Self-reported exposure to severe events on the labour ward among Swedish midwives and obstetricians: A cross-sectional retrospective study

Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings: A scoping review and thematic analysis

PROBLEM

Whistleblowing, which involves raising concerns about wrongdoing, carries risks yet can be crucial to ensuring the safety of health service users in maternal and newborn healthcare settings. Understanding of the experiences of health care professionals that enact whistleblowing in this context is currently limited.

BACKGROUND

Notable inquiries involving maternity services such as those reported upon by Ockenden and Kirkup and the Lucy Letby case in the United Kingdom have shone an international spotlight on whistleblowing failures.

AIM

To identify and synthesise available literature addressing the experiences of healthcare professionals enacting whistleblowing in maternal and newborn care settings.

METHODS

This scoping review followed Arksey and O'Malley's framework. Five academic databases were systematically searched for documents published between January 2013 and October 2023 with additional searches of Google Scholar and related reference lists.

FINDINGS

Whilst 35 papers from international sources were identified, the majority originated from the United Kingdom, where recent high-profile incidents have occurred. Thematic analysis identified three main themes: 'Structural Power', 'Perfectionism' and 'Bravery, Hope and Disappointment', each with sub-themes.

DISCUSSION

Whistleblowing is frequently an altruistic act in a hierarchical system. It exposes poor practices and disrupts power dynamics, especially in challenging workplace cultures. Open disclosure, however, requires psychological safety. Obstacles persist, emphasising the need for a culture of trust and transparency led by individuals who embody the desired values.

CONCLUSION

Primary research on whistleblowing in maternal and newborn healthcare settings is limited. This study sheds light on power dynamics and factors that affect whistleblowing.

The impact of severe perinatal events on maternity care providers: a scoping review

BACKGROUND

Severe events during the perinatal period can be experienced as traumatic by pregnant women, their partners or others who are closely involved. This includes maternity care providers who can be affected by being involved in or observing these events. This may have an impact on their personal well-being and professional practice, influencing quality of care. The aim of this study is to map research investigating the impact of severe events during the perinatal period on maternity care providers, and how these experiences affect their well-being and professional practice.

METHOD

A scoping review following the manual of the Joanna Briggs Institute was undertaken. The electronic bibliographic databases included PubMed/MEDLINE, CINAHL, PsycINFO, PsycARTICLES, SocINDEX, Cochrane, Scopus, Web of Science and databases for grey literature. Records passing the two-stage screening process were assessed, and their reference lists hand searched. We included primary research papers that presented data from maternity care professionals on the impact of severe perinatal traumatic events. A descriptive content analysis and synthesis was undertaken.

RESULTS

Following a detailed systematic search and screening of 1,611 records, 57 papers were included in the scoping review. Results of the analysis identified four categories, which highlighted the impact of traumatic perinatal events on maternity care providers, mainly midwives, obstetricians and nurses: Traumatic events, Impact of traumatic events on care providers, Changes in care providers' practice and Support for care providers; each including several subcategories.

CONCLUSION

The impact of traumatic perinatal events on maternity care providers ranged from severe negative responses where care providers moved position or resigned from their employment in maternity care, to responses where they felt they became a better clinician. However, a substantial number appeared to be negatively affected by traumatic events without getting adequate support. Given the shortage of maternity staff and the importance of a sustainable workforce for effective maternity care, the impact of traumatic perinatal events requires serious consideration in maintaining their wellbeing and positive engagement when conducting their profession. Future research should explore which maternity care providers are mostly at risk for the impact of traumatic events and which interventions can contribute to prevention.

Which events are experienced as traumatic by obstetricians and gynaecologists, and why? A qualitative analysis from a cross-sectional survey and in-depth interviews

OBJECTIVES

To explore the events perceived as traumatic by obstetricians and gynaecologists (O&G), and to examine factors contributing to the perception of trauma.

DESIGN

Mixed methods: cross-sectional survey and in-depth interviews.

SAMPLE AND SETTING

Fellows, members and trainees of the Royal College of Obstetricians and Gynaecologists (RCOG).

METHODS

An online survey was distributed to 6300 fellows (May-June 2017), members and trainees of RCOG; 1095 (17%) completed surveys were returned. Of these, 728 (66%) reported work-related trauma experience, with 525 providing a brief description of an event. Forty-three participants with trauma experience were purposively sampled and completed an in-depth interview (October 2017-March 2018), which were analysed using Template Analysis. Information regarding the scale and impact of trauma experience is presented elsewhere. The present analysis provides new information describing the events and perceptions of why events were traumatic.

PRIMARY OUTCOME MEASURES

The nature of traumatic events in this clinical setting, taken from survey descriptions of perceived traumatic events and information from the in-depth interviews.

