Neonatal Resuscitation: A Critical Incident Technique Study Exploring Pediatric Registered Nurses' Experiences and Actions : Advances in Neonatal Care

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Professional Growth and Development

Neonatal Resuscitation

A Critical Incident Technique Study Exploring Pediatric Registered Nurses' Experiences and Actions

Karlsson, Lina RN; Gustafsson, Ulrica RN; Thernström Blomqvist, Ylva PhD, RN; Wallström, Linda MD, PhD; Broström, Anders PhD, RN

Editor(s): Zukowsky, Ksenia PhD, APRN, NNP-BC, Section Editor

Author Information
Advances in Neonatal Care 23(3):p 220-228, June 2023. | DOI: 10.1097/ANC.0000000000001063
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Neonatal resuscitation involves emergency care of seriously ill newborns.1,2 Approximately 1 in 10 newborns are in need of some support after birth,3 but for 1 in 1000, the situation will be life-threatening and advanced neonatal resuscitation is required. The neonatal resuscitation program (NRP) guidelines are issued by the European Resuscitation Council1 in collaboration with the International Liaison Committee on Resuscitation.2 The implementation of NRP protocols in neonatal intensive care units (NICUs) and relevant disciplines aims at having a trained team at every resuscitation event. In Sweden, as in many other countries, protocols for the NRP are used for structured training in technical skills, compliance to recommendations, team communication, and simulation of resuscitation. Resuscitation is a team effort. It involves staff from different professions coming together in acute and unexpected situations where action must take place in a quick, safe, and structured manner.4 All Swedish NICUs have routines for emergencies involving a newborn infant at the delivery ward or the operating theater, but routines and team constitution vary between units.

Successful teamwork in emergency situations is characterized by effective communication,5 clear division of roles,6 distinct but nonhierarchical leadership, common goals and knowledge, and efficient use of existing resources.7 Examples of identified challenges concerning teamwork during neonatal resuscitation are indistinct division of roles, insufficient preparation, vague leadership, and shortcomings in communication and cooperation.6,8 Team members' competence and skills are crucial for the care of the newborn infant.9 It is essential that healthcare professionals master technical (eg, bag-mask ventilation) and nontechnical (eg, teamwork and communication) skills.10

It is important that collaboration between the different professions works well, and that communication with the infant's parents is effective.3,11 Simulation-based training is a method to strengthen confidence and competence of pediatric registered nurses (pRNs).10 Team-based simulation training improves communication, teamwork, and leadership,3,12 and has been shown to reduce the need of chest compression in connection with the birth of an infant.13

In Sweden, the pRN is a registered nurse (RN) with further training similar to what in the United States is called advanced practice registered nurse (APRN). They have a specialist training in healthcare for children and young people. After this further education, these pRNs can work in all healthcare settings for children and young people, even the NICU.

During neonatal resuscitation situations, pRNs are assigned practical tasks such as inserting peripheral venous catheters or preparing and assisting with umbilical catheterization, intraosseous approach, intubation, and administering prescribed drugs.14 Everyone in the team is expected to have knowledge of alarm routines, the resuscitation table, technical and surveillance equipment, performance of mask ventilation, chest compressions, documentation, and parental support.3

Previous studies have identified that healthcare professionals involved in neonatal resuscitation experience the situations as demanding and stressful.3,8,15 Even though factors of importance for interprofessional collaboration during neonatal resuscitation (eg, collaboration, coordination, and networking) have been identified,8 and simulation training has been shown to increase pRNs' confidence,10 there is still a gap in understanding pRNs' experiences and actions in such situations. This needs to be studied, preferably with in-depth exploratory studies. The findings can be used to further develop the role of pRNs in all kinds of neonatal emergencies. In the present study, we aimed to describe pRNs' experiences of, and actions during, neonatal resuscitation that takes place in direct connection to the birth of the infant.

What This Study Adds

  • This study identifies important factors of an effective interdisciplinary team such as high individual competence, structured alarm routines and approach, clear communication, clear division of roles, clear leadership, debriefing, and availability of a senior neonatologist.
  • This study highlights how pRNs are faced with various critical situations that affect both the whole team and individual team members. Neonatal resuscitations are complex situations where pRNs are affected psychologically and feel dependent on the team to be able to provide the infant with quality care.
  • This study finds that, even though the situations are complex and stressful, pRNs experience great satisfaction and a feeling of performing meaningful work.


