the patient\u0026rsquo;s observations in 15 minutes, when the midwife had expressed concerns about a pregnant patient with a headache.\u003c/p\u003e \u003cp\u003eThis resulted in the use of the emergency buzzer a few minutes later to alert the on-call team. All the doctors on labour ward rushed to MAU, leaving labour ward attended. This was pointed out to the consultant, who then reassigned staff to perform various tasks. Mellie consultant and Tina SHO went to MAU to review patients there.\u003c/p\u003e \u003cp\u003eAll patients were reviewed on MAU and appropriate plans were made.\u003c/p\u003e \u003cp\u003eThe patient with AFLP was recognised as being very unwell though the consultant was not very clear on the diagnosis at first and needed prompting and help coming up with a plan. The management plan was discussed with the coordinator midwife and arrangements were made to transfer the patient to labour ward. Plans were made to contact the appropriate members of the multidisciplinary team (MDT) for support.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaya was asked to review patients on MAU by the consultant as soon as the handover was completed.\u003c/p\u003e \u003cp\u003eHad an appropriate approach to patients- went through the list of patients, appropriately asked for relevant immediate investigations like CTGs to be completed by the midwife. Reviewed the patient with the abdominal pain and vomiting in person as appropriate. Enquired about blood test results- identified very low blood sugars and initiated immediate emergency protocol. Needed prompting to review the observations. Escalated appropriately with the use of emergency buzzer to alert the rest of the team. There was some confusion as to who would go to MAU at that point. Initially, the consultant wanted to go but realised she was required in theatre to supervise Hana performing the instrumental delivery and so Catherine went to MAU instead. Asked Maya to organise transfer of patient to labour ward by speaking to the midwife coordinator. Prompted to think about involving the MDT team and further management to stabilise the patient. Bloods were reviewed but diagnosis of AFLP was established with some prompting, and it was clear to the team that this patient was seriously unwell (noting the body language and tone of voice which demonstrated anxiety).\u003c/p\u003e \u003cp\u003eGood SBAR communication with consultant to update her about patient. But no further follow-up of patient and confusion as they lost track of where the patient went to after telling the MAU midwife to transfer the patient.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn theatre for instrumental birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eST5\u003c/p\u003e \u003cp\u003e\u0026bull; Communicate to the consultant that supervision is required in theatre for the required training e-portfolio evidence\u003c/p\u003e \u003cp\u003e\u0026bull; Perform the WHO check using the WHO check list\u003c/p\u003e \u003cp\u003e\u0026bull; Clean and drape\u003c/p\u003e \u003cp\u003e\u0026bull; Catheterise\u003c/p\u003e \u003cp\u003e\u0026bull; Confirm vaginal findings\u003c/p\u003e \u003cp\u003e\u0026bull; Communicate with anaesthetist, midwife, and patient\u003c/p\u003e \u003cp\u003e\u0026bull; Decide to proceed with rotational instrumental birth\u003c/p\u003e \u003cp\u003e\u0026bull; Perform the rotation of foetal head between contractions\u003c/p\u003e \u003cp\u003e\u0026bull; Apply forceps and perform forceps delivery using the correct technique\u003c/p\u003e \u003cp\u003e\u0026bull; Perform an episiotomy at the time of crowning of the foetal head\u003c/p\u003e \u003cp\u003e\u0026bull; Deliver the baby and handover to the midwife after delayed cord clamping\u003c/p\u003e \u003cp\u003e\u0026bull; Manage the third stage of labour and deliver the placenta with controlled cord traction\u003c/p\u003e \u003cp\u003e\u0026bull; Examine the perineum including rectal examination to identify any tears\u003c/p\u003e \u003cp\u003e\u0026bull; Repair the episiotomy using the appropriate technique\u003c/p\u003e \u003cp\u003e\u0026bull; Enquire about blood loss and manage appropriately\u003c/p\u003e \u003cp\u003e\u0026bull; Perform a swab and instrument count with the theatre staff at the end of the procedure\u003c/p\u003e \u003cp\u003e\u0026bull; Sign out of theatre at the end\u003c/p\u003e \u003cp\u003e\u0026bull; Debrief patient and staff after procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eJoseph communicated his requirement for supervision very clearly before going to theatre to the consultant.\u003c/p\u003e \u003cp\u003eThere was good communication between the theatre team and Joseph though he delegated too many tasks to one person. Displayed moderate level of anxiety in his body language and forgot some basic steps like cleaning, draping and catheterisation that were performed after prompting by the midwife in theatre. He reflected in the focus group discussion about being too keen to perform the procedure that he forgot the basic steps.\u003c/p\u003e \u003cp\u003ePerformed the WHO check using the checklist as appropriate.