A Qualitative Exploration of the Impact of a Distressed Family Member on Pediatric Resuscitation Teams

This was a qualitative study used to examine FPDR-related themes raised by pediatric resuscitation team members after a resuscitation simulation. This study was part of a multicenter interventional study used to examine the effects of team training on adherence to resuscitation guidelines.¹⁹  This study was conducted between 2011 and 2015 at the simulation centers affiliated with 4 academic children’s hospitals located across Canada. Institutional review board approval was granted at each institution, and written informed consent was obtained from all participants. Participants were made aware of the study’s primary objective but were unaware of the specific challenges built into the scenarios ahead of time as well as the specific research question for this study.

As part of the team training educational intervention, pediatric resuscitation teams, composed of nurses, respiratory therapists, and resident physicians, participated in a video-recorded simulated event in which they attempted to resuscitate an infant in asystole (Supplemental Information). The teams ranged in size from 5 to 7 participants, with varying levels of previous exposure to one another. During the scenario, a confederate actor played the role of “parent.” Actors were trained to act concerned, ask the team questions, and remain in the room. They were not allowed to become physical with the team or intentionally prevent patient care, such as covering the patient with their body. They were instructed to adjust their known presence in the room depending on if they were addressed by the resuscitation team or not. There was no specific previous training provided to participants regarding effective management of the parent; however, teams were trained on concepts related to effective teamwork, including the importance of managing distractions.

Video-recorded debriefs occurred immediately after each simulation, facilitated by 1 or 2 trained instructors. The advocacy-inquiry framework²⁰  was used to structure each debrief, and teamwork was the primary focus of the discussion, with less emphasis placed on medical or clinical issues.

All debrief events were reviewed by the study team for audio quality and richness of participant discussion. On the basis of this review, a purposive sampling technique was then implemented to identify a subset of debrief discussions that provided a wide variety of participant perspectives and study site representation. The selected video recordings were then transcribed verbatim.

Transcripts were coded and analyzed via thematic analysis to saturation. Consideration was given to code versus meaning saturation.²¹  Thematic analysis was used to identify and group themes.²²  Using NVivo software,²³  the lead author generated the initial codes, and the constant comparison method was employed to expand or merge thematic codes. Two coauthors independently coded a subset of the videos. Discussion then took place to compare codes and create a final code index. This final coding scheme was then applied to all transcripts by the lead author and second coder to ensure relative consistency of code application to FPDR-related comments. On the basis of this coding, themes were identified, and a thematic map was developed. Themes were further defined and named before the development of a final model that described the interaction between themes. Throughout this process, the theories of team adaptive processes were applied as a sensitizing concept.

Thirteen postsimulation video debriefs were analyzed, sampled from the original data set of 42 videos. A total of 74 participants took part in these simulations and debriefs, including 32 nurses, 15 respiratory therapists, and 27 resident physicians. Analysis revealed 15 major and 29 minor themes, which were mapped to 5 factors, namely resuscitation environment, affective responses, cognitive responses, behavioral responses, and team dynamics (Fig 1).

Three major themes were identified regarding how the presence of a parent changed the resuscitation environment: (1) “additional voice and questions” (teams voiced struggling with the added volume and questions the parent brought to the situation, sometimes making it difficult to hear and focus on tasks); (2) “parent physically in the way” (team members described the parents physical location in the room interfering with access to medical equipment, the patient, and/or not being able to perform necessary procedures); and (3) “limited people” (teams reported not having enough members to dedicate someone to the parent, a role they reported as needed) (Table 1).

The second factor addressed how the team reported feeling emotionally during the simulation. Four major themes were identified. “Environmental reactions” involved how team members mentioned the realism of the parent (ie, confederate actors), affirming that they thought it was common for parents to not understand, ask questions, want to be close to their child, and want to be present. Many noted that the parent may have exacerbated an already stressful situation, making the event more challenging to manage, and that it was another energy and voice, so everything was heightened.

The parents’ well-being was a common concern of the team and was captured by the theme “need to support parent.” Participants commented on how they felt the need to talk to the parent, give them good news, reassure them, and to overall support them. If this could not be done, some expressed feelings of anxiety and guilt. They described having a difficult time ignoring the parent and wanted someone (themselves or another) to be with the parent for the entire resuscitation.

Next, teams discussed “struggles with the parent.” They voiced frustration and feeling uncomfortable when the parent was physically in the way. Others expressed anxiety over how the parents may behave (eg, interfering with resuscitation or becoming violent) when they were left without support. Many expressed not feeling confident in their approach to managing and speaking to the parent, which led to noted feelings of helplessness, guilt, irritation, and frustration.

The final major theme was “affective reactions towards FPDR.” Immediately after the simulation, participants articulated pro- and anti-FPDR views. Pro-FPDR comments included feelings that the parent should be in the room during the resuscitation, citing that it helped the parent, the parent should be there because the child may die, it was a right of the parent, and it was in accordance with family-centered care. Anti-FPDR comments, although uncommon, stated that the resuscitation process would be more effective if the parent was not present. It was expressed that no matter where they put the parent in the room, it would “hamper” some team member(s) and that the ideal situation is no parent in the room (Table 2).

