The impact of transmural multiprofessional simulation-based obstetric team training on perinatal outcome and quality of care in the Netherlands
© Banga et al.; licensee BioMed Central Ltd. 2014
Received: 15 July 2014
Accepted: 14 August 2014
Published: 21 August 2014
Perinatal mortality and morbidity in the Netherlands is relatively high compared to other European countries. Our country has a unique system with an independent primary care providing care to low-risk pregnancies and a secondary/tertiary care responsible for high-risk pregnancies. About 65% of pregnant women in the Netherlands will be referred from primary to secondary care implicating multiple medical handovers. Dutch audits concluded that in the entire obstetric collaborative network process parameters could be improved. Studies have shown that obstetric team training improves perinatal outcome and that simulation-based obstetric team training implementing crew resource management (CRM) improves team performance. In addition, deliberate practice (DP) improves medical skills. The aim of this study is to analyse whether transmural multiprofessional simulation-based obstetric team training improves perinatal outcome.
The study will be implemented in the south-eastern part of the Netherlands with an annual delivery rate of over 9,000. In this area secondary care is provided by four hospitals. Each hospital with referring primary care practices will form a cluster (study group). Within each cluster, teams will be formed of different care providers representing the obstetric collaborative network. CRM and elements of DP will be implemented in the training. To analyse the quality of care as perceived by patients, the Pregnancy and Childbirth Questionnaire (PCQ) will be used. Furthermore, self-reported collaboration between care providers will be assessed. Team performance will be measured by the Clinical Teamwork Scale (CTS). We employ a stepped-wedge trial design with a sequential roll-out of the trainings for the different study groups.
Primary outcome will be perinatal mortality and/or admission to a NICU. Secondary outcome will be team performance, quality of care as perceived by patients, and collaboration among care providers.
The effect of transmural multiprofessional simulation-based obstetric team training on perinatal outcome has never been studied. We hypothesise that this training will improve perinatal outcome, team performance, and quality of care as perceived by patients and care providers.
The Netherlands National Trial Register, http://www.trialregister.nl/NTR4576, registered June 1, 2014
KeywordsMultiprofessional Simulation-based obstetric team training Deliberate practice Crew resource management Quality of care
Perinatal mortality in the Netherlands
Perinatal mortality and morbidity in the Netherlands is relatively high compared to other countries in Europe, shown by Peristat I (data of 1999)  and Peristat II (data of 2004) [2–4]. Initiated by the Dutch Minister of Health, a Committee Project group Pregnancy and Birth was started in 2008, just after publication of Peristat II. The main goal was to improve quality of obstetric care in the Netherlands. Beside several implementations such as regional Obstetric Cooperatives and the Dutch Perinatal Audit, a nation-wide research programme on pregnancy and birth of the Netherlands Organization for Health, Research and Development (ZonMw) was developed. Recently, the data of the third Euro-Perinatal European Perinatal Health Report (data of 2010) were launched . Perinatal mortality in the Netherlands has declined with 14% between 2004 and 2010, however the current mortality rate still represents a poor international position, which is even more remarkable considering that the Netherlands was ranked second highest in Europe concerning welfare . In 2004, the Netherlands featured the third highest perinatal mortality (out of 26 countries). In 2010, the Netherlands ranked the sixth highest perinatal mortality out of 29 European countries. The perinatal mortality in the Netherlands should decrease faster than in other European countries in order to be ranked in the top.
Risk of home delivery
A recent Dutch study showed a higher risk of delivery related perinatal mortality among women with planned delivery in primary care (at home or in hospital) compared to women who started delivery in secondary care. An even higher risk of perinatal mortality was found in women who were referred from primary to secondary care during delivery . Another Dutch study did not find a significant difference between a planned home and hospital delivery among low-risk women in primary care . However, the results of these two Dutch studies cannot be compared because different groups and different comparisons were studied: the first study compared planned primary care delivery with planned secondary care delivery while the second study compared planned home delivery with planned hospital delivery in primary care. The British Birthplace cohort study concluded that nulliparous low risk women with a planned home delivery have an increased incidence of adverse perinatal outcome. For multiparous women, there were no significant differences in adverse perinatal outcome by planned place of birth. Interventions during delivery were substantially lower in all non-obstetric unit settings .
