Problem

Providing optimal care in a neonatal intensive care unit (NICU) is important for short-term and long-term outcomes of infants born premature or who are severely ill.1 2 However, this can be difficult as the NICU is characterised by a dynamic, multidisciplinary and emergent environment.3 Guidelines are created to offer guidance, but there is still considerable variation in care.4–6 Consequently, the variability suggests that there is opportunity to learn from each other and to improve care. Video recording of real-time performed procedures provides an objective view and can be used for improving complex procedures.7–14

Recording video and physiological parameters of neonatal resuscitation at birth have been used for research in the NICU of the Leiden University Medical Center (LUMC) since 2009, capturing only imaging of the neonate and providers’ hands. The LUMC is a tertiary-level hospital with a 25-bed level-III NICU, annually admitting approximately 650 inborn and outborn patients. The ward consists of 16 single-patient rooms and 4 twin rooms. On average, 125 providers work on the NICU who are involved in hands-on care, including 95 nursing staff members and 30 medical staff members. From 2014 onwards, the recordings of neonatal stabilisation were reflected on weekly, traditionally with mostly medical staff. This improved guideline compliance and documentation.5 15–17 Neonatal care providers viewed video review (VR) of neonatal stabilisation as beneficial, but emphasised that a safe learning environment was essential. Members of the medical and nursing staff expressed an interest in expanding VR with audio to evaluate non-technical aspects as well, such as communication and teamwork.18 Additionally, staff members wished for all providers to be able to participate in VR, including nursing staff. Finally, providers took an interest in recording medical procedures in the NICU environment as well, next to recording procedures in the delivery room.

Implementation of VR to (1) include audio, (2) record procedures in the NICU environment as well as in the delivery room, (3) involve not only the medical staff but also the nursing staff in VR sessions and (4) strive for a safe learning environment during the sessions is a relatively unexplored area in the use of VR.7 18–21 The primary aim of this study was to evaluate how to successfully use VR in our NICU. We aimed to organise 18 VR sessions in 9 months evaluating real-time audio–visual recordings of neonatal procedures. Procedures had to be recorded on a voluntary basis, by different providers of the NICU team. During each session, we aimed to have an equal distribution of members from the medical and nursing staff. We were also interested in whether providers attending VR regarded the sessions as positive and felt that a safe learning environment was present. During the implementation of VR, we (re)defined our guideline for VR using continuous improvement cycles.

Background

VR has proven to be beneficial for guideline compliance and clinical performance of emergency and intensive care teams.7 12 17 22 Although use of VR is becoming more accepted in healthcare, using real-time recordings of clinical procedures is not standardly used as a tool for improving care.7 When videos are used for VR with all providers present, it can give feelings of distress for being recorded.23 Providers can fear criticism or judgement from colleagues or the risk of being seen as less competent.24 25 Next to that, VR can be time consuming.26 27 Studies on VR are often not focused on reporting how to set up regularly organised, interprofessional VR in a way that is safe and suitable for daily practice and can be embedded on the long term.27–29 There were no practical guidelines available for the implementation of this particular application of VR into the daily practice in an intensive care setting. We started the design of a new, expanded VR program, and named this the Neoflix project. Increasing the understanding of what is needed to successfully implement and use VR in the daily routine of emergency or intensive care departments might help other departments to make use of the potential VR has to offer.

Measurement

A previous study in our unit on the use of VR,15 conducted between February 2018 and February 2019, was used as a baseline indicator. This study showed that 3 VR sessions were organised each month, with on average 14 medical staff members and 1 nursing staff member attending. The procedures that were recorded included neonatal stabilisation only. Imaging of the hands of the providers and the neonate were captured without audio, resulting in unidentifiable videos.

This study used routinely collected data on VR from December 2021 to September 2022. Procedures that could be (audio-visually) recorded included neonatal stabilisation, sterile line insertions and endotracheal intubation/surfactant administration. Outcome measures included the number of providers who recorded any of these procedures, how many recordings were made per procedure and the number of providers attending the VR sessions. Other outcome measures included the opinion of the providers on the VR sessions and on the safe learning environment.

