An exploration of the cognitive and affective processes for anaesthetists when performing an emergency front of neck airway*

Summary

Emergency front of neck airway (eFONA) is a potentially lifesaving but very high‐stress procedure. We explored the cognitive and affective processes involved via semi‐structured interviews with 17 UK anaesthetists who had attempted eFONA within the previous two years. Thematic analyses generated two meta‐themes: ‘Making the decision is the hardest part; the doing is easier’ and ‘What helps make the decision?’. We found concerns around scrutiny, lack of a flat hierarchy, unfamiliarity with the situation and the lack of a model for transitioning to eFONA. Culture change, using a shared mental model, priming and emotional disengagement, assisted with eFONA decision‐making. Conclusions and implications for practice are presented.

Introduction

An estimated 1 in 50,000 patients undergoing general anaesthesia will suffer a potentially fatal ‘can't intubate, can't oxygenate’ (CICO) situation, accounting for over 25% of anaesthesia‐related deaths [1, 2]. Management of a CICO situation typically requires an emergency front of neck airway (eFONA).

Reluctance to perform eFONA is likely to be the most common cause of delay [3] and is associated with harm [1]. Research into human factors in airway management is of increasing interest [4, 5].

After the Fourth National Audit Project (NAP4), interviews with participants experiencing airway emergencies identified on average four human factor contributions per case [6]. This study predates current Difficult Airway Society (DAS) guidelines [7] and used a petrochemical industry‐based interview tool [8]. Recent qualitative studies in Australia examined cognitive pathways in airway management [9] and identified factors split into enablers (equipment location/storage; experience/learning; and teamwork/communication) and barriers (resource limitations; teamwork/communication; equipment location/storage; experience/learning; insufficient back‐up planning; and equipment preparation), but with different training and management algorithms to the UK and without consideration of emotions [9, 10, 11].

Historically, the focus has been on infrastructural human factors surrounding decision‐making and performance. We sought a greater focus on the cognitive and affective processes and how these interact with the decision‐making process, to help facilitate eFONA decision‐making.

Methods

The Royal College of Anaesthetists (RCoA) Patient, Carer and Public Involvement focus group helped with protocol development. Ethical approval was obtained from the Bath Spa University Research Ethics Committee (6032022EW).

Eligible participants were UK‐based anaesthetists of any grade actively involved in performing eFONA following a CICO event within the previous 2 years in hospital. Participants were recruited via purposive sampling [12] through the RCoA Airway Leads network and Twitter (now X) [13] (Appendices 2 and 3). In‐depth interviews were deemed the most appropriate method to explore our research question [12]. Qualitative methodology meant that sample size could not be fully determined a‐priori [14], but literature suggests a sample of 12 as appropriate [15, 16]. Data type, iterative analyses and research team discussions informed the final sample size [17].

A research psychologist experienced at interviewing doctors about sensitive topics [16, 18] performed semi‐structured telephone interviews. The interview schedule, piloted and amended (Appendix 4), was grounded in the knowledge gaps within the current literature, hence focused on exploring the cognitive and affective enablers and barriers to making the decision to start eFONA. Interviews were audio‐recorded, transcribed verbatim and anonymised. Participants were offered a £10 voucher in appreciation for their time.

Standardised strategies to ensure credibility and quality at each research stage were employed [19, 20]. To ensure transparency, the research team met and debriefed regularly [21, 22]. We acknowledged and thought reflexively about the possible impact of our clinical experience and in clinical research (LK, CN), and in health psychology and qualitative methods (EW, PW) on how we approached data collection and analyses [23].

