White Paper: Increasing patient safety in obstetrics through training in safe communication

Patient safety is one of the highest goals of healthcare and, since 2022, the tenth national health goal in Germany. Care errors contribute significantly to temporary or permanent impairment, prolonged hospital stays, or even death of patients. Although the topic has received considerable attention in the USA since the publication of "To err is human" in 2000, there remains a significant need for action. Adverse events triggered in the treatment context cannot be completely prevented given the complexity of medical treatments and the range of patient pre-existing health conditions. Strategies to improve the quality of care therefore focus on preventing avoidable adverse events. These are defined as those that would not occur if current medical standards were adhered to. The Patient Safety Action Alliance (APS), an alliance of representatives of healthcare professions, institutions, associations, and patient organizations, has been committed to implementing strategies to prevent adverse events since its founding in 2005. Treatment errors usually occur within complex and collaborative contexts. Against this backdrop, the APS considers collaborative learning from mistakes to be the most important tool for improving patient safety [1]. To enable and successfully implement this, open communication is essential.

>> The World Health Organization (WHO) has launched a global plan for increasing patient safety for the years 2021-2030, which must also be implemented in Germany. The action plan defines patient safety as "a framework of organized activities that creates cultures, processes, procedures, behaviors, technologies, and environments in health care that consistently and sustainably reduce risks, reduce the occurrence of preventable harm, make errors less likely, and lessen the impact of harm when they occur" [2]. In addition to government officials, the target audience includes all institutions that provide health care services or advocate for good care. The framework for action contains specific strategies, including "engaging and empowering patients and families to support the journey toward safe health care" and "inspiring, educating, training, and protecting health workers to contribute to the design and implementation of safe care systems."
Secure communication as a strategy to reduce avoidable adverse events
Communication plays a key role in ensuring safe patient care, both within interprofessional teams and with and from patients [3]. Even the best technical equipment standards and the highest medical expertise cannot be optimally utilized without binding agreements and clear information sharing and a culture of error prevention. Strategies to increase patient safety, as defined by the WHO Action Plan, must, on the one hand, reach employees in their everyday work structures and, at the same time, enable patients to articulate themselves in the care situation, perceive their own needs and wishes, and consciously express and demand them. To achieve both goals, communication skills and an awareness of the importance of their application are fundamental prerequisites. It is also known that insecure communication, combined with time constraints in everyday clinical practice, contributes significantly to the occurrence of avoidable adverse events [4]. Against this background, it is a great advantage that improved communication skills can be taught at manageable costs and with limited time. Tailored to the respective target group, it reaches both healthcare workers and patients. If training is successful, it also contributes to increasing employee satisfaction. Given the increasing shortage of skilled workers in healthcare, economic pressure, and the resulting staff overload, employee satisfaction not only contributes to a more positive working atmosphere but can also contribute to retention in the healthcare profession. This is even more so if the proportion of so-called "second victims," i.e. employees who are permanently stressed by a triggered error, is reduced [5]. A prerequisite for successful and effective communication training is the consideration of the specific requirements of the respective disciplines with regard to the patient groups to be cared for, with regard to their demographics, the degree of involvement of family members, the type of illness and its treatment options and chances of recovery, among other things. When addressing patients, it is necessary to consider their existing health literacy and personal needs.
Patient safety in obstetrics
Within the medical disciplines, obstetrics is characterized by several special features: the birth process concerns the health and well-being of two people, both the mother and the child or children. Furthermore, it does not care for 'traditional' patients expecting an improvement or cure for an illness, but rather predominantly healthy women who wish to give birth with the greatest possible autonomy and usually accompanied by their partner or another trusted person. To do so, they do not require traditional treatment, but rather support during the birth process, including routine medical monitoring with the offer of anesthesia for pain relief, as well as care for potential complications. However, unexpected, highly acute, time-critical emergency situations can arise that require immediate, often interdisciplinary intervention to protect the health and life of mother and child. Another special feature of obstetrics is the care provided by the professional groups (1) physicians, who are responsible for pathological births, and (2) midwives, who are responsible for accompanying physiological births. In clinical obstetrics, physicians and midwives also collaborate with nurses and, if necessary, anesthesiologists and pediatricians. These professional groups often have contrasting approaches and habits in decision-making processes, the consideration of patient preferences, and the corresponding communication behavior [6]. These different working styles in the context of time-critical coordination can promote the occurrence of "unsafe" communication and preventable adverse events (AAE).
During a physiological "low-risk" birth, the care of the woman in labor should ideally be provided by a midwife on a one-to-one basis, starting from the active dilation phase. In the event of a risky situation, the presence of medical staff must be ensured, depending on the hospital's level of care. During births, time-critical medical interventions may be necessary, for which other professional groups such as anesthesiologists or pediatricians must be consulted. Particularly at the transition to pathological birth and when external professional groups such as anesthesiologists and pediatricians, as well as managers of their own disciplines, precise and clear communication, including an understanding of the respective roles and responsibilities of others, is a prerequisite for optimal processes and the avoidance of errors and avoidable adverse events (AAEs). Collaboration in critical situations often takes place under considerable time and decision-making pressure, which leaves no room for interprofessional debriefing. There is often no time for a detailed discussion of the upcoming decisions and treatment steps with the mother and her caregiver. In this context, misunderstandings can arise, trust can be reduced, and misunderstandings and misinterpretations of decisions and interventions can arise [7]. If there is no time for explanations and no space is regularly provided for debriefing, this leads to strains on the future climate of cooperation. The quote from a research paper from the aforementioned project [8] vividly illustrates how this can increase the risk of VUEs:
• "When a doctor comes into a situation and tells the midwife that we have to perform a Caesarean section, trust is broken (...) if she [the doctor] sees reasons that the midwife does not. Yes, I sometimes have the feeling that the flow of information is being sugarcoated. That the doctor only receives information that does not give her a starting point for her indication for a Caesarean section" (midwife).