RESULTS

Events perceived as traumatic by O&G were similar between consultants, trainees and other RCOG members no longer working in O&G. Maternal or neonatal death/stillbirth, haemorrhage and events involving a difficult delivery were most frequently reported. Sudden and unpredictable events, perceived preventability, acute sensory experiences and high emotionality contributed to trauma perception. Respondents' trauma was compounded by an absence of support, involvement in investigation procedures and pre-existing relationships with a recipient of care.

CONCLUSIONS

Identification of events most likely to be perceived as traumatic, and wider circumstances contributing to the perception of trauma, provide a basis on which to focus preventative and supportive strategies for O&G. Training on the nature of traumatic events, self-help for early stress responses, processing support and rapid access to trauma-focused psychological input (where required) are needed.

Feelings of being a second victim among Spanish midwives and obstetricians

Aim

The aim of this study was to determine the prevalence of feelings of being a second victim among midwives and obstetricians in Spain and to explore possible differences between the two professions.

Design

Cross‐sectional descriptive‐analytical observational study.

Methods

An online survey collecting several variables was administered throughout the Spanish territory. Spanish version of the Second Victim Experience and Support Tool (SVEST) was used. The data collection period was from May to December 2020.

Results

A total sample of 719 obstetricians and midwives were studied. There were significant differences between the two groups with respect to seven dimensions of SVEST: greater feelings of being a second victim among obstetricians in the dimensions physical distress/p ≤ .001, non‐work‐related support/p ≤ .001 and absenteeism/p ≤ .001 and greater feelings of being a second victim among midwives in the dimensions psychological distress/p ≤ .001, supervisor support/p = .011, professional self‐efficacy/p ≤ .001 and intention to change jobs/p ≤ .001.

Adverse events as transitional markers - Using liminality to understand experiences of second victims

Healthcare professionals are socialized into a tacit, professional identity of competences and skills - to save lives, repair trauma and facilitate good and trustful relational care. When severe adverse events happen, healthcare professionals may struggle to accept their own fallibility, and the event may pose a threat to the selfdeclared 'superior' or 'infallible' professional identity. The consequences of a sudden identity shift between the 'potentially infallible HCP' and 'potentially fallible HC P' caused by an adverse event is the analytical object of this study. The aim of the paper is to derive new understandings of how HCPs in maternity services experience adverse events by using Arnold van Gennep's and Victor Turner's 'rites of passage' theorizations and the concept of liminality to explain the process of transition between the two professional identities. Through five focus groups conducted in June 2018 with midwives and obstetricians-gynecologists, we have examined i) how second victim experiences can be understood using theories of transition and liminality, and ii) how the organizational procedures in a Danish university hospital may serve as a ritual for the involved HCPs in the aftermath of adverse events. The findings suggest that the inconsistency in the level of support contributes to the chaos that may be experienced by the healthcare professional. The organizational structure does not provide rites of transition or any other ritual processes, except for debriefings that, in many cases, are experienced as deficient. Since liminal states suggest danger and threat, because the previous professional identity is replaced by ambiguity and separation, the lack of clear rituals and support may put further strain on the HCP adding to the associated psychological and social distress. Considering the liminality and the need for structured transition rites within the work environment may prove useful when constructing adequate second victim support programs.

Action after Adverse Events in Healthcare: An Integrative Literature Review

Adverse events are common in healthcare. Three types of victims of patient-related adverse events can be identified. The first type includes patients and their families, the second type includes healthcare professionals involved in an adverse event and the third type includes healthcare organisations in which an adverse event occurs. The purpose of this integrative review is to synthesise knowledge, theory and evidence regarding action after adverse events, based on literature published in the last ten years (2009–2018). In the studies critically evaluated (n = 25), key themes emerged relating to the first, second and third victim elements. The first victim elements comprise attention to revealing an adverse event, communication after an event, first victim support and complete apology. The second victim elements include second victim support types and services, coping strategies, professional changes after adverse events and learning about adverse event phenomena. The third victim elements consist of organisational action after adverse events, strategy, infrastructure and training and open communication about adverse events. There is a lack of comprehensive models for action after adverse events. This requires understanding of the phenomenon along with ambition to manage adverse events as a whole. When an adverse event is identified and a concern expressed, systematic damage preventing and ameliorating actions should be immediately launched. System-wide development is needed.

How does video case-based learning influence clinical decision-making by midwifery students? An exploratory study

BACKGROUND

Clinical decision-making skills are essential for providing high-quality patient care. To enhance these skills, many institutions worldwide use case-based learning (CBL) as an educational strategy of pre-clinical training. However, to date, the influence of different learning modalities on students' clinical decision-making processes has not been fully explored. This study aims to explore the influence of video and paper case modalities on the clinical decision-making process of midwifery students during CBL.