Data were analysed thematically [24, 25]. Excel for Mac (Version 16.16.27) and Word for Mac (Version 16.16.27; Microsoft Corporation, Redmond, USA) were used to organise the analyses. An inductive approach was used, deriving themes from the data and researcher reflexivity. Researchers (EW and PW) repeatedly read transcripts allowing immersion in the data. Codes (salient data features) facilitated organisation by common meaning. Next, these were combined into broader themes to interpret the data and make arguments about the phenomena of interest. Themes were reviewed and named, with coding and recoding debated between the whole research team, discussing minor differences in accordance with the methodical guidance [26] to arrive at a final thematic framework. The COnsolidated criteria for REporting Qualitative research (COREQ) checklist [27] was adopted.

Results

A total of 17 doctors were interviewed (Table 1). The interviews took place from October 2020 to August 2021, averaging 41 min each. While no gender exclusions were imposed, all participants were male (Appendix 5). Analyses generated two broad meta‐themes (MTs): ‘Making the decision is the hardest part; the doing is easier’ and ‘What helps make the decision?’, with related themes (Ts) and sub‐themes (STs) (Fig. 1), discussed below and supported by illustrative verbatim quotations (Appendix 1).

Table 1.

Summary of participant characteristics (n = 17). Stage of training has been recorded verbatim, explaining the discrepancy in terminology.

Participant number	Age	Gender	Stage of training at the time of event?	UK medical graduate?	Working full‐time at the time of event?	Sub‐speciality training?	Other comments
1	40–49	Male	Senior ICM training	Yes	Yes	ICM	Several cases discussed but one (most recent) in more depth. All eFONAs successful. Patients survived
2	50–59	Male	Consultant	No	Yes	None	On ICU. eFONA successful. Patient died several hours later
3	30–39	Male	Consultant	Yes	Yes	PHEM	In hospital. eFONA successful. Patient did not survive
4	30–39	Male	ST7	Yes	Yes	None	On ICU. eFONA successful. Patient survived
5	40–49	Male	Consultant	Yes	Yes	None	In theatre. eFONA successful. Patient did not survive
6	50–59	Male	Consultant	Yes	Yes	None	In theatre. eFONA successful. Patient survived
7	20–29	Male	ST3	Yes	Yes	None	On ward. eFONA successful. Patient died several days later
8	30–39	Male	Consultant	Yes	Yes	None	On ward. eFONA successful. Patient died several days later
9	30–39	Male	Staff grade	Yes	Yes	ICM	On ICU. eFONA successful. Patient died several days later
10	40–49	Male	Consultant	Yes	Yes	ICM	On ward. eFONA successful. Patient survived
11	30–39	Male	ST4, registrar	Yes	Yes	ICM	On ward. eFONA unsuccessful. Patient did not survive
12	30–39	Male	Clinical Fellow	Yes	Yes	None	In ED. eFONA successful Patient died several hours later
13	50–59	Male	Associate Specialist	No	Yes	Pain	In ICU. eFONA successful. Patient survived
14	30–39	Male	ST3	Yes	Yes	None	eFONA successful. Patient survived
15	30–39	Male	ST5	Yes	Yes	ICM	On ICU. eFONA successful. Patient died several days later
16	30–39	Male	Consultant	Yes	Yes	ICM	On ICU. eFONA successful. Patient died several hours later
17	30–39	Male	Trainee	Yes	Yes	PHEM	In hospital. eFONA successful. Patient did not survive

ED, emergency department; eFONA, emergency front of neck airway; ICM, intensive care medicine; ICU, intensive care unit; PHEM, prehospital emergency medicine; ST, specialty trainee.

Figure 1.

Cognitive and affective meta‐themes and sub‐themes identified in anaesthetists' experience of emergency front of neck airway events.

There were four distinct themes within MT1, highlighting the challenges of eFONA decision‐making. Whilst models of transitioning (transition is ‘the phase of care leading up to, and including, a committed declaration of a CICO event’ [11]) from a failure of an alternative airway management technique to eFONA do exist and some participants mentioned these, the prevailing sentiment in the moment was the belief that events could be managed without eFONA. Thus, many anaesthetists lacked a real‐life conceptual model for navigating from struggling to accepting failure (MT1:T1). Furthermore, concerns about peer scrutiny, the ‘once in a lifetime’ moment and the associated anxiety were linked to apprehension about failure and blame that occupied participants' narratives.