A qualitative interview study based on the critical incident technique (CIT)16 was used to describe pRNs' experiences of, and actions during, neonatal resuscitation. The technique aims to identify critical experiences and actions taken for a specific purpose.16 In this study a critical incident was defined as a situation that was significant and important to the pRN and that affected subsequent behavior and actions.

Study Subjects and Setting

Participant selection was strategic, limited to pRNs with at least 1 year of clinical experience in a NICU and with experiences of neonatal resuscitation. All interviewed pRNs had undergone both theoretical tests and practical training in neonatal resuscitation. Participants were recruited from NICUs at 4 university hospitals in Sweden. The included NICUs were level III and IV units with a bed capacity between 16 and 24. In 3 NICUs, a neonatologist was on-site 24 hours a day. In the fourth unit, a neonatologist was present daytime and during nights a pediatrician was on-site with an anesthesiologist available for managing the airways during resuscitation until the neonatologist on-call arrived.

Characteristics of participants (N = 16) are shown in Table 1.

TABLE 1. - Sociodemographic Description of Pediatric Registered Nurses (N = 16) Who Participated in the Study
Gender, female, n (%) 16 (100)
Age, Median (range), y 38 (26-56)
Years as a registered nurse, Median (range) 13.9 (3-36)
Years as a pediatric registered nurse at an NICU Median (range) 7.2 (1-32)
Highest academic education, n
Master's degree 12
Doctoral degree 2
Pediatric registered nurse (3 y) 2
Abbreviations: NICU, neonatal intensive care unit.

An ethical evaluation was conducted by the ethical review board at Jönköping University. According to the statement from the review board and guiding documents from the Swedish Research Council,17 a study carried out on healthcare personnel (eg, pRNs), not focusing on ethically sensitive aspects and not revealing sensitive personal data, does not need ethical approval. However, before the start of every interview, pRNs received written and oral information about the study and were informed that participation was voluntary, that the data would be treated confidentially, and that they could withdraw at any time in accordance with the ethical principles for medical research involving human subjects as stated in the Helsinki Declaration from the World Medical Association.18

Data Collection

Semi-structured interviews were used for data collection. An interview guide was designed to be suitable for the CIT16 by the authors, who have long experience of neonatal resuscitation and the CIT. A pilot interview was conducted to evaluate the interview guide and procedure. After minor changes were made, data collection began. Prior to the interviews, pRNs received written information about the study's purpose along with instructions on preparing for the interview. A neonatal resuscitation situation was defined as the time span from when the team was alerted that a critically ill infant had been born or was about to be born, to the moment when the infant was either stable or declared dead and/or when the team gathered afterward for debriefing. Neonatal resuscitation situations took place in a designated place with a resuscitation table close to the operating theater, the delivery ward or in the delivery room.

During the interviews, pRNs were asked to describe a significant neonatal resuscitation situation they had experienced. No time frame was used. The interviews were conducted in February and March 2021, held via video conferencing due to the COVID-19 pandemic. Two authors attended all interviews and took turns interviewing and observing. The interviews lasted between 27 and 58 minutes and were audiotaped and transcribed verbatim. The data comprise 288 double-spaced A4 pages.

Data Analysis

The method used was a thematic qualitative content analysis where critical incidents were the basis for the breakdown of data into meaningful units.16,19 When the CIT is used as a method, the number of critical incidents is decisive for whether the data collected are sufficient. According to Flanagan,20 there should be at least 50 to 100 critical situations to achieve a credible result. In this study, the researchers read the transcribed interviews several times to become familiar with the text and to obtain a sense of the whole. The interviews were analyzed in a 2-step model with 2 separate data analyses. The first analysis focused on experiences and the second on actions.16 In the data reduction, the researchers marked the critical incidents. An incident was identified as critical if it was related to the aim of the study. Behavioral quotations were examined and grouped based on similarities and association regarding the content, creating subcategories that were then analyzed, grouped, and discussed to form categories. The categories were grouped under main areas that covered the underlying categories. Care was taken when forming categories to ensure that there were distinct differences between them. Each step in the emerging inductive analysis process was carefully discussed throughout the process until consensus was established.


