Original article
Developing a CTG simulator app: theory and practice Jessica Ford1,*, Catherine Langley1,*, Adrian Molyneux2,* and Clifford Shelton1,* 1 2
North Western Postgraduate Deanery, Manchester, UK Medical School, Keele University, Stoke-on-Trent, UK
SUMMARY
Background: Cardiotocograph (CTG) interpretation is a core skill for health care professionals working on the labour ward; however, training appears to be deficient in respect of the development of decision-making skills relating to CTG findings. Simulation offers a potential solution to address such ‘human factors’. Current access to simulators is limited by cost and operational complexity. We therefore decided to develop an accessible CTG simulator application (‘app’) that could be operated on a smartphone, a
technology already possessed by the majority of health care professionals in the UK and elsewhere. Context: A multidisciplinary team with backgrounds in obstetrics, anaesthesia and information technology was assembled to undertake the software development process. An evaluation of the pilot software was undertaken by trainee obstetric doctors. Innovation: A software development project was undertaken in order to produce a mobile app that simulates CTG accurately and dynamically. This process was based on Davis’ Technology
Acceptance Model, in which usefulness and ease of use are the central principles. Implications: Mobile technology can be used to run simulation software that is both useful and easy to use; however, our evaluation indicated that in order to use the app effectively the operator requires some expertise in the behaviour of the CTG in response to interventions, in common with all current patient simulators. We envisage using this app in hybrid simulation scenarios, in which a live actor and a simulated monitor are used together.
CTG interpretation is a core skill for health care professionals working on the labour ward
*Joint first authors © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 1–5 1
Up to 94 per cent of health care professionals find their CTG training insufficient
INTRODUCTION
T
he cardiotocograph (CTG) is a means of electronically recording the foetal heart rate and pattern of uterine activity. National guidelines in the UK recommend CTG monitoring where there is increased risk to the foetus, and the analysis of the ‘trace’ can have profound influences on obstetric management.1 Cardiotocograph interpretation is therefore a core skill for health care professionals working on the labour ward; however, training appears to be inconsistent, with up to 94 per cent of health care professionals finding their CTG training insufficient.2 Furthermore, the majority of deficiencies in intrapartum care relate to poor decision making associated with CTG abnormalities, rather than their recognition.3 These factors, combined with the favourable attitude of health care professionals to technology-enhanced CTG training,4 present an opportunity for the development of simulation-based teaching to support existing training. Simulation is a dynamic field within medical education, advancing with the emergence of new methodology, research and technology. Modern whole- patient obstetric simulators are suitable for in-situ simulation, in which the simulator is used in the clinical environment; however, the expense of such devices and the level of training required to operate them makes them a very limited resource.5
Hybrid simulation, where an actor works in combination with a task-trainer or simulated patient monitor offers a solution to some resource issues associated with whole-patient simulation. Additional benefits include increased fidelity and an emphasis on interpersonal skills.6,7 Furthermore, scenarios can be run ad hoc, when the labour ward is not unduly busy. We therefore
hoped to introduce this simulation method to our practice, but existing CTG simulators were only available packaged with hardware and proved prohibitively expensive. We therefore developed a cost-effective solution that could be operated using hardware that we already possessed. The introduction of Apple’s iPhone in 2007 paved the way for the mass adoption of smartphones, and mobile devices have driven the personal technology agenda for the past decade. Contemporary devices feature the ability to install software known as ‘apps’, expanding their functionality beyond telecommunications into the realm of portable personal computing. Smartphone use is near ubiquitous amongst medical professionals in the UK: a 2012 study found that 75 per cent of junior doctors owned a smartphone, 76 per cent of whom used apps related to medical practice.8 The integration of mobile devices into health care means that nearly every health care worker already owns hardware with the potential to run a CTG simulation, and this provided the opportunity to develop our CTG simulator app.