Design

We considered that the implementation of VR needed to be organised and adjusted step-by-step along the way, together with the providers who deal with VR in practice. Therefore, this study was designed, using an action research approach, to ensure implementation was provider driven. First, a Neoflix study team was formed, consisting of members from the senior and junior medical staff, nursing staff, a physician assistant and a member from the quality and patient safety department. This group was composed to represent all different stakeholders involved in neonatal care. A predefined guideline was designed for implementation of VR (online supplemental file 1), including which procedures were to be recorded on a voluntary basis (ie, neonatal stabilisation at birth, intubation and surfactant administration and sterile line insertions) (figure 1), the consent procedure for providers and patients, and details on the organisation of VR in general. We aimed to use the providers’ perspective to drive continuous improvement cycles during implementation to improve and adapt the guideline after each VR session to overcome challenges that influenced the rate of adoption and acceptance. The Neoflix study group met every 2 weeks to monitor the implementation and make adjustments.

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Figure 1

Record: recording equipment in the delivery room and on the neonatal intensive care unit (NICU): (1) eye-tracking glasses used for recording interventions performed on the NICU providing a point-of-view recording; (2) microphone; (3) camera, recording the hands of the providers during neonatal stabilisation; (4) camera, recording room-view during neonatal stabilisation. Review: during Neoflix sessions, medical and nursing staff evaluate a video.

Strategy

From December 2021 until September 2022, the preparation, the organisation and the conduct of the VR sessions were observed by a researcher (VH). Aspects of the sessions with regard to the safe learning environment, privacy, technical aspects, logistics and organisational aspects were reported in field notes, in consistence with the standards in qualitative research. After each VR session, all providers who participated in the session were also asked to complete an anonymous questionnaire via a QR code and time was taken to let them fill it in. This questionnaire consisted of five questions using a Likert Scale (1—‘strongly disagree’, to 5—‘strongly agree’) questioning participants about their experience of the review session and three open questions with a free text comment area available for remarks or comments (online supplemental file 2).

The observations regarding the implementation of VR and the feedback from the questionnaire from that session were interpreted by the Neoflix study group. The study group evaluated what could be improved about the guideline for VR. Action research was used to implement adjustments or expansions. These were tested and re-evaluated during following VR sessions. The results of the adjustments made through each improvement cycle to the guideline were noted and analysed by VH and RW, using content analysis to quantify concepts, themes and keywords.30 The qualitative data analysis software Atlas.Ti (V.23) was used for coding. In consensus meetings, the study group identified the potential success factors and preconditions for successful VR that were included in the adjusted guideline. Using the framework of Rogers’ diffusion of innovation theory,31 the success factors and preconditions were divided into different factors that influenced the rate of adoption of VR: (1) complexity (the degree to which VR as a tool is perceived as difficult to organise and use, (2) trialability (the degree to which VR can be tried for use by providers), (3) observability (the degree to which the results of VR can be observed and used in practice, (4) compatibility (the degree to which using VR for quality improvement is perceived as similar to beliefs and values of the neonatal care providers and (5) relative advantage (the degree to which providers perceive how VR improves their current practice).

Participants’ responses to the questionnaire were analysed qualitatively using conventional content analysis.30 Quantitative data were analysed using IBM SPSS Statistics V.25 (IBM Software, Chicago, Illinois, 2016).

Lessons and limitations

Although VR has proven to be beneficial for guideline compliance and clinical performance of emergency care teams,7 9–12 17 32 studies have not focused on resolving challenges that influence implementation.19 29 This study describes a novel way of using VR as an initiative to improve neonatal care by recording three different procedures and discussing these in interprofessional VR sessions, focused on having a safe learning environment. Recognising the dynamic and contextual nature of VR, we chose action research over the Plan, Do, Study, Act methodology to make implementation provider driven and empowering.33 Through this approach, the study group, informed by both observations and provider feedback, planned and implemented actions, and evaluated their effectiveness within the context of VR. As it is difficult to measure the effect of individual adjustments, the study group used the Diffusion of Innovation model to identify key characteristics influencing VR adoption and defined the preconditions and success factors for its ongoing implementation.31 34 Our results show that implementation was successful with a total of 18 sessions that could be organised and completed without any major objections and with a consistent attendance of providers. There were on average 17 providers attending each session, with an equal distribution of medical and nursing staff. Also, different providers recorded neonatal procedures continuously during the study period. The healthcare providers were positive about VR in our department and felt that there was a safe learning environment present during the sessions, which could be attributed to our improved guideline for implementing VR. Based on our findings, we would recommend using an action research approach for implementing VR as it is important to include the stakeholders in the organisation. Also, following the observed preconditions and success factors, we recommend to focus implementation of VR on keeping it safe, small and simple.