Causes of perinatal death
Analysis of Dutch data showed that 85.2% of perinatal mortality is caused by one or more of the four following disorders, together the so called Big 4: small for gestational age (SGA: birth weight below 10th percentile), preterm delivery before 37 weeks of gestation, congenital anomaly and low Apgar score (Apgar score below 7). Big 4 disorders are overlapping each other often, creating a multiple diagnosis. Accumulation of Big 4 disorders obviously increases mortality rate. The group with exclusively one Big 4 disorder causing perinatal death is small. Of all pregnancies, 16.3% represents a Big 4 disorder. Of all Big 4 pregnancies, 29% starts delivery in primary care. This indicates that risk selection is inadequate. [9, 18–20]. These data suggest that evaluation and improvement of process management of pregnancies complicated by a Big 4 disorder will be beneficial for perinatal outcome.
Process parameters and communication audit
Analysis of all term perinatal death cases in 2010 by the Dutch Perinatal Audit revealed one or more substandard factors (SSF) in 52% of the cases. In 56% of the cases with SSF, multiple care providers were involved. In 44% of the cases with SSF there was a possible or (very) probable relation with perinatal death. International research described a possible or (very) probable relation with perinatal death in 25-30% of all perinatal death cases with substandard care . The Dutch Perinatal Audit has recommended the following: develop uniform care paths, focus on standardised communication and handovers based on the SBAR system (Situation, Background, Assessment, Recommendation), and organise team trainings . It has become clear that within the entire obstetric collaborative network process parameters can be improved. Communication between obstetric care providers within one discipline as well as between different disciplines is important to guarantee an optimal referral process. Moreover, adequate and uniform communication towards the patient (and partner) is important for positive perception [9, 18, 22].
Quality of care as perceived by patients
During the last decade, there has been growing interest in quality of care as perceived by patients. With increasing attention to patient-centered care, indicators of care quality more and more involve perceived quality of care and patient satisfaction [23–26]. Measuring patient-reported outcomes is a common strategy used to monitor quality of care in a number of countries. Because of the unique obstetric care system in the Netherlands with different care levels, pregnant women often see different care providers . Recently published data showed that patients who had been referred from primary to secondary care report lower quality of care . These patients received care in more than one institution, from several care providers. Referral during pregnancy and delivery may have a negative effect on a systematic way of communication towards the patients and might cause inconsistency in advice, information, and protocols .
Simulation-based team training
The proposed research concerns a transmural multiprofessional simulation-based obstetric team training regarding process management of the Big 4 causes of perinatal mortality. The obstetric collaboration network consisting of ambulance staff, maternity nurses, primary care midwives, obstetric nurses, hospital midwives, residents and obstetricians will be trained.
Prior to the intervention, focus group interviews were performed. This resulted in insight in topics relevant to patients and care providers, concerning adequate communication and process management. The input of the focus group interviews was used for development of questionnaires for patients and care providers. The focus groups were organised separately in the following categories:
● The pregnant women and women who recently gave birth. These focus group interviews were used to explore what is important to women regarding care during pregnancy and delivery. Based on these focus groups, the Pregnancy and Childbirth Questionnaire (PCQ), to measure quality of care as perceived by women who recently gave birth, has recently been developed and validated . The PCQ will be used for an assessment of all women who recently gave birth before and after the training, concerning the entire Consortium of Brabant.
● The primary care (independent) midwife. The midwives were interviewed to evaluate most common problems in communication. This implies referral of patients to secondary/tertiary care but also aspects of communication when a client is referred back to primary care (during pregnancy/after delivery). The most relevant items were used to construct a questionnaire that will be sent out to all independent midwives for an assessment before and after the training.
● The ‘maternity nurse’. This care provider was interviewed in the focus group together with the primary care midwife. The maternity nurse assists the community midwife during a home delivery. Besides that, after the delivery, she provides care to mother and child at home for about five until eight days. The communication between this nurse, the primary midwife and the patient is very important.
● Secondary care (hospital) midwife. This is an important target group because these midwives are often the first person to contact in case of referral from primary to secondary/tertiary care. Moreover, she is (together with the resident) the first person to contact the obstetrician to inform about the patient.
● The obstetrician and obstetric resident. In case of referral these medical doctors are the finals responsible for the follow-up of pregnancy/delivery. This group was interviewed to evaluate which aspects are crucial in the communication during medical handovers.