APP DEVELOPMENT PROCESS In order for a technology to succeed potential users must commit to it. Multiple models for the adoption of technologies exist; however, Davis’ Technology
Acceptance Model (TAM) is one of the most well established, and has been validated by numerous studies.9 Two theoretical constructs are emphasised: the perceived usefulness of a technology (PU), and its perceived ease of use (PEU) (Figure 1). In order to focus the project in these areas, a multidisciplinary team was assembled to undertake the app development process, comprising a software engineer with educational experience, two obstetricians with an interest in medical education and an anaesthetist with experience of simulation- based teaching. The integration of potential users into the team allowed us to reflect on the PU and PEU of the app during the development process, before holding a formal evaluation session. Perceived usefulness Davis defines PU as ‘the degree to which a person believes that using a particular system would enhance his or her job performance’.9 It was decided that in order to enhance the ‘job’ of running a dynamic hybrid simulation scenario, the app must offer a number of key features (Box 1). Amongst the key features, the reproduction of the graphical foetal CTG trace proved to be the most challenging to achieve. Traces are classified by four main qualities: baseline foetal heart rate; variability (the degree to which the heart rate varies around the baseline); and
Figure 1. Technology Acceptance Model. (Reprinted with permission from Elsevier: Davis FD, User acceptance of information technology: system characteristics, user perceptions and behavioral impacts. The International Journal of Man–Machine Studies 1993;38:475–487.)
2 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 1–5
user expects to be able to use a system ‘out of the box’. On this basis, we assigned equal importance to usability and usefulness.
Box 1. Key features of the cardiotocograph (CTG) simulator app • Realistic reproduction of visual and auditory CTG signals. • Ability to display normal and pathological CTG traces, and to replicate common errors. • Ability to display maternal observations (heart rate, blood pressure, oxygen saturations). • Capacity to operate on a single device or to link two devices together as a monitor and a remote. • Ability to pause, speed-up and review the CTG recording. • Real-time dynamic alteration of the CTG and vital signs, in response to deterioration or interventions.
accelerations and decelerations (increases and decreases above or below the baseline rate by a specified level and duration). In order to allow the user to manipulate these qualities, a mathematical model of each was developed and programmed. The models were subsequently refined through an iterative process, aiming for an accurate representation of a real CTG trace. In this respect it was essential to have obstetricians on the team who were able to use their clinical experience to optimise the ‘feel’ of simulated traces (Figure 2). Perceived ease of use Perceived ease of use is defined as ‘the degree to which a person
believes that using a particular system would be free from effort’.9 PEU has a causal influence upon PU (Figure 1): i.e. a system that is too difficult to use is not a useful system.9 Davis’ original findings suggested that PEU was less important than PU;9 however, this should be interpreted in the context of the original research. Usability expectations in the 1980s are likely to have been radically different to those in the ‘age of the app’. Although little evidence exists in the scientific literature to support this, there is compelling evidence in everyday life: it is now rare for computer software and hardware to be supplied with instruction manuals, indicating that the modern
Developing a user interface is a challenging aspect of software design, and an intuitive user experience is frequently stated to be the ideal model for human– computer interaction. The appropriateness of the word ‘intuitive’ is, however, controversial. Jef Raskin, the software engineer behind the Apple Macintosh, states that interfaces that appear to be intuitive are merely similar to other systems with which the user is already accustomed.10 He therefore suggests that ‘familiar’ is a more appropriate description, and this provides direction for producing easy-to-use software. We therefore decided to make use of a conventional control interface (Figure 3), combined with frequently-used smartphone ‘gestures’, such as turning the device from portrait to landscape to change from the control screen to the monitor screen, and swiping left and right to review the CTG trace.
Key feature is realistic reproduction of visual and auditory CTG signals
Evaluation An obstetric simulation day for junior doctors provided an opportunity to evaluate the initial
Figure 2. Screen shot of the tracings produced by the cardiotocograph (CTG) simulator app
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 1–5 3
monitor, and the creation of a ‘home screen’ to simplify the process of linking devices together wirelessly.