By promoting an open culture of error and trust, the risk of errors can be actively reduced, as one doctor explains:
• "What's really important is that you're not afraid of looking stupid. That is, as a junior doctor, I can ask my senior physicians at any time, even if I actually feel like I should know. (...). That even in a situation where I might feel stupid, I can simply say, 'This is about the safety of the patient or the baby, I'll just ask my senior physician now,' and that can be applied to all combinations of professional groups. That the nursing staff has the opportunity to speak to the doctor at any time, even (...) at three in the morning, or the midwives in the same way, if something happens during labor, that you simply have the courage to speak up if you're unsure or feel stupid."

With communication based on mutual understanding, the job satisfaction of those involved increases, which can have a positive effect on their professional retention in clinical care [9], as one obstetric manager explains:
• "So the team discusses (...) what happened and how it happened (...). But we're working on finding the source of the error and not just looking for the fault in the person. Most of the time, errors are in the organization, or errors could have been avoided if everyone were on the same page. So we're already working on that, and that's why all employees are invited, whether they're doctors, midwives, or nurses. And then we don't discuss it on a personal level, but rather how such an error could have been avoided. And I think that's a good solution, because it would be more goal-oriented than just blaming someone and then it's all over."

And a young midwife confirms from her perspective:
• "When I was still training, there were many more colleagues from the older generation. There was still a certain amount of domination, and now it's a very young team, and I have the feeling that since things have become more relaxed among each other, significantly more midwifery students want to stay (...). We're getting more and more applications (...). So we discuss things very often after (...), our management is very committed to ensuring that we debrief, and often there's a lot going on, and then it's maybe four minutes where you take a quick look again. Exactly, and if there really wasn't enough time, or communication wasn't going well, or the situation was overall unpleasant, then our management [senior physician and head midwife] also enforced that you actually take a short time after the birth and, for example, look at the CTG, discuss it again, explicitly. Yes, and that happens after the shift or something, so you usually can't talk for long during that time."
The Innovation Fund supports research project on interprofessional
Communication improvement
Although regular continuing education and training courses are offered to optimize care processes as part of clinical risk management to ensure patient care, communication plays only a minor role beyond focused emergency training. However, communication – as in all other disciplines – can reduce the occurrence of VAEs in obstetrics. To investigate the extent to which communication training can increase the safety of women in labor and their newborns in obstetrics, while simultaneously increasing professional and personal satisfaction and communication skills, the Patient Safety Action Alliance, together with two university maternity clinics and a health insurance company, conducted a research project approved and funded by the Innovation Fund under the scientific direction of a health psychologist [10]. The core of the intervention study was communication training:
1) Interactive communication training sessions conducted in person for the interprofessional obstetric teams at the two research sites
2) Online training in groups of expectant mothers (and fathers) who planned to give birth at one of the two clinics

