Exploring the recovery journey of COVID-19 critical care survivors during the first year after hospital discharge.

Objectives: To explore the longitudinal recovery of patients admitted to critical care following COVID-19 over the year following hospital discharge. To understand the important aspects of the patients' recovery process and key elements of their caregivers' experiences during this time. Design: A longitudinal qualitative study using semi-structured interviews. Setting: Two acute hospitals in South East England and follow-up in the community. Participants: Six COVID-19 critical care survivors from the first wave of the pandemic (March-May 2020) and five relatives were interviewed 3 months after hospital discharge. The same six survivors and one relative were interviewed again at 1 year. Interviews were transcribed verbatim, anonymised and a reflexive thematic analysis was conducted. Results: Three themes were developed: (1) 'The cycle of guilt, fear and stigma'; (2) 'Facing the uncertainties of recovery' and (3) 'Coping with lingering symptoms - the new norm'. The first theme highlights survivors' reluctance to share their experiences associated with contracting the disease. The second theme, explores challenges faced by the survivors and their relatives in navigating the recovery process, given the unknown nature of the illness. The final theme illustrates the mechanisms survivors develop to come to terms with the remnants of their illness and critical care stay. Conclusions: The longitudinal nature of the study highlighted the persisting symptoms of long COVID-19, their impact on survivors and coping methods amidst the ongoing pandemic. Further research into the experiences of those affected in the first and subsequent waves of the COVID-19 pandemic, is desirable to help guide the formulation of the optimally supported recovery pathways.

The Hospital to Home study (H2H): smartwatch technology-enabled rehabilitation following hip fracture in older adults, a feasibility non-randomised trial.

Introduction: Hip fractures are associated with significant morbidity and mortality. This study assessed the feasibility of smartwatches supporting rehabilitation post-surgical fixation. Methods: This UK-based non-randomised intervention study recruited patients who had sustained a hip fracture (age ≥65 and Abbreviated Mental Test Score ≥8/10), following surgical fixation, at one hospital to the intervention group, and at a second hospital to a usual care group. The intervention group received a smartwatch (Fitbit Charge 4) and app (CUSH Health©). Feasibility measures included retention and completion of outcome measures. Results: Between November 2020 and November 21, 66 participants were recruited (median age 78 (IQR 74-84)). The intervention cohort were younger, with no significant differences in frailty or multi-morbidity between the cohorts. Hospital stay was shorter in the intervention cohort (10 days (7-16) versus 12 (10-18), p=0.05). There were 15 falls-related readmissions in the control cohort, including 11 fractures, with none in the intervention cohort (p=0.016). In the intervention group, median daily step counts increased from 477 (320-697) in hospital, to 931 (505-1238) 1 week post-discharge, to 5,352 (3,552-7,944) at 12-weeks (p=0.001). Of the intervention cohort, 12 withdrew. Conclusion: This study found that smartwatch-supported rehabilitation was feasible in this cohort. A significant proportion of patients either chose not to participate or withdrew; such a decrease in participants must be addressed to avoid digital exclusion. Falls and fracture-related readmissions were more frequent at the control site compared with the intervention site.

Feasibility of an electronic fluid balance chart to detect and understand the significance of oliguric acute kidney injury in a general ward setting: a prospective observational cohort study.

Background: Outside critical care environments, few studies have assessed the significance of oliguric acute kidney injury (AKI). This study investigated the feasibility of an electronic fluid balance chart to diagnose oliguric AKI. Data were used to determine if oliguric AKI was met earlier than creatinine AKI and to establish outcomes of those who developed AKI. Methods: A single-centre prospective cohort study investigated Kidney Disease Improving Global Outcomes oliguric and creatinine AKI criteria on general surgical wards. Results: 2,149 cases were included in the analysis. Incidence of oliguric AKI was significantly higher than creatinine criteria (73 versus 10.1%) and detection occurred earlier (2.1 versus 6.1 days, p<0.05). In cases with oliguric AKI, 8.1% also developed AKI by creatinine criteria. In cases not meeting oliguric AKI criteria, fewer cases developed creatinine AKI, as compared to those meeting oliguric AKI criteria (7.9% versus 11%, p=0.043). There was a high incidence of missing data. Conclusions: Oliguric AKI was met in a high proportion of cases and occurred earlier than by changes in creatinine. Barriers to consistency of recording must be addressed before oliguric criteria could be implemented in clinical practice.