[The App] offers the potential for health care professionals to develop and access simulationbased education who were previously unable to do so
Figure 3. Screen shot of the control screen of the cardiotocograph (CTG) simulator app
prototype app. Eight doctors with a median of 1.5 years of clinical obstetric experience gave informed consent to participate. The process consisted of 30 minutes of practise with the app followed by the completion of an individual anonymous standardised questionnaire, concentrating on realism (the only subjective PU variable) and PEU, and then concluded with a focus group involving all eight participants. To properly assess PEU it was decided to withhold instruction on using the app in advance, encouraging participants to discover how to use it during the practise time. The focus group was recorded digitally, then transcribed and anonymised. Using the method described by Braun and Clarke,11 a thematic analysis of the data was undertaken by one author (CS) in order to organise themes relating to PU and PEU. All participants found the app easy to use and operate effectively. Suggested refinements included clarification that turning the device from portrait to landscape mode allowed the user to switch from controller to
Realism presented more of a challenge, and although the feedback was positive overall, it was noted by one participant that a degree of operator expertise is required in order to make the trace ‘reasonably realistic’, and by another that it would be more realistic if changing the maternal observations automatically impacted on the CTG trace (i.e. a maternal pyrexia would provoke a foetal tachycardia). These are valid observations, and provide insight into a universal truth about the current state of technology in simulation: that the person operating the simulator needs to understand the scenario and the implications of interventions. The evaluation results were used to further refine the app, and we were able to take account of all of the suggestions for improving PEU. The suggestions for improving PU were not implemented in full as this would require the development of an algorithm for the interactions between a patient’s organ systems, which is too complex a task for our small team to undertake.
CONCLUSION The development of a CTG simulator app has been a challenging and engaging process. We are currently on the cusp of publishing the iOS version on the Apple App Store, and although we have used a theory-based approach to app development and evaluation, this is merely the start of the journey for this software: the proof of our proverbial pudding will be in the eating. We hope that it will be well received by the people who choose to use it, and look forward to using the App Store’s
4 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 1–5
built-in feedback to inform further improvements, as well as conducting further evaluation and research once the app is implemented in our own educational practice. One of the most exciting aspects of developing a patient monitoring simulation app is that it offers the potential for health care professionals to develop and access simulation- based education who were previously unable to do so. It is our hope that this article will provide motivation and advice for others who wish to undertake similar projects. REFERENCES 1. National Institute for Health and Care Excellence (NICE). Intrapartum care: care of healthy women and their babies during childbirth. CG190. London: NICE; 2014. 2. Stewart J, Guildea Z. Knowledge and skills of CTG interpretation. British Journal of Midwifery 2002;10:498–504. 3. Young P, Hamilton R, Hodgett S, Moss M, Rigby C, Jones P, Johanson R. Reducing risk by improving standards of intrapartum fetal care. J R Soc Med 2001;94:226–231. 4. Pehrson C, Sorensen JL, AmerWåhlin I. Evaluation and impact of cardiotocography training programmes: a systematic review. BJOG 2011;118:926–935. 5. Nehring WM, Ellis WE, Lashley FR. Human patient simulators in nursing education: an overview. Simulation and Gaming 2001;32:194–204. 6. Friederichs H, Weissenstein A, Ligges S, Möller D, Becker JC, Marschall B. Combining simulated patients and simulators: pilot study of hybrid simulation in teaching cardiac auscultation. Adv Physiol Educ 2014;38:343–347. 7. Kneebone R, Kidd J, Nestel D, Asvall A, Paraskeva P, Darzi A. An innovative model for teaching and learning clinical procedures. Med Educ 2002;36(7):628–634. 8. Payne KF, Wharrad H, Watts K. Smartphone and medical related app use among medical students
and junior doctors in the United Kingdom (UK): a regional survey. BMC Med Inform Decis Mak 2012;12:121.
9. Davis FD. Perceived usefulness, perceived ease of use, and user
acceptance of information technology. MIS Quarterly 1989;13:319–340.
10. Raskin J. Intuitive equals familiar. Communications of the ACM 1994;37:17.
11. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006;3:77–101.