\u003c/p\u003e \u003cp\u003eWas able to confirm the vaginal findings and proceed with appropriate skill to rotate the baby and carry out the instrumental delivery, delivery the baby and manage the third stage of labour.\u003c/p\u003e \u003cp\u003eDid communicate with the theatre team but did not ensure he had assistance should he need it (e.g., having the SHO in theatre).\u003c/p\u003e \u003cp\u003eBody language changed and he became more confident after the baby was delivered. Management of third stage and repair of episiotomy were performed very confidently and maintained casual communication with the theatre team.\u003c/p\u003e \u003cp\u003eSigned out after the procedure and debriefed the patient.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHana had communicated requirement for supervision to the consultant immediately after the handover. The consultant did come to theatre to supervise this procedure but repeatedly stepped out to labour ward.\u003c/p\u003e \u003cp\u003eHana appeared diffident, and this showed in the body language and communication with the theatre team and patient.\u003c/p\u003e \u003cp\u003eThe steps of the procedure including performing the WHO check was performed accurately.\u003c/p\u003e \u003cp\u003eBody language became more confident after delivery of the baby. The consultant noticed this as well and was able to leave theatre to leave Hana to complete the third stage management and episiotomy repair.\u003c/p\u003e \u003cp\u003eDue to the workload and being called away from theatre after repair of the episiotomy, the sign out and the debrief of the patient was very rushed.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCognitive phase of technical skill learning (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e):\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCognitive phase of learning noted during the antenatal ward round\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ldquo;.. I learnt that I didn\u0026rsquo;t know a huge amount.. There was a lady with severe preeclampsia that was getting worse and just trying to make plans about when you are going to deliver people is actually quite a tough call.. and unless you know what you are doing I guess\u0026rdquo;\u003c/p\u003e \u003cp\u003eUma ST3, discussed their experience of conducting an antenatal ward round for the first time (focus group interview)\u003c/p\u003e \u003cp\u003eUncertainty was present about certain situations that required further review of guidelines. Was calm and thinking things through.\u003c/p\u003e \u003cp\u003eObservation about Uma ST3 by the antenatal midwife (research diary)\u003c/p\u003e \u003cp\u003eAntenatal ward was neglected- SHO (Justina) was sent eventually after some time but forgot to catchup with the consultant about what was going on there.\u003c/p\u003e \u003cp\u003eObservation by the antenatal midwife (focus group interviews)\u003c/p\u003e \u003cp\u003eAntenatal midwife to Justina: \u0026ldquo;Did you feedback about the unwell patient on antenatal ward?\u0026rdquo;\u003c/p\u003e \u003cp\u003eJustina: \u0026ldquo; I went to Hana, but she was still in theatres and didn\u0026rsquo;t get a chance.\u0026rdquo;\u003c/p\u003e \u003cp\u003eAntenatal ward midwife :\u0026rdquo;That\u0026rsquo;s something even Hana didn\u0026rsquo;t communicate back. So, there was a patient on the ward who was quite unwell. Two people took rounds, but that information wasn\u0026rsquo;t communicated down to the team\u0026hellip;.\u0026rdquo;\u003c/p\u003e \u003cp\u003eConversation between the antenatal ward midwife and Justina (focus group interviews)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCognitive phase of learning noted during the process of taking the patient's consent before the instrumental delivery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCatherine ST3 went to room 1. Found it difficult to use patient friendly language to talk. Maybe she has never done this before? Maintained good eye contact and used open hand gestures.\u003c/p\u003e \u003cp\u003eObservation of the ethnographic researcher (research diary)\u003c/p\u003e \u003cp\u003eJoseph ST5 consented the patient for the instrumental delivery. Displayed inclusive body language, kneeling down, making eye contact when explaining complications. The discussion about complications made the patient more and more anxious and this was not picked up by Joseph. It was like he was trying to remember the complications rather than having a conversation with a person.\u003c/p\u003e \u003cp\u003eObservation of the ethnographic researcher (research diary)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere were two junctures in the simulation when the trainees consistently experienced the cognitive phase of learning:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDuring the discussion of the instrumental birth with the patient to take their consent for the procedure\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePerforming the antenatal ward round\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThey appeared unsure when performing these tasks as documented by the ethnographer and the faculty who had noted body language and facial expressions that were consistent with appearing nervous and anxious. The trainees admitted to