Context
Previously identified challenges on our L&D unit during consults and transfers of care provided the need for which we designed our IE-informed research study, and the tabletop simulation approach presented below.
Inspired by our learning about IE principles in the preceding IE-informed study, we subsequently initiated this project to explore the feasibility and value of designing and implementing tabletop simulation scenarios focused on everyday and everynight work. Our data collection and analyses reported below did not, however, focus on gaining further insights about work and the texts that govern work on the L&D unit. Instead, we used our preceding experiences conducting the larger study as points of contrast for exploring the value-add, the ‘implementation fidelity’ (i.e., did we yield insights about work at all?), the lessons learned, and the challenges experienced in implementing an IE-informed tabletop simulation modality. In conducting both projects, we received and complied with research ethics board approval from our organization (Protocol # 17-358).
In the list below, we provide a brief summary of our IE-informed study findings to give further context regarding the hospital setting where we conducted our tabletop simulation scenarios: (i) we found that intersections of health and law provided the foundation for how the work of midwives, obstetricians and nurses was socially organized, (ii) that a medicine-centric governance of the unit and midwives’ practices appeared to perpetuate observed challenges, (iii) that the electronic fetal monitor (EFM) and how it was presented provided a ‘text’ that contributed to interprofessional conflicts, and (iv) that our efforts to make the multiple issues we uncovered on the unit explicit to the various healthcare professionals led to efforts toward collaborative, interprofessional change to unit policies and procedures [5].
Piloting
We first piloted a tabletop simulation scenario (based on a previously observed case) with our research team that included intrapartum clinicians from the L&D unit: obstetricians (N = 2), nurses (N = 2), midwives (N = 2), a pediatrician (N = 1), and two family medicine physicians (N = 2). Feedback from the team prompted us to focus future scenarios less on medical ambiguity and thresholds for clinical management and more on the ambiguity of prolonged (over multiple hours) interprofessional interactions.
Developing the scenarios
After receiving hospital REB approval, we designed three new scenarios. Each scenario probed a key interprofessional challenge during consults and transfers of care that emerged from the data we had previously collected through incident analysis team reports, field observations, and interviews within our IE-informed study [5].
Simulation materials
We needed two separate rooms to simulate staff working in different locations throughout the scenario (on-site, off-site, or elsewhere in the hospital) and two facilitators in each room (Fig. 1). Our simulation educators prepared clinical and content prompts on cue cards that they distributed throughout the simulation to progress each scenario.
Sampling and recruitment
As the participants for our small data collection, we recruited clinicians involved in L&D unit decision-making, leadership, and educational administration. We sampled this population to probe varying perspectives and to collect feedback about how this modality might translate as a policy-informing or educational tool. We held simulation sessions with two different groups of clinicians and conducted two tabletop scenarios per session between May and September 2019.
Conducting the simulation
All participants were pre-briefed to expect being questioned about what they do and what prompts them to work that way in their everyday experiences (see Additional file 1). Following the pre-brief, all participants read a case stem (example in Fig. 2) and asked any immediate questions. Participants then dispersed to their respective locations (Fig. 1) to receive the first content prompts (example in Fig. 2). Each of these prompts accelerated the timeline of the scenario to moments where participants might typically decide to work interprofessionally (e.g., when a MW client’s OB-induced labour has progressed to the MW taking over care). Once participants explained what they would do in response to each prompt, the facilitators asked semi-structured follow-up questions to clarify what motivated them to take certain actions (i.e., 'why would you do it that way?'). Throughout the scenario, participants would move in and out of the rooms to simulate being in the same clinical space or apart from their colleagues (Fig. 1). As needed, participants would call each other by phone from the separate rooms to converse as usual. Simulation educators kept each other temporally-aligned by updating which time stamps their participants were currently working through via text-messages. Time-stamps on each prompt represented the progression of time in the scenario, enabling us to simulate a 24-h case in approximately 20 min.
After each scenario, the facilitators conducted an approximately twenty-minute semi-structured debrief, which borrowed from the “Promoting Excellence and Reflective Learning in Simulation” (PEARLS) framework [18].
Field notes and reflective analysis
Throughout all the simulations, authors RB and LN were present to take field notes both during the scenarios and during the debriefs that followed. Once the participants left the simulation space, we met with the simulation educators (authors CN and KS) to discuss their insights and to document any adjustments or divergent points independently in our field notes. LN, RB, and DMC then met to synthesize their notes from across all the delivered scenarios. Next, LN, RB, and DMC presented their insights to the full research team at ongoing monthly meetings. Our collective reflections at these meetings were distilled into themes reflecting our perspectives on the value propositions of the tabletop simulation, the specific outputs generated for our simulation program team, and the lessons learned during design and implementation.