Table 3 Illustrative quotations for Theme 1—current culture on neonatal units
From: Attitudes towards the neurological examination in an unwell neonate: a mixed methods approach
Subtheme | Quotation | Interviewee (No., Grade, Speciality, Gender) |
|---|---|---|
Significance: Low Priority | ||
Obvious who needs hypothermia treatment | I suppose, often, you put it down to a gut-feeling, um, without sort of doing a systematic, structured examination | 2, Tr, PNeurol, M |
Emergency and procedures are prioritised | Priority is always, and rightfully so, “ABC”—they are the priority. But, yeah, a neuro exam, a proper neuro exam, is definitely taken back-seat to the tasks, the ‘fun’. Neonatal, task-orientated trainees want to do lines and tubes and X-rays and all that exciting stuff, rather than wash your hands and lay your hand on the baby and actually examine the baby | 4, Tr, Neo, M |
Other systems are seen as more important | Because people find [other systems] life-threatening that they can support immediately, whereas the bit of the neurological examination that you need to support is the respiratory component….So, it’s not a system that you immediately support | 3, C, Neo, M |
Don’t see usefulness of neurological examination | I’m not sure that I get any useful information about… when I assess sick babies from the neurological point of view. And I’m not sure how useful that is in the long term. That’s probably why | 10, C, Neo, M |
if you don’t think it’s important, then you’re not going to do it. But sometimes you don’t think it’s important because you don’t understand why it’s important, | 21, Tr, Paed, F | |
Neurological examination is time consuming | In my head there’s this, er, idea that neurological examination is really time-consuming | 18, Tr, Paed, F |
Cannot examine after muscle relaxation | It’s only when you sort of get to a point of stabilisation, erm, and after the stabilisation has occurred, that people remember, ‘maybe we should do a neurological examination’, which of course is difficult to do if they’ve been muscle relaxed | 11, C, Paed, M |
Relying on other investigations rather than neurological examination | When it comes to neurological assessment and management, we get driven by tests rather than clinical assessment. This my feeling | 16, C, Paed, M |
Significance: Important | ||
Important | It is an absolutely essential part of the examination, so it needs to be done. It is invaluable information for err very important decision making | 9, C, Neo, F |
Justifying decisions about hypothermia | The documentation is for someone else to understand why I did what I did, which is really important for me. It’s not because ten years later lawyers will sue me | 5, C, Neo, M |
Importance of monitoring change over time | Although there are many ways of assessing a neurological system of a newborn, what is important is the trend. We look at the change over time in a sequence of neurological assessments to be able to determine the status and the prognosis | 14, C, Neo, F |
The neurological examination is fun! | I think examination skills in people need to be inspired by the senior doctors: to see the importance and the pleasure you can get from being a Sherlock Holmes and looking out… looking out for signs and making a clever diagnosis. It can be a motivation, can’t it? | 12, C, PNeurol, M |
The neurological examination is quick | They don’t realise how quick it is, if you just learn to do it properly it’s very quick | 14, C, Neo, F |
It should not disturb a sick baby | The neurological examination doesn’t disturb the baby. Unless you have to sit and turn around and put him prone and all of that, but the neurological examination of the baby that is sick should not include any of these | 14, C, Neo, F |
Aspects can be performed / observed at times of procedures | I do a lot of lines still. I see that as an opportunity really. How babies react to procedures tells you a lot about them and neurology is part of it… I see procedures as an opportunity to assess babies even better because you are spending a lot of time next to them | 5, C, Neo, M |
Challenges to the neurological examination | ||
Sedation | I certainly think [examining a sedated baby] is worth it. As long as you are aware… you document that they are on a medication that is going to affect the neurological examination. But you wouldn’t not do a respiratory examination because they’re intubated. You wouldn’t not do a cardio examination because they’re on cardiac medications. You’re still going to do those assessments. And I think people always would do those assessments. But for some reason they don’t in neurology because they’re on neurology medications | 2, Tr, PNeurol, M |
Cardiovascular instability | When they become unstable physiologically it becomes effectively impossible to safely do it | 11, C, Paed, M |
Time and developmental care philosophies | When you are in the neonatal unit the nurses… there’s always this thing in the nurses eyes, “don’t disturb the baby!” | 18, Tr, Paed, F |
Communicating results via telephone | If you ring… somebody rings you in the middle of the night, um, which happened last weekend… it’s really hard to get a sense of how people assess neurological status or degree of encephalopathy | 5, C, Neo, M |
Don’t actually know how to do a neurological examination | A lot of what we do is, you know, extrapolated from children at adult settings, where it’s just not really appropriate | 7, C, Neo, M |
I think it’s a general reluctance and that’s not because people are lazy, I think it’s because people don’t know what they are doing. And so… people would rather go and do other things than do the neurology | 8, Tr, Neo, F | |
I think everybody is afraid of the neurological exam. Everyone is afraid of getting it wrong erm and for some reason it’s very daunting | 21, Tr, Paed, F | |