their feelings of inadequacy in the focus group discussion when reflecting on these two tasks. When performing the antenatal ward round, information regarding a crucial patient was not discussed with the consultant, potentially compromising patient safety. The lapse in communication (an NTS) was due to a lack of knowledge required to manage obstetric conditions independently as well as unfamiliarity with the TS required to perform a ward round independently, which requires both TS and NTS. These findings were observed by the faculty as well as the participants in both groups showing their learning was in the cognitive phase of skill development, where the trainee was not entirely confident in the knowledge-based decisions they were making and could not effectively integrate it with the NTS required in performing the ward round.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eIntegrative phase of technical skill learning (Table \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e and \u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e):\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntegrative phase of learning noted during the performance of the instrumental delivery in theatre\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJoseph ST5 is the clear leader in charge of the procedure in theatre. Displayed body language that showed medium level of stress (probably appropriate considering this is a rotational delivery). In theatre, a relaxed atmosphere, friendly attitude was maintained.\u003c/p\u003e \u003cp\u003eObservation made in research diary of the ethnographic researcher during the performance of the instrumental delivery for group 2\u003c/p\u003e \u003cp\u003eHana ST5 appeared diffident, and this showed in the body language and communication with the theatre team and patient. The steps of the procedure was performed accurately.\u003c/p\u003e \u003cp\u003eObservation made in research diary of the ethnographic researcher during the performance of the instrumental delivery for group 2\u003c/p\u003e \u003cp\u003e\u0026ldquo;If it had been in a room, I would have been able to kind of trick myself. But because it was so different, in theatre..\u0026rdquo;\u003c/p\u003e \u003cp\u003eHana ST5 when asked to reflect on her experience performing an instrumental delivery in a theatre which she has never done in real life before.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntegrative phase of learning noted during the performance of the labour ward round\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMellie Consultant: \u0026ldquo; Examine her and just check that she is on the correct antibiotics, fluids and septic screen results.\u0026rdquo;\u003c/p\u003e \u003cp\u003eCoordinator midwife: \u0026ldquo;Ok. She is just looking a bit unwell, she is warm to touch, her uterus is quite tender, and it\u0026rsquo;s a little bit big, below the umbilicus\u0026rdquo;\u003c/p\u003e \u003cp\u003eMellie Consultant: \u0026ldquo;Ok, so let\u0026rsquo;s continue with the IV (intravenous) antibiotics to cover for endometritis, and make sure she has some fluids, and chase the septic screen results.\u0026rdquo;\u003c/p\u003e \u003cp\u003eConversation between the consultant from group 1 and coordinator midwife during the labour ward round (transcript).\u003c/p\u003e \u003cp\u003eDaisy Consultant: \u0026ldquo;We have done the ward round for the three patients.\u0026rdquo;\u003c/p\u003e \u003cp\u003eCatherine ST3: \u0026ldquo;I\u0026rsquo;ve examined the lady in room 1 and she is doing really well. The foetal head is 0/5th palpable in the abdomen. But she is LOP (left occipito-posterior) at +\u0026thinsp;1/spines. She has a good working epidural and I\u0026rsquo;ll speak to her about the process, but I think she\u0026rsquo;ll need a trial in theatre.\u0026rdquo;\u003c/p\u003e \u003cp\u003eDaisy Consultant: \u0026ldquo;I agree with that. Are you happy with the CTG (cardiotocography)?\u0026rdquo;\u003c/p\u003e \u003cp\u003eCatherine ST3: \u0026ldquo;She has some variable decelerations when she is pushing.\u0026rdquo;\u003c/p\u003e \u003cp\u003eDaisy Consultant: \u0026ldquo;In that case it\u0026rsquo;s still reasonable when it\u0026rsquo;s a compensated CTG to go for a swift category two trial. In which case, would you be able to liaise with Hana ST5. Why don\u0026rsquo;t we go find her together and it\u0026rsquo;s something she would like to do and then why don\u0026rsquo;t you join us for the round?\u0026rdquo;\u003c/p\u003e \u003cp\u003eConversation Daisy Consultant and Catherine ST3 regarding the findings after the examination of a patient in room 1.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe trainees were familiar with performing a straightforward instrumental birth on a part task simulator, having practised this TS during the RoBUST simulation course. However, they had never performed a rotational instrumental birth in theatre before. During the simulation, the trainees entered the integrative phase of skill learning when they performed the rotational instrumental delivery in theatre. At this level of training, whilst the trainee would have assisted in a rotational instrumental birth in theatre, they would never have had the opportunity to perform it independently. In this simulation, it was evident that the trainees were able to practise their instrumental delivery skills in the integrative phase in the context of a theatre setting.