Socially assistive robots in health and social care: Acceptance and cultural factors. Results from an exploratory international online survey.

AIM: This study explored the views of an international sample of registered nurses and midwives working in health and social care concerning socially assistive robots (SARs), and the relationship between dimensions of culture and rejection of the idea that SARs had benefits in these settings. METHODS: An online survey was used to obtain rankings of (among other topics) the extent to which SARs have benefits for health and social care. It also asked for free text responses regarding any concerns about SARs. RESULTS: Most respondents were overwhelmingly positive about SARs' benefits. A small minority strongly rejected this idea, and qualitative analysis of the objections raised by them revealed three major themes: things might go wrong, depersonalization, and patient-related concerns. However, many participants who were highly accepting of the benefits of SARs expressed similar objections. Cultural dimensions of long-term orientation and uncertainty avoidance feature prominently in technology acceptance research. Therefore, the relationship between the proportion of respondents from each country who felt that SARs had no benefits and each country's ratings on long-term orientation and uncertainty avoidance were also examined. A significant positive correlation was found for long-term orientation, but not for uncertainty avoidance. CONCLUSION: Most respondents were positive about the benefits of SARs, and similar concerns about their use were expressed both by those who strongly accepted the idea that they had benefits and those who did not. Some evidence was found to suggest that cultural factors were related to rejecting the idea that SARs had benefits.

Surviving severe COVID-19: Interviews with patients, informal carers and health professionals.

BACKGROUND: The COVID-19 pandemic has been associated with an unprecedented number of critical care survivors. Their experiences through illness and recovery are likely to be complex, but little is known about how best to support them. AIM: This study aimed to explore experiences of illness and recovery from the perspective of survivors, their relatives and professionals involved in their care. STUDY DESIGN: In-depth qualitative interviews were conducted with three stakeholder groups during the first wave of the pandemic. A total of 23 participants (12 professionals, 6 survivors and 5 relatives) were recruited from 5 acute hospitals in England and interviewed by telephone or video call. Data analysis followed the principles of Reflexive Thematic Analysis. FINDINGS: Three themes were generated from their interview data: (1) Deteriorating fast-a downhill journey from symptom onset to critical care; (2) Facing a new virus in a hospital-a remote place; and (3) Returning home as a survivor, maintaining normality and recovering slowly. CONCLUSIONS: Our findings highlight challenges in accessing care and communication between patients, hospital staff and relatives. Following hospital discharge, patients adopted a reframed 'survivor identity' to cope with their experience of illness and slow recovery process. The concept of survivorship in this patient group may be beneficial to promote and explore further. RELEVANCE TO CLINICAL PRACTICE: All efforts should be made to continue to improve communication between patients, relatives and health professionals during critical care admissions, particularly while hospital visits are restricted. Adapting to life after critical illness may be more challenging while health services are restricted by the impacts of the pandemic. It may be beneficial to promote the concept of survivorship, following admission to critical care due to severe COVID-19.

Enactment of compassionate leadership by nursing and midwifery managers: results from an international online survey.

AIM: To explore the views of an international sample of nursing and midwifery managers concerning attributes that they associate with compassionate management. METHOD: A cross-sectional online survey. Using a snowballing sampling method, 1217 responses were collected from nursing and midwifery managers in 17 countries. A total of complete 933 responses to a question related to which actions and behaviours indicated that a manager was exercising compassionate leadership were analysed for this paper. First, content analysis of the responses was conducted, and second, a relative distribution of the identified themes for the overall sample and for each participating country was calculated. RESULTS: Six main themes were identified describing the attributes of a compassionate leader: (1) Virtuous support, (2) Communication, (3) Personal virtues of the manager, (4) Participatory communication, (5) Growth/flourishing/ nurturing and (6) Team cohesion. The first three themes mentioned above collectively accounted for 63% of the responses, and can therefore be considered to be the most important characteristics of compassionate management behaviour. CONCLUSION: The key indicators of compassionate management in nursing and midwifery which were identified emphasise approachability, active and sensitive listening, sympathetic responses to staff members' difficulties (especially concerning child and other caring responsibilities), active support of and advocacy for the staff team and active problem solving and conflict resolution. While there were differences between the countries' views on compassionate healthcare management, some themes were widely represented among different countries' responses, which suggest key indicators of compassionate management that apply across cultures.