Three themes were identified describing cognitive influences of FPDR. One of the more concerning themes was the “increased cognitive load” brought by the parent’s presence. A typical resuscitation requires high amounts of information processing, which requires cognitive energy and creates a cognitive load. The parent appeared to add to this existing cognitive load by asking questions. This created a dilemma about whether and how to answer, as well as increased worry for the parent and engagement in actively trying to tune them out. This may have led to the team describing that the parent could cause a “loss of focus” on the task because they were a source of distraction. Whereas some identified the extra excitement the parent brought to the code or the addition of their voice to the situation as a possible source of distraction, many participants emphasized the parent asking questions as the primary challenge. Some reported being distracted even when the parent was asking other team members questions. Team members spoke of being concerned by the distraction because they feared it drew focus away from the patient and their tasks and led to forgotten tasks or disruption of normal procedure. Possibly in reaction to this, members described making a conscious decision to “prioritize patients” over the parent. Some even stated that parent management was not their job (Table 3).

Teams often recognized early on that they required a dedicated person to take on a “parent management role.” This was approached in 1 of 3 ways, as detailed by participants: (1) leaders either took on the management role themselves or assigned it to a team member, (2) team members self-assigned to the role in full or in addition to their current roles, or (3) availability dictated who took on this role, resulting in people on the team taking turns with the parent rather than having 1 person on the team dedicated to the parent. The third approach appeared to be the most common path chosen.

Next, “parent management approach” was identified as a major theme. These ranged from exclusive to inclusive. If the parent was deemed to be a distraction and there was no one able to manage them, then respondents stated that the parent should be removed from the room. Team members spoke of an ultimatum in which the parent could watch but they had to cooperate. Some members spoke of tuning the parent out so as to not be distracted, or giving them minimal attention, which typically included a cursory explanation followed by ignoring them. On the more inclusive side, some people reported seeing the value in the parent’s presence in terms of providing a possible history. However, it appeared to put a strain on the team to assign a team member to leave and take the history. Others described actively interacting with the parent with the purpose of giving the parent updates. Cited reasons for updating the parent included to (1) comfort and reassure the parent, (2) calm them down so as to aid the team (decrease questions and emotions), and (3) instruct them (ask them to give the team space to work and to physically move) (Table 4).

The fifth factor concerned the identification of crucial team processes and states that were affected during the resuscitation simulation.

Effectively managing the parent required additional team “coordination,” as team members discussed dealing with a lack of people, having to call for help, taking turns with the parent, and providing back-up behaviors for teammates. Although some of this was done implicitly (ie, it was done without being verbally asked), people highlighted the need for explicit coordination because some assumptions led to disappointment when team members did not exhibit desired behaviors. However, the parent posed a challenge to closed-loop communication by adding to both the volume in the room and the number of questions asked, which participants noted made it difficult to hear and easy to miss information. One protective factor discussed as crucial for maintaining high performance was mutual monitoring, a cognitive action in which teammates regularly observe each other to catch slips, mistakes, or errors, so they can correct them as rapidly as possible,²⁴  and back-up behavior via verbal feedback and/or assistance.^25–27  This was especially helpful in instances in which an individual was attempting to do their job while simultaneously trying to answer the parent’s questions. In such cases, ideally, other team members would take on the parent management role to help the team member refocus on their task.

Members’ “roles” were affected during the process in numerous respects. Role confusion occurred during uncertainty about who should be managing the parent. This led to the occurrence of dual roles despite many individuals reporting that dual roles created focus and situational awareness challenges. To include the extra role of parent management into the resuscitation, team members described finding that they had to effectively alternate roles on the fly. This was supposedly due to the leader reassigning roles for periods of time, then temporarily taking on the role of parent management, or helping out a team member and switching roles with them. The key to this being done successfully was mentioned numerous times as effective usage of closed-loop communication.

Finally, team members expressed attempting to maintain “team situation awareness,” which is a “shared understanding of a situation among team members at one point in time.”²⁸  Some teams were able to achieve situational awareness more efficiently than others and maintain it throughout the scenario, usually attributing this to strong closed-loop communication. However, individuals noted that it was challenging to maintain strong team situation awareness after engaged with the parent because they lost track of the team’s activity (Table 5).

In the current research, we identified themes representing teams’ responses to family presence. This was done by analyzing debriefings of a simulated resuscitation event with the presence of a distressed confederate parent. In general, the presence of a parent created a change in the environment that most team members felt unprepared to handle. The parent was found to be distracting because of questions, physical positioning, and added noise level. Teams typically reported that the parent had to be actively managed to minimize potential effects on the team. However, this appeared to pose numerous challenges such as identifying how best to manage the parent, identifying whose responsibility it was to take on this task, and maintaining high performance.