\u003c/p\u003e \u003cp\u003eAnother instance of integration of TS and NTS was seen with the management of the patients on labour ward and the labour ward round from the very start of the simulation. Once the coordinator midwife discussed the patients on the labour ward board, the team had to use a combination of knowledge and NTS such as delegation, leadership, and prioritisation to ensure the appropriate management plans were initiated (Table \u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTransition from integrative to autonomous phase (Table \u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e):\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTransition from the integrative and the autonomous phase occurred in the operating theatre\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaisy Consultant : \u0026ldquo;I think I find I am willing to trust my colleagues to do their job and delegate\u0026hellip; I saw Hana ST5 do the trial and I let her deal with whatever tears and postpartum haemorrhage. I felt comfortable with that...\u0026rdquo;\u003c/p\u003e \u003cp\u003eReflection of Daisy Consultant about task delegation in theatre (focus group discussion)\u003c/p\u003e \u003cp\u003eThe body language visibly relaxes, Joseph ST5 smiles at patient, is chattier... Consultant leaves the operating theatre.\u003c/p\u003e \u003cp\u003eObservations of the ethnographic researcher about the change in body language of Joseph ST5 immediately after the delivery of the baby\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe thematic analysis of the data revealed a distinct phase which marked the transition from the integrative to the autonomous phase. This is evidenced within the events that occurred in the operating theatre where the baby was handed over to the midwife, the placenta was delivered and the perineum was evaluated for suturing, immediately after the baby was delivered, in both the groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eAutonomous phase of skill learning (Table \u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e and \u003cspan refid=\"Tab10\" class=\"InternalRef\"\u003e10\u003c/span\u003e):\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAutonomous phase of skill learning seen during the repair of the episiotomy after delivery of the baby\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn theatre, Joseph ST5 became confident once he started to suture the perineum, making casual conversation with the team and patient.\u003c/p\u003e \u003cp\u003eObservations of the ethnographic researcher of the body language of the Joseph ST5 during the episiotomy repair.\u003c/p\u003e \u003cp\u003e\u0026ldquo; \u0026hellip; when you started suturing, you looked super confident doing that. Because you knew how to do it very well. I could see that switch between having to think through every step you were doing to when you can actually relax and enjoy it\u0026hellip;\u0026rdquo;\u003c/p\u003e \u003cp\u003eDiscussion between the ethnographic researcher and Joseph ST5 (focus group discussion)\u003c/p\u003e \u003cp\u003eI did feel like that as well suddenly it was like I can relax now\u003c/p\u003e \u003cp\u003eReflection made by Joseph ST5 about the relief he felt when he was repairing the episiotomy\u003c/p\u003e \u003cp\u003e\u0026ldquo;During the suturing, would say someone might be very happy sitting and suturing and you do have to be present in the moment and maybe you have some awareness of what\u0026rsquo;s going on outside, but you have to be present in the suturing at that time.\u0026rdquo;\u003c/p\u003e \u003cp\u003eStatement by the observer from group 2 during the focus group discussion about the relationship between performing the technical skill of suturing that is familiar with the situational awareness required when in theatre and on call on labour ward\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab10\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 10\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAutonomous phase of skill learning seen during the diagnosis of the unwell patient in MAU\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn MAU, Mellie consultant was unsure of diagnosis of AFLP (Acute fatty liver of pregnancy) but correctly identified that patient was very sick\u0026hellip;\u003c/p\u003e \u003cp\u003eObservation of ethnographic researcher (field diary)\u003c/p\u003e \u003cp\u003eCatherine ST3: \u0026ldquo;She is 36 weeks, and she has had epigastric pain. She has got raised liver enzymes and low platelets. So, we\u0026rsquo;re thinking she has acute fatty liver of pregnancy. Her GCS (Glasgow Coma Scale) score is a little bit low so I\u0026rsquo;m about to call the anaesthetist, but we have managed to stabilise her and send off some bloods. We\u0026rsquo;re hoping to bring her around to the observation area to stabilise her before delivery.