Using Smartwatches to Observe Changes in Activity During Recovery From Critical Illness Following COVID-19 Critical Care Admission: 1-Year, Multicenter Observational Study.

BACKGROUND: As a sequela of the COVID-19 pandemic, a large cohort of critical illness survivors have had to recover in the context of ongoing societal restrictions. OBJECTIVE: We aimed to use smartwatches (Fitbit Charge 3; Fitbit LLC) to assess changes in the step counts and heart rates of critical care survivors following hospital admission with COVID-19, use these devices within a remote multidisciplinary team (MDT) setting to support patient recovery, and report on our experiences with this. METHODS: We conducted a prospective, multicenter observational trial in 8 UK critical care units. A total of 50 participants with moderate or severe lung injury resulting from confirmed COVID-19 were recruited at discharge from critical care and given a smartwatch (Fitbit Charge 3) between April and June 2020. The data collected included step counts and daily resting heart rates. A subgroup of the overall cohort at one site-the MDT site (n=19)-had their smartwatch data used to inform a regular MDT meeting. A patient feedback questionnaire and direct feedback from the MDT were used to report our experience. Participants who did not upload smartwatch data were excluded from analysis. RESULTS: Of the 50 participants recruited, 35 (70%) used and uploaded data from their smartwatch during the 1-year period. At the MDT site, 74% (14/19) of smartwatch users uploaded smartwatch data, whereas 68% (21/31) of smartwatch users at the control sites uploaded smartwatch data. For the overall cohort, we recorded an increase in mean step count from 4359 (SD 3488) steps per day in the first month following discharge to 7914 (SD 4146) steps per day at 1 year (P=.003). The mean resting heart rate decreased from 79 (SD 7) beats per minute in the first month to 69 (SD 4) beats per minute at 1 year following discharge (P<.001). The MDT subgroup's mean step count increased more than that of the control group (176% increase vs 42% increase, respectively; +5474 steps vs +2181 steps, respectively; P=.04) over 1 year. Further, 71% (10/14) of smartwatch users at the MDT site and 48% (10/21) of those at the control sites strongly agreed that their Fitbit motivated them to recover, and 86% (12/14) and 48% (10/21), respectively, strongly agreed that they aimed to increase their activity levels over time. CONCLUSIONS: This is the first study to use smartwatch data to report on the 1-year recovery of patients who survived a COVID-19 critical illness. This is also the first study to report on smartwatch use within a post-critical care MDT. Future work could explore the role of smartwatches as part of a randomized controlled trial to assess clinical and economic effectiveness. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.12968/ijtr.2020.0102.

Towards a national strategy for the provision of spiritual care during major health disasters: A qualitative study.

BACKGROUND: Spirituality is beneficial to health. Evidence around the benefits of Spiritual care (SC) is advancing, and training is becoming part of healthcare professional development. As the COVID-19 crisis showed, during major health disasters (MHDs), the demand for SC grows exponentially, while the burden of care and focus on preserving life often hamper its provision. Nonetheless, existing health emergency strategic frameworks lack preparedness for the provision of SC. AIM: The aim of this study was to identify the components for a National Strategy (NS) for the provision of SC during MHDs. METHODS: Descriptive, cross-sectional, qualitative phenomenological design based on individual, semi-structured e-interviews with nursing managers and National Health Service/volunteer chaplains based in England. Thematic analysis of 25 e-interview data was performed based on a dialogic collaborative process. RESULTS AND DISCUSSION: Eleven themes were identified as components of the proposed NS. From these components, specific recommendations for practical actions are provided. An integrated framework approach and smart investments in resources, staff training and technologies should be led by the paradigm of culturally competent and compassionate care. CONCLUSION: The need to have strategic frameworks, both national and local, that better equip a country healthcare sector to prevent, face, and recover from MHDs is paramount. Catering for the spiritual needs of the affected population should be a key aspect of any health emergency strategy to ensure the preservation of quality care.

A qualitative exploration of care homes workers' views and training needs in relation to the use of socially assistive humanoid robots in their workplace.

