A key focus of midwifery practice is to ensure the safety of both mother and baby. At times, childbirth can lead to emergent situations, and the midwife must be equipped to deal with all potential outcomes, from a natural birth to an obstetric emergency. In the circumstance of fetal distress or maternal distress, an emergent caesarean section is often the treatment strategy.
Having midwives skilled in circulating and instrument roles has enabled time from deciding to perform a caesarean section to making the incision to be significantly reduced, allowing for continuity of care for the mother and baby. Because midwives are not routinely educated in performing the role of a perioperative nurse and in the interests of safe patient outcomes, a tailored educational program focusing on perioperative nursing knowledge and skills was developed. This educational program provided midwives with the opportunity to enhance their understanding of the significance of perioperative nursing procedures for optimal patient outcomes.
This study was undertaken in the maternity unit of the largest private hospital in Western Australia. The delivery suite includes 10 delivery rooms and a dedicated obstetric operating room. Approximately 3,500 babies are born each year within the facility; 46% of these births are by caesarean section. Although an on-call perioperative team operates within the hospital, these personnel only routinely attend caesarean sections during the hours of 7:00 AM to 3:30 PM. Traditionally, any routine uncomplicated nonelective caesarean sections required outside of these hours have been attended by the midwives in the delivery suite to perform the instrument and circulating roles specifically for caesarean sections.
The instrument and circulating roles are separate and distinct, and cannot be performed simultaneously. Both of these roles involve clear and open communication with all members of the surgical team and are integral to perioperative practice. The instrument role involves an individual working directly with the surgeon within the sterile field. Instrument duties involve (but are not limited to) planning and gathering supplies; performing a surgical scrub; gowning and gloving in an aseptic manner; establishing and maintaining the sterile field; performing a count of accountable items; anticipating the needs of the surgeon; passing instruments, sponges, and other items required for a procedure; coordinating care of the patient; following policies and procedures for disposal of sharps and biohazardous waste; removing gown and gloves in an aseptic manner; and signing and checking that all perioperative documentation is complete (Australian College of Operating Room Nurses [ACORN], 2012).
The circulating role involves assisting in managing the nursing care of a patient during surgery. The circulating role involves (but is not limited to) planning and gathering supplies, performing a count of accountable items, completing the preoperative check of the patient and the World Health Organization’s (WHO, 2009) Surgical Safety Checklist, assisting in positioning the patient prior to surgery, assisting the surgical team in gowning in an aseptic manner, attaching and activating any surgical equipment, observing for breaches in surgical asepsis, anticipating and coordinating the needs of the surgical team, managing accountable items, and signing and checking that all perioperative documentation is complete. In this role, the midwife is not in direct contact with the sterile field, but rather manages the operating room environment during the procedure (ACORN, 2012).
Currently, 50 midwives are employed within the delivery suite at St. John of God Subiaco Hospital. The majority of these caregivers are both RNs and registered midwives with some degree of prior perioperative experience and knowledge. However, direct-entry midwives have been a recent, valuable addition to the delivery suite team, and the majority of these caregivers have had no prior experience or training in the perioperative setting.
In 2010, the organization’s education team and the obstetric and newborn services management team recognized that there was a need for perioperative education for midwives performing the instrument and circulating roles for caesarean sections in the delivery suite operating room. To ensure optimal outcomes for patients, newborns, and midwifery, nursing, and medical caregivers, it was determined that all clinical delivery suite midwives would attend a training program to enhance their existing knowledge and skills in alignment with ACORN standards for perioperative nurses.
The overall aim of this course was to support midwives in the transition from being a novice practitioner to an advanced beginner in the instrument and circulating roles for caesarean sections. As no such program existed in Australia, it was determined the perioperative staff development team and the delivery suite staff development midwives would design a training program that would satisfy these requirements. The purpose of the program was to improve knowledge and skills of midwives who had practical application of skill but limited formal theoretical knowledge or understanding of best practice in the perioperative nursing environment according to ACORN standards.
The training program consisted of one 6-hour study day that included both didactic and practical educational sessions. Participants were required to complete professional development activities, self-directed learning packages, and an average of four clinical shifts, during which one-on-one training was provided by an experienced perioperative practitioner in the clinical setting. During these clinical shifts, participants were required to complete a comprehensive workbook (developed directly from the ACORN standards) to provide evidence of their competence. The combination of self-directed learning, didactic instruction, and clinical shifts totaled 48 continuing professional education contact hours.
