Table 3.

Descriptive theme iteration and SoF development

Q	Early descriptive theme	Emergent themes	SoF	Studies contributing
Q1	Clinical skills to avoid instrumental birth	Non-technical skills	Non-technical skill expertise is essential to the optimal use of AVD	Bahl 2010; Bahl 2013b; Simpson 2015; Alexander 2001; Sarangapani 2018 [17, 19, 21, 41, 43]
	Behaviours
	Decision making (multiple points of decision-making)
	Clinical skills-assessing the clinical picture	Clinical skills-assessing the clinical picture	Broader clinical skills are essential to the optimal use of AVD	Bahl 2013b; Hodges 2015; Alexander 2001; Ramphul 2012; Sarangapani 2018; Simpson 2015 [16, 20, 34, 36, 40, 42]
	Additional tools	Technical skills	Technical skills expertise is essential to optimal use of AVD	Bahl 2008; Bahl 2013a; Simpson 2015 [17, 19, 42]
	Rotating the fetus
	Angles and force
	Checklist
Q2	Specific training	Proactive teaching, specific training and supervision	Proactive teaching, specific training and supervision are essential to achieving competence and expertise	Evans 2009; Smith 1991; Simpson 2015; Hamz 2020; Hankins 1999; Healy and Laufe 1985 [28, 31–33, 42, 43]
	Close supervision
	Proactive teaching
	Poor communication by staff (rationale/lack of explanation)
	Implementing learning following training
	Exposure to being taught AVD	Exposure and gaining experience	Exposure to AVD including a range of instruments and the provision of opportunities to gain experience is essential to achieving competency and expertise	Bofill 1996a; Bofill 1996b; Healy and Laufe 1985; Saunier 2015; Crosby 2017; Eichelberger 2015; Powell 2007; Rose 2019; Sanchez del Heirro 2014; Smith 1991; Wilson and Casson 1990; Alexendar 2001; Al Watter 2017; Chinnock 2009; Fauveau 2009; Friedman 2020; Hamza 2020; Robson and Pridmore 1999; Sarangapani 2018 [15, 16, 22–25, 29–31, 33, 35, 37–41, 43, 45, 46]
	Experience
	Expectation of the course/program leads
	Lack of exposure/opportunity
	Safety and/or litigation concerns	Attitudes /beliefs	The attitudes and beliefs evident in the training programme, work environment or individual practitioners appears to influence the attainment of competence and continued use of AVD	Bofill 1996a; Bofill 1996b; Hankins 1999; Devjee 2015; Eichelberger 2015; Powell 2007; Ramphul 2012; Robson and Pridmore 1999; Smith 1991; Wilson and Carson 1990 [23, 24, 27, 33, 36–38, 44, 46, 47]
	Attitudes /beliefs
Q3	Challenges when teaching others	Access (or lack of) to teachers/training	Access (or lack of) to training courses and/or willing clinical mentors influences the implementation of AVD training	Devjee 2015; Powell 2007; Healy and Laufe 1985; Rose 2019; Wilson and Casson 1990; Sarangapani 2018; Bahl 2008; Al Watter 2017 [15, 17, 26, 33, 35, 38, 40, 45]
	Lack of opportunity
	Lack of experienced teachers/mentors
	Increased consultant cover
	Access to teachers/ training
	Colleagues proactive in teaching skills of AVD
Q4	Wanting more training	Training needs	Access to training in AVD is sought after and valued by some practitioners	Biringer 2019; Al Watter 2017; Devjee 2015; Bofill 1996b; Wilson and Casson 1990; Powell 2007 [15, 21, 23, 26, 35, 45]
	Concerns regarding lack of training/skills
	Training increases competence and confidence	Training relates to competence, confidence, job satisfaction and influences later clinical practice	Training enhances competence, confidence, job satisfaction and influences later clinical practice for some practitioners	Evans 2009; Alexander 2001; Biringer 2019; Eichelberger 2015; Powell 2007; Al Watter 2017; Chinnock 2009; Smith 1991 [15, 16, 21, 24, 28, 35, 43, 46]
	Increased job satisfaction
	Competence influences later clinical practice
	Videos as a supportive teaching tool	Supportive teaching tools	Practical teaching tools were valued by participants	Sarangapani 2018; Al Watter 2017; Devjee 2015; Healy and Laufe 1985; Rose 2019 [15, 26, 33, 38, 40]
	Simulation as a supportive teaching tool