A total of 577 behavioral quotations were identified and divided into 306 experiences and 271 actions before subanalysis was done. Critical situations were categorized into experiences (Table 2) and actions (Table 3).

TABLE 2. - Pediatric Registered Nurses' Experiences: Main Areas, Categories, and Quotes
Main Areas Categories Quotes
Individual-focused experiences Variation of alarms “When the alarm goes off I know that it can be a very sick newborn and possibly very unexpected.” (Informant 4)
Psychological impact “Of course I've been sad [because of an] infant who has passed away and so on. But this was the first time I was really sobbing. Yes, it was really, really difficult.” (Informant 12)
Parental presence “There was a father present all the time. He was sitting behind me so I saw him all the time out of the corner of my eye.” (Informant 8)
Team-focused experiences Structured working methods “We have a very well-developed way of proceeding when there is an alarm and an emergency cesarean section.” (Informant 5)
The team's interaction “The pediatrician took on a leadership role; it was very good. You need that in a team, you need a clear leader. There is too much uncertainty when there is no clear leader.” (Informant 16)
Professional experience and resource availability “This was a very experienced assistant nurse, so I felt very safe because we have worked together as long as I have been here.” (Informant 10)
The impact of the environment “So this emergency cesarean section was in a different operating room than what we are used to. The resuscitation table was also in a different room than usual. It was very stressful.” (Informant 9)

TABLE 3. - Pediatric Registered Nurses' Actions: Main Areas, Categories, and Quotes
Main Areas Categories Quotes
Actions based on the individual Being prepared “I tried to think it what will my role be in this. Like a bit of visualizing what I will encounter.” (Informant 11)
Managing the psychological impact “I do not get particularly stressed as a person, but I get focused and very structured in my way of thinking.” (Informant 14)
Adopting a professional attitude toward parents “I really encouraged her to come into the room – come and see! I asked her to come forward and touch her infant. I had a pretty active role in just getting her to the infant.” (Informant 3)
Actions based on the team Working in a structured way “So we start according to the neonatal resuscitation program as we secure the airway and I prepare the intubation equipment.” (Informant 1)
Competence/resource reinforcement “So I just think I need to offer my help, both as more experienced but also as a leader in the team.” (Informant 8)

Pediatric Nurse's Experiences

Two main areas emerged that described pRNs' experiences of neonatal resuscitation: individual-focused experiences and team-focused experiences (Table 2).

Individual-Focused Experiences

Variation of Alarms. pRNs presented variations in how they were alerted when an infant in need of resuscitation was born. They were part of the emergency team for critical and unexpected events in the delivery ward or operating theater. pRNs could be notified before a planned or acute caesarean section that the infant may need resuscitation. This gave them some time to prepare, although the amount of time varied. They could also be called as part of the team to the maternity ward before a vaginal delivery, or by the physician or neonatologist who was attending a sick newborn infant.

Psychological Impact. pRNs indicated that they felt an adrenaline rush when the alarm went off. In some cases, anxiety and stress were related to the uncertainty of the infant's condition before their arrival, and in other cases this was expressed as a positive feeling of anticipation. Not knowing what to expect could be perceived as both exciting and intriguing, as this is linked to the professional task. pRNs with many years of experience and those who described alarm routines as well established felt that the adrenaline rush was not stressful but rather helped them to focus on the oncoming situation. pRNs were emotionally affected and experienced feelings of frustration in situations where stabilization of the infant failed or was delayed. Additional causes of stress included leaving other assigned infants in the NICU, the seriousness of the situation, occasions where the team's skills were insufficient, and the infant being exposed to unnecessary suffering. When the infant was stabilized, pRNs felt joy, pride, and satisfaction that their contribution and skills were meaningful. They described confidence in their professional roles, skills, and experiences. They also described feelings of emptiness, sadness, failure, and grief when an infant did not survive. pRNs felt it was important to let themselves be human and to show sadness in parents' presence, which they described as making a positive connection in a moment of grief. Despite feelings of grief, pRNs could feel satisfaction in their work even when an infant died as long as they knew that the infant had received dignified care. Debriefing was not carried out routinely at all NICUs. Debriefing conversations were appreciated, missed when they were absent, and described as crucial in some cases so that team members could process their feelings after a situation and be able to move on. Lack of time was given as the main reason why debriefing was not performed. Debriefing was most common in cases where the infant had not survived resuscitation, but pRNs emphasized the importance of debriefing when the resuscitation situation had gone well as an opportunity to give and receive positive feedback.