AIM: The study aimed to explore the views and attitudes of care home workers about the socially assistive robot that was trialled in their workplace, in order to identify training needs in relation to the hypothetical future use of these robots in their workplace. BACKGROUND: Care home workers face challenging workload conditions which may require the exploration of new solutions such as the use of socially assistive robots (SARs). METHODS: This is a qualitative descriptive study which used semi-structured interviews. Care home workers (n = 23) in the UK participated in the study, and data collection took place between October 2019 and January 2020. NVivo software was used for data management, and a thematic inductive analysis was conducted. RESULTS: Findings indicated that many participants were open to the use of robots and valued the potential usefulness of SARs in the care setting. However, some participants showed resistance to the use of robots and did not feel comfortable with the idea of working alongside them. Participants wished to receive technical training that would enable them to be competent in using SARs. Participants took seriously their duty of care to the older people and thus wanted to ensure that the use of the SAR would not negatively impact on the care being provided. Robots were viewed as having potential to be supplementary to human carers, such as sharing the workload and improving upon the care already being provided. CONCLUSIONS: Care home workers express both positive and negative views in relation to the hypothetical future deployment of socially assistive humanoid robots in their workplace. IMPLICATIONS FOR PRACTICE: The findings highlighted the importance of values around person-centred care which should be taken into account when planning for the implementation of robots in social care settings and training care home workers in how to work with robots.

Ventilation With or Without Endotracheal Tube Leak in Prolonged Neonatal Asphyxia.

Background Severe and prolonged asphyxia can result in either intrauterine fetal death and stillbirth or multiorgan failure in surviving neonates. Establishing effective ventilation is the primary aim of resuscitation in newborns with asphyxia. The objective of this study was to compare the outcome of resuscitation by applying an endotracheal tube (ETT) with less, an ETT with moderate, and an ETT with high leakage during mechanical ventilation in swine neonates after prolonged perinatal asphyxia. Materials and methods A prospective, randomized controlled laboratory study was performed. Thirty Landrace/large white pigs, aged one to four days and weighted 1.754±218 gr, were randomly allocated into three groups depending on the ETT size: Group C (less leak: ETT no 4.0, n=10); Group A (high leak: ETT no 3.0, n=10); and Group B (moderate leak: ETT no 3.5, n=10). Mechanical asphyxia was performed until their heart rate was less than 60 bpm or their mean arterial pressure was below 15 mmHg. All animals with return of spontaneous circulation (ROSC) were monitored for four hours for their hemodynamic parameters, arterial oxygen saturation, and lactate acid levels. Results We demonstrate that 70% of the surviving animals were ventilated with an ETT with a leak (no. 3.5 and 3). A statistically significant difference was noted in PO2 (p=0.032) between Group B (126.4±53.4 mmHg) compared to Group A (72.28±29.18 mmHg) and Group C (94.28±20.46 mmHg) as well as in the right atrial pressure (p<0.001) between Group C (4.5 mmHg) vs Groups A (2 mmHg) and B (2 mmHg) during ROSC time. Lactate levels were statistically significantly lower (p=0.035) in Group C (mean=0.92 ± 0.07mmol/L) as compared to Group A (mean=1.13 ± 0.1 mmol/L) and Group B (mean= 1.08 ± 0.07 mmol /L; p = 0.034) at 4h post-ROSC. Conclusion We provide preliminary evidence that ventilation with ETT with moderate leakage improves survival after 2h of ROSC, along with oxygenation and hemodynamic parameters, in a porcine model of neonatal asphyxia and resuscitation, compared to less leakage ETT.

Spiritual Support During COVID-19 in England: A Scoping Study of Online Sources.

Spiritual support is a key element of holistic care, and better healthcare professionals training and stronger strategic guidelines become urgent in light of health disasters and emergencies, such as the COVID-19 pandemic. To this end, the aim of this study was to explore spiritual support provision within mass and social media and the websites of spiritual leaders, institutions and NHS chaplaincy units during COVID-19 in England, between March and May 2020. A scoping review design informed by Levac and colleagues' five-staged framework was adopted, and adapted with a multi-strategy search to scope the different domains of online sources. Results revealed that spiritual support for dying patients, their families, health care staff, spiritual leaders and chaplains, had to be drastically reduced, both in quality and quantity, as well as being provided via different technological devices or domestic symbolic actions. No mention was found of a central strategy for the provision of spiritual support. This study points to the importance of developing centralized strategies to prepare healthcare systems and professionals in relation to spiritual support provision, both routinely and during health disasters and emergencies. Further research will have to explore innovative practices, in particular the role of digital technologies, in spiritual support provision.

The Importance of Being a Compassionate Leader: The Views of Nursing and Midwifery Managers From Around the World.

