We developed a team training to the subject of “emergency caesarean” that is realistically applicable in the framework of the German health care system [14]. The aim of the study was to evaluate the training in regard to the levels of Kirkpatrick [16].
To test hypothesis (a), the scales require qualitative consideration. Almost all scales showed acceptable to good values and can be applied to evaluate our developed training. It is noticeable that all scales describing people’s collaboration have slightly lower values of Cronbach’s alpha. The scales can be used excluding the scale “extinction”, which does not fulfil the criterion of further use. In our interpretation, this is a result of the complex situation of a multiprofessional healthcare. The terms “colleague” and “supervisor” can be interpreted differently in the questionnaire (question: supervisors do not care if I use the skills learned in training, as long as I get the job done). The regular hierarchy in this teams is not comparable to other organization, as each individual department has full responsibility for its actions. As example, a conflict of interest occurs in the situation of an emergency caesarean, if the anaesthesiologist needs to preoxygenate the patient prior induction and the obstetrician wants an instant beginning of anaesthesia. The manner of leadership in obstetric emergencies is a widely discussed topic [20].
The second question of scale extinction deals with the question of the applicability of the training content (question: have so little chance to use some of the skills learned since training, that I probably could not perform them now). The method of “Climate for Transfer” Model was primarily developed in the context of a training for flight engineer [21]. In this working environment, professionals are regularly confronted with recurring situations. The character of the emergency event is accompanied by the fact that the confrontation of the participant with the situation varies. So, the question is not suitable for the entire group of participants. Therefore, we recommend checking the necessity of the scale extinction and possibly developing new items.
To test hypothesis (b) (positive reaction and transfer to clinical practice), we applied the valid questionnaires. The rating on all individual scales is good to very good. If the employees are recognized as experts in the situation, the course is rated excellent in regard of usefulness and transfer (Kirkpatrick level 3).
In Sweden, it could be shown that after simulation-based team trainings, the number of nurses quitting their jobs and nurse assistants’ time sick leave was reduced [22]. In the same study, the safety attitudes questionnaire (SAQ) Index [23], one of the most validated “safety climate” measuring tools, increased. With current staff shortage in German hospitals [24], a simulation course offered to the employees, could be an important argument for staff retention. After our work confirmed the transfer to the clinic, the increase in SAQ and effects on the availability of professionals could be a parameter for further studies.
There are no differences in the assessment of the training between the professional groups. This result justifies the situation emergency cesarean to be equally relevant for the entire team.
The lowest rating for the transfer, indicates the value of “negative reinforcement”. Introduction of SOP requires continuous efforts and the value should be better after continuous training over time. Implementation and compliance with SOP are challenging [25], as a procedure can be successful in a variety of ways. In the context of other critical situations, it is known that SOP improves patients care [26].
In our study, we were unable to show any impact of training on outcome parameters of the newborn (hypothesis c). The effect sizes were very low. Significant results could only be expected with a higher number of cases. This observation is in-line with the study by Heller et al., which has integrated 40,000 cases into account [2]. Our number of cases was limited, as we observed existing emergency caesarean. The observation period should intentionally not be extended beyond 1 year, as we assumed an eased training effect as shown in with other training contents [27]. Heller reported an effect at the 10- and 20-min mark, which we could not show in our setting. As a university hospital with about 3000 births a year, we always have an anesthesia team available. So, the DDI time was almost always shorter than 10 min (Table 1) before training and the mean child outcome data in our study can be classified on the best cohort of Heller’s scale. We interpret the structure of the authors own clinic regarding newborn’s outcome as being good prior training. This study underlines that a training effect with the known parameters can only achieved through large numbers of cases in different level of care hospitals.
Studies show that a considerable financial outlay is made for the posttraumatic care of woman and that negative experiences of a delivery have a negative effect on mother–child relationships. In our study group, we evaluated a subjective quality catalog for women which needed an emergency caesarean [28]. As a result, it was found that external behavior of the team with professional appearance, an emphatic anesthetists and clear announcements reduce threat of the situation to the mother. It is conceivable that training of a procedure will liberate cognitive recourses of the team, to improve these factors. Experiences from resuscitation training—a situation with similar pressure of performance—show clearly, that team performance can be improved by team training [26]. One thesis could be that the quality of care for the awake women until anesthesia starts reduces the threat and the occurrence of posttraumatic stress disorder. We recommend a further development of hypotheses for relevant outcome parameters for the situation of emergency caesarean (e.g. posttraumatic stress disorder).
The reduction of reported possible adverse events could also become an outcome parameter for training. However, since reports are voluntary and anonymous, not every event automatically triggers a report.
There is an existing variety of different training concepts in the area of delivery rooms. However, the designation of the term interprofessional and multiprofessional remains unclear. It can stand for several professions and departments of one hospital are involved [29] or for example a complete obstetric collaborative network is trained [30]. Therefore, when assessing and comparing studies, the collective which has been trained and in which way must be taken into account. In Germany, currently there is no obligation for practical training in interprofessional delivery room teams. Nevertheless, there are various local projects, that differ in composition of training group, duration and goal setting. Skill training of procedures with actors [12], team training of physicians and midwifes using low fidelity simulation [13] and combinations of knowledge gain, practical skill- and non-technical skill training using high fidelity simulation over 2 days can be attended [11].