The debriefs contained a wide range of strategies for parent management, all with potentially different levels of effectiveness. Most were chosen from an individual’s past experiences or via improvisation. However, many expressed lacking confidence in their chosen strategy. Furthermore, this reactive, disjointed strategy resulted in multiple individual strategies being employed simultaneously instead of a possibly more effective united team-based strategy. Interestingly, not all teams fell victim to this fractured approach to parent management. Although still relying on past experience and improvisation in most cases, we found that some teams effectively managed the situation by using closed-loop communication to create a shared mental model, redistributing roles to meet demands, and applying back-up behavior to prevent errors.

Given our observations, there appears to be the potential for FPDR to compromise team performance, potentially adversely affecting patient outcomes. Team members noted the parent sometimes took focus away from their tasks. Behaviors that exacerbated the issue included asking questions, being another voice in the room, being physically in the way, and causing anxiety in team members. This was usually compounded because there were not enough people to have someone dedicated to the parent, which allowed us to see more clearly the effects of the parent on the team without the presence of a support person.

When individuals think about an off-task demand, it has been shown that this decreases the likelihood that they will perform to their full potential.²⁹  If a team member’s cognitive load is too great then there is an increased risk of error. These demands may be further amplified if they elicit an emotional response. If team members are unable to control their affective responses, then arousal, anxiety, and rumination may affect the effectiveness of task-related information processing and thereafter performance.^29–31  These effects can be exacerbated when performance is highly complex,²⁹  like resuscitation. Although there was discussion of selective attention, which is deciding what to pay attention to (usually what is highly relevant and important) and can improve under times of high stress,³²  it is common for perceived threatening stimuli to be categorized as highly relevant; thus, attention can be directed to task-irrelevant stimuli.³¹  This may mean many team members may still have been distracted by the parent even if they engaged in conscious prioritizing of the patient. This may result in too high a cognitive load, increasing risk of errors.³¹ 

This study has several limitations. First, the resuscitation was a simulation, which may question the generalizability of our findings to real life. However, simulation can be effective when environmental, physical, and psychological fidelity are high.³³  We argue that our study simulations met these requirements (see Supplemental Information). Therefore, it is reasonable to assume that team members behaved similarly to how they would have during a real event, making their responses recorded during the debriefs valid. Second, there may not have been adequate standardization of the confederate actors’ portrayals of the parent. Although scripted, there was still some variation in actor behavior; however, we believe this may increase the generalizability of our findings. Family members’ reactions can be extremely varied during a resuscitation, suggesting that variance in performances from the confederate actors may have aided in eliciting and capturing a wider range of themes than a completely standardized scenario would have. Third, although we feel we were able to capture an encompassing range of responses that ideally reflect the majority of themes that would emerge, our findings may not be applicable to parent behavior that would be characterized as representing ends of the spectrum (be it an extremely quiet and distant family member or an extremely loud and disruptive family member). Fourth, the confederate actors were known to participants in many cases because they held a clinical position at the hospital, which could have impacted the realism of the scenario. However, provided the range and intensity of the themes identified by health care professionals, we believe the effects, if any, were limited. A final potential limitation is the makeup of the team and scenario. For example, team leaders were resident physicians, and at their stages of training, they may not be as comfortable with resuscitation to also deal adequately with the added complexity of FPDR.

We present 4 recommendations that may help future researchers and educators address some of the themes identified in this study. (1) Guidelines that require a support person dedicated to managing the parent at all times should be incorporated. This will help to prevent the parent from being physically in the way, redirect their questions away from the team, and overall reduce any distraction and anxiety in the team. (2) Strategies to best manage FPDR should be developed further. The literature would benefit from the continued proposal and experimental testing of strategies for educators to use when providing training on this topic. (3) Teams should be educated and trained in managing FPDR. This will likely increase team members’ comfort with FPDR and increase comfort with communicating with the parent.³⁴  Training may help decrease team members’ anxiety and, ideally, reduce their cognitive load. Education can also help teams have a contingency plan for how best to manage the parent.³⁵  (4) Teams should be trained in effective overall team skills. Teamwork behaviors, such as closed-loop communication and back-up behaviors, likely translate into decreased error and consequent improvements in patient safety.^36–39 

Our objective with this research was to identify themes of how team members responded to the presence of a distressed family member during a resuscitation. This was approached from multiple angles including affective, cognitive, behavioral responses, and team dynamics. Using this more holistic view, we believe we now better understand how resuscitation team members respond and adapt to parents’ presence, how they may struggle, and how patient safety may be affected. Policy, education and training, and teamwork skills were identified as areas for future growth to better equip health care providers to effectively manage FPDR.

This work was made possible by the help and assistance of Logan Van Roessel and Jobair Jaber who volunteered their time to help review and code the videos. We thank Dr Jocelyn Lockyer for her consultation and guidance on the method. We also thank those who assisted with running the simulations and debriefs, as well as the health care providers who took part in the simulations, because they contributed to further advancing our knowledge on this topic.