METHODS

CBL involving a normal pregnant woman was provided for 45 midwifery students. They were divided into 12 groups; six groups received the video modality, and six groups received the paper modality. Group discussions were video-recorded, and focus groups were conducted after the CBL. Transcripts of the group discussions were analysed in terms of their interaction patterns, and focus groups were thematically analysed based on the three-stage model of clinical decision-making, which includes cue acquisition, interpretation, and evaluation/decision-making.

RESULTS

The students in the video groups paid more attention to psychosocial than biomedical aspects and discussed tailored care for the woman and her family members. They refrained from vaginal examinations and electric fetal heart monitoring. Conversely, the students in the paper groups paid more attention to biomedical than psychosocial aspects and discussed when to perform vaginal examinations and electric fetal heart monitoring.

CONCLUSION

This study clarified that video and paper case modalities have different influences on learners' clinical decision-making processes. Video case learning encourages midwifery students to have a woman- and family-centred holistic perspective of labour and birth care, which leads to careful consideration of the psychosocial aspects. Paper case learning encourages midwifery students to have a healthcare provider-centred biomedical perspective of labour and childbirth care, which leads to thorough biomedical assessment.

The perceived effect of serious adverse perinatal events on clinical practice. Can it be objectively measured?

OBJECTIVE

Obstetrics involves a high degree of clinical risk. While serious adverse events resulting in substantial maternal or neonatal morbidity or mortality are relatively rare it has been shown that exposure to a such an event can have a predominantly negative personal and professional impact on the healthcare professionals who are involved. There is little in the published literature to show an objective change in clinical practice as a result of an adverse event. The aim of this study was to identify if it was feasible to design a study that could objectively demonstrate if a change in labour ward clinical activity occurred in the 28 days following a serious adverse perinatal event. If this proved possible, the second aim was to identify if these changes could be attributed to the preceding adverse event.

STUDY DESIGN

This study was conducted in a large tertiary teaching hospital in Ireland. This was a retrospective observational study conducted using data from a 25-month period from August 2013 to September 2015. Six of the most serious adverse perinatal events that occurred over that time period were identified from the hospital's clinical risk register. Various outcome variables in the form of aggregate data on all deliveries that occurred in CUMH for the 28 days preceding and succeeding the events were collected by the lead author. The medical records for each severe adverse perinatal event were reviewed and the clinical case details recorded. Based on these clinical details individual hypotheses were created for each event. Data was analysed using IBM-SPSS.

RESULTS

Aggregate data relating to 6180 deliveries was collected and analysed. Data analysis revealed some statistically significant changes in clinical activity in the 28 days following five of the six adverse events. These changes in clinical activity did not, however, always match what we had expected from our original hypotheses.

CONCLUSION

This novel study aimed to identify if it was possible to objectively demonstrate this practice change. We identified some statistically significant changes in clinical activity in the 28 days following five of the six adverse events but were unable to definitively conclude if the change in activity was a direct result of each event.

The erratic pathway to regaining a professional self-image after an obstetric work-related trauma: A grounded theory study

BACKGROUND

It is known that healthcare providers might be affected by severe medical events in which patients are badly hurt. In birth care, escalating situations can result in death or injury to a mother or new-born child.

OBJECTIVE

To explore the process that Swedish midwives and obstetricians go through after a severe event in the maternity unit.

DESIGN

A modified Constructivist Grounded Theory analysis, based on fourteen in-depth interviews with birth care professionals.

PARTICIPANTS

Seven midwives and seven obstetricians.

RESULTS

A core category, 'regaining of a professional self-image', was constructed and interpreted as being constituted of six main categories illustrating a frequently erratic pathway to the regaining of a professional self-image. The process included a search for external acceptance for the re-establishment of belongingness by obtaining corroboration from the woman, work colleagues and manager, and the medico-legal system. Media exposure was invariably seen as something negative. Internal processes involved coping with emotions of guilt and shame and the vulnerability that the work entails, as well as contemplating future work. The possibility to fully regain one's professional self-image depended on having a sense of confidence and an urge to support others in similar situations by sharing gained insights. However, the process could also result in reconsidering one's professional self-image by setting up boundaries, creating a better work-life balance, or creating mental back-up plans in case of similar recurrences. For others, the process led to a change of professional identity and a search for roles away from emergency obstetrics or the specialty as such.

CONCLUSIONS

Many midwives and obstetricians will experience severe obstetric events that might affect them, sometimes severely. The vulnerability that healthcare professionals are exposed to should not be underestimated and preparedness in terms of collegial support, as well as an awareness in the workplace of how badly affected employees might be, is important. Growth as well as leaving birth care can be the results of the process following a severe event.