A total of 120 staff completed the survey. The characteristics of those who completed the survey are presented in Table 1. The majority of respondents (71.7%, n = 86) were midwives and 17% (n = 20) percent of staff were obstetricians. The median time staff had worked at Monash Health was 8 years (IQR 3–13 years) and 60% (n = 70) of them worked at the larger Clayton site. A number of staff worked across more than one site. The response rates were highest for midwives at the Casey site (58%) and Obstetric staff (88%) at the Dandenong site compared to the other sites respectively (Midwives response rate: 22% Clayton, 38% Casey and Obstetric response rate: 44% Casey and 24% Clayton). Almost everyone (96%) who completed the survey had direct experience using the guideline.
Table 1
Characteristics of Staff Surveyed
| n = 120 |
Profession | |
Midwife | 86 (73.50%) |
Obstetrician | 20 (17%) |
GP-Obstetrician | 1 (0.85%) |
HMO/Registrar | 10 (8.6%) |
Number of years working at Monash Health | |
Median (IQR) | 8 (3–13) |
Site* | |
Clayton | 70 (60%) |
Dandenong | 35 (30%) |
Casey | 34 (29%) |
Experience using guideline | |
Yes | 115 (96%) |
No Not reported | 2 (2%) 3 (2%) |
Number (%) unless otherwise stated |
*note some staff worked across multiple sites. |
Responses to the 10 statements are presented in Table 2. The majority (81%, n = 97) of staff agreed that there was a need for these clinical guidelines at Monash Health but almost 60% (n = 67) reported that additional education for staff about the guidelines was needed. When considering the content and procedures within the guidelines, the majority of staff thought the reason the guideline existed was clear (79%, n = 95), the criteria to define who they applied to was clear (83%, n = 99) and the procedures and instructions within the guideline were clear (74%, n = 89). Staff reported an increase in workload following the implementation of the guideline (72%, n = 86). Despite this, the majority (65%, n = 78) agreed that the guideline implementation was a good thing. Fifty-six percent (n = 67) of staff agreed the guidelines had improved the care of south Asian women, 28% (n = 34) neither agreed nor disagreed and 8%(n = 10) did not believe they had improved outcomes. One quarter of staff (n = 30) surveyed also believed the implementation of the guideline had negatively impacted the care of other women at the Monash Health. Overall almost half of staff surveyed (47% (n = 55)) said their experience with the guidelines was positive, 34% felt indifferent (n = 41) and 12% (n = 14) reported their experience of the guidelines was negative. For all questions between 9 and 11 staff (8%) did not indicate their agreement or disagreement.
Table 2
Staff Agreement experience statements
| Strongly Agree | Agree | Neither Agree or Disagree | Disagree | Strongly disagree | Did not answer |
There is a need for these clinical care guidelines at Monash Health. | 39(33%) | 58(48%) | 8(7%) | 3(3%) | 2(2%) | 10 (8%) |
Monash Health staff need extra education or information about the new guidelines. | 16 (13%) | 51(43%) | 24(20%) | 19(16%) | 0(0%) | 10 (8%) |
The rationale for the guidelines is clear | 24(20%) | 71(59%) | 10(8) | 6(5%) | 0 | 9(8%) |
The criteria for who the guidelines apply to are clear | 24(20%) | 75(63%) | 6(5%) | 3(3%) | 1(1%) | 11(9%) |
The procedures and suggested processes are clear | 12(10%) | 77(64%) | 14(12%) | 7(6%) | 0(%) | 10(8%) |
The introduction of the guidelines has increased my workload directly | 42(35%) | 44(37%) | 15(12%) | 10(6%) | 0(0%) | 9(8%) |
The introduction of the guideline has affected the care of other women in a negative way | 10(8%) | 20(17%) | 30(25%) | 43(36%) | 7(5%) | 10(8%) |
I think the new guidelines are a good thing | 14(12%) | 64(53%) | 23(19%) | 7(6%) | 2(2%) | 10(8%) |
I think they have improved the care of women | 9(8%) | 58(48%) | 34(28%) | 7(6%) | 3(3%) | 9(8%) |
My experience of the guidelines has been positive | 5(4%) | 51(43%) | 41(34%) | 11(9%) | 3(3%) | 9(8%) |
Staff Concerns Identified In Open Ended Questions
Overall just under half (46%, n = 55) of staff surveyed reported concerns about the guidelines, the majority of these concerns were from midwifery staff. Staff concerns related to (i) increased workload and insufficient resources to meet the changes in care; (ii) potential harm and/or patient safety; (iii) accessing the monitoring; (iv) scientific rationale and evaluation of the guidelines; and (v) staff knowledge, education and communication.
