Impact of the neonatal resuscitation video review program on neonatal staff: a qualitative analysis

A qualitative approach was taken to examine individual clinicians' detailed responses to NRVR. A social constructivist approach was used, in which learning occurs through interaction with the help of others.²⁷ The processes of NRVR are consistent with social constructivism in that physicians observe a resuscitation and are then guided by a facilitator as they observe and reflect on the event.

Video review procedure for newborn resuscitation

Video recordings of resuscitation of infants born in Year 1, Biopac, Acqknowledge, USA are made.

For the group discussion, videos are selected (DB) to either demonstrate a specific scenario or discuss lessons learned from resuscitation (e.g., strengths and areas for future improvement). If a video captures a significant deviation from the standard of care or a potentially distressing event for the clinical team, such as a death during resuscitation, it will be forwarded to the NICU director for comment prior to broadcast.

Description of NRVR sessions

Individual session

Doctors recorded leading a resuscitation can first review their video with a senior doctor (DB). In a one-on-one discussion session, the recording is viewed in full without interruption until physiological stability is achieved. The video is then periodically restarted and paused to identify moments of clinical significance, facilitate review of resuscitation, and identify points for future improvement. After individual review, physicians may decline to show the video in group sessions.

Group meeting

The group sessions were attended by 4 to 10 people, which may have included the doctors who were present at the birth and appear on the video. At the beginning of each session, all participants sign an agreement to maintain confidentiality regarding the identity and performance of the recorded individuals and all discussions during the session. This written agreement includes the basic assumption: “We believe that everyone featured in this video and participating in the video review is intelligent, capable, doing their best and wants to improve.”²⁸ The moderator repeats the basic assumption verbally before starting the session. As with individual reviews, the recording is first shown in its entirety to give viewers an overview of the resuscitation. After a break to discuss first impressions, the video starts again. The moderator (DB, a senior physician with experience in video teaching) frequently pauses the video and guides the discussion. Key areas of focus include preparation for resuscitation, quality of communication, clinical decision making, and physiological response of the newborn. When the video is paused, participants are encouraged to discuss what happened and ask questions.

During the study period, regular video review teaching sessions (1–3 per month) were held separately for physicians and nurses. This is partly due to scheduling difficulties in coordinating sheltered teaching for nurses and physicians and partly due to maintaining smaller group sizes. Clinicians in training (e.g., residents, fellows, junior nurses) are encouraged to participate in NRVR sessions as part of their training. Transferring medical or nursing students may also attend NRVR sessions.

Study participants

The study population consisted of physicians and nurses who had attended an NRVR session in the past 6 months. Potential participants were recruited via email or text message containing an explanation of the study. Interested participants contacted us again and an interview was arranged. Interviews were conducted in a private room or via Zoom with written consent.

Interview protocols were reviewed regularly to ensure that clinicians with varying levels of experience were represented among study participants. A targeted approach to recruitment was used in the later part of the study period to ensure senior clinicians were adequately represented.

Data collection

All interviews were conducted (by ZW or AK) using a semi-structured interview guide (Appendix 1) developed by the research team and pilot tested prior to data collection. Questions included topics such as resuscitation (e.g., “What do you think helps resuscitation go well?”) and their experiences with NRVR (e.g., “How do you find the experience of reviewing videos in a group?”). Where possible, questions were asked open-ended to encourage discussion without restricting answers.

Before beginning the interview, participants were informed that their answers would be confidential and that identifying data would not be shared outside the research team. The interviews were audio recorded and a verbatim written transcript was created using transcription software (Otter.ai, USA), with identifying data (e.g. names) manually removed. Audio recordings were reviewed to ensure nuances were correctly interpreted and transcripts were checked for accuracy. Participant characteristics (e.g., job title and experience level) were also recorded. If desired, participants were able to listen to the interview recording or read the transcript. Repeated interviews were not conducted.

Data analysis

Transcripts were analyzed using Braun and Clarke's six-stage model of reflexive thematic data analysis.²⁹ Five researchers (ZW, DB, AK, DN, and AB) shared transcript analysis, and each transcript was examined and coded by at least two researchers. Coding involved identifying ideas or concepts that a researcher finds interesting in a participant's response.²⁹

Several meetings were then held at which the researchers presented their coding results.²⁹ Where there were discrepancies in the coding results, these were discussed by all present to reach consensus. Codes were identified that recurred frequently and were considered important by the research team. During these meetings, multiple theoretical perspectives were considered in interpreting the coding results, using Kolb's theory of experiential learning to construct the process of participant learning in NRVR.³⁰

Related or similar codes were then transformed into themes aimed at identifying the underlining ideas in participants' responses. These topics were also discussed, reviewed and refined.²⁹ A statement on reflexivity detailing each researcher's role and relevant experiences can be found in Appendix 2.

Theoretical support

Kolb's experiential learning theory was used as a theoretical basis to understand participants' responses to NRVR (Fig. 2). Kolb describes learning as a four-stage cycle in which, after a “concrete experience” (i.e. participating in NRVR), the learner reflects on their experience (e.g. watching the video, reflecting and participating in the replay) and identifies relevant learning points (i.e. abstract conceptualization) and puts new skills into practice from these earlier phases; “active experimentation”.³⁰