Parental Presence. pRNs aimed to consider the infant's integrity and protect the infant's environment and interests while working with the medical team during resuscitation. They stated that, initially, the focus was on the infant's need of support and thus it usually took some time before they noticed if parents were in the room. The maternity staff initially supported parents, but pRNs described situations where no one on the team had time to take responsibility for parents, and they recalled this with feelings of frustration and insufficiency. They described it as challenging to include and support parents early in the neonatal resuscitation process due to medical priority, but parents were informed and encouraged to get close to the infant as soon as possible. pRNs perceived that it was stressful for parents to watch the resuscitation procedure, although it was even harder for parents if they were not allowed to attend. The presence of parents in resuscitation situations was perceived as important and positive.

Team-Focused Experiences

Structured Working Methods. pRNs emphasized the importance of team preparation. A sense of security was created if there was time to prepare equipment and drugs and for team members to brief each other before the infant was born. The interviewed pRNs described feelings of insecurity and a lack of control when confronted with emergencies where they had no prior information about the maternal medical history, pregnancy, delivery, or the infant. The structure of alarm routines was important, and pRNs felt confused when alarm routines were not followed. The national neonatal resuscitation guidelines provided directions for the team, and in stressful situations pRNs found it useful to have the NRP poster clearly visible near the resuscitation table.

The Team's Interactions. The importance of clear leadership was highlighted as a cornerstone in the team's ability to perform resuscitation in a structured manner. Most commonly, a neonatologist led the medical team. pRNs indicated that a lack of clear leadership led to the team becoming unstructured and insecure, potentially delaying treatment efforts. The experienced pRNs stated that they felt professionally secure in taking over the leadership role, while the less experienced pRNs stated that they were not ready to take on this responsibility. Routines designating team members' positions around the resuscitation table contributed to a feeling of security and an understanding of what was expected by each member in acute situations. pRNs emphasized that good communication in acute situations included clear, calm dialogue and was essential in team collaboration. They indicated that inadequate communication caused confusion in evaluating resuscitation steps and hampered team efforts.

Professional Experience and Resource Availability. pRNs had participated in simulation-based resuscitation team training. They described it as important in developing confidence in their role in the team and said that it helped them feel more prepared for real-time situations. pRNs represented units with different levels of access to resources, and not all NICUs had neonatologists on-site 24 hours a day. The professional experience of the neonatologist affected pRNs' feelings of security, and acute situations were described as calm and methodical, with shorter times for decision-making when a senior physician was involved. pRNs emphasized the importance of having extra resources available. They described the need for “extra hands” when many procedures had to be performed at the same time, and it was always appreciated when a colleague came to assist.

The Impact of the Environment. Being familiar with the environment and the equipment at the resuscitation table contributed to a sense of security. Being in a new environment without access to the usual equipment created stress and uncertainty in the team. pRNs felt that an unfamiliar environment could adversely affect the infant's well-being. A work environment where team members felt comfortable communicating openly and expressing their thoughts to all team members was appreciated and created a positive atmosphere within the team. A feeling that all team members were equals was important for pRNs.

Pediatric Nurses' Actions

Two main areas emerged describing the actions of pRNs at the critical event: actions based on the individual and actions based on the team (Table 3).

Actions Based on the Individual

Being Prepared. On occasions when it was known before the infant was delivered that the neonatal team would be needed, pRNs were able to consider possible scenarios and mentally prepare themselves to meet the anticipated needs during primary stabilization. When the report was incomplete or missing, pRNs tried to remain neutral until they arrived at the resuscitation table and then tried to stop for a few seconds to assess the situation. An oral report was requested from the midwife or obstetrician. There were local routines of what the pRN should bring, in terms of equipment and drugs, in emergency situations at the delivery ward.