Increased workload and insufficient resources
Overwhelmingly an increase in workload, lack of resources, a lack of available appointment times, short appointment lengths, only one of the 3 health service sites able to offer the monitoring and increased numbers of inductions performed were reported by staff as concerns. Concerns about workload were also linked with safety concerns. Examples of comments made include:
‘If the research indicates that this is a positive move for the safety of babies then these guidelines are a good thing, however, the extra workload that it has created needs to be addressed.’ [ID001]
‘Increased workload directly on Fetal Monitoring Unit MMC and birth suites with no change to infrastructure or staffing in either of those units’. [ID079]
‘It would be nice to have more resources to enable the smooth running of our birth unit- often we have a build-up of women waiting to have monitoring & plans put in place. I don’t think this is a particularly safe option.’ [ID094]
Potential harm and/or patient safety
Concern that the increase in workload was putting women at risk was also reported. This related to additional harms due to the increased intervention and stress placed on women. A number of staff were also concerned women would not access care if they experienced reduced fetal movements if they had a routine monitoring appointment booked. Examples of comments include:
‘Impact on workload and having enough resources to provide the care required either for the amount of monitoring or the increased demand for induction of labour spaces - which could put other women at risk. This also adds to stress for the women and staff, when trying to facilitate the extra scans/CTGs/IOL required under the new policy and having to negotiate and prioritise which patient is most urgent, with the limited spaces available.’ [ID043]
‘Concerned that women are awaiting fetal monitoring appointment instead of utilising PAU (Pregnancy Assessment Unit) to report reduced fetal movements’ [ID096]
Accessing the monitoring
Access to care was also highlighted as a concern. This included difficulties for South Asian women to attend a different health service site for their monitoring and also other women, who were unable to access monitoring due to the increased demand. Examples of comments made include:
‘Inconvenience caused: Some women who require travelling from other sites to Clayton for their twice weekly monitoring found the demand excessive and inconvenient. Many partners needed to take time off work in order to bring the women to Clayton.’ [ID086]
‘Not the guideline per se....BUT The guideline has significantly impacted the workload of birthing units esp for IOLs, increased workload for managers, decreased timely access to care for other Non-SA women, created frequent capacity issues.’ [ID108]
Some staff also detailed concerns relating to the monitoring only being available at one location, thus fragmenting the care of women. An increase in wait times for women other than those from South Asia were reported and concern that staff may not use their clinical judgment. Examples of comments made include:
I believe this has impacted on the level of care to other women with longer wait times and poorer care due to the increase in workload’. [ID006]
‘they sometimes take away from good clinical judgement’ [ID051]
‘It has fragmented care for women with the location of monitoring often away from site of booking.’ [ID108]
Scientific rationale and evaluation of the guidelines
Staff reported concerns about the rationale underpinning the need for earlier monitoring, the number of monitoring episodes performed and whether they were improving outcomes or causing harm. Examples of comments include:
‘A comparison between the perinatal outcomes in this specific ethnic group before and after the guideline implementation needs to be conducted in order to evaluate whether the guideline has a positive impact on the perinatal outcomes.’ [ID098]
‘I think more research needs to be done on whether placentas do in fact "age", as this may cause certain decisions to be made that may not be relevant.’[ID029]
Staff Knowledge, Education and Communication
Staff reported concerns around the lack of education about the guidelines. This included why they were being implemented and who they specifically applied to. Examples of comments include:
‘Ongoing education of medical and midwifery staff is essential to ensure the guidelines are applied to the correct group of women, and to make sure the rationale is explained to each woman so informed patient choice is possible.’ [ID069]