Corresponding author’s contact details: Clifford Shelton, North Western Postgraduate Deanery, Manchester, UK. E-mail: [email protected]
Funding: None. Conflict of interest: We intend to make the CTG simulator app available on the Apple App Store for a small fee. Acknowledgements: None. Ethical approval: As this was a software development process, ethical approval was not required and was not sought. The evaluation process involved discussion with National Health Service employees, and therefore ethical approval was not required for this (confirmed with institutional R&D department); however, the principles of the declaration of Helsinki were maintained through informed written consent, anonymisation and secure data storage. doi: 10.1111/tct.12462
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 1–5 5
Developing a CTG simulator app: theory and practice Jessica Ford1,*, Catherine Langley1,*, Adrian Molyneux2,* and Clifford Shelton1,* 1 2
North Western Postgraduate Deanery, Manchester, UK Medical School, Keele University, Stoke-on-Trent, UK
SUMMARY
Background: Cardiotocograph (CTG) interpretation is a core skill for health care professionals working on the labour ward; however, training appears to be deficient in respect of the development of decision-making skills relating to CTG findings. Simulation offers a potential solution to address such ‘human factors’. Current access to simulators is limited by cost and operational complexity. We therefore decided to develop an accessible CTG simulator application (‘app’) that could be operated on a smartphone, a
technology already possessed by the majority of health care professionals in the UK and elsewhere. Context: A multidisciplinary team with backgrounds in obstetrics, anaesthesia and information technology was assembled to undertake the software development process. An evaluation of the pilot software was undertaken by trainee obstetric doctors. Innovation: A software development project was undertaken in order to produce a mobile app that simulates CTG accurately and dynamically. This process was based on Davis’ Technology
Acceptance Model, in which usefulness and ease of use are the central principles. Implications: Mobile technology can be used to run simulation software that is both useful and easy to use; however, our evaluation indicated that in order to use the app effectively the operator requires some expertise in the behaviour of the CTG in response to interventions, in common with all current patient simulators. We envisage using this app in hybrid simulation scenarios, in which a live actor and a simulated monitor are used together.
CTG interpretation is a core skill for health care professionals working on the labour ward
*Joint first authors © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 1–5 1
Up to 94 per cent of health care professionals find their CTG training insufficient
INTRODUCTION
T
he cardiotocograph (CTG) is a means of electronically recording the foetal heart rate and pattern of uterine activity. National guidelines in the UK recommend CTG monitoring where there is increased risk to the foetus, and the analysis of the ‘trace’ can have profound influences on obstetric management.1 Cardiotocograph interpretation is therefore a core skill for health care professionals working on the labour ward; however, training appears to be inconsistent, with up to 94 per cent of health care professionals finding their CTG training insufficient.2 Furthermore, the majority of deficiencies in intrapartum care relate to poor decision making associated with CTG abnormalities, rather than their recognition.3 These factors, combined with the favourable attitude of health care professionals to technology-enhanced CTG training,4 present an opportunity for the development of simulation-based teaching to support existing training. Simulation is a dynamic field within medical education, advancing with the emergence of new methodology, research and technology. Modern whole- patient obstetric simulators are suitable for in-situ simulation, in which the simulator is used in the clinical environment; however, the expense of such devices and the level of training required to operate them makes them a very limited resource.5
Hybrid simulation, where an actor works in combination with a task-trainer or simulated patient monitor offers a solution to some resource issues associated with whole-patient simulation. Additional benefits include increased fidelity and an emphasis on interpersonal skills.6,7 Furthermore, scenarios can be run ad hoc, when the labour ward is not unduly busy. We therefore
hoped to introduce this simulation method to our practice, but existing CTG simulators were only available packaged with hardware and proved prohibitively expensive. We therefore developed a cost-effective solution that could be operated using hardware that we already possessed. The introduction of Apple’s iPhone in 2007 paved the way for the mass adoption of smartphones, and mobile devices have driven the personal technology agenda for the past decade. Contemporary devices feature the ability to install software known as ‘apps’, expanding their functionality beyond telecommunications into the realm of portable personal computing. Smartphone use is near ubiquitous amongst medical professionals in the UK: a 2012 study found that 75 per cent of junior doctors owned a smartphone, 76 per cent of whom used apps related to medical practice.8 The integration of mobile devices into health care means that nearly every health care worker already owns hardware with the potential to run a CTG simulation, and this provided the opportunity to develop our CTG simulator app.
