An Exploration of Cognitive Ergonomics in Neonatal Resuscitation

  • Author / Creator
    Zehnder, Emily
  • Each year 13-26 million infants worldwide will require neonatal resuscitation at birth. Care provided during neonatal resuscitation can range from suctioning the infant’s airways and providing stimulation to endotracheal intubation and chest compressions. Healthcare providers (HCPs) must be able to evaluate the infant and provide appropriate interventions rapidly and effectively. However, human errors in neonatal resuscitation occur in 16-55% of cases. Most medical errors that result in poor patient outcomes are due to deficiencies in non-technical rather than technical skills. Non-technical skills involve the interpersonal and cognitive skills that underpin technical performance.
    Several non-technical skills that have been examined in neonatal resuscitation include information gathering, situation awareness, decision making, communication, and teamwork. Many of the existing studies of non-technical performance in neonatal resuscitation examine these aspects independently of one another and take place in simulated settings. Cognitive task analysis is a group of methods used in the study of cognition in applied or naturalistic settings. These methods allow for the study of clinical practice as a social and situated task.
    In this thesis, I examined the cognitive processes of a group of HCPs who acted as airway leads during neonatal resuscitation. I also characterized HCPs’ perceptions of workload during neonatal resuscitation.
    I recorded ten clinical neonatal resuscitations from the point-of-view of the HCP acting as the airway manager using mobile eye-tracking glasses. These glasses record the procedure from the point of view of the wearer and record where the wearer is looking by analyzing pupillary movements. Following the resuscitation, I asked the individual who wore the eye-tracking glasses to participate in a debriefing study and review the own-point-of-view eye-tracked recording of the resuscitation. While watching the video, HCPs were asked to “think aloud,” verbalizing their thought process throughout the resuscitation. The participants’ retrospective think-alouds were paired with semi-structured interviews. The debriefing studies were audio-recorded, transcribed, and coded using thematic analysis.
    Five overall themes were identified in the debriefings: situation awareness, performance, working in teams, addressing threats to performance, and perception of eye-tracking review.
    During the debriefings, excess workload was identified as a potential threat to HCPs’ performance. This relationship has been described in many clinical settings where excess workload has been associated with delays, errors, and negative effects on the healthcare team, such as fatigue, stress, and illness. Therefore, our second project aimed to characterize workload experienced by HCPs who participate in neonatal resuscitation. In this project, we also examined the effect that parental presence during resuscitation had on HCP experience of workload to address concerns that parents' presence may contribute to HCP workload and therefore compromise care.
    Perceived workload was measured using a multi-dimensional retrospective National Aeronautics and Space Administration Task Load Index (NASA TLX) survey. The NASA TLX collects data on six dimensions: mental, physical, and temporal demand, performance, effort, and frustration. Each dimension is rated independently by participants on a scale of 0-20 (0 being lowest and 20 being highest). The Raw-TLX score is a composite score of all dimensions and is presented on a scale of 0-100. HCPs completed a paper and pencil survey after attending delivery room resuscitations over a three-month period. A total of 204 surveys were completed. The overall median (interquartile range) Raw-TLX was 34(18-49). The scores varied by dimension. Overall workload of neonatal HCPs was higher during resuscitation of infants with lower 5-minute Apgar scores and those who required more invasive procedures. Overall workload of HCPs was significantly lower when at least one parent was present compared to when no parent(s) were present during the resuscitation.
    These studies were limited in their scope and size, but they demonstrate the feasibility of two novel methods in this setting. The study of HCP non-technical performance may inform policy, equipment design, team assignment, and training in neonatal resuscitation. Ultimately this may improve the safety of neonatal resuscitation.

  • Subjects / Keywords
  • Graduation date
    Fall 2020
  • Type of Item
  • Degree
    Master of Science
  • DOI
  • License
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