Recruitment and intervention
All obstetric care providers being part of the Consortium Brabant were invited for participating in the study. The Consortium Brabant consists of six hospitals with in total 60 obstetricians. The surrounding primary care consists of approximately 120 primary care midwives organised in about 45 independent midwifery practices. One hospital, St Anna hospital Geldrop with lowest annual delivery rate of around 1.000, decided not to join the team trainings because of logistic reasons. The region of the Máxima Medical Centre was used for a pilot study, leaving four study groups with annual around 9,000 deliveries for this study project. Every hospital with its regional Obstetric Cooperation accounts for one study group. Within the study group, training teams will be formed consisting of ambulance staff (two per team), maternity nurses (one or two per team), primary care midwives (two to five per team), obstetric nurses (two per team), secondary care midwives (one or two per team), residents (one to three per team) and obstetricians (one to three per team), representing the entire obstetric collaborative network with a total of 12–18 care providers per team. There will be two instructors/facilitators per training: one medical instructor (obstetrician) and one communication expert. An expert panel, consisting of representatives of all obstetric care levels, designed obstetric scenarios for the team training, taking into account the topics that have resulted from the focus groups. Training will focus on process management of Big 4 disorders. The focus will mainly be on non-technical skills such as CRM, communication tools and using SBAR, and less on medical technical skills. The team training will take place at the medical education and simulation centre in Eindhoven, the Netherlands (Medsim) . The medical simulation centre pursues a safe learning environment for trainees.
Unexpected home delivery of fetus in breech presentation
Extreme preterm delivery starting at home
Home delivery with fetal distress and unexpected SGA
Unexpected resuscitation of newborn with unexpected congenital heart abnormality at home.
The scenarios are based on national and international guidelines [41–52]. Prior to the training, teams will receive an explanation concerning the equipment and environment. Each trainee will participate actively in at least one scenario and often more. Each scenario will start with an introductory briefing video. Thereafter, the team moves to the simulation room where they manage the simulated patient. State of the art high fidelity patient simulators will be used (Noelle™ and Newborn Hal™, Gaumard, Miami, Florida) and patient actresses. All scenarios will be videotaped (using B-Line Medical® software, Washington, DC). After each scenario a debriefing with reviewing the video recordings will be provided. The instructors will provide feedback on teamwork and skills (medical technical and non-technical) using video recordings. Learning goals based on CRM will be evaluated during the debriefing, such as: attention situational awareness, self-awareness, leadership, assertiveness, decision-making, flexibility, adaptability, and communication tools. There will be a focus on standardised communication and handovers based on the SBAR system (Situation, Background, Assessment, Recommendation).
A syllabus concerning communication tools, CRM and medical knowledge about Big 4 disorders has been written and will be handed out prior to the training. To stimulate the motivation and concentration of the trainee a multiple choice exam prior to the training will be performed.
Learning objects:a. prior to the training, all trainees will be asked to define an individual learning goal
learning goals will be defined per specific scenario and will be evaluated during the debriefing
take home messages will be hand over to the teams at the end of the training. The teams will work on implementing learning goals in their Obstetric Cooperation.
This training will not sufficiently be able to focus on an (individual) appropriate level of difficulty. In general, the scenarios have an increasing difficult level.
This training is a one-time training making focused and repetitive practice not achievable. However, to achieve repetitive awareness and use of communication tools based on CRM and SBAR, the study groups will use pocket charts with communication tools in daily practice.
Rigorous, reliable measurements: the knowledge of the trainees will be assessed by a multiple-choice exam before and after the training.
Feedback will be provided during the debriefing. After each scenario a debriefing session will take place. The debriefing will exist of three phases: reaction of trainees, analysis of performance and take home messages. By reviewing video recordings, feedback will focus on predefined learning goals, on team performance and application of medicals skills.
Monitoring and error correction will be performed by reviewing videotaped performance during the debriefing.
Evaluation and performance that may reach a master standard: this is not achievable, since there is no definition of what the master standard would be
Advancement to the next task: this is not realistic with a one-day training.
After the training, all trainees will fill in an evaluation form about their experiences concerning the training in which they will score (0–5) for 36 different items.