This retrospective study was undertaken to determine the impact of the program, specifically in relation to the enhancement of the perioperative knowledge and skills of the participants. This article examines the extent to which the participants’ clinical practice, knowledge, and skills were enhanced in the instrument and circulating roles specifically in relation to caesarean sections and ACORN standards. The results highlight the patient safety outcomes and the satisfaction in regard to the level of knowledge and skills among participants.
Emergent caesarean section places both mother and baby at significant clinical risk (Lagrew, Bush, McKeown, & Lagrew, 2006; Lilford, van Coeverden de Groot, Moore, & Bingham, 1990). However, when an emergent caesarean section is undertaken with patient safety as the primary focus, excellent standards of care are maintained, and good outcomes for both mother and baby are achieved (Bloom et al., 2006). Involving midwives in emergent caesarean sections as instrument and circulating nurses provides continuity of patient care (Moes & Thacher, 2001), midwives’ satisfaction with their role, and the overall clinical performance of the multidisciplinary team (Wardle, Beale, & Zehr, 2010).
The authors’ hospital has an operating room within the delivery suite, which is used for both elective and emergent caesarean sections. The authors contacted other facilities of similar size, patient populations, and procedure numbers to determine whether they had such surgical capacity, and the findings suggested that this structural and functional design is unique. In addition, a review of the literature showed no evidence of midwives in acute care hospitals within Australia undertaking the extended function of instrument and circulating roles during caesarean section, as is currently the practice at St. John of God Subiaco Hospital.
However, since the mid-1990s, both the United States and Canada have developed credentialing programs allowing midwives to undertake this advanced practice. The literature indicated the main impetus for this was the distinct lack of resident medical officers or other suitably qualified medical practitioners to undertake the role of first assistant during an acute emergency (Moes & Thacher, 2001; Wardle et al., 2010). In developing the credentialing programs, regulatory bodies and state laws and regulations were consulted to ensure that a robust and credible program was developed to adequately prepare midwives to perform this extended scope of practice (Wardle et al., 2010).
Moes and Thacher (2001) reported an analysis of the first program instituted by the New York Presbyterian Hospital showed “…no increase in liability insurance, no increase in duration of caesarean section, decreased interval from decision to incision, and increased satisfaction when the nurse-midwife was a member of the surgical team” (p. 307). Since then, programs have been implemented in several hospitals in both the United States and Canada. However, reporting of these programs has been limited to describing the training and credentialing process without providing specific data on the number of midwives who have an extended scope of practice or reporting on the outcomes of the program (Moes & Thacher, 2001). Despite the lack of reported evidence to support the enhanced scope of practice, it has been suggested that allowing midwives to assist in emergent caesarean section is beneficial in assisting to resolve some of the existing resource shortages and has been proven to be financially viable with cost savings to the health care system by not having to call in staff to attend these deliveries (Wardle et al., 2010).
Conversely, a 2009 consensus statement from the United Kingdom relating to staffing of obstetric theaters recommends “…that the instrument/scrub role…must be assumed…by an operating departmental practitioner or a registered nurse” (Kilvington, Gilmour, & Warwick, 2009, p. 6). The statement continues that “…should a midwife need to assume this role she should have formally demonstrated competence to do so” (Kilvington et al., 2009, p. 6).
Impact Survey Development
As there are no known impact surveys to measure the enhancement of the midwife role to include assisting in emergent caesarean section, a survey tool was developed. The impact survey was developed collaboratively by the researchers. Face and content validity were assessed during the survey development process (Polit & Beck, 2010). The face validity of the survey was assessed by the learning and development expert in consultation with the lead researcher. In addition, to ensure the items would adequately cover the procedural knowledge and skill development for the perioperative circulating and instrument role in caesarean sections, content validity of the tool was assessed by both the perioperative nurse expert and the expert midwife. This survey was not piloted before use due to the small sample size and has not been tested for validity (beyond face and content) or reliability.
The impact survey sought standard demographic information along with items relating to procedural knowledge and skill for the perioperative circulating and instrument roles in caesarean section. The survey collected the following information:
- Age and gender demographics.