The dual cognitive tracks of patient and self, which can be difficult to manage, were evident among participants (MT1:T2), who also expressed how hierarchy status, whether at the top or bottom, can be restrictive (MT1:T3). The scrutiny that comes with seniority was expressed by both trainees and consultants, including the burden of correct decision‐making due to concerns that others might feel hesitant to question participants' decisions. Furthermore, when a senior figure acts outside of guidelines, it can potentially hinder team decision‐making. Finally, MT1:T4 captured a contrast between eFONA and routine clinical practice – analyses suggested that some perceived a CICO event as a failure, contrary to prior training and expectations.

Meta‐theme 2 encapsulated factors that facilitate decision‐making in an eFONA situation. Many interviews addressed a patient in or nearing cardiac arrest, highlighting the clinical severity and the explicit need for eFONA. Meta‐theme 2 quotes (Appendix 1) illustrate how clinical need overrides hesitation and reinforces eFONA as a patient‐centric management strategy. Importantly, a supportive team greatly enhances the eFONA process and empowerment from anaesthetic and multidisciplinary colleagues underscores the benefits of a flattened hierarchy, which facilitates the shared mental model (MT2:T2). Analyses revealed the positive impact of shared mental models for eFONA within a hierarchy and how support from multidisciplinary and senior staff alleviates worry and scrutiny, reducing the isolating burden in CICO situations.

Anaesthetists mentioned the value of past experience (MT2:T3), including tracheostomy experience on the intensive care unit, previous eFONA, and training; all of which serve as psychological preparation and reinforce the practical feasibility of eFONA, aiding the performance of the procedure. Participants reflected on a state of eFONA anticipation that may be present throughout one's career. Furthermore, familiarity through training, simulation and experience automates the motor component in emergency airway management.

Meta‐theme 2, theme 4, was summarised by participant 11: ‘if you fail to get the tube in, you are a failure – that's kind of the old culture’. Being UK‐based, DAS guidelines [7] were most commonly referenced and according to the participants, these facilitated decision‐making, allying some of the concerns regarding scrutiny. Analyses suggested that eFONA is not a failure but rather a form of duty, and the time‐critical nature of the decision‐making process did not hinder it, with participants being cautious not to delay decision‐making since ‘the reality is people criticise you more for not doing it’ (participant 12).

Meta‐theme 2, theme 5, highlighted the positive impact of being emotionally unencumbered, either due to individual personality differences, or ‘being the rescuer’ (i.e. not the primary anaesthetist) coming ‘from a completely different psyche’ (participant 17); some participants alluded to a detached surgical mindset whilst others felt it was more of a personality trait.

Discussion

We used qualitative methodology to study the cognitive processes in UK‐based eFONA attempts and how they influenced decision‐making. Analyses identified concerns around scrutiny, lack of a flat hierarchy, unfamiliarity with the situation and the lack of a model for transitioning to eFONA. Culture change, using a shared mental model, priming and emotional disengagement assisted with eFONA decision‐making.

Unlike previous studies on emergency airway events which mainly focused on human factors tied to infrastructure [6, 8] and cognitive pathways [9, 10], our approach explored both cognitive and affective aspects. Qualitative analysis has been applied in assessing airway training [28] and following simulated emergencies [29]. However, it is relatively underutilised in the context of eFONA non‐technical skills (cognitive, social and personal skills complementing technical skills and serving as strategies to mitigate harm [4]). Schnittker et al. reported longer interviews [9], arguably the protocol differences strengthen our findings in terms of their similarity.