\u0026rdquo;\u003c/p\u003e \u003cp\u003eConversation between the Catherine ST3 and the coordinator midwife\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn this simulation, the skill for which the participants consistently entered the automatization phase was during the episiotomy repair, in theatre after the forceps delivery. By ST2 in the obstetric training programme, most trainees would be comfortable repairing a straightforward episiotomy and would have been performing this skill independently both in simulation and in real life. The level of comfort with performing the repair is demonstrated during the simulation from the following statements recorded through observations and in the transcript (Table \u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother instance where automatisation was noted was the recognition of the unwell patient in the maternity assessment unit. ST1-2s are very familiar with the working of the maternity assessment unit (MAU) and are often left to manage the patients there on their own under indirect supervision. This real-world experience is evident during the simulation, where the junior most members of the team in both groups were assigned to see patients in MAU and in both groups the acutely unwell patient was recognised and escalated appropriately.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eChanged behaviour after participating in a combined technical and non-technical skill simulation (Table \u003cspan refid=\"Tab11\" class=\"InternalRef\"\u003e11\u003c/span\u003e):\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab11\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 11\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChanged behaviour at work after one session of technical-nontechnical skill combined simulation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ldquo;I think it\u0026rsquo;s been nice to do a trial run as a team and have that knowledge that you are not going to be all by yourself on delivery suite. That there should always be someone who is going to support you. So, it takes the pressure off.\u0026rdquo;\u003c/p\u003e \u003cp\u003eReflection by Mellie consultant during the focus group interview\u003c/p\u003e \u003cp\u003e\u0026ldquo;I guess that conversation we just had about mental rehearsal but reemphasising that. If you had asked me this morning what is an important thing to do before we go into theatre, I would have hopefully said mentally rehearse everything, but I still didn\u0026rsquo;t do it. And so, re-emphasising that.\u0026rdquo;\u003c/p\u003e \u003cp\u003eReflection by Joseph ST5 about the benefit of practicing the steps of the procedure in simulation and mentally rehearsing it in real life\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;I think where it was a board round it felt more realistic as we do that all the time anyway\u0026hellip;Whereas other moments like pretending to go in and see a patient or theatre felt a lot more artificial but still valuable.\u0026rdquo;\u003c/p\u003e \u003cp\u003eMellie consultant reflecting on the value of participating in this simulation\u003c/p\u003e \u003cp\u003e\u0026ldquo;I felt that as it went on it felt more real. But that might have been because I just relaxed more. And then you sort of go with it.\u0026rdquo;\u003c/p\u003e \u003cp\u003eUma ST3 who felt it became easier to suspend disbelief and participate in the simulation as it progressed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the focus group discussion, the trainees were asked if the experience they had would help prepare them to perform their jobs better, including managing a labour ward and performing a delivery in theatre. Both groups felt that whilst there was some dissonance between reality and the simulation in terms of realism, it had helped them formulate a mental model they could rely on when using these skills in real life.\u003c/p\u003e \u003cp\u003eTwo of the participants in group 2 found it difficult to suspend disbelief but felt it was a beneficial feeling as it helped them not to panic when taking on more responsibility than they would have been comfortable with in real life (Table \u003cspan refid=\"Tab12\" class=\"InternalRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab12\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 12\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReflections of trainees who found it difficult to suspend disbelief in the simulation but had a beneficial experience\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ldquo;I thought because it doesn\u0026rsquo;t feel a 100% real it was a good thing cause otherwise you would be so panicked and stressed that you wouldn\u0026rsquo;t be able to explore.. like in a real-life situation if someone asked you to go and do an antenatal ward round.. I would be like aaahhhh.. I can try and, but I wouldn\u0026rsquo;t be making any decisions but here I felt like I was able to just push myself and see cause nothing bad is going to happen and no one is going to die.so that\u0026rsquo;s kind of a good thing. yea I definitely felt that.. a part of it is to have a plan in your mind if you have to do it again, you have already done it before\u0026hellip; like now I\u0026rsquo;ll know what my first step is..