There was noticeable inconsistency of levels of understanding amongst staff (ie not understanding the frequency of monitoring, not understanding the commencement for monitoring, mistaken non South Asian countries as South Asia, and confusion in commencing other non South Asian women's monitoring at different gestation).’ [ID086]
‘Are women of Indian descent but born in Malaysia or Fiji, for example, still considered to require earlier post term monitoring?’[ID092]
The challenges of explaining a new clinical practice to South Asian women and ensuring informed consent was also highlighted by staff. Examples of comments include:
‘Explaining same to women whom English is not their main Language and even when using an Interpreter to explain same to them they do not always fully understand reason for same.’[ID030]
‘Women are not given alternative options and true informed consent. Induction of labour has become routine for these women without risks v benefits being fully discussed including the cascade of intervention, increased risk of epidural, forceps, ventouse, and CS. Women of any SE Asian descent even if they don't necessarily identify fully with this label and not counselled (ie mixed race, born and raised in Australia). These guidelines are not individualised which lends them to being discriminatory in nature to one ethnic group.’ [ID036]
Staff Suggestions For Improvement Identified In Open Ended Questions
Fifty-one staff also provided suggestions for improvement, including: (i) increasing staffing and resources; (ii) information and communication to support informed decision-making; (iii) making changes to the guideline; and (iv) evaluating impact of the guidelines. Examples of comments for each theme are given below.
Increasing staffing and resources
An increase in the numbers of staff, resources available including additional monitoring sites and increased appointment times were suggested as improvements. Examples of comments include:
‘Provide more resources to accommodate the increased workload that is expected. It is not possible to provide quality care and accommodate the changes needed if there are insufficient resources.’ [ID043]
‘needing more time in Antenatal clinic appointments to discuss these aspects of care & their importance’ [ID111]
Greater number of sites offering post dates monitoring’ [ID014]
Information and communication to support informed decision-making
Staff also indicated that improved educational materials for women in their native language are needed to ensure women understand, are not unnecessarily concerned and to ensure informed consent. Examples of comments include:
‘information fact sheet for south Asian women to take home and read. In multiple appropriate languages.’ [ID009]
‘A clear and concise handout for the women affected, explaining the rationale and reminding women strongly that the choice of management remains with her.’ [ID056]
‘Continuing emphasis of the importance of fetal movements to our patients and of the need to report decreased fetal movement as quickly as possible.’ [ID078]
Staff also highlighted the desire for more staff education and training, clearer more detailed information on who the guideline applies to, and how to have conversations with women about the additional monitoring. Examples of comments include:
‘Before any guidelines being introduced, education sessions should be provided to team leaders/senior staff of the units/departments. If there is any revision of the guidelines, the new revised guidelines should be highlighted and well communicated to all staff to prevent any inconsistency and confusion.’ [ID086]
‘Better education with the implementation of the guideline to assist junior staff in providing balanced counselling. [ID119]
Changes to the guideline
A number of suggestions were made by staff to improve the guideline. These included a reduction in the number of scans performed, the addition of other monitoring approaches and different monitoring approaches depending on the initial monitoring results. Examples of comments include:
‘and the right for women to ask for weekly scans if they have a normal or above normal AFI and continue with CTGs twice a week as a lot of women have concerns around the increased ultrasounds during pregnancy.’ [ID067]
‘Perhaps inclusion of MCA Doppler measurement’ [ID035]
Evaluating impact of the guidelines
Evaluation of the impact of the guideline was also suggested as an improvement. Examples of comments include:
‘Suggest continued review of the outcomes in terms of improvements or reductions in stillbirth so that any improvement can be quantified over time. If no improvement is demonstrable, the guidelines should be reviewed. I expect that this is already planned.’ [ID090]