The limitations of our study include the lack of female participants. Female healthcare professionals generally exhibit a higher response rate to research invitations [30] but not universally [31]. Notably, 11 (16.9%) of initial respondents were female (which is still low considering that 38% of the UK anaesthetic workforce are women [32]); however, 10 were ineligible due to time elapsed since the event and one later declined. Participants' gender only became evident during study write‐up due to the early anonymisation of data. Importantly, qualitative research does not conform to the typical statistical‐probabilistic generalisability and qualitative analysis has different ontological and epistemological foundations [33], thus arguably our analyses represent views from unique individuals with diverse perspectives and backgrounds. Nonetheless, gender bias within the data exists and results should be interpreted with this in mind, and an omission of equality and diversity screening was a limitation of the study design. It may be that female anaesthetists' eFONA decision‐making differs; this is totally unexplored in this study and warrants investigation.

Second, we solely recruited anaesthetists for whom the eFONA event occurred within the UK. This was deliberate to reduce heterogeneity produced by national variations in guidelines, systems and training. Whilst this might limit the validity of this study in other healthcare systems, many of the themes generated resemble Schnittker et al. Australian findings in terms of enablers and barriers, including the fact that some aspects (e.g. teamwork and communication) could be both depending on the personnel and situation [10].

Third, by simple virtue of volunteering, participants could have a stance to project or reason for participating. Similarly, the recruitment process may have favoured individuals with positive eFONA outcomes. While clinical results varied (Table 1), most eFONAs were successful. Subtle cognitive processes may occur for those with unsuccessful eFONAs, although this was not evident in the data. Additionally, all respondents overcame the potential challenges in performing eFONA. Nonetheless, studying this group can provide valuable insights for improving practice and does not take away from the strengths of our study which include a clear description of the target population, sampling strategy, planned and actual sample size and rich data subjected to rigorous analyses. Finally, our decision not to triangulate (member check) the analyses was informed by the literature and linked to the strategy not being fully in accord with the adopted constructivist epistemology [34].

It is increasingly recognised that emergency airway management is a multidisciplinary event [9] and the shared mental model theme echoes this sentiment. Most literature surrounding this refers to head and neck surgeons as part of the difficult airway team yet even within this group, inconsistencies between preferred technique and nomenclature exist [35]. Anaesthetists and other surgical specialities are no different [36]. Whilst shared mental models clearly facilitate performance, clarity of communication between anaesthetists and within the multidisciplinary team is vital [37]. Unambiguous communication is vital in remote in‐hospital areas where surgeons may be called for assistance. Closed claim analyses indicate a higher risk of airway complications in these locations [38], where a more emotionally disengaged and therefore unencumbered anaesthetic colleague acting as the ‘rescuer’ is typically unavailable. One qualitative study showed many anaesthetists felt surgeons would be most appropriate to perform eFONA in a CICO situation, potentially emphasising the value of a team approach [37].

Furthermore, preparation for CICO events is crucial. This involves mental rehearsal, visualising high‐risk situations and gaining procedural familiarity through regular simulation training. Emphasis should go beyond technical skills and encompass the decision‐making process. An ongoing culture shift towards a shared mental model in airway emergencies is essential [37]. This approach fosters a multidisciplinary team approach and may reduce delays in CICO response, ultimately lessening cognitive burden.

In our study, the rarity of CICO events at the individual level created a degree of exceptionalism, as observed in the literature [39], with a tendency to depend on what normally works despite the exceptional nature of these situations. Varying psychological readiness was evident here, with a lack thereof shifting the balance to a fear of not performing rather than a fear of doing eFONA. Anticipation following clinical assessment, and the accompanying psychological preparedness made this transition easier. The preparedness of participants was greatly aided by previous experience. Procedural familiarity from percutaneous tracheostomies, routine departmental training and psychological priming contributed to automatic motor performance. The value of this cannot be overstated [1]; although preparation alone is insufficient to address delays in isolation [28]. Specifically, the lack of a model for transitioning was a theme in its own right. This challenge of transition in a CICO is well‐established [39]. While some participants explicitly mentioned cognitive models involving transition [40], deviating from established and routine practices remains an obstacle. Developing models with transition embedded is necessary and future work should focus on human factors, ongoing training and psychological preparedness to address transition challenges and facilitate decision‐making.

