Maternity staff experiences of asking for help using escalation visual management tools: the significance of colours and their meanings for supporting shared decision-making.

Visual management tools (VMTs) in healthcare are used to relay information quickly for shared cognition. They can include quality improvement display boards, and coloured corridor markings. This doctoral study focused on 3 types of VMTs to investigate their role inthe context of acute illness and escalation of care in maternity settings. Methods included interviews with 55 maternity staff to explore their experiences of asking for help using VMTs, in particular how the content and design of escalation VMTs contributes to team decision making in maternity services.This research evidenced the importance of colour in healthcare visual management for sharedunderstandings. Where RAG ratings (Red/ Amber/ Green) were employed, red was observed by users to create noise, providing permission for staff to shout loudly. This focusing of attention empowered staff to bypass hierarchies of accountability and initiate rescue. Amber was seen as a middle of the road colour which might buy staff time in delaying escalations, but which came with an increased workload in terms of repeated observations. White shaped professional levels of engagement, providing reassurance that doctors could move on to the next patient. Colour specificity was a factor in escalation, and colour was seen as a tool for learning in an industry with a heavy reliance on locum staff with geographical mobility. This research highlights the significance of VMTs for efficiency (allocation of resources), shared repertoires (shared language), and for providing legitimacy for staff voice in bridging hierarchical and professional boundaries.