Sample characteristics
The majority of the professionals (71.9%, n= 46) had clinical experience in the labor ward for no more than five years (53.2% of midwives, n= 17, and 90% of the obstetricians, n=29). The midwifery students (n=32) participated in the last training year and the resident obstetricians had a mean duration of clinical experience of 2.5 years. The mean age of the participants was 40.4 years (38.3 years for the midwives and 42.7 years for the obstetricians). The majority of the professionals (67.2%, n= 43) reported that they felt confident about interpreting CTG traces (59.4% of midwives, n= 19, and 75% of the obstetricians, n=24). However, approximately only half of the professionals (54.7%, n= 35) reported that they felt that their training adequately prepared them for CTG usage (56.3% of midwives, n= 18, and 53.1% of the obstetricians, n=17).
Questionnaire refinement results
Reliability assessment: Internal Consistency and Test-Retest Reliability.
The Cronbach’s alpha coefficient of internal consistency for the 10-item scale was 0.89, the corrected item total correlations ranged from 0.45 to 0.85, indicating sufficient inter-relationships in the data to conduct an exploratory factor analysis and none of the items improved the scale’s Cronbach’s alpha estimate if deleted. The test-retest reliability of the scale for the two administrations was correlated at 0.85 (p<0.01).
Factor structure of the EFMKS
The Kaiser-Meyer-Olkin value was 0.824 and Bartlett’s test of sphericity reached statistical significance (χ2 = 747, df = 45, p < 0.001). These findings indicated that the data were suitable for a factor analysis [40]. All initial communalities were ≥ 0.35, and all of them ranged from 0.629 to 0.885 (Table 1). The exploratory factor analysis suggested three factors with eigenvalues greater than 1, accounting for 72.99% of the variance (Table 1). All factors with an eigenvalue more than >1 showed consistency with the visual scree plot.
Factor interpretation and naming
Inspection of the derived factors revealed meaningful groupings of the items. Factor 1 had four strongly loading items: on Q1 “range and determinants of fetal heart rate (FHR) baseline”, on Q2 “range and determinants of fetal heart rate variability”, on Q3 “key characteristics (accelerations) of a reactive NST”, and on Q4 “identification and attribution of variable decelerations” (Table 1). Substantively, the considered interpretation of this factor seems best focused on the midwives’ and doctors’ knowledge on key elements of CTG and on identification of normal CTG patterns. The factor was therefore named as “key elements of CTG and normal CTG patterns”.
Factor 2 had three strongly loading items: on Q5 “identification and attribution of late decelerations”, on Q6 “management of bradycardia during labor” and on Q10 “classification of CTG traces from compensatory to abnormal”.Two items (5, 6) also loaded on Factor 1, but they were assigned to the factor with the highest loading. For Factor 2, the underlying concept seemed to be on abnormal CTG and on CTG during labor. The factor was therefore designated as “suspicious and abnormal CTG patterns”.
Factor 3 had three strongly loading items: on Q8 “risk of neurological defect and acidosis”, on Q7 “association between Apgar score, accelerations during labor and acidosis” and on Q9 “association between progressive hypoxia and CTG traces”. The factor was therefore designated as “hypoxia, acidosis and CTG traces”.
Discriminant and construct validity
To determine whether EFMKS is sensitive to differences in clinical experience of participants, a t-test was used. The significant and positive associations between the mean score of EFMKS scale and the professional experience of participants suggested that EFMKS achieved discriminant and construct validity. The sensitivity analysis detected a significant difference in mean test score between obstetricians and residents (t= 5.717, p = 0.020) and between midwives and student midwives (t=4.553, p = 0.033), indicating acceptable test construct abilities.
The strength of associations between the derived scales of the EFKMS scale was tested. Positive, medium and statistically significant associations were obtained among the factors: that is, the factor “key elements of CTG and normal CTG patterns” with the factor “suspicious and abnormal CTG patterns” (r = 0.695, p<0.001) and with factor “hypoxia, acidosis and CTG traces” (r = 0.689, p<0.001), and the factor “suspicious and abnormal CTG patterns” with factor “hypoxia, acidosis and CTG traces” (r = 0.654, p<0.001).