Recognising the failure of routine airway management is crucial, with acceptance being a pivotal step in the decision‐making process (i.e. deliberation time) [28]. Denial, pride and guilt – often considered barriers to acknowledging failure [39], were not mentioned by our participants. Nonetheless, ‘failure’ – a phrase with strong connotations – was frequently conceptualised, not only in terms of routine airway management but also the anaesthetists' own skills or judgement. Linked to this, scrutiny from colleagues or in the form of legal proceedings played on participants' minds. Coupled with the perception of failure, this is potentially detrimental in a time‐critical emergency. Our analyses suggest that this need not inhibit decision‐making, thus scrutiny can work both ways; it may deter individuals in exceptional situations but can also motivate someone to perform an eFONA. This was part of the larger theme of a ‘change in culture’, which incorporates the impact of cognitive aids and guidelines.

Familiarity with guidelines and their impact clearly strengthened decision‐making. Relatedly, cognitive aids provide a shared mental model for a team [4, 5]. In some cases, decision‐making was facilitated with verbal, non‐verbal or physical prompts. There were many situations where the decision was not simply supported by the team but made with the team. This kind of just environment is to be commended [41].

Guidelines and cognitive aids can mitigate hierarchy in emergencies [1, 4]. Despite obvious advancements in non‐technical skills training, the hierarchy remains influential during emergencies. Some individuals in our study viewed seniority as both an asset and a limitation, aligning with findings from a related study of trainee anaesthetists [42]. This underscores the importance of a supportive environment for challenging decisions while acknowledging that seniority carries ultimate accountability.

In conclusion, preparation for a CICO event through mental rehearsal and training may ameliorate some of the cognitive barriers involved in this procedure. The value of the multidisciplinary team in the decision‐making and the performance of this technique is enormous. Embedding principles of human factors, regular training and psychological preparedness can all help overcome potential transition inertia, in the knowledge that making the decision is probably the hardest part of eFONA cognitive process.