Understanding what abnormal signs mean and interpreting the results | So, people can do the individual bits, but what they don’t know is, how to work out what that picture truly signifies. And I suspect we’re all doing that for Neurology | 3, C, Neo, M |
No agreed structure to the examination | The dedicated, sequential neurological assessment is lacking in neonatal set-up | 16, C, Paed, M |
Poor or no training | We don’t teach it in medical school very well. We don’t stress about it in the medical curriculum at all. So there are days and days of teaching about how to examine the upper limb and how to examine the lower limb in an adult. But there is very little teaching in the medical school about neurological examination in the newborn infant | 9, C, Neo, F |
Doctors don’t get any dedicated neonatal neurology examination training | 16, C, Paed, M | |
There’s a lack of interest in the neurological assessment of children and babies. Full stop. And the training is grossly inadequate | 10, C, Neo, M | |
I think everybody, sort of, assumes that you can do it and that you will pick it up as you go along | 19, Tr, Paed, F | |
Don’t know how to document it | I think we don’t have sometimes the words and the structures to document what we see in front of us | 7, C, Neo, M |
Consultants struggle too | I don’t think consultants do it very well | 23, C, PNeurol, F |
No modelling by consultants | Trainees just don’t see enough neurological examinations being done. I think that’s part of the issue | 1, SG, PNeurol, F |
Assessing competency | Sadly, I have not even done any CEXs for them about, you know, examinations | 17, C, Paed, F |
Wider problem involving all of paediatrics | I think to a degree it is the same across all ages in the neurological examination. But I think it’s… it’s more so exaggerated in neonates. Because I think people find the examination more difficult | 2, Tr, PNeurol, M |
I think neurology, generally, if I go back, you know, years and years, I think it is probably the thing that people are the least comfortable with for whatever reason. I don’t think it’s specific to neonates. So, I think in paediatrics it’s the same: people don’t really examine the neurology properly | 8, Tr, Neo, F | |
Response to challenges: Avoidance | ||
Avoidance or cursory examination | You’d always think, “Oh, this is not an emergency, I’ll let someone else do that or someone who kind of knows what they’re doing.” | 1, SG, PNeurol, F |
One of my bug bears that I think that people often go with ‘AF normal, tone okay’. That’s not really a neurological examination. That is a box-ticking exercise | 9, C, Neo, F | |
Legitimate challenges become excuses | So, because we don’t think hard enough about it, we use, for want of a better expression, excuses to not do the examination rather than think about… when, with another system like respiratory, we think about ‘oh what can I do?’, with neurology, we default to ‘I can’t do that’ | 9, C, Neo, F |
So similarly, um, we perhaps shouldn’t, you know, be using [the fact the baby is sick] as an excuse because obviously there can be findings there that determine how we manage this patient and whether the management will be different, or not | 18, Tr, Paed, F | |
It is almost a… a get out-of-jail card if they’re on medications that affect your nervous system because people will just say, “can’t assess neurology because… because they’re on such and such medication.” | 2, Tr, PNeurol, M | |
I don’t think the nurses would stop you if you wanted to assess the baby—that’s an excuse! | 17, C, Paed, F | |
Delayed or missed diagnoses | There’s lots of, sort of, anecdotal stories, isn’t there, of babies who, you know, it’s only a week later that someone realises they’re not really moving their legs and they’ve got a spinal cord problem for example or, um, they’ve got a… I don’t know, they’ve got some focal signs that it would have been helpful or… you know, they should have had a scan earlier or something like that | 1, SG, PNeurol, F |
Response to challenges: Solutions sought | ||
Self-taught or trained abroad | Because my training was from a different, distant country, examination was… was drilled in. If you didn’t do an examination properly you were properly told off | 6, C, Neo, M |
I read lots of things about it. And I tried it out on babies when it was needed | 9, C, Neo, F | |
Introducing examination proformas into units | We have actually put this examination sheet on the network website for people to therefore look at it and try and make a better assessment of that | 6, C, Neo, M |
Using standardised examinations | Out of several examinations available, we summarised the HNNES (Hammersmith Neonatal Neurology Examination) for babies undergoing hypothermia | 14, C, Neo, F |
Improving training | Since I’ve joined here, err, I started doing 6 monthly erm neurological days study days and one of the topics which we do cover is the neonatal neurological examination | 20, C, Neo, F |
Embedding new culture in unit | ||
Low priority culture | It is just a self-perpetuating thing. You don’t do it. You don’t know why. And then you think there is no problem with that | 6, C, Neo, M |
The problem is not the lack of a tool. It is one of the problems- but it is not the main problem. The main problem is the culture. The main problem is the way we are trained to think of the neurological examination being a ‘not important’ part of the newborn examination. And I think that is what needs to change | 9, C, Neo, F | |
Culture of importance | I think part of it is about, um, you know, changing our culture, um, and the way we, sort of, approach neurological examination in general. Um, and that can be fun and nice, and quick. And it doesn’t need to be this absolute mountain that you have to climb every time | 18, Tr, Paed, F |
If you work in a hospital where there is a perinatal hypoxia management protocol that mandates that the doctor has to go back and examine the baby, it’s done. If that’s not there, then very unusual, very unusual. It’s definitely an overlooked bit of the neurological examination | 9, C, Neo, F | |