- Employment status.
- Midwifery experience.
- Years of service at the site.
- Self-reported pre- and postdevelopment of knowledge.
- Self-reported changes in practice.
The tool provided quantitative and qualitative data for analysis using manual thematic review and basic statistical analysis.
Recruitment and Inclusion and Exclusion Criteria
All of the midwives who were permanent caregivers in the delivery suite were included in the educational program. These midwives then were invited to participate in the research. Midwives who would normally perform the clinical team leader role were excluded from the program since their role is predominantly clinical management.
The research was conducted using a mixed methods approach. Qualitative and quantitative data were gathered using the newly developed, paper-based copy of the impact survey. Midwives who had previously attended the educational sessions were provided with a copy of the survey. The surveys were distributed to the potential participants by internal mail. A total of 48 staff participated in the training, and 20 surveys were returned for a return rate of 42%.
The survey tool explored four main themes:
- Knowledge of ACORN standards (five items).
- Competence and knowledge of the main roles during a caesarean section (i.e., instrument and circulating roles) (nine items).
- Knowledge of local policies and procedures (two items).
- Patient safety (one item).
Five items collected yes or no responses and allowed for a short written response. Two items asked participants to provide one example of improved knowledge and patient safety. One item provided an opportunity for participants to include any additional comments.
In addition, all of the participants underwent a mandatory clinical assessment of skills and knowledge. The assessment occurred under the direct supervision of senior perioperative nurses, perioperative clinical nurses, and perioperative staff development nurses, and participants were required to demonstrate and understand the role of the midwife in both the circulating and instrument roles during an emergent caesarean section as described by ACORN standards (2012).
Data Analysis and Interpretation
The impact data (quantitative) were analyzed using SPSS® software (Allen & Bennett, 2008). Given the small number of participants completing the questionnaires, nonparametric statistical analysis of the bivariate nominal data was performed with simple descriptive statistics, frequencies, and crosstabs.
Content analysis of the qualitative comments on the impact survey was performed. Major themes were identified individually by each of the four researchers and collaboratively interpreted, thereby gaining an explicit understanding of the initial key research questions (Braun & Clarke, 2006; Joffe & Yardley, 2003; Vaismoradi, Turunen, & Bondas, 2013).
The combination of both quantitative and qualitative data provided the opportunity to ensure that a thorough insight into the impact of the continuing education opportunity was possible. The qualitative results support the results in the four theme areas, as well as illustrate the emergence of an additional theme.
Data for this research were collected from a total of 20 participants at the completion of the program. All of the participants were women. Sixty percent of the participants were older than age 45, and 70% of the participants had extensive experience in midwifery (>10 years). Demographics are shown in the Table. The following postprogram results illuminate the key outcomes of knowledge (ACORN standards, roles and responsibilities, and local policies), clinical skills (self-reported clinical competence), and patient safety.
Characteristics of Participants
Knowledge of ACORN Standards
Although all of the data were collected after completion of the program, the first eight items of the survey required participants to reflect on their knowledge and skill prior to attending and completing the program and respond with either a yes or no answer. The majority of participants (85%) reported that they were aware of the ACORN standards prior to undertaking the program and that they were aware of the correct procedure for scrubbing and gowning (95%), preparing the surgical field (85%), and performing skin preparation (85%). Sixty-five percent of participants reported they were aware that the surgical count was the primary responsibility of the instrument and circulating personnel. Less than half (45%) of the participants reported they were aware that a radiograph was required if an initial count was not completed according to ACORN standards.
Competence and Knowledge of Instrument and Circulating Roles
The majority of participants (90%) reported that they had performed the circulating and instrument roles in the delivery room operating theater prior to undertaking the program. However, knowledge of both role requirements was increased as a direct result of the course, with 80% of participants reporting improved knowledge of the instrument role and 70% of participants reporting improved knowledge of the circulating role. Increased skill and confidence in performing the roles after the program was not as strongly reported; however, at least 50% of the participants reported increased skill and confidence in both roles. Increased knowledge and skill perception was self-reported by the participants on the basis of comparing their knowledge and skills before and after completion of the program.
Participants also were asked to provide one example of how their knowledge base had improved after the program. The majority of participants provided an example, with the mostly frequently cited response being improved documentation (20%), followed by affirmation of existing knowledge (15%).