Table 1
Factor structure of the Electronic Fetal Monitoring Knowledge Scale (EFMKS)
Item/ Item statement
|
Loading
|
Communality
|
Factor1 (Eigenvalue = 3.32, variance explained = 33.27%, α = 0.85
|
3/ Key characteristics of a reactive NST
|
0.812
|
0.771
|
4/ Definition and attribution of variable decelerations
|
0.805
|
0.669
|
1/ Range and determinants of FHR baseline
|
0.778
|
0.793
|
4/ Range and determinants of FHR variability
|
0.751
|
0.832
|
Factor 2 (Eigenvalue = 2.41, variance explained = 24.12%, cumulative variance explained = 57.39%, α = 0.82
|
10/ Classification of CTG traces from compensatory to abnormal
|
0.860
|
0.885
|
6/ Definition and management of severe bradycardia
|
0.725
|
0.635
|
5/ Definition and attribution of late decelerations
|
0.712
|
0.680
|
Factor 3 (Eigenvalue = 1.56, variance explained = 15.6%, cumulative variance explained = 72.99%, α = 0.80
|
7/ Progressive hypoxia and CTG traces
|
0.785
|
0.637
|
8/ Identification of risk for neurological defect and ph
|
0.749
|
0.629
|
5/Apgar score, accelerations and risk of acidosis
|
0.745
|
0.769
|
NST: Non stress test, FHR: Fetal Heart Rate, CTG: Cardiotocography
|
Descriptive findings of the EFMK scale
The score of the 10-item EFMK scale ranged from 0 (indicating no correct answers) to 10 (indicating all correct answers), and professionals with scores of greater than five (the mid-point) were classified as having good knowledge about EFM, and those with scores of four and below were classified as having poor knowledge. The rationale for using a cut off of 5 for the knowledge scale was pragmatic as 5 represented the midpoint and the median of the scale. The terms good and poor imply an absolute standard against which knowledge is judged. Such a standard should and is planned to be developed in the future. For the present, however, the only standard is a relative one, that is, knowledge is judged as poor in the context of the scale’s median.
The mean score for the total EFMKS was 6.84 (SD = 3.11), for the subscale measuring the “key elements of CTG and normal CTG patterns” with range from 0 to 4, the mean score was 2.31 (SD=1.7); for the “suspicious and abnormal CTG patterns” subscale (range from 0 to 3), the mean score was 2.21 (SD=0.96), and for the “hypoxia, acidosis and CTG traces” subscale (range from 0 to 3), the mean was 2.31 (SD= 0.85). Taking into consideration the midpoint of the scale (5), the mean score of our sample indicated a good level of knowledge. More specifically, 73.4% of the total sample (71.9% of the professional midwives and 75% of the professional obstetricians) had a good level of knowledge (score of more than 5 points).
Correlations between professionals’ characteristics and EFMK Scale score
The association between participants’ level of knowledge and their characteristics was explored (Table 2). No statistically significant difference was observed between group of midwives and group of obstetricians in terms of total knowledge score (p=0.768). Professionals with longer experience in the labor ward had statistically higher mean scores in subscales measuring “suspicious and abnormal CTG patterns” and “hypoxia, acidosis and CTG traces” than professionals with shorter clinical experience. No statistically significant relationship was observed between knowledge level and professionals’ age. Interestingly, the professionals reporting being confident and adequately prepared for CTG usage had significantly higher mean knowledge scores.
Table 2
Associations between Electronic Fetal Monitoring Knowledge Scale (EFMKS) and characteristics of the professionals involved in the study.
|
EFKM Scale and Subscales (means)
|
Professionals’ characteristics
|
Total EFKM scale
|
Subscale: ‘Key elements of CTG and normal CTG patterns’(means)
|
Subscale: “suspicious and abnormal CTG patterns”(means)
|
Subscale:
“hypoxia, acidosis and CTG traces”(means)
|
Professional Midwives
|
6.46
|
2.62
|
1.68
|
2.15
|
Professional Obstetricians
|
7.21
|
2.75
|
2.00
|
2.46
|
p value
|
0.768
|
0.498
|
0.315
|
0.246
|
Years of labor ward experience < 5
|
6.43
|
2.01
|
2.08
|
2.01
|
Years of labor ward experience ≥ 5
|
7.88
|
2.50
|
2.88
|
2.72
|
p value
|
0.010
|
0.336
|
0.003
|
0.045
|
Professionals reporting not being confident for CTG interpretation
|
4.04
|
1.61
|
0.76
|
1.66
|
Professionals reporting confident for CTG interpretation
|
8.20
|
3.20
|
2.37
|
2.62
|
p value
|
0.010
|
0.004
|
0.002
|
0.038
|
Professionals not feeling adequately trained for CTG usage
|
4.86
|
1.93
|
1.03
|
1.89
|
Professionals feeling adequately trained for CTG usage
|
8.48
|
3.31
|
2.51
|
2.65
|
p value
|
0.001
|
0.006
|
0.005
|
0.048
|
CTG: Cardiotocography
|