INTRODUCTION: Despite the importance of compassionate leadership in health care, many of the existing publications do not account for the effect of culture. The aim of this study is to explore the views of nursing and midwifery managers from different countries in relation to the definition, advantages, and importance of compassion. METHODOLOGY: A cross-sectional, descriptive, exploratory online survey was conducted across 17 countries, containing both closed and open-ended questions. Data from N = 1,217 respondents were analyzed using a directed hybrid approach focusing only on qualitative questions related to compassion-giving. RESULTS: Four overarching themes capture the study's results: (1) definition of compassion, (2) advantages and importance of compassion for managers, (3) advantages and importance of compassion for staff and the workplace, and (4) culturally competent and compassionate leadership. DISCUSSION: Innovative research agendas should pursue further local qualitative empirical research to inform models of culturally competent and compassionate leadership helping mangers navigate multiple pressures and be able to transculturally resonate with their staff and patients.

Collegial surface acting emotional labour, burnout and intention to leave in novice and pre-retirement nurses in the United Kingdom: A cross-sectional study.

Aim: To investigate the relationship between surface and deep acting in nurses' patient-focused and collegial emotional labour, with emotional exhaustion, depersonalization and personal accomplishment and intention to leave. Design: A cross-sectional descriptive study using the Emotional Labour Scale, the Maslach Burnout Inventory and intention to leave Yes/No questions with 118 Registered Nurses to measure patient-focused and collegial emotional labour, burnout and intention to leave. Results: Surface acting in patient-focused and collegial emotional labour was found to have positive associations with burnout and intention to leave their current job. Only surface acting in patient-focused emotional labour was positively associated with intention to leave the organization and/or the profession. The novice nurses carried out more deep acting collegial emotional labour than the pre-retirement nurses. Conclusions: Collegial emotional labour is significant to nurses' intention to leave their current job but not their intention to leave the organization and/or the profession.

Risk Factors for Poststroke Shoulder Pain: A Systematic Review and Meta-Analysis.

OBJECTIVE: To identify the risk factors identified within 1-month poststroke that predict the onset of poststroke shoulder pain (PSSP) within the first year after stroke. METHODS: Five databases (AMED, CINAHL, EMBASE, Medline, and PubMed) were searched from inception to April 2019. Prospective cohort studies that measured a potential risk factor for PSSP within the first month after stroke were included. Two authors independently reviewed and selected articles for inclusion. Risk of bias was assessed using the Quality in Prognosis Studies tool. Data extracted included raw data for odds ratio (OR) calculations, definition and measurement of pain, study limitations, and baseline characteristics of participants. The review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Nine articles were retrieved that met the inclusion criteria, and 6 presented data to use in meta-analysis. Fifty-four different factors were identified as potential risk factors. Meta-analysis was possible for 4 factors; sex (OR .93, confidence interval [CI] .75-1.15), laterality (OR .78, CI .59-1.05), diabetes (OR 2.09, CI 1.16-3.78), and history of shoulder pain (OR 2.78, CI 1.29-5.97). Reduced motor function in the upper limb was also identified as a significant risk factor through qualitative synthesis. CONCLUSIONS: Reduced motor function in the upper limb, diabetes, and a history of shoulder pain were identified as significant risk factors for the development of PSSP within the first year after stroke. Recommendations to standardize future studies in this area have been made, and it is suggested that defining subtypes of PSSP may aid future interventional studies.

Enablers and barriers to the implementation of socially assistive humanoid robots in health and social care: a systematic review.