Verbatim quotations from interviews

Meta‐theme/theme	Quotation
Meta‐theme 1: Making the decision is the hardest part: the doing is easier	‘making the decision is probably 90 percent, and I think after that things fall into place’. (P1) ‘A lot of it is about the decision making … and the transition from “this isn't working” to “I'm going to do something I've never done before”’. (P6) ‘You know I have said to most people beforehand that in reflecting on when I did it for the first time, was that the actual practical procedure is not usually the most difficult bit, it is the decision making to actually do it in the first place’. (P16)
Meta‐theme 1; Theme 1: ‘You haven't got a model for transitioning’	‘These rare events are rare and what has always worked will not work so you haven't got a model for transitioning.’ (P6) ‘Because it's so rare it never happens to, you know, most anaesthetists it will never happen in their entire career. So when it does happen the things that you hear people say is, you know, the feeling they have is this is … it's only temporary because I've had things like this but it's always been okay when I've done this. So they keep doing x, y and z because that's always worked for them before. Because they've never had a failure, they can't … not they can't see but they don't perceive that there will be a failure, this is just a particularly difficult one but it will be alright like the other 5000 that I've done before. Whereas these rare events are rare and what has always worked will not work so you haven't got a model for transitioning’. (P6)
Meta‐theme 1; Theme 2: Impact of scrutiny	‘“Oh, this is it then. This is me doing front of neck access. Is this this once in a lifetime, once in a career moment that you get?” That was in the back of my mind, so I was very shaky and nervous because of that, as well as thinking, “Wow, this is something that is going to be potentially spoken about in mortality and morbidity meetings, in the anaesthetic meetings every month or every two months, about my practice and about my decision making”’. (P11)
Meta‐theme 1; Theme 2: Impact of scrutiny	‘Even while resuscitating someone, you think, ‘Is there any chance that the whole world will blame me for failing?’ And personally, I don't think it determines … well I know it doesn't determine the course of action, what you do and what you think. You're not … well, I'm pretty sure I can say I'm not changing what I'm doing and how I'm doing what I'm doing because of that, or to make it less unpleasant in front of the coroner. That's not the case. But you cannot delete this concern am I going to be the one they are going to blame or am I just doing my very best alongside everyone else?’ (P2)
Meta‐theme 1; Theme 2: Impact of scrutiny	‘you're not just worried about the patient, you're also worried about your own career’. (P15) ‘There's a level to which you're not just worried about the patient, you're also worried about your own career which sounds … Well I don't think it does sound selfish, it's a perfectly reasonable sort of place to find yourself, but you just think have I done something, have we made an error somewhere down here, down this course of action that we've taken because you do your best, but you don't know if you've forgotten something, you don't know if you've missed something’. (P15)
Meta‐theme 1; Theme 3: Hierarchy can be challenging; ‘Burden of being senior’	‘You want to be the consultant who can come in and troubleshoot, but you are clearly aware that, I don't know, there's a lot more people watching you’. (P1, trainee) ‘I mean I did worry slightly because I'm the senior person in there. I had the experience, I'd done it before and I did say right okay, I said it out loud, I verbalised what we were doing. Okay, we've got this patient, he's not going to get any better, he's going to die imminently if we don't do something. We haven't got a history, I think we should probably do this. I was slightly concerned that people agreeing with me were just agreeing with me because you know, I'm the boss, or … I'd like to think they would have said if they thought it was the wrong thing to do or anything else we should have done first … I just hoped at the time … I remember at the time thinking well I'll crack on but I hoped someone would say something if they thought otherwise’. (P10, consultant)
Meta‐theme 1; Theme 3: Hierarchy can be challenging; ‘Getting senior permission’	‘There was a consultant with me who was doing the top end and trying to intubate but couldn't. I had a scalpel in my head, because I'd just done a thoracostomy, so, you know, it was sort of there, and it was a very, very prolonged intubation attempt, and I sort of said, “Do you want me to do a front of neck access?” And she was like, “No, no, no, we'll keep persisting at the top end.” And I was like, ‘But she's probably quite hypoxic by this point.’ So, there was a bit of a back and forth there, but I was quite junior, so I didn't want to push too hard, and she was a consultant, etc. And eventually, it was a sort of, “Yeah, go ahead”’. (P9, staff grade)
Meta‐theme 1; Theme 4: Outside our ordinary practice	Especially for anaesthetists, having to perform a surgical airway is always, whatever the opinion leader says … is an admission of failure. That is not what we've trained … we failed to secure the airway the way we've been trained and we've performed for decades. And at this particular moment we have to make a big cut or a cut in a patient's neck and this is in a situation when they are close to death because of what we've initiated and then unable to complete, i.e. inserted a relatively low invasive airway the conventional way. So that it's really terrible situation. (P2)
Meta‐theme 2