Knowledge of Policies and Procedures
Most of the participants (75%) reported increased awareness of the hospital’s specimen handling policy. A majority of the participants (85%) also reported they gained increased knowledge of the electronic and paper-based documentation required after a caesarean section.
Participants were asked to provide one example of how they had improved patient safety after the program. Sixty-five percent of the participants provided an example, with the most frequent response being the implementation of time-out recommended by the WHO’s (2009) Surgical Safety Checklist (25%), followed by obtaining a radiograph if a discrepancy in the surgical count occurred (10%).
Consistent with the quantitative results, qualitative comments were grouped into the same theme areas, that is, knowledge of ACORN standards, competence and knowledge of instrument and circulating roles, knowledge of policies and procedures, and patient safety. The following exemplar statements are reflective of the open-ended responses provided by participants in these four areas.
Participants reported that they were better able to ensure that their practice adhered to ACORN standards and with policies and procedures of the organization. As one participant noted, “Time-out procedure ensures correct patient, correct site. . . and team is introduced.”
Competence and knowledge of the main roles during a caesarean section were advanced as a consequence of the program, with participants reporting they were able to gain new knowledge as well as reinforce existing knowledge. Participants’ comments included, “It was good to revise and reinforce knowledge,” and “I feel this course sharpened my knowledge.”
Participants also linked their own knowledge improvement to patient outcomes, particularly patient safety. Participants were able to directly associate elements of the program with specific patient benefits. One participant commented, “Improved scrubbing therefore reducing the risk of infection. We no longer get interrupted unnecessarily during the count.” Another participant stated, “Standards are very different in a private compared to a government hospital. Everything was new! I now feel confident to scrub and scout according to ACORN standards.”
An additional theme that emerged from the qualitative comments was professional relationships and team building. Participants of the program reported that the perioperative staff were supportive of their learning and their roles in emergent caesarean sections. One participant noted, “Great to do [course] in general operating theaters…I really appreciated support…building better rapport between labor ward and general operating theaters.”
In reviewing participants’ qualitative comments, it also was noted that some staff had previously completed a course or other training in these roles and felt that this training offered nothing further. One participant noted, “I had been thoroughly instructed [previously] and had been practicing for years prior to completing this course.” Comments of this nature were limited, and most of the participants who made this type of comment felt that they were given the opportunity for a refresher course that was valuable for their ongoing practice.
Clinical competence required 100% compliance with the ACORN standards and hospital-specific policies in all areas. Competence was assessed by the perioperative staff development nurse. All of the participants demonstrated 100% competence when evaluated in the clinical area. Participants received a certificate of attendance for the 6-hour study day and a certificate of completion for the course.
Patient safety in the operating suite is paramount. The findings of this study indicate that there are a variety of ways in which patient safety was improved as a direct consequence of the innovative educational program including implementing time-out, the use of radiographs, and checking patient consent.
ACORN (2012) developed and documented standards to guide perioperative nurses’ practice, ensuring the best possible outcomes for patients. The importance of the instrument and circulating roles in the perioperative environment must not be underestimated. They are a key aspect of perioperative practice. In each role, the caregiver must function at all times primarily as a patient advocate (ACORN, 2012). Therefore, it is imperative that a midwife who is expected to perform these roles during an emergent caesarean section has the appropriate education and technical skill recommended by ACORN. Although the majority of participants in the program were aware of the ACORN standards prior to attending, clinically significant improvements in knowledge concerning joint responsibility for the surgical counts by the circulating and instrument nurses and the need for radiographic follow up when the count was incorrect were realized.
In addition, the program specifically increased participants’ knowledge if implementing the time-out procedure. The time-out procedure is part of the WHO’s (2009) three-part Surgical Safety Checklist. The first part, sign-in, occurs prior to induction of anesthesia. The second part, time-out, occurs prior to the initial incision when all of the surgical team members introduce themselves and their role; verbally confirm patient identity, planned surgical procedure, and operative site; discuss plans for any anticipated critical events that may occur during surgery; confirm whether antibiotic prophylaxis was administered within the past 60 minutes; and ascertain availability of any imaging required for surgery, if applicable. The third part is sign-out, which occurs prior to the patient leaving the operating suite. Each phase confirms that the surgical team has completed the listed tasks before proceeding with the operation (WHO, 2009).