\u0026rdquo;\u003c/p\u003e \u003cp\u003eJustyna SHO who was asked to perform an antenatal ward round, which they had never done in real life\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think I felt more comfortable doing things in simulation than I would in real because I felt like I could take my time and discuss things and be more like.. but with a patient I think I would be more uncertain to make my decision.\u0026rdquo;\u003c/p\u003e \u003cp\u003eCatherine ST3, talking about the benefit of participating in this simulation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePrevious studies in obstetrics have demonstrated the efficacy of using simulation to learn TS and practise NTS (\u003cspan additionalcitationids=\"CR37 CR38\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). This study aligns with the findings from the wider literature and makes a case for combining TS and NTS into one simulation session to enhance the training experience. Participants\u0026rsquo; experiences suggested that the integration of the two modalities of simulation training, TS and NTS, helped them practise both TS and NTS in a more realistic simulation setting by integrating the two as would be expected in real clinical practice. Guided by Kopta\u0026rsquo;s theory of learning technical skills, our study underscores the importance of providing trainees the opportunity to practise in integrated simulations alongside TS and NTS only simulations during their training years (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe use of rapid ethnography as a methodology to study simulation is relatively recent (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Unlike other methodologies, including quantitative and qualitative, rapid ethnography allowed us to capture the training experience from multiple view points simultaneously, in real time, as the simulation played out. Rapid ethnography lends itself to be used for observing and interpreting behaviour and experiences in a wide range educational settings, both real and simulated. Nuances including facial expression and body language, which otherwise would not be accounted for, was recorded during the ethnographic study.\u003c/p\u003e \u003cp\u003eThis study was a deviation from the traditional approach to simulation in obstetrics, where the focus is on either TS development or team training for NTS (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). With the limited time trainees have for educational activities including simulation within their training programmes, innovative solutions are required to maximise the learning opportunities from each session (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Previous solutions explored in the literature include the development of simulation curricula that integrate TS and NTS training, practising TS and NTS in a simulated theatre setting, courses like the Advanced Trauma Life Support (ATLS), and the introduction of crisis resource management for anesthetists (\u003cspan additionalcitationids=\"CR45 CR46 CR47\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Our work expands on the existing literature by increasing the complexity of the activities trainees had to perform within one simulation, including managing a labour ward board, performing a procedure in theatre etc. The findings suggest that we can use each simulation training opportunity to enhance the skills beyond a single skillset, whilst increasing the fidelity of the simulation by making it feel more real.\u003c/p\u003e \u003cp\u003eThe findings of this study demonstrate the possibility of practicing TS in all three phases of learning (as per Kopta\u0026rsquo;s theory), though it is best used to practice TS in the integrative and automation phases. A combined simulation as described in this study does not allow the time and instruction needed to learn a new TS in the cognitive phase. The cognitive phase of TS learning is best practised, as demonstrated in numerous studies, using part task simulation (\u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe scope to use combined TS and NTS simulation goes beyond ST1-2 training. The model we have described is easily modified to varying levels of difficulty depending on the seniority of the trainees by changing the clinical scenarios presented within the simulation. The TS within the simulation can also be modified, based on the learning objectives and the trainees\u0026rsquo; level of experience. This type of simulation could be used to support those returning to training after a career break (after maternity leave, research break, illness, etc.) as one session can be used to deliver multiple training opportunities. The study findings highlighted the importance of the design of the simulation which must be tailored to the experience level of the group participating, with a few tasks they are very comfortable performing and some tasks where they are pushing the boundary of their skill and experience. For example, for trainees in this study who were confident with episiotomy repair, it was easy to perform that task at an autonomous level. Similarly, unfamiliar tasks could only be performed at the cognitive phase. For the integrative phase, trainees are required to have some prior knowledge and had previously practised on a simulation model (e.g. an instrumental delivery on a model during the RoBUST course) or in real life before it could be performed with integration with the NTS. The level of difficulty (to get the trainees to practise integration of skills) should be slightly higher than their current level of training but cannot be vastly more difficult without it compromising the phase of skill learning they achieve in the simulation.