APP DEVELOPMENT PROCESS In order for a technology to succeed potential users must commit to it. Multiple models for the adoption of technologies exist; however, Davis’ Technology
Acceptance Model (TAM) is one of the most well established, and has been validated by numerous studies.9 Two theoretical constructs are emphasised: the perceived usefulness of a technology (PU), and its perceived ease of use (PEU) (Figure 1). In order to focus the project in these areas, a multidisciplinary team was assembled to undertake the app development process, comprising a software engineer with educational experience, two obstetricians with an interest in medical education and an anaesthetist with experience of simulation- based teaching. The integration of potential users into the team allowed us to reflect on the PU and PEU of the app during the development process, before holding a formal evaluation session. Perceived usefulness Davis defines PU as ‘the degree to which a person believes that using a particular system would enhance his or her job performance’.9 It was decided that in order to enhance the ‘job’ of running a dynamic hybrid simulation scenario, the app must offer a number of key features (Box 1). Amongst the key features, the reproduction of the graphical foetal CTG trace proved to be the most challenging to achieve. Traces are classified by four main qualities: baseline foetal heart rate; variability (the degree to which the heart rate varies around the baseline); and
Figure 1. Technology Acceptance Model. (Reprinted with permission from Elsevier: Davis FD, User acceptance of information technology: system characteristics, user perceptions and behavioral impacts. The International Journal of Man–Machine Studies 1993;38:475–487.)
2 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 1–5
user expects to be able to use a system ‘out of the box’. On this basis, we assigned equal importance to usability and usefulness.
Box 1. Key features of the cardiotocograph (CTG) simulator app • Realistic reproduction of visual and auditory CTG signals. • Ability to display normal and pathological CTG traces, and to replicate common errors. • Ability to display maternal observations (heart rate, blood pressure, oxygen saturations). • Capacity to operate on a single device or to link two devices together as a monitor and a remote. • Ability to pause, speed-up and review the CTG recording. • Real-time dynamic alteration of the CTG and vital signs, in response to deterioration or interventions.
accelerations and decelerations (increases and decreases above or below the baseline rate by a specified level and duration). In order to allow the user to manipulate these qualities, a mathematical model of each was developed and programmed. The models were subsequently refined through an iterative process, aiming for an accurate representation of a real CTG trace. In this respect it was essential to have obstetricians on the team who were able to use their clinical experience to optimise the ‘feel’ of simulated traces (Figure 2). Perceived ease of use Perceived ease of use is defined as ‘the degree to which a person
believes that using a particular system would be free from effort’.9 PEU has a causal influence upon PU (Figure 1): i.e. a system that is too difficult to use is not a useful system.9 Davis’ original findings suggested that PEU was less important than PU;9 however, this should be interpreted in the context of the original research. Usability expectations in the 1980s are likely to have been radically different to those in the ‘age of the app’. Although little evidence exists in the scientific literature to support this, there is compelling evidence in everyday life: it is now rare for computer software and hardware to be supplied with instruction manuals, indicating that the modern
Developing a user interface is a challenging aspect of software design, and an intuitive user experience is frequently stated to be the ideal model for human– computer interaction. The appropriateness of the word ‘intuitive’ is, however, controversial. Jef Raskin, the software engineer behind the Apple Macintosh, states that interfaces that appear to be intuitive are merely similar to other systems with which the user is already accustomed.10 He therefore suggests that ‘familiar’ is a more appropriate description, and this provides direction for producing easy-to-use software. We therefore decided to make use of a conventional control interface (Figure 3), combined with frequently-used smartphone ‘gestures’, such as turning the device from portrait to landscape to change from the control screen to the monitor screen, and swiping left and right to review the CTG trace.
Key feature is realistic reproduction of visual and auditory CTG signals
Evaluation An obstetric simulation day for junior doctors provided an opportunity to evaluate the initial
Figure 2. Screen shot of the tracings produced by the cardiotocograph (CTG) simulator app
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 1–5 3
monitor, and the creation of a ‘home screen’ to simplify the process of linking devices together wirelessly.