In situ simulation
Four months after the intervention, the effect of training on team performance will be measured by so-called unannounced (as far as possible) in situ simulations, during which care providers are assessed on their teamwork within their own working environment. The in situ simulation will consist of one or two scenarios which will be managed by a team consisting of primary and secondary care providers, located at a delivery room in the hospital. The in situ simulation will be videotaped and analysed by independent experts.
Multiprofessional simulation-based obstetric team training, using CRM and elements of DP, will improve perinatal outcome, team performance, quality of care as perceived by patients and collaboration of care providers.
Does multiprofessional simulation-based obstetric team training improve perinatal outcome?
Does multiprofessional simulation-based obstetric team training improve team performance as assessed by an unannounced in situ simulation?
Does multiprofessional simulation-based obstetric team training improve quality of care as perceived by patients?
Does multiprofessional simulation-based obstetric team training improve collaboration of care providers?
Primary outcome will be a composite adverse perinatal outcome as defined by perinatal mortality and/or NICU admission. Data on the primary outcome will be obtained from the Netherlands Perinatal Registry (PRN).
1.Team performance. For measuring team performance, an independent panel of experts will evaluate the videotaped team training sessions and calculate the Clinical Teamwork Scale (CTS) .
Quality of care as perceived by patients. This will be measured before and after the training by using a questionnaire consisting of the validated PCQ and some additional questions regarding pregnancy, delivery and the first postpartum week .
Care providers’ satisfaction with teamwork and collaboration between and within the different levels of care. This will be measured before and after the training using a questionnaire which is partly based on the validated Doctors’ Opinions on Collaboration (DOC) questionnaire for general practitioners and medical specialists and adjusted to the obstetric care field .
Big 4 disorders defined as :
Small for gestational age, defined as a birth weight below the 10th percentile
Preterm delivery before 37 weeks
number of Big 4 pregnancies starting delivery in primary care
fetal mortality rate
neonatal mortality rate
admission to neonatology unit (non-NICU)
ventouse or forceps delivery
hemorrhage postpartum (>1000 ml of blood loss)
third or fourth degree perineal trauma
Sample size calculation
In 2010 perinatal mortality rate was 0.9% and the NICU admission rate 2.3%. To avoid double telling, a composite rate of mortality and NICU admission will be around 3%. . The sample size for the study was calculated by using the formula as proposed by Woertman and De Hoop . This formula calculates the design effect required on top of the sample size calculation for a standard randomised clinical trial (RCT). To show a reduction in perinatal mortality and NICU admission rate from 3% to 1.65%, with an alpha of 0.05 and a power of 80%, a total of 4,000 deliveries would be needed for a simple RCT design. The design effect was calculated assuming an intracluster correlation (ICC) of 0.05, a cluster size of 1,800 deliveries per year, and four clusters or study groups. Taking into account the design effect, we need 565 deliveries per measurement period per cluster. To achieve this number we need 16 weeks for each period, adding up to a total study period of 82 weeks including a 16-week control period before the first training. A mixed effects model will be used to model the data and test the hypothesis of no effect from team training to accommodate cluster effects and time effects. Statistical significance will be accepted at a two-sided p-value < 0.05. In the study region 9,000 deliveries occur per year, with a minimum of around 1,806 deliveries per year per study group (cluster) and a maximum of around 3,500.
As far as we know now, transmural multiprofessional simulation-based obstetric team training, using CRM and elements of DP, integrating the entire obstetric collaborative network, has never been studied before. We hypothesise that this obstetric team training improves perinatal outcome, team performance, quality of care as perceived by patients, and collaboration between care providers. The current project fits well within one of the main goals of the Dutch government to set up research that can prevent avoidable perinatal mortality and morbidity. Management of obstetric scenarios, based on the Big 4 causes of perinatal mortality, will be practiced in a medical simulation centre by teams with representatives of the obstetric collaborative network. The innovative aspect of the current project is the focus on non-technical skills (CRM, SBAR) rather than technical skills with the application of the elements of DP and defining learning goals based on CRM and the fact that different care providers will be trained together in one integrative cooperating team. Because team training and communication training has shown to be effective in secondary obstetric care , there is no reason to believe that this will not work within team training with integrating care providers from primary, secondary and tertiary care. To achieve a better ranking position concerning perinatal mortality rates in Europe, it is necessary to intensify an integrative organisation of obstetric care in the Netherlands in which all different care levels will integrate, in which uniform care paths will be developed forming ‘patient centered care’. This is in line with the recent letter of the Minister of Health which has been sent to the House of Parliament in which she focuses on the development of an integrative obstetric health system.