\u003c/p\u003e \u003cp\u003eFinally, beyond of the context of obstetrics, similar simulation programmes could be organised in any surgical speciality. The recent global consensus statement on simulation based practice in healthcare emphasises the importance of TS and NTS training that should be delivered to all healthcare professionals though current training does not meet this need (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Our study describes a valuable technique that can be employed with relatively no increase in resource burden.\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eStudy Limitations\u003c/h2\u003e \u003cp\u003eThis study reports the experience of one group of trainees of similar skill set at one point in time. This may impact the generalisability of the findings to beyond the context in which the study was conducted. The faculty members involved in the development of the simulation materials and the conduct of the simulation are experienced with both the speciality and with delivering simulation training. This potential bias may have influenced their views of the data collected. We have minimised the influence of these biases by involving two of the authors in data analysis, who have education and simulation backgrounds but no obstetric knowledge.\u003c/p\u003e \u003cp\u003eObstetrics and gynaecology trainees are familiar with using simulation for technical and non-technical skills training separately. This may not be the case with all surgical specialities and therefore more participant preparation may be required prior to the commencement of the simulation to acclimatise them to the simulation setting. Another limitation is the lack of multidisciplinary team representation within this iteration of the simulation. The roles of coordinator midwife, antenatal ward midwife and maternity assessment unit midwife could have been played by midwifery staff with simulation experience.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCombining TS and NTS simulation into a single training session enhanced trainee learning with no increase of trainee or trainer burden. We recommend the use of combined TS and NTS simulation in a large variety of contexts- various surgical specialities and to support return to training, as it can be easily modified to suit a variety of learning objectives. The model of simulation presented in this study could be a valuable resource in the current context of healthcare post pandemic with several training deficits, a workforce with low morale and a recognition that long-term workforce planning should include simulation based education as a modality to enhance development opportunities for all healthcare professionals.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eATLS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdvanced Trauma Life Support\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTRG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eClinical Trials and Research Governance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEWTD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEuropean Working Time Directive\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNOTSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon Technical Skills for Surgeons\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNTS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon Technical Skills\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePROMPT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePRactical Obstetric Multi- Professional Training\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCOG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRoyal College of Obstetricians and Gynaecologists\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eROBuST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRCOG Operative Birth Simulation Training\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSenior House Officer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eST1\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpecialist Trainee Year 1\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eST2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpecialist Trainee Year 2\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eST3\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpecialist Trainee Year 3\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eST5\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpecialist Trainee Year 5\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTechnical Skill\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003eThe authors declare that they have no competing or conflict of interests. No funding was received for this project.