This document discusses the Fetal Observation and Notification Training (FONT) program in NSW, Australia, which was developed to improve safety and outcomes in maternity care through interprofessional education. It describes issues that led to the development of FONT, including clinical incidents related to fetal monitoring. FONT provides education to midwives, obstetricians, and GPs on fetal welfare, obstetric emergencies, and neonatal resuscitation. The document discusses challenges of implementing interprofessional education and reducing power dynamics between professions. It also examines how FONT has empowered midwives and improved communication and outcomes.

1. Learning and
Communicating – The
Power Interplay
Dr Helen Cooke
Clinical Midwifery Consultant
NSW Pregnancy and newborn Services Network
(PSN)

2. FONT
• Fetal Welfare, Obstetric Emergency, Neonatal
Resuscitation Training
• Developed in 2007 -8 as a strategy to
improve safety and outcomes in maternity
care

3. Why did NSW need FONT
• 36 reported clinical incidents in the area of fetal
welfare assessment between 2005 and 2006
(McCann & Lahoud 2006).
• Characterised by an inability of clinicians to clearly
identify a fetus at risk of serious complications,
particularly during labour.
• Issues of concern revealed the misinterpretation of
FHR pattern anomalies during labour
• Issues identified around communication

4. What is FONT?
• Interprofessional education for all providers of
maternity care working within the NSW Public
Health System
• Midwives, Obstetricians and General Practitioners all learning the
same educational material and teaching and learning from each
other
• FONT is the largest program of postgraduate IPE
ever developed
• Approximately 5,500 clinicians across NSW
• Working at 80 hospitals
• Each site provides birthing services (range 100 – 5000 births p.a.)

5. Interprofessional Education
• “members (or students) of two or more
professions associated with health or social
care, engaged in learning with, from and
about each other” (Barr et al. 2005, p. xxiii)
• WHY IPE?
• Promotion of teamwork and collaborative practice
• Improve communication
• Develop strength and capacity across NSW

6. The Clinical Environment
• Over the past 20 years much has changed
in the way clinical care is provided
• Length of stay has decreased significantly
• Patient acquity is higher
• Many more staff work part time
• Medical staff work less hours
• Staff are much more transitory
• Overall there are more members of the team
• It would appear that the strong relationships with our
medical colleagues are not so evident

7. Clinical Relationships
• Cornerstone of a strong functioning team and
relationships are built on:
• Trust
• Mutual Respect
• Equality
• Openness
• Clear communication

8. Confusing and varied terminology
• The current literature around EFHR Monitoring continues
to show;
• There is confusion around the terminology used to describe the
FHR pattern
• the language most likely to be associated with errors in decision
making is the description and definition of FHR decelerations
• Review of the critical incidents across NSW found that
the varied language and definitions had been responsible
for many of the risks associated with FHR monitoring
• These risks can be identified as poor communication, lack of
escalation and failure to understand or act appropriately

10. SAC 1 Events
Pre-FONT Cohort Post-FONT Cohort
Year 2006 2007 2008 2009 2010 2011
SAC 1 & 2 Events where
errors in fetal monitoring
were described as causative
factors
18 24 18 23 25 23
Number of births in *Public
Hospitals in NSW
70815 73587 73292 72809 73013 74026

11. Term – Admit NICU – Fetal Distress -
Neonatal Death Rate – Vaginal Birth
NND 2006-2008 2009-2011
Fetal Distress 237 255
NND 34 24
Vaginal Birth 16 (47%) 3 (12%)
P = 0.0037

12. Challenges of post graduate
education
• Education has always appeared to have been a top down
approach
• Sideways, medical clinicians will always admit they worked
with some great midwives who, informally, taught them a
whole lot about pregnancy, labour and birth
• Formal interprofessional education comes with it’s own
complexities
• It’s often difficult to show your blemishes in public,
particularly when you hold a position of power
• True teamwork should allow this to happen

13. Training – What we know
• Junior medical staff – residents and some junior
registrars attend training
• Some senior registrars provide the training
• Very poor attendance by Private Obstetricians

14. • “they’re used to the attitude that they are the pilot of the
aeroplane and everyone else is up the back and I think
it’s quite difficult for some of those obstetricians to learn
in a team work type environment” (Interview 12, Clinical
Leader).

15. • “medical staff never want to expose themselves
to the midwives and to the other junior staff, they
don’t want to be seen to be ignorant” (Interview
16 Clinical Leader).
• “some of them are a bit out of touch with some
practices, their clinical skills are not so good, that
sort of thing. They’ve probably got this image to
maintain” (Interview 13 Midwifery Educator).

16. • “we did it one afternoon for all the consultant staff”
(Interview 7 Obstetrician).
• “I sort of broke the rules a bit and had a Saturday where
I got over 20 of the VMOs to come and I said we’ll pay
for lunch and afternoon tea, I know it is not ideal but at
least they were there” (Interview 11 Clinical Leader).

17. • “I mean there’s a real simplicity. I mean you’re like,
you’re reading ABC… I think there is a triteness [to the
educational content]” (Interview 9 Obstetrician).
• “people see it as part of their junior education… CTGs,
you know they want a magical solution they don’t actually
want to work at it“ (Interview 7, Obstetrician).
• “I also felt that the FONT was not very well tailored to
consultants, that there was probably about 50% of the
material that I thought that was not really necessary for
consultant obstetricians” (Interview 12 Clinical Leader).