Managing the Psychological Impact. pRNs stated that they handled situations as they arose and that they did not stress themselves unnecessarily because they could not do more than their best. Critical situations were handled by being focused, thinking in a structured way, and actively trying to remain calm. By talking in a low and calm tone of voice, they were able to calm a stressful situation. As their experience of participating in resuscitations increased, pRNs found that they were able to deal effectively with any strong emotions that arose. They indicated that, after an emergency, the psychological impact was best handled when reflected through feedback. pRNs provided direct feedback to team members or during debriefing conversations in groups. It was important to gather the members of the team immediately after the resuscitation to check whether anyone needed comfort, support, or a collegial conversation.

Adopting a Professional Attitude Toward Parents. The infant's medical condition varied in different alarm situations. Assessment of the infant's breathing and tone was performed in parallel with pRNs presenting themselves and briefly speaking to parents. When the infant's condition was critical, the focus was on the infant and not on parents. A 3-step approach was described. In the first step, team members focused on the infant; in the second step, they took in what the others in the team were doing, and then, in the third step, they could broaden their perspective to include parents in the situation. When the urgency of the situation subsided, pRNs encouraged parents to come to the resuscitation table and hold their infant's hand. pRNs recounted some situations where parents did not want to be present and left the emergency department. pRNs handled this by actively inviting and encouraging parents to attend, informing them that it was good for the infant to have the parent present.

Actions Based on the Team

Working in a Structured Way. The team prepared the resuscitation table, and the work was performed in a structured, familiar, flexible, and effective way with team members helping each other. The team needed to adapt preparation according to the received medical report. Before the infant was born, pRNs gathered the team for briefing and clarified the division of roles in the team. Team members could then address uncertainties as part of the preparation. In the cases where the team arrived in a situation where neonatal resuscitation had already been initiated by the maternity staff, team members identified the current step in the NRP, did a quick evaluation, and then took over and continued resuscitation. When the infant did not respond to the interventions, the infant's condition was reevaluated, and the team tried to identify the cause of sustained distress. pRNs assisted the doctor with intubation and umbilical catheterization, and team members took turns performing chest compressions, making sure no one got tired. For successful collaboration it was of utmost importance that everyone on the team knew who did what tasks. When the teamwork went well, the efforts were done quickly and efficiently without a sense of stress. pRNs described situations where the physician on call was inexperienced, and in these situations the experienced nurses took on the role of a team leader. The less experienced pRNs did not take over the leadership role in these situations and described the workflow as awkward as well as stressful. Team communication was handled by pRNs using clearly addressed communication with feedback (ie, closed-loop method). This was also helpful in guiding less experienced or stressed team members to complete their tasks. Clear communication, relevant key words, and active contributions of all team members were important for pRNs.

Competence/Resource Reinforcement. pRNs perceived themselves to be responsible for reviewing the staffing needs of the team with a view to minimizing the effects on patients in the ward due to the shift of resources. Extra support was preferably summoned at an early stage of resuscitation to secure optimal competence for the infant. When pRNs were called to the resuscitation room as reinforcement, they interpreted the situation as serious.


In this study, clear leadership, communication, standardized roles and positions, and team preparation were highlighted as beneficial for pRNs' experience of security in a situation of neonatal resuscitation. These structures are known and included in the protocol for NRP training.2

In this study, pRNs, regardless of experience, indicated that they became stressed when the infant did not respond to their efforts and when the team's competence did not feel sufficient, and they expressed feelings of frustration and grief if the infant did not survive. This is strengthened by Groombridge et al,21 who describe that stress elicited in a delivery room or a NICU environment could be intensified if life of an infant is threatened. Paliatsou et al22 described that when risk factors for the need of neonatal resuscitation (eg, prematurity, low birth weight, and meconium-stained amniotic fluid) were identified early pRNs felt prepared and had a limiting effect on stress and anxiety. The use of the NRP protocol and role allocation to specific positions around the resuscitation table are factors that can help pRNs feel more prepared for the neonatal situations and thus reduce stress and anxiety.