Crew resource management
Clinical teamwork scale
Doctors’ opinion on collaboration
Medical education and simulation centre Eindhoven
Neonatal Intensive Care Unit
Obstetric high care
National Dutch Perinatal Registry
Situation, Background, Assessment, Recommendation
Simulation-Based Medical Education
Small for gestational age
the Netherlands Organization for Health, Research and Development.
This study is funded by ZonMw, the Netherlands Organization for Health, Research and Development, project number 2009020010.
- Buitendijk SE, Nijhuis JG: High perinatal mortality in the Netherlands compared to the rest of Europe. Ned Tijdschr Geneeskd. 2004, 148: 1855-1860.Google Scholar
- Mohangoo AD, Buitendijk SE, Hukkelhoven CW, Ravelli AC, van Driel GC R, Tamminga P, et al: Higher perinatal mortality in the Netherlands than in other European countries: the Peristat-II study. Ned Tijdschr Geneeskd. 2008, 152: 2718-2727.Google Scholar
- Zeitlin J, Mohangoo A, Cuttini M, EURO-PERISTAT Report Writing Committee: The European Perinatal Health Report: comparing the health and care of pregnant women and newborn babies in Europe. J Epidemiol Community Health. 2009, 63: 681-682.View ArticleGoogle Scholar
- EURO-PERISTAT project in collaboration with SCPE, EUROCAT and EURONEOSTAT: European perinatal health report. 2008, http://www.europeristat.com.Google Scholar
- Euro-Peristat Project with SCPE and EUROCAT: European Perinatal Health Report. The health and care of pregnant women and babies in Europe in. 2010, http://www.europeristat.com.Google Scholar
- Eurostat: The Eurostat Regional Yearbook. 2011, Publications Office of the European Union: Luxembourg.Google Scholar
- The Netherlands Perinatal Registry: Trends 1999–2012. 2013, The Netherlands Perinatal Registry: UtrechtGoogle Scholar
- Commissie verloskunde van het CVZ: Verloskundig vademecum 2003. 2003, Diemen: College voor zorgverzekeringenGoogle Scholar
- Franx A: Lijn der verwachting. 2011, Utrecht University: UtrechtGoogle Scholar
- Stuurgroep zwangerschap en geboorte: Een goed begin. 2009, Utrecht: Stuurgroep zwangerschap en geboorteGoogle Scholar
- PRN 2007: Perinatale Zorg in Nederland 2007. 2009, Utrecht: PRN, http://www.perinatreg.nl/uploads/150/116/Jaarboek_Perinatale_Zorg_2007.pdf.Google Scholar
- Amelink-Verburg MP, Verloove-Vanhorick SP, Hakkenberg RM, Veldhuijzen IM, Bennebroek GJ, Buitendijk SE: Evaluation of 280,000 cases in Dutch midwifery practices: a descriptive study. BJOG. 2008, 115: 570-578.View ArticleGoogle Scholar
- Van Eyck JPM, Offermans AC, Bolte KM, Sollie-Szarynska KWM, Bloemenkamp SG, Oei MP, Heringa FK, Lotgering JJ, Duvekot A, Schaap AHP: OHC rapportage 2008. Ned Tijdschr Geneeskd. 2008, 152: 2121-2125.Google Scholar
- de Neef T, Hukkelhoven CW, Franx A, Everhardt E: Uit de lijn der verwachting. Nederl Tijdschrift Obstet Gynaecol. 2009, 122: 341-342.Google Scholar
- Evers AC, Brouwers HA, Hukkelhoven CW, Nikkels PG, Boon J, van Egmond-Linden A, Hillegersberg J, Snuif YS, Sterken-Hooisma S, Bruinse HW, Kwee A: Perinatal mortality and severe morbidity in low and high risk pregnancies in the Netherlands: a prospective cohort study. BMJ. 2010, 341: c5639.View ArticleGoogle Scholar
- de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B, Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S: Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. BJOG. 2009, 116: 1177-1184.View ArticleGoogle Scholar
- Birthplace in England Collaborative Group: Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ. 2011, 343: d7400.View ArticleGoogle Scholar