[The App] offers the potential for health care professionals to develop and access simulationbased education who were previously unable to do so
Figure 3. Screen shot of the control screen of the cardiotocograph (CTG) simulator app
prototype app. Eight doctors with a median of 1.5 years of clinical obstetric experience gave informed consent to participate. The process consisted of 30 minutes of practise with the app followed by the completion of an individual anonymous standardised questionnaire, concentrating on realism (the only subjective PU variable) and PEU, and then concluded with a focus group involving all eight participants. To properly assess PEU it was decided to withhold instruction on using the app in advance, encouraging participants to discover how to use it during the practise time. The focus group was recorded digitally, then transcribed and anonymised. Using the method described by Braun and Clarke,11 a thematic analysis of the data was undertaken by one author (CS) in order to organise themes relating to PU and PEU. All participants found the app easy to use and operate effectively. Suggested refinements included clarification that turning the device from portrait to landscape mode allowed the user to switch from controller to
Realism presented more of a challenge, and although the feedback was positive overall, it was noted by one participant that a degree of operator expertise is required in order to make the trace ‘reasonably realistic’, and by another that it would be more realistic if changing the maternal observations automatically impacted on the CTG trace (i.e. a maternal pyrexia would provoke a foetal tachycardia). These are valid observations, and provide insight into a universal truth about the current state of technology in simulation: that the person operating the simulator needs to understand the scenario and the implications of interventions. The evaluation results were used to further refine the app, and we were able to take account of all of the suggestions for improving PEU. The suggestions for improving PU were not implemented in full as this would require the development of an algorithm for the interactions between a patient’s organ systems, which is too complex a task for our small team to undertake.
CONCLUSION The development of a CTG simulator app has been a challenging and engaging process. We are currently on the cusp of publishing the iOS version on the Apple App Store, and although we have used a theory-based approach to app development and evaluation, this is merely the start of the journey for this software: the proof of our proverbial pudding will be in the eating. We hope that it will be well received by the people who choose to use it, and look forward to using the App Store’s
4 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 1–5
built-in feedback to inform further improvements, as well as conducting further evaluation and research once the app is implemented in our own educational practice. One of the most exciting aspects of developing a patient monitoring simulation app is that it offers the potential for health care professionals to develop and access simulation- based education who were previously unable to do so. It is our hope that this article will provide motivation and advice for others who wish to undertake similar projects. REFERENCES 1. National Institute for Health and Care Excellence (NICE). Intrapartum care: care of healthy women and their babies during childbirth. CG190. London: NICE; 2014. 2. Stewart J, Guildea Z. Knowledge and skills of CTG interpretation. British Journal of Midwifery 2002;10:498–504. 3. Young P, Hamilton R, Hodgett S, Moss M, Rigby C, Jones P, Johanson R. Reducing risk by improving standards of intrapartum fetal care. J R Soc Med 2001;94:226–231. 4. Pehrson C, Sorensen JL, AmerWåhlin I. Evaluation and impact of cardiotocography training programmes: a systematic review. BJOG 2011;118:926–935. 5. Nehring WM, Ellis WE, Lashley FR. Human patient simulators in nursing education: an overview. Simulation and Gaming 2001;32:194–204. 6. Friederichs H, Weissenstein A, Ligges S, Möller D, Becker JC, Marschall B. Combining simulated patients and simulators: pilot study of hybrid simulation in teaching cardiac auscultation. Adv Physiol Educ 2014;38:343–347. 7. Kneebone R, Kidd J, Nestel D, Asvall A, Paraskeva P, Darzi A. An innovative model for teaching and learning clinical procedures. Med Educ 2002;36(7):628–634. 8. Payne KF, Wharrad H, Watts K. Smartphone and medical related app use among medical students
and junior doctors in the United Kingdom (UK): a regional survey. BMC Med Inform Decis Mak 2012;12:121.
9. Davis FD. Perceived usefulness, perceived ease of use, and user
acceptance of information technology. MIS Quarterly 1989;13:319–340.
10. Raskin J. Intuitive equals familiar. Communications of the ACM 1994;37:17.
11. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006;3:77–101.
Corresponding author’s contact details: Clifford Shelton, North Western Postgraduate Deanery, Manchester, UK. E-mail: [email protected]
Funding: None. Conflict of interest: We intend to make the CTG simulator app available on the Apple App Store for a small fee. Acknowledgements: None. Ethical approval: As this was a software development process, ethical approval was not required and was not sought. The evaluation process involved discussion with National Health Service employees, and therefore ethical approval was not required for this (confirmed with institutional R&D department); however, the principles of the declaration of Helsinki were maintained through informed written consent, anonymisation and secure data storage. doi: 10.1111/tct.12462
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 1–5 5