\u003c/p\u003e \u003cp\u003e \u003cb\u003eHuman ethics and consent to participate\u003c/b\u003e \u003c/p\u003e \u003cp\u003e This work received Ethics exemption from Clinical Trials and Research Governance (University of Oxford) and was registered as a quality improvement project. All participants provided written consent for participating, audio recording and publication/ presentation of the work.\u003c/p\u003e \u003cp\u003e \u003cb\u003eClinical trial number\u003c/b\u003e \u003c/p\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.S.: Concept development, Design of study and simulation material, data collection, data analysis, manuscript writing, manuscript editingN.M.T. and D.M.: Development of simulation material and faculty in the simulation during the study R.H., D.A., H.H.: Project supervisor, manuscript editingAll authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eMiss Flora Wong and Miss Sarah Louise Smyth alongside two of the co-authors to participate as faculty in the simulation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJohannsson H, Ayida G, Sadler C. Faking it? 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European Journal of Obstetrics \u0026amp; Gynecology and Reproductive Biology. 2021;260:159\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFreeth D, Ayida G, Berridge EJ, Mackintosh N, Norris B, Sadler C, et al. Multidisciplinary obstetric simulated emergency scenarios (MOSES): Promoting patient safety in obstetrics with teamwork-focused interprofessional simulations. Journal of Continuing Education in the Health Professions. 2009;29(2):98\u0026ndash;104.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWinter C, James M, Draycott T. Evaluating a Training Package for Obstetric Emergencies. Simulation in Healthcare. 2006;1(3):199.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBligard KH, Lipsey KL, Young OM. Simulation training for operative vaginal delivery among obstetrics and gynecology residents: a systematic review. 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Simulation as tool for evaluating and improving technical skills in laparoscopic gynecological surgery. BMC surgery. 2019;19:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Obstetric simulation, Technical skill simulation, non-technical skill simulation, surgical simulation, ethnography","lastPublishedDoi":"10.21203/rs.3.rs-4735683/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4735683/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eObstetric training requires competence in both technical and non-technical skills (TS and NTS). Traditionally the acquisition of these skills is dependent on experience more than formal teaching. Simulation training can be an opportunity to bridge this gap in a safe environment. This study explores the impact of merging TS and NTS simulation into a single session of an obstetric on call on a simulated labour ward.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eAll obsetric specialist trainees year 1 and 2 (ST1-2) from the Thames Valley Deanery (n\u0026thinsp;=\u0026thinsp;14) participated in a 40 minute simulated labour ward oncall,managing patients on the labour and antenatal wards and maternity assessment unit. The trainees were divided into two groups, each group participated in the simulation followed by a focus group discussion. This study used rapid ethnography with in-situ observation, audio recordings, field notes and focus group interviews. Data analysis used Kopta\u0026rsquo;s 3 phase theorical framework of technical skill learning- cognitive, integrative and autonomous.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eTrainees learnt TS in all three Kopta\u0026rsquo;s phases during this simulation. The trainee\u0026rsquo;s familiarity with the TS determined the phase of learning they achieved. For less familiar tasks, trainees were in the cognitive phase. The integrative phase was seen when the TS was partially familiar and required them to perform it in conjunction with the appropriate NTS. There was autonomous TS and NTS integration with tasks they were skilled in.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eIntegrating TS and NTS simulation optimised the learning opportunities within one training session. This model is adaptable to various skill levels and specialities, without increasing trainee, faculty, or resource burden. Further exploration can broaden applicability of this approach across other specialities.\u003c/p\u003e","manuscriptTitle":"Exploring the trainee experience during a combined technical and non-technical skills obstetric training session on a simulated labour ward: A rapid ethnographic study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-26 11:28:21","doi":"10.21203/rs.3.rs-4735683/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a2f0fa3a-7494-4ea5-9b07-b7ead170af40","owner":[],"postedDate":"August 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-13T10:24:03+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-26 11:28:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4735683","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4735683","identity":"rs-4735683","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}