Internal hospital policies and procedures provide guidance related to the delivery of patient care services and provide an outline of responsibilities to ensure that all employees are made aware of their individual obligations and comply with the requirements of the organization. Hospital policies and procedures are based on best practice guidelines, legislative requirements, and industry standards, and are updated regularly to ensure information is current. Despite the widespread circulation of local policies, 30% of the participants in this research indicated that they were not aware of all of their responsibilities in relation to the surgical count when undertaking the instrument or circulating role.
ACORN standards and hospital policies provided the basis for the curriculum of the program. This ensured that all of the midwives were undertaking their roles according to the most up-to-date best practice guidelines. The patient has the right to the highest achievable standards of care. Ensuring that midwives who perform these roles are competent and knowledgeable of these standards is imperative for patient safety and risk minimization.
This research was conducted in a single center (private hospital). The sample size was small due to the organizational features of the setting. In addition, participants’ previous experience in perioperative nursing was not established in the demographic component of the questionnaire. Data were only gathered postprogram, with participants asked to reflect on their preprogram knowledge and skill. Generalizability of the findings to other centers and settings both within Australia and internationally must be determined with these factors in mind.
The following clinical practice recommendations are made on the basis of the study findings. It is recommended that an educational program to skill midwives in the instrument and circulating roles for caesarean sections be required for all midwives undertaking these roles in emergent situations. The program should be completed by all permanently employed midwives and all new midwives prior to commencing these roles within the delivery suite operating room. However, it is recommended that midwives who have previously completed an approved perioperative training program should not be required to complete this program.
Further research is recommended to understand the impact of the training on outcomes for mothers and their babies, including any reduction in incision to birth time when caesarean section is emergent and the rate of wound infections. In addition, future research should evaluate operating room incident rates, obstetrician and midwife satisfaction with the enhanced role, and the need for ongoing refreshment of the training for midwives who have an enhanced role.
This research has reported on the outcomes of an established educational program to enhance the skills of midwives in the instrument and circulating roles for caesarean sections. The program ensures that those midwives who are required to fulfill the instrument and circulating roles during emergent caesarean sections have the required knowledge and competence to perform the roles and to maintain patient safety. The research findings demonstrate that such a program is warranted and that all midwives who undertake these roles should complete a structured training program. An additional benefit of the program was an improved working relationship between the perioperative staff and delivery ward staff.
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- Australian College of Operating Room Nurses. (2012). 2012–2013 ACORN standards for perioperative nursing. Adelaide, Australia: Author.
- Bloom, S.L., Leveno, K.J., Spong, C.Y., Gilbert, S., Hauth, J.C., Landon, M.B. & Gabbe, S.G. (2006). Decision-to-incision times and maternal and infant outcomes. Obstetrics & Gynecology, 108, 6–11. doi:10.1097/01.AOG.0000224693.07785.14 [CrossRef]
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- Lagrew, D.C., Bush, M.C., McKeown, A.M. & Lagrew, N.G. (2006). Emergent (crash) cesarean delivery: Indications and outcomes. American Journal of Obstetrics & Gynecology, 194, 1638–1643. doi:10.1016/j.ajog.2006.03.007 [CrossRef]
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Characteristics of Participants
| 25 to 34||3 (15)|
| 35 to 44||5 (25)|
| 45 to 54||11 (55)|
| 55 to 64||1 (5)|
| Total||20 (100)|
| Full time||7 (35)|
| Part time||13 (65)|
| Total||20 (100)|
| RM only||1 (5)|
| RN and RM||19 (95)|
| Total||20 (100)|
| Hospital certificate||8 (40)|
| PG Cert Mid||2 (10)|
| PG Dip Mid||8 (40)|
| Master’s Mid||2 (10)|
| Total||20 (100)|
|Years of midwifery practice|
| 3 to 5||4 (20)|
| 6 to 10||2 (10)|
| 10+||14 (70)|
| Total||20 (100)|
|Years of employment|
| 0 to 2||1 (5)|
| 3 to 5||5 (25)|
| 6 to 10||4 (20)|
| 10+||10 (50)|
| Total||20 (100)|