When an infant was successfully stabilized, they experienced feelings of pride, happiness, and meaningfulness. These findings are in line with previous research highlighting neonatal resuscitation as a stressful situation for pRNs.15 In the delivery room and in the NICU, acute situations arise quickly and sometimes unexpectedly, thus neonatal resuscitation can be psychologically challenging and can lead to discomfort and lack of certainty.10 Neonatal resuscitation is perceived as stressful, which may depend on that it is a relatively rare situation. Simulation training promotes teamwork during neonatal resuscitation, improves team effectiveness, increases pRNs' confidence, and potentially reduces their stress and anxiety. Debriefing is also an effective strategy for reflection that can reduce stress and anxiety.23 pRNs described debriefing as a helpful method to process the feelings that arise in connection to resuscitation efforts. Debriefing provides an opportunity for reflection and knowledge development,24,25 which was also described as important by pRNs in the present study.

All interviewed pRNs were positive toward parental presence during neonatal resuscitation, which is in line with the NRP's recommendations that advocate parental presence when possible.2 Even if parents are anxious, their presence gives them an opportunity to be involved in the resuscitation process and to receive information and reassurance.26 Zehnder et al27 found parental presence to be associated with a reduced total workload, which is in contrast to our findings, where pRNs described increased stress and feelings of insufficiency and being torn between their responsibilities to both the infant and the parent(s). The difference in perceived workload during parental presence might be due to the chosen study design. Whereas Zehnder et al27 performed a prospective study that included evaluation of many resuscitation episodes, in this study pRNs were asked to recall one situation for the interview. In our interviews, parental presence during neonatal resuscitation was described as important and wanted, and pRNs were aware of the complexity of their role in performing resuscitation and finding a moment to initiate an early connection between the infant and its parents.

It was crucial for the workflow in the resuscitation situation that someone on the team took on the leadership role. Most often it was a senior neonatologist. When a physician did not take on a clear leadership role, the experienced pRNs felt secure with the responsibility of taking the lead. It was more difficult for the less experienced pRNs, who instead became more stressed and insecure. Regardless of profession, everyone on the team has a responsibility to ensure that the care of the infant is optimal and a responsibility to react if the work does not progress,28 but it may be difficult for a pRN to take on full leadership as it often entails making medical decisions.

Assigning specific roles and a specific position around the resuscitation table is one way to ensure that the role distribution is standardized in each neonatal resuscitation situation.25 When this is clear, the situation becomes safe and calm and the infant's physical and mental environments are both promoted.29 In the present study, the division of roles differed between the NICUs. The team strived to be as prepared as possible for potential situations, and pRNs gathered the team for briefing before the infant was born and clarified the division of roles in the team. pRNs described the division of roles, team interactions, and workflow as beneficial if team members had worked together previously. This is further strengthened by Sandström et al,30 who also suggested clear communication as a method to bridge situations when team members did not know one another. pRNs described simulation-based resuscitation team training as important for their professional confidence and as support in preparation for real-time situations, which are in line with previous studies that have stated that simulation training increases competence, improves team communication and team performance, and increases patient safety.24,31–33

pRNs in our study perceived that clear communication was a decisive factor for good collaboration within the team during stressful resuscitation situations. Unclear communication is correlated with poor compliance with the guidelines.34 Facilitators of communication include speaking out loud, sharing thoughts, and clarifying what is heard.11 pRNs indicated that they handled this by communicating with closed-loop communication, which is considered the same as “clarifying what is heard.”11 Open and clear communication improves the quality of care and reduces the risk of errors.35 In our study, clear leadership and communication, standardized roles and positions, and team preparation were highlighted as beneficial for the experience of security in a situation with resuscitation. These teamwork skills can be practiced, and we believe our findings reinforce the use of protocols in the NRP to training of healthcare professionals for emergencies and for required actions.

As there is no standardized analysis method within the CIT, a manifest content analysis was chosen, where critical situations were the basis for the breakdown of data into meaningful units. The data were considered to be rich. The CIT is a suitable method to use when the purpose is to identify people's experiences and actions.16 Participant selection was strategic, limited to pRNs with at least 1 year of clinical experience in neonatal care and neonatal resuscitation. The decision to limit pRNs to describing a critical situation that started when the team was alerted that a critically ill infant had been born or was about to be born, and ended when the infant was either stable or declared dead and/or when the team gathered afterward for debriefing can be seen as a strength, as pRNs describe a specific situation and not general thoughts about neonatal resuscitation. This study has not explored the real situation, and it is based on pRNs' descriptions of experiences and actions linked to the concepts. This can be seen both as a limitation and a strength.