18. • “elite professional education, they’re all elite, the
more elite you make it sound the more you will
get…we got some comments like well we don’t
need to do that we’ve all written essays about
this… there was this bit of [attitude] please don’t
bore me with such trivial matters” (Interview 7
Obstetrician).

19. • “several of our doctors have refused to present [a
FONT session] because they feel that the information
in FONT is dangerous and that some of the [CTG] traces
and the suggested management would be something
that would actually be causing the death of the baby”
(Interview 6, Midwife).

20. • “it is frustrating to attend a course where you are
taught by a midwife…there are an enormous number
of very potent egos in obstetrics who really find that
very offensive” (Interview 9, Obstetrician).
• “I think some of the medical officers don’t really
appreciate a midwife teaching them something such
as fetal heart rate monitoring, [implying they would
think] ‘I’m not going along if a midwife is teaching
me’” (Interview 3, Midwife).

21. • “we’ve got an escalation plan… but it doesn’t always
work… people are scared to bother other people. Some
of the junior staff are afraid about escalation because
they don’t want their head bitten off” [by a senior doctor]
(Interview 11 Clinical Leader)

22. • “more midwives are feeling empowered with
the knowledge” (Interview 1 Midwife) and:
“now the junior midwives have been educated
and empowered” (Interview 6 Midwife).
• “So, I think the midwives have got a whole lot
more confident. You see it in midwives who
have been qualified a couple of years have
time to think about their practice” (Interview 7
Obstetrician).

23. • then you get the difficult questions and I think
people asking difficult questions is great but it’s
often there to test the person who is doing the
training and the moment that the trainer
stumbles on the difficult questions that’s when
they have lost the audience” (Interview 16
Obstetrician).

24. • “the quality of midwifery input and discussion has
been increasing with confidence and that always
meets with an interesting reaction, a predicable
reaction of stages of threat from medical officers,
(Interview 2 Clinical Leader).
• “midwives have taken it up as a critical learning
opportunity, they have developed confidence in
regards to interpreting CTGs and they will politely
say they disagree with the interpretation, and
communicate that to the doctor, generally that’s
constructively done… its been a good thing from a
communication point of view” (Interview 2 Clinical
Leader).

25. Leadership
• “I’ve identified some discomfort and some
difficulty in participation because of
knowledge (from medical staff) but we always
put that out there as one of our ground rules
as well identifying that there are different
levels of skill and we try and make it as safe
an environment as possible” (Interview 3
Midwife).

26. Leadership to reduce the power
influence
• “where you sit together with no hierarchy, no
agenda and try and just chew the fat together
without looking like an idiot or [experiencing]
retribution for your ideas or whatever. So I
think it is the key to cultural change”
(Interview 9 Obstetrician).

27. Needs to be Valued
• “it’s about leadership in learning… about
commitment to learning together that I think
makes a difference, if you look at the VMOs
or senior staff specialists not coming to the
table then that gives a strong message that I
don’t have to learn with you… So the key to it
being successful is the fact that they value it”
(Interview 3 Midwife).

28. IPE/Interprofessionality/IPP

29. Reciprocity (IPE)
• create time for personal connections/ chatting/
socialising/sharing food
• recognition of individual professional roles and the
value each brings to IPE
• face to face education is encouraged and supported
• recognition of the knowledge and skills of individuals
• selected skilled individuals are encouraged to share
and support others in small group activities

30. Equality (IPE)
• clear expectations of IPE are set for everyone and the
ground rules should remain the same for all involved;
• everyone’s opinion is equal and program review is
inclusive of the trainers opinions;
• trainers taught to respect everyone’s opinion and
encourage individual discussion and comment;
• support for FONT/IPE is demonstrated by clinical
leaders and managers who ‘drop-in’ to educational
days
• managers to ensure balanced professional
representation for both participants and trainers at
workshops.

31. Status (IPE)
• encouragement by leaders for individuals to attend and
value add to the educational day
• value experience and encourage everyone to attend
and learn how staff communicate and respond for
escalation or emergency situations
• attempt to balance working groups with experienced
clinicians who can teach the less experienced
• the FONT education package alterations are done in
consultation with a wide range of experienced clinicians
from across the state.

32. Patient (the women)
Interprofessionality
• focus the education on the safety needs of the woman
(patient) and her family
• all discussion at the educational days are continually
focused on the clinical skills each professional brings
to improve clinical outcomes for the patient (woman)
and family
• decision making remains focused on the best possible
outcome for the woman and her family
• Prior to any decision making the individual asks
themselves ‘what would be my best decision for this
woman’s ongoing safety and care provision.

33. Experience (IPP)
• encourage attendance by all professional groups so
that skills can be demonstrated
• attendees at FONT/IPE should replicate the everyday
professional team that works together most of the
time
• in small group work the experienced clinician is to be
encouraged to help and offer advice.

34. Connection (IPP)
• the individual roles and responsibilities of each
professional group are highlighted throughout the
education
• case discussion is to centre on the individual roles and
responsibilities for clinical care and management
highlighting how each is dependent on the other
• contribution from experienced clinicians is to be
encouraged to assist with the development,
implementation and teaching of the educational material.

35. Trust (IPP)
• provide an educational focus that fosters and supports
strong processes and consistent communication
through the use of ISBAR*
• consistent terminology continues to be supported by
state guidelines
• education all supporting communication and
documentation strategies continue to use the principles
taught in FONT/IPE