704 Exploring the impact of human factors and hierarchy in communication and followership during paediatric and neonatal emergency situations: a qualitative study

Abstract

<h3>Background</h3> Paediatric and neonatal emergencies are rare but may be associated with high morbidity and mortality, and require skilled leadership, good communication including ability to call-out critical information, active followership and teamwork. Hierarchy may also impact on those factors and affect the outcome. <h3>Objectives</h3> Our study explores human factors and hierarchical structures that impact communication, call out and followership during paediatric and neonatal emergencies. <h3>Methods</h3> A semi-structured audio recorded interview study was carried out across multiple UK hospitals. Health professionals from different backgrounds (doctors, nurses, nurse practitioners and midwives) involved in neonatal and paediatric emergencies were invited to reflect on their experience of resuscitation scenarios. Their views on human factors and hierarchy were also explored. Demographic data and self-reported confidence during certain aspects of resuscitation were also collected. These interviews were transcribed and analysed using an inductive approach according to grounded theory framework. <h3>Results</h3> 25 people were interviewed, describing 60 scenarios: Within the scenarios discussed, communication issues occurred in 44%, followership and teamwork issues occurred in 24%, and hierarchy had a negative impact in 40% of cases. Barriers to communication included lack of experience or familiarity of team members, unfamiliar environments or being within a big team. Ability of members to do a call-out depended on fear of undermining colleagues, having had a prior negative experience and a steep, rigid hierarchy. Parents had a significant negative impact on effective communication, particularly discussions regarding stopping resuscitation and on the ability to call-out. Followers were likely to act passively based on their personality, experience, exposure and reflection to previous scenarios, but more likely to follow actively if there in a smaller group, supported by other team members, with good role allocation and having a clear leadership encouraging a shared mental model during the resuscitation. There were different expectations and perceptions of leadership from different team members within the hierarchies experienced, with leadership unclear in 21% of scenarios. Leadership varied depending on the case, team composition, type of scenario and hospital. Flattened hierarchical structures were seen in paediatrics and neonates, but expression and experience of an innate ‘chain of command’ persisted across all professional participants. Team members in tertiary hospitals were more exposed to complex cases, had more regular resuscitation training and felt more confident with intensive care unit support on-site. They therefore were more active followers during resuscitation scenarios. <h3>Conclusions</h3> Human factors impact on communication, call-out, teamwork, leadership, followership and hierarchy during paediatric and neonatal emergencies. These seemed to improve with regular in-house simulation training involving multiple specialities. The presence of parents in this study also had a significant negative impact on communication, including decision to stop resuscitation and performing call-outs. Human factor training should focus on dealing with this aspect during resuscitation, along with finding ways to establish clear leadership, and for leaders to be able to empower passive followers within the team.