Previous studies recommend informing the participants on the purpose of VR, to create a sense of urgency and motivation.35 36 We also observed that creating enthusiasm as well as a sense of safety among the providers is important. In concurrence with previous studies, it is important to be fully transparent about the project and consent procedures.20 21 27 The pathway for obtaining consent and preparing the VR session was defined to enable providers to have the final say in whether a video would be used for VR. Although no one objected to the use of their recordings for the review sessions, we are not sure whether participants felt duty-bound. Further studies are needed to investigate this.

As VR has been used in several domains of healthcare, for example, patient care, quality improvement, research and education, its use is also complicated by conflicting issues and requirements in each of these domains.37 The different stakeholders and ethical values surrounding VR could withhold other centres from implementing it. Although it requires careful consideration of the different benefits and disadvantages to the stakeholders, we hope our approach offers some guidance in setting up VR. The goal of VR on our department was to improve the practice of neonatal care and the non-identifiable recordings were already part of standard care; therefore, no patient consent was asked for these recordings. However, if parents were visible in the identifiable recordings, they were asked for consent for protection of privacy, but were also offered the possibility of reviewing the recording. Previous research showed that parents appreciated this openness and transparency from providers, making them less likely to hold providers responsible for medical errors.38 Providers always needed to consent for the identifiable recordings in order to protect their privacy and to make recording voluntarily. Because VR was meant for quality assurance purposes, identifiable recordings were deleted at the end of the project, potentially limiting the use of VR for further research. Of note, if an adverse event had occurred during an intervention, this had to be reported regardless of whether a video had been made or not. Although recordings used for quality improvement are often protected by law, it is not clear if they can be used as evidence in court.37 Medicolegal problems with video recording have so far not been reported,28 39 nor did we encounter these.

We did not record every intervention as standard procedure and for this reason, a selection bias in the recorded procedures could have occurred. However, the goal of VR was to start the conversation between the members of the medical and the nursing staff about how they wished to improve procedures together. It was more about sharing different points of view on clinical care than about recording and assessing every procedure standardly. Nevertheless, we made sure that the barrier to record a procedure with recording equipment was as low as possible. Although more cameras present to record the procedures would provide a more comprehensive view, it would also take more time to set up. Therefore, we chose one or two camera angles to record the neonatal procedures to minimise the time required to prepare for recording. During implementation, we observed that the safe learning environment was an ongoing learning process. This can be influenced by team dynamics, the team’s experience, but also by the set-up of the meetings with effective ‘feedback’ rules. Den Boer et al already noticed that previous VR meetings on our department evolved into more open discussions when VR sessions were performed regularly.15 Assigning different dedicated chairs to guide the sessions and guarding the safe learning environment were considered a success factor. Putting emphasis on including nursing staff was seen as a key factor in achieving valuable discussions during VR.

VR is now embedded in our department as an educational tool and for quality improvement. The structured pathways and corresponding strategies added to the guideline were useful to implement lessons learnt from VR for improving quality. Therefore, the staff members who were not present during VR would know what insights or lessons were learnt from the sessions and how they would be used to drive change. We currently did not aim for measuring the effect of VR on improving care, but we will use our improved guideline and perform studies with the focus on the value of VR for improving neonatal procedures.

The study group who evaluated the VR sessions consisted of different stakeholders, who were supposed to represent the different perspectives involved in neonatal care. They influenced how improvement cycles were used to change the set-up and organisation of VR. To include all providers and give them equal voices in this process, the anonymous questionnaire was added, which gave all providers equal opportunity to provide input on how they felt experienced VR. Our questionnaire did not evaluate clinical outcomes but self-reported perceptions of the VR sessions. However, it did show that VR was well received and ongoing studies on our department will focus on the effect of interprofessional VR on quality of care and clinical outcomes.

We report an implementation in a single institution where providers were already familiar with VR. This might have influenced the success of the implementation and limits the generalisability of our results. However, the use of identifiable videos with audio and discussing this with members of the medical and nursing staff together was new to all providers.