- Bonsel GJ, Birnie E, Denktas S, Poeran J, Steegers EAP: Lijnen inde Perinatale Sterfte, Signalementstudie Zwangerschap en Geboorte 2010. 2010, Rotterdam: Erasmus MCGoogle Scholar
- Ravelli ACJ, Eskes M, Tromp M, van Huis AM, Steegers EAP, Tamminga P, Bonsel GJ: Perinatale sterfte in Nederland 2000–2006; risicofactoren en risicoselectie. Ned Tijdschr Geneeskd. 2008, 152: 2728-2733.Google Scholar
- Tamminga P, Rijninks-van Driel G, Mohangoo A, Hukkelhoven C, Nijhuis J, Buitendijk S, Ravelli ACJ: Neonatale uitkomsten. Nederl Tijdschrift Obstet Gynaecol. 2009, 122: 83-87.Google Scholar
- Richardus JH, Graafmans WC, Verloove-Vanhorick SP, Mackenbach JP, EuroNatal International Audit Panel; EuroNatal Working Group: Differences in perinatal mortality and suboptimal care between 10 European regions: results of an international audit. BJOG. 2003, 110: 97-105.View ArticleGoogle Scholar
- Stichting Perinatale Audit Nederland: A terme sterfte 2010. Perinatale audit: eerste verkenningen. 2011, Stichting Perinatale Audit Nederland: UtrechtGoogle Scholar
- Lledo R, Rodríguez T, Trilla A, Cararach V, Restuccia J, Asenjo M: Perceived quality of care in pregnancy. Assessment before and after delivery. Eur J Obstet Gynecol Reprod Biol. 2000, 88: 35-42.View ArticleGoogle Scholar
- Wildman K, Blondel B, Nijhuis J, Defoort P, Bakoula C: European indicators of health care during pregnancy, delivery and the postpartum period. Eur J Obstet Gynecol Reprod Biol. 2003, 111: 53-65.View ArticleGoogle Scholar
- Draycott T, Sibanda T, Laxton C, Winter C, Mahmood T, Fox R: Quality improvement demands quality measurement. BJOG. 2010, 117: 1571-1574.View ArticleGoogle Scholar
- Siassakos D, Bristowe K, Draycott TJ, Angouri J, Hambly H, Winter C, Crofts JF, Hunt LP, Fox R: Clinical efficiency in a simulated emergency and relationship to team behaviours: a multisite cross-sectional study. BJOG. 2011, 118: 596-607.View ArticleGoogle Scholar
- Posthumus AG, Schölmerich VL, Waelput AJ, Vos AA, De Jong-Potjer LC, Bakker R, Bonsel GJ, Groenewegen P, Steegers EA, Denktaş S: Bridging between professionals in perinatal care: towards shared care in the Netherlands. Matern Child Health J. 2013, 17 (10): 1981-1989.View ArticleGoogle Scholar
- Truijens SEM, Pommer AM, Van Runnard Heimel PJ, Verhoeven CJM, Oei SG, Pop VJM: Development of the Pregnancy and Childbirth Questionnaire (PCQ): evaluating quality of care as perceived by women who recently gave birth. Eur J Obstet Gynecol Reprod Biol. 2014, 174: 35-40.View ArticleGoogle Scholar
- Draycott T, Sibanda T, Owen L, Akande V, Winter C, Reading S, Whitelaw A: Does training in obstetric emergencies improve neonatal outcome?. BJOG. 2006, 113: 177-182.View ArticleGoogle Scholar
- Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ, Hamstra SJ: Technology-enhanced simulation for health professions education; a systematic review and meta-analysis. JAMA. 2011, 306: 978-988.Google Scholar
- McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB: Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med. 2011, 86: 706-711.View ArticleGoogle Scholar
- Ericsson KA: Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Review. Acad Med. 2004, 79 (10 Suppl): S70-S81.View ArticleGoogle Scholar
- Helmreich RL, Merrit AC, Wilhelm JA: The evolution of crew resource management in training in commercial aviation. Int J Aviat Psychol. 1999, 9: 19-32.View ArticleGoogle Scholar
- Grogan EL, Stiles RA, France DJ, Speroff T, Morris JA, Nixon B, Gaffney FA, Seddon R, Pinson CW: The impact of aviation-based teamwork training on the attitudes of health-care professionals. J Am Coll Surg. 2004, 199: 843-848.View ArticleGoogle Scholar