Meta‐theme 2: What helps make the decision?	‘And having that facilitated by knowing that the kit is prepared, and you know how to use it, that you have already talked about what would be the trigger point to move from one to the other, and then having enough people in the team who you know, hand the kit, or you know nod, making eye contact … makes it much easier’. (P16) ‘So I think [what helped make the decision] a mixture of, you know, explicit discussions with my colleagues, reference to knowledge they already had and a kind of almost intuition of the severity of the situation’. (P7)
Meta‐theme 2; Theme 1: Clinical need is paramount	‘it was a very dire situation and it wasn't as if I was going to make things any worse if that makes sense. He was poorly oxygenated, he was struggling with his airway. It wasn't like some … you do something to them to salvage something, it was slightly the opposite in that anything that I could do would be better than he was in at the moment’. (P10) ‘It was very clear cut that there wasn't an alternative [to eFONA] because he was rapidly heading to cardiac arrest’. (P13)
Meta‐theme 2; Theme 1: Clinical need is paramount	‘it's quite an extreme thing to do, to perform front of neck, and I think having the knowledge that he [consultant] had briefly appraised the situation and had given his approval I think made me feel as though I was not going to be criticised for doing it. So I think feeling as though I had that permission or I had that kind of senior support and backing was probably I think what helped’. (P7)
Meta‐theme 2; Theme 1: Clinical need is paramount	‘So I knew we'd gone down as far as we could in that route in the context of someone who has an advanced upper airway involving cancer. So at that point in my mind, the only option was to do front of neck and that was it. There wasn't anything else’. (P8)
Meta‐theme 2; Theme 2: A shared mental model	‘I'd had a fairly experienced ODP who'd come with me and who was kind of on the same wavelength as me, and we just went straight for front of neck access’. (P11) ‘team decision to go ahead with a surgical airway’. (P9)
Meta‐theme 2; Theme 2: A shared mental model, ST2	‘I think feeling as though I had that permission or I had that kind of senior support and backing was probably I think what helped’. (P7, trainee)
Meta‐theme 2; Theme 3: ST1: Previous front of neck experience	‘Well I think, to be fair, the familiarity of having done it before probably made me more confident to do it. As I say, because … because I knew that I could, or I most likely could’. (P12) ‘I found myself performing it almost automatically, and I think that that was through having done training in it before’. (P7)
Meta‐theme 2; Theme 3: ST2: Psychological preparation	‘It's the scary moment, going through training as an anaesthetist, that you think you may well come across once, if at all, during your career, so you're always kind of mentally prepared for the situation’. (P11) ‘but I do a lot of them electively. So I'm very used to the kit. I'm very used to the … I didn't have to think about the motor programmes and what I was going to do or what kit I needed out. It was I knew exactly … I actually made a point of having a kit there that I would use normally’. (P10)
Meta‐theme 2; Theme 3: ST3: Role of priming; Automatic motor performance	‘It just all happened quite robotically … there wasn't a lot of thought process going in because it was almost an automatic process to go through the technique’. (P10)
Meta‐theme 2; Theme 4: Change in culture	‘‘You should get the tube in the first place, and the optimal attempt should be the first attempt to get the tube in. And if you fail to get the tube in, you are a failure.’ That's kind of the old culture of it. But I think these days there's a much healthier attitude to that, which is the process around and decision making around a procedure, i.e. which procedure to do, when to do it’. (P11)
Meta‐theme 2; Theme 4: Change in culture; ST1: ‘Guidelines ease the burden’	‘it takes the decision making part away from the individual. Stops it being a judgement and turns it into a protocol’. (P6) ‘“Shall I, shan't I, shall I, shan't I,” causes hesitation. The fact that there's a choice makes it more difficult. And sometimes standardisation of protocols eases the burden of decision making for us and makes it simpler’. (P11)
Meta‐theme 2; Theme 4: Change in culture; ST2: eFONA is not a failure	‘And I'm always – I suppose scared is the right way, or nervous about the time that that happens and being hesitant. I don't want to be that hesitant anaesthetist who potentially puts a patient's best interests on the line because of a decision that you may delay’. (P11) ‘[anaesthetists are] duty bound, aren't you? If you can't get anything in through the mouth then you have to go through the neck, don't you?’ (P4) ‘And I'm always – I suppose scared is the right way, or nervous about the time that that [CICO] happens and being that hesitant anaesthetist’. (P11)
Meta‐theme 2; Theme 5: Emotional disengagement; ST1: Individual differences	‘Some people just have that very much surgical way of looking at things, or some people are a bit more … I don't mean wishy‐washy in a derogative way, I mean just in a different way of looking at things. So for me, it was cognitive. It was quite straightforward. But I'm not sure, it's just because of the way my brain works really’. (P10)
Meta‐theme 2; Theme 5: Emotional disengagement; ST1: Individual differences	‘I have a diagnosis of being on the autistic spectrum and I find that that, in a sense, makes it arguably easier for me in these type of situations because, you know, in a slightly Mr Spock Vulcanist way I can actually put emotions aside and just concentrate on rational thought’. (P13)
Meta‐theme 2; Theme 5: Emotional disengagement; S2: The rescuer	‘when secondary rescuer comes in it will be easier for them emotionally just to transition because it's not their fault. They can see there's an emergency, it's already happened. They know that there's a competent person at the top end who's unable to rescue therefore, “I'll just need to do this really nasty thing”’. (P6)

