“Nothing Comes to Mind…”: Challenges With Identifying One’s Own Role in Preventable Adverse Outcomes in Interprofessional Birthing Unit Teams, and the Implications for Quality Improvement Initiatives

TL;DR

This study explores how birthing unit staff struggle to recognize their own role in preventable adverse outcomes, which can hinder quality improvement efforts.

Contribution

The study introduces the concept of dissonant self-schemas in interprofessional teams and their impact on quality improvement initiatives.

Findings

Staff created more flattering self-schemas than the schemas their colleagues formed about them.

Participants easily identified others' errors but struggled to acknowledge their own role in poor outcomes.

Dissonant schemas may hinder accurate self-assessment and team competence.

Abstract

Preventable adverse perinatal outcomes have a devastating impact on patients and providers and form the basis of many quality improvement (QI) and patient safety initiatives in birthing unit teams, including fetal health surveillance (FHS) training programs. Birthing unit staff attitudes regarding the role of interprofessional relationships on FHS decisions remain largely unexplored with respect to preventable adverse outcomes.

In this intervention-primed, constructivist grounded theory study, members across all five professions providing intrapartum care at one academic centre attended an interprofessional workshop on improving their FHS interpretation, response, communication, and teamwork skills. Twenty-three birthing unit team members across midwifery, obstetrics, family medicine, nursing, and obstetrical trainees were purposively sampled and completed semi-structured interviews. Self-serving bias theory was used as a sensitizing concept to explore the social phenomena observed.

Birthing unit staff constructed a self-schema of their role in FHS management that was more flattering than the person-schema created by their colleagues about them. The schemas encoded four categories of information that included (1) Identifying the offender, (2) Assigning blame (3) Aligning with the “right” philosophy of care, and (4) Defending one’s profession. Participants demonstrated distorted perceptual processes where they described errors other team members had made with ease but struggled to acknowledge their own role in poor outcomes.

Dissonant schemas can be barriers to the accurate self-assessment of one’s skills and have significant implications for interprofessional team competence. QI initiatives may be of limited efficacy given these findings, but addressing these distorted perceptual processes in QI initiatives could improve team performance.

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