OBJECTIVES: Socially assistive humanoid robots are considered a promising technology to tackle the challenges in health and social care posed by the growth of the ageing population. The purpose of our study was to explore the current evidence on barriers and enablers for the implementation of humanoid robots in health and social care. DESIGN: Systematic review of studies entailing hands-on interactions with a humanoid robot. SETTING: From April 2018 to June 2018, databases were searched using a combination of the same search terms for articles published during the last decade. Data collection was conducted by using the Rayyan software, a standardised predefined grid, and a risk of bias and a quality assessment tool. PARTICIPANTS: Post-experimental data were collected and analysed for a total of 420 participants. Participants comprised: older adults (n=307) aged ≥60 years, with no or some degree of age-related cognitive impairment, residing either in residential care facilities or at their home; care home staff (n=106); and informal caregivers (n=7). PRIMARY OUTCOMES: Identification of enablers and barriers to the implementation of socially assistive humanoid robots in health and social care, and consequent insights and impact. Future developments to inform further research. RESULTS: Twelve studies met the eligibility criteria and were included. None of the selected studies had an experimental design; hence overall quality was low, with high risks of biases. Several studies had no comparator, no baseline, small samples, and self-reported measures only. Within this limited evidence base, the enablers found were enjoyment, usability, personalisation and familiarisation. Barriers were related to technical problems, to the robots' limited capabilities and the negative preconceptions towards the use of robots in healthcare. Factors which produced mixed results were the robot's human-like attributes, previous experience with technology and views of formal and informal carers. CONCLUSIONS: The available evidence related to implementation factors of socially assistive humanoid robots for older adults is limited, mainly focusing on aspects at individual level, and exploring acceptance of this technology. Investigation of elements linked to the environment, organisation, societal and cultural milieu, policy and legal framework is necessary. PROSPERO REGISTRATION NUMBER: CRD42018092866.

The Influence of Culture on Attitudes Towards Humanoid and Animal-like Robots: An Integrative Review.

PURPOSE: The aim of the present review is to explore the influence of culture on attitudes towards humanoid and animal-like robots. DESIGN: An integrative review of current evidence. METHODS: Medline, CINAHL, PsycInfo, PubMed, and Google Scholar were searched from 2000 to 2017. A total of 22 articles met the inclusion criteria and were retrieved and analyzed. FINDINGS: Culture influences attitudes and preferences towards robots, but due to the limitations of the reviewed studies, concrete conclusions cannot be made. More consistent evidence was found with regard to the influence of culture on nonverbal behaviors and communication styles, with people being more accepting of a robot that behaved more closely to their own culture. CONCLUSIONS: The research field of human-robot interaction provides the current evidence on the influence that culture has on attitudes towards humanoid and animal-like robots, but more research that is guided by strong theoretical frameworks is needed. CLINICAL RELEVANCE: With the increased use of humanoid robots in the healthcare system, it is imperative that nurses and other healthcare professionals explore and understand the different factors that can affect the use of robots with patients.

Views of nurses and other health and social care workers on the use of assistive humanoid and animal-like robots in health and social care: a scoping review.

BACKGROUND: Robots are introduced in many health and social care settings. OBJECTIVES: To provide an overview of the existing evidence related to the views of nurses and other health and social care workers about the use of assistive humanoid and animal-like robots. METHODS: Using the Joanna Briggs Institute guidelines we searched MEDLINE, PUBMED, CINHAL, EMBASE, PsycInfo, Web of Science, and IEEE Xplore digital library. Nineteen (19) articles met the criteria for inclusion. RESULTS: Health care workers reported mixed views regarding the use of robots. They considered an array of tasks that robots could perform; they addressed the issue of patient safety and raised concerns about privacy. CONCLUSIONS: A limited number of studies have explored the views of health care workers about the use of robots. Considering the fast pace with which technology is advancing in the care field, it is critical to conduct more research in this area. Impact Statement: Robots will increasingly have a role to play in nursing, health and social care. The potential impact will be challenging for the healthcare workforce. It is therefore important for nurses and other health and social care workers to engage in discussion regarding the contribution of robots and their impact not only on nursing care but also on future roles of health and social care workers.

A comparison between the two methods of chest compression in infant and neonatal resuscitation. A review according to 2010 CPR guidelines.

AIM: The quality of chest compression (CC) delivered during neonatal and infant cardiopulmonary resuscitation (CPR) is identified as the most important factor to achieve the increase of survival rate without major neurological deficit to the patients. The objective of the study was to systematically review all the available studies that have compared the two different techniques of hand placement on infants and neonatal resuscitation, from 2010 to 2015 and to highlight which method is more effective. METHODS: A review of the literature using a variety of medical databases, including Cochrane, MEDLINE, and SCOPUS electronic databases. The following MeSH terms were used in the search: infant, neonatal, CPR, CC, two-thumb (TT) technique/method, two-finger (TF) technique/method, rescuer fatigue, thumb/finger position/placement, as well as combinations of these. RESULTS: Ten studies met the inclusion criteria; nine observational studies and a randomized controlled trial. All providers performed either continuous TF or TT technique CCs and the majority of CPR performance was taken place in infant trainer manikin. CONCLUSIONS: The majority of the studies suggest the TT method as the more useful for infants and neonatal resuscitation than the TF.