Trustworthiness is supported by the researchers' knowledge of and experiences with neonatal resuscitation. The preunderstanding has been useful in that it enabled the researchers to ask relevant follow-up questions to get the richest possible descriptions of critical situations. Flanagan20 states that if informants get stuck on a question, interviewers can use their preunderstanding to reformulate the question. Recall bias was received as a minor problem based on the significance of the studied situation. Like many other qualitative methods, the CIT is dependent on the informants' memory and there is a risk that they remember poorly when the situations occurred some time ago. What speaks for trustworthiness in this case is that the critical situation was so significant that it stayed in mind, which in itself minimizes the fact that the truth is changed afterward.20,36

Credibility was strengthened by the fact that the data analysis has been carried out both individually and jointly and discussed in the research team. Reliability is strengthened by the fact that all interviews were conducted jointly, thus increasing the probability that the interview guide would be used in the same way in all interviews.37 It is important to consider the ethical aspects involved in studies where participants share their feelings and thoughts about topics that may evoke strong emotions.17 Participants may also choose not to share situations that reflected poorly on themselves. For this reason, it was clearly stated that the material was treated confidentially.16

Confirmability is strengthened by clear descriptions of the steps of the analysis, from behavioral quotations to main areas. Transferability is based on the context studied and is promoted by a clear description of the sample, participants, and the context.37 However, as the data are based on the experience and actions of individual pRNs, there is no guarantee that the same results will be seen when the study is repeated.


High individual competence in everyone on the team, structured guidelines, team collaboration, clear communication, clear division of roles, debriefing, and always having a senior neonatologist available are factors that promote a well-functioning neonatal resuscitation situation, increasing pRNs' security and giving them an opportunity to further develop in their professional role.


pRNs are faced with several critical situations that affect them as individuals and as members of a team. Neonatal resuscitations were described as complex situations where pRNs are emotionally affected and dependent on the team to be able to provide the infant with the best possible care. They experience an adrenaline rush when the alarm goes off, but also a feeling of meaningfulness and professional satisfaction. Preparing themselves and the team, both psychologically and practically, and adopting a professional approach toward parents were emphasized by pRNs as active and helpful ways to handle acute and unexpected situations. pRNs' experiences and actions of a well-functioning neonatal resuscitation situation consist of factors such as having competent staff on the team, which preferably includes senior neonatologist who has the role of team leader. Healthcare professionals qualified to perform neonatal resuscitation are expected to follow NRP protocols. There is limited research about adherence to these guidelines; therefore, it would be interesting to study this further.

- Summary of Recommendations for Practice and Research
What we know:
  • Teamwork during neonatal resuscitation is essential.

  • It is difficult to predict which newborn infant may need neonatal resuscitation, and these acute situations are demanding for pRNs and the neonatal resuscitation team.

  • Clear division of roles, possibility of debriefing, and effective communication in the team are factors that are important in interprofessional teamwork during resuscitation.

What needs to be studied:
  • How pRNs cope with leaving other patients in need of care in the NICU when acute situations of neonatal resuscitation arise in the delivery ward.

  • How pRNs are affected in their performance during resuscitation according to role division, team leadership, and team constitution.

  • Whether frequent team simulation training can improve the results of neonatal resuscitation and whether it promotes pRNs' experience of security in the situations.

What we can do today:
  • Implement a structure in the NICU with a clear division of roles as a complement to the neonatal resuscitation program.

  • Implement a structure to have dedicated personnel to support parents who are present during the resuscitation, and to reduce stress of pRNs.

  • Integrate factors that have been shown to be beneficial for effective teamwork in simulation training of neonatal resuscitation to promote a sense of security and developing competence for pRNs.


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infant; interview; neonatal intensive care; neonatal resuscitation; neonatology; nursing; pediatric nurses qualitative research; teamwork

© 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the National Association of Neonatal Nurses