- Kirkpatrick D: Evaluating training programmes; the four levels. 1994, San Francisco, CA: Berrett-Kochler PublishersGoogle Scholar
- Fransen AF, van de Ven J, Merién AER, de Wit-Zuurendonk L, Houterman S, Mol BW, Oei SG: Effect of obstetric team training on team performance and medical technical skills: a randomised controlled trial. Br J Obstet Gynaecol. 2012, 119: 1387-1393.View ArticleGoogle Scholar
- Brown CA, Lilford RJ: The stepped wedge trial design, a systematic review. BMC Med Res Methodol. 2006, 8: 6-54.Google Scholar
- Woertman W, de Hoop E, Moerbeek M, Zuidema SU, Gerritsen DL, Teerenstra S: Stepped wedge designs could reduce the required sample size in cluster randomized trials. J Clin Epidemiol. 2013, 66 (7): 752-758.View ArticleGoogle Scholar
- Mdege ND, Man MS, Taylor Nee Brown CA, Torgerson DJ: Systematic review of stepped wedge cluster randomized trials shows that design is particularly used to evaluate interventions during routine implementation. J Clin Epidemiol. 2011, 64 (9): 936-948.View ArticleGoogle Scholar
- Medical Education and Simulation Centre (Medsim): the Netherlands: Eindhoven, http://www.medsim.nl.
- Dutch Society of Obstetrics and Gynaecology: Multidisciplinary guideline of preterm birth. 2012, NVOG: Utrecht, http://www.nvog.nl.Google Scholar
- Dutch Society of Obstetrics and Gynaecology: Guideline prevention of recurrence of preterm birth. 2007, NVOG: Utrecht, http://www.nvog.nl.Google Scholar
- Dutch Society of Obstetrics and Gynaecology: Guideline calculation of gestational age. 2011, NVOG: Utrecht, http://www.nvog.nl.Google Scholar
- Dutch Society of Obstetrics and Gynaecology: Multidisciplinary guideline of extreme preterm birth. 2010, NVOG: Utrecht, http://www.nvog.nl.Google Scholar
- Royal College of Obstetricians and Gynaecologists (RCOG): The Investigation and Management of the Small–for–Gestational–Age Fetus. RCOG green Guidline NO 31. 2013, London: RCOGGoogle Scholar
- Dutch Society of Obstetrics and Gynaecology: Small-for-Gestational-Age Fetus. 2008, NVOG: UtrechtGoogle Scholar
- Royal College of Obstetricians and Gynaecologists (RCOG): Electrical fetal monitoring. National Evidence-based Clinical Guideline. 2001, London: RCOG PressGoogle Scholar
- Health, National Collaborating Centre for Women’s and Children’s: Intrapartum Care: care of healthy women and their babies during childbirth. NICE Clinical guideline 55. 2007, Londen: RCOG PressGoogle Scholar
- Nederlandse Reanimatie Raad/Belgische reanimatieraad: Resuscitation of newborns; guidelines resuscitation in the Netherlands. 2010, Nederlandse Reanimatie Raad: Uden, http://www.reanimatieraad.nl.Google Scholar
- Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin C, Koster RW, Wyllie J, Böttiger B: ERC Guidelines Writing Group. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation. 2010, 81 (10): 1219-1276.View ArticleGoogle Scholar
- Dutch Society of Obstetrics and Gynaecology: Guideline unexpected findings with 18–20 week scan. 2008, NVOG: UtrechtGoogle Scholar
- Dutch Society of Obstetrics and Gynaecology: Guideline late termination of pregnancy. 2007, NVOG: UtrechtGoogle Scholar
- Guise JM, Deering SH, Kanki BG, Osterweil P, Li H, Mori M, Lowe NK: Validation of a tool to measure and promote clinical teamwork. Simul Healthc. 2008, 3: 217-223.View ArticleGoogle Scholar
- Berendsen AJ, Benneker WH, Groenier KH, Schuling J, Grol RP, Meyboom-de JB: DOC questionnaire: measuring how GPs and medical specialists rate collaboration. Int J Health Care Qual Assur. 2010, 23: 516-526.View ArticleGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/14/175/prepub
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