Recruitment materials (RCoA)

Recruitment materials (X/Twitter)

https://x.com/frontofneck/status/1745803523764138198

Anaesthetic e‐FONA semi‐structured interviews

How do cognitive and affective processes interact with the decision to perform e‐FONA?

Warm up

Before questions, I will remind participants that:

1. they do not have to answer any questions if they do not want to

2. they can withdraw at any time without giving a reason

3. we are bound by strict ethical guidelines (and I will reiterate those to do with confidentiality and anonymity e.g. the interviewee will try not to state any details that might make any person identifiable, and any such details will be removed/pseudonymised straight away at data transcription stage. I will also reiterate those to do with their own psychological safety, where they can get support from, I will stop the interview at signs of distress etc – see our full ethics form)

Please can you tell me your….

1. Age bracket 20‐29; 30‐39; 40‐49; 50‐59; 60‐69; over

2. Gender identity

3. When CICO occurred (year)

4. Deanery, now and also at the time of the CICO situation?

5. Stage of training/working, now and also at the time of the CICO situation?

6. Did you gain your primary medical qualification in the UK?

7. Sub‐speciality training options (i.e. ICM, Pain Medicine), now and also at the time of the CICO situation

8. Are you FT or LTFT training now and also at the time of the CICO situation

Semi‐structured interview questions:

1. Can you describe as fully as possible the CICO situation (prompts: when was it, who was in the room, what were their roles, what was happening, can you describe a timeline of events, how did things end, what happened afterwards)

2. Can you talk me through how you made the decision about whether or not to conduct e‐FONA?

3. Can you talk me though any thoughts you remember about the decision making?

4. Can you talk me through any feelings you remember about the decision making?

5. What (else) influenced your decision making about whether or not to conduct e‐FONA?

6. What (else) hindered you in the process of making the decision about conducting e‐FONA?

7. What (else) helped you in the decision making process about whether or not to conduct e‐FONA?

8. What, if anything, could have been changed to support you in the decision‐making process?

9. What coping strategies, if any, did you use at the time?

10. Looking back is there anything you would change if you could go back to the CICO situation that we have not covered?

11. Is there anything else you would like to say that we have not covered?

NB For all questions, the interviewer will use their judgement and expertise to employ the following probes as needed:

Elaborative

For answers which might initially be ‘yes’ or ‘no’ – add ‘why?’ ‘why not?’ then further probes:

Can you give me an example of that?

Do you think that this is typical of x?

Can you tell me a bit more about that?

What did you think/feel about that?

Why is that/why do you think that is?

Retrospective

Can I take you back to something you said earlier?

You said … could I ask you a bit more about that?

Comparative

How does that compare with your experience of?

How could things have been different?

What advice would you offer to someone in a similar position to you?

How would you improve x?

Probes and question styles adapted from:

Banister, P. et al. (1994) Qualitative Research Methods in Psychology: A Research Guide. Buckingham: Open University Press.

Bowling, A. (2002). Research Methods in Health: Investigating Health and Health Services. Second Edition. Maidenhead: Open University Press.

Kreuger, R. (1998) The Focus Group Kit. Thousand Oaks: Sage.

Richardson, J.T.E. (1996). Handbook of Qualitative Research Methods for Psychology and the Social Sciences. Oxford: Blackwell.

Silverman, D. (1997) Qualitative Research: Theory, Method and Practice. London: Sage.

CONSORT flow diagram of recruitment process