The results of the maternal training sessions were evaluated using a randomized design. This means that both the intervention group and a control group were surveyed before and after birth using a standardized approach regarding their perceived communication skills and subjective sense of security. Supplementary qualitative interviews were conducted with participants in the intervention group. The training concept was adapted to each individual's needs and delivered by a midwife and a physician, a communication provider experienced in obstetrics. Despite the limited training sessions of two and a half hours, positive effects were measured in the quantitative and qualitative evaluations [11, 12]. (Table 1.).
Interprofessional staff training
The staff training sessions took place at two university maternity clinics with midwives, physicians, and nurses in groups of half-day (4 hours) during office hours. For evaluation, participants' own communication behavior and the perceived impact on patient safety, as well as their own behavioral changes, were surveyed before and after the training sessions in a standardized manner [13]. The evaluation showed that the training was rated positively by participants, although some had expressed skepticism about the time commitment prior to its introduction. Perceived risks to patient safety were reported to be lower after the training, and confidence in their own ability to manage risks increased. The effects were greatest among younger staff with shorter professional experience.
In addition to the significant improvement in communication behavior and satisfaction, as well as in perceived risks for patient safety, a decrease in adverse events (AAEs) was also observed in the year following the training compared to the previous period [11]. These data were taken from clinical birth records [14]. To conduct a solid evaluation of preventable adverse events, a systematic analysis of preventable adverse events was conducted, building on international research. Existing risk factors due to maternal pre-existing health conditions were considered [15, 16]. These data, collected and interpreted for the first time in Germany, can be used as a basis for addressing obstetric adverse events (AAEs) in Germany.
Communication training for future
Mothers/parents
In the research project, the parent training sessions were conducted online, lasting approximately two and a half hours. The decision to use the online format was made due to COVID-19 containment measures. However, it turned out that, in addition to preventing infection, participants rated being able to participate from home during advanced pregnancy as extremely beneficial. It was also possible for expectant fathers to join from another location.
The training content was similar to that of the training for obstetric staff. However, greater scope was given for the perception and reflection of one's own wishes and needs, including in relation to those of other women giving birth. Furthermore, the "speaking up" technique was focused on communication with healthcare professionals [12]. Dealing with fears and stressful situations was also practiced. The quantitative evaluation of the training showed that the mothers in the training group had greater self-confidence, rated their communication skills higher, and reported a better birth experience than the participants in the control group [11]. For many women and couples, the training session provided an incentive to actively address the expectations of their partner's role, as participants stated in the qualitative evaluation [12]:
• "And then I started communicating very clearly to my husband. These are worries, these are fears. I'm afraid of a perineal tear. My husband looks at me and says: Okay, what is a perineal tear?"
• "And I never thought about what I actually imagined during childbirth. What was emotionally important to me? I had somewhat blocked that part out because I was so focused on health. And I found that very helpful in the seminar, because I became a bit more aware of what I was actually afraid of or what was important to me. I then articulated this more clearly in the following conversation so that the doctor was also more aware of how insecure I felt in the situation. (...) I was able to communicate this much more clearly."

The right to ask questions taught in the course was actively applied, as one participant described:
• "I kept asking until someone explained what it meant. That I had the courage to ask maybe five more times until I finally understood, and not just nod at the first halfway reasonable answer, 'yes, that's fine, I understand.' No, I kept repeating, 'did I understand correctly that this, this, this, and this means?' In that sense, it helped me."

Even participants who were already familiar with some of the communication techniques emphasized the effectiveness of the current reflection related to the birth process:

• "I work in communications myself. So, I'm well-versed in all these, let's say, theoretical constructs. And yet, it was helpful in this online course to simply think about it again and really think, 'Okay, that's right. If this is the case, then maybe I should phrase it this way. Or not send hidden messages. Instead, I should make clear statements to my partner about what I want. So, I think it was also quite good that we were very well coordinated as a couple after this training."
The communicative behavior of the professional staff was rated positively:
• "I actually had the feeling that the doctors and midwives communicated in a much more patient-focused way, let's say. I did think you could tell they were trained accordingly and that they put a lot of effort into implementing this. During the birth, for example, the doctor came to me and summarized what had happened so far and why certain things were done the way they were. She simply asked if I had any questions. I thought everyone I encountered was very communicative and tried to convey the feeling, 'Okay, do you really understand what's happening here?' and that decisions aren't being rushed into your head."

The increased understanding of the needs of the care staff and the communication of empathy were also presented as helpful for communication:
• "What I particularly liked was putting yourself in the shoes of other professionals. Putting yourself in the shoes of the doctor, the midwife, everyone involved. Because when you were in the delivery room, you remembered, okay, they're very busy right now, and everyone has their own area of responsibility, and for you this is an exceptional situation, but for them what they're doing here is completely everyday life. And that was, especially when it came to communication, that you weren't too demanding, but rather took into account a little bit, okay, let them do their rounds now and if you have a detailed question, they'll take the time. And that helped me. Absolutely."
Communication training in app format
The training units were translated into a web app format and integrated in such a way that an asynchronous training program could be provided. The evaluation showed that the interactive online training was superior to the app format [17]. This is due, among other things, to the fact that the app format offers the advantage of time-autonomous use, but at the same time has the disadvantage of a lack of social interaction. A major problem was user motivation: Many participants had difficulty using all of the app's training content, i.e., staying with it until the end. Therefore, integration into other pregnancy-related apps seems advisable for expectant mothers. The results of the employee training can, in turn, be consolidated through the use of the app as a regular refresher of the training content. A further development of the app, in which the user perspective was more strongly considered, shows corresponding potential in terms of motivation to continue using the app, but also in terms of effectiveness and satisfaction. This app can still be used, namely for
• Health professionals,
• Pregnant women and
• Partners, support and companions

You can choose between German and English and it can be used on both a computer and a mobile device such as a tablet or smartphone:
https://teambaby.health/.
Simply enter "https://teambaby.health/" into your browser (e.g., Google Chrome, Firefox, or Microsoft Edge); there's no need to download it from an app store.
Conclusions and recommendations
Healthcare workers are burdened by diverse structural demands that challenge ward teams in their daily care work. The analysis of interviews with obstetric staff also revealed how decisions and regulations made outside the team impact daily work [8]. While this increases the need for secure and reliable communication, it cannot, on the other hand, offset the stresses triggered at other organizational levels. However, successful training significantly contributes to improving the quality of communication, job satisfaction, and, on the part of expectant mothers, to the perceived self-efficacy and quality of birth (Fig. 1).
The positive impact of communication training on increasing patient safety has not yet been sufficiently utilized in Germany to reduce avoidable adverse events and increase patient and staff satisfaction. However, they are an effective tool for increasing patient safety that can be easily implemented into everyday work. The results of the research project in obstetrics have shown that even limited, four-hour training sessions have achieved measurable success [13, 18]. The training content can be flexibly adapted to the needs of different patient populations by professional providers. Training courses in a train-the-trainer format are also possible, in which hospital staff are trained as multipliers and are available for flexible deployment. The use of the app (https://teambaby.health/) can provide an innovative addition in the context of increasing digitalization. Given the plans to increase the transparency of the quality of clinical care through registries as part of the upcoming hospital reform, hospitals should utilize all measures to improve quality and increase satisfaction.