Simulation in Neonatal Resuscitation

Potential benefits and challenges of simulation-based neonatal resuscitation competition: A survey analysis of provincial competition in China

Background

Simulation-based neonatal resuscitation training has been implemented worldwide with good educational and clinical results. Simulation-based competition (SBC), as an innovative derivative of neonatal resuscitation training, has been practiced recently but its potential effectiveness and challenges of competition are rarely studied. We tested the hypothesis that after SBC, participants could improve compliance with NRP® algorithm and teamwork, achieve lower stress and higher confidence in neonatal resuscitation.

Methods

In February 2023, 108 health care providers in 27 teams from different regional centres participated in provincial SBC. Each team consisted of 4 members (NICU physician [lead], NICU nurse, midwife and obstetrician). The teams were to complete a resuscitation scenario (16 min) and their performance was evaluated. All participants were encouraged to take part in a post-resuscitation questionnaire survey voluntarily immediately after the scenarios finished. Demographic characteristics and questionnaire results of participants were collected, including the confidence and perceived stress levels before and after the competition.

Results

Ninety-eight (90.7%) participants completed the survey with 114 post-resuscitation questionnaire surveys. Participants perceived top benefits of SBC including improved compliance with NRP® algorithm, technical skills and teamwork, with the least benefit in improving self-confidence (vs. other benefits, P < 0.001). The confidence level did not change before and after the competition, whereas stress was reduced after the competition.

Conclusions

Participants in SBC might be benefited with improved compliance with NRP® algorithm, technical skills and teamwork. However, the impact, influence and sustainability of these benefits are uncertain. Further research is needed to explore ways to improve self-confidence and decrease stress in neonatal resuscitation.

The perceived workload of first-line healthcare professionals during neonatal resuscitation

Background

Neonatal resuscitation is stressful for healthcare professionals as measured using the National Aeronautics and Space Administration-Task Load Index (NASA-TLX). Little is known regarding the perceived workload and associated factors among healthcare professionals including medical doctors (MDs) and nurses/midwives who have differences in training and experiences. We aimed to characterize and compare the perceived workload between MDs and nurses/midwives who provided neonatal resuscitation.

Methods

In a prospectively designed, cellphone-based surveillance, perceived workload and stress of MDs and nurses/midwives during neonatal resuscitation was evaluated using a modified multi-dimensional NASA-TLX survey in three tertiary Neonatal Intensive Care Units in China. The NASA-TLX data on mental, physical, temporal demand, performance, effort, and frustration were independently rated by participants and collated to a composite score of all dimensions. Demographics of participants and deliveries were also collected for statistical analyses using univariate comparison and multiple linear regression.

Results

From 410 valid surveys (187 (46%) MDs; 223 (54%) nurses/midwives), significant differences were noted between MDs and nurses/midwives including working years and dimensional and overall NASA-TLX scores. While MDs had lower overall NASA-TLX scores than nurses, their scores were inversely related with simulation-based training. More team members presence during resuscitation was associated with higher NASA-TLX scores. Other independent factors associated with NASA-TLX scores included gestational age, Apgar score at 1 min, year of practice for MDs and all resuscitation questions asked by nurses/midwives.

Conclusions

MDs and nurses/midwives attending deliveries had different perceptions in workload and stress which could be lowered from simulation-based training in neonatal resuscitation.

SimCapture app video performance assessment versus real-time instructor-based performance evaluation of undergraduates in neonatal resuscitation-an agreement study

Undergraduates are trained in the basic neonatal resuscitation programme (NRP) and evaluated for skill acquisition by NRP performance evaluation test (PET). Video use improves the validity of assessment when video-information adequacy, intrusiveness to students, and educational purpose are adequately balanced. We evaluated whether there was a difference between instructor's real-time assessment and video-based assessment done by another independent assessor using videos recorded via the SimCapture application. Undergraduates were trained in basic neonatal resuscitation and were evaluated at the end for skill acquisition by PET as a part of a randomized control trial (RCT). Video recording of the PET assessment was done with the SimCapture app. Independent assessors evaluated recorded videos to evaluate and validate real-time instructor performance evaluation time assessments. We conducted an agreement study to evaluate the difference between a real-time instructor and video assessments. We trained 143 students; 139 videos were evaluated. The Bland-Altman plot showed good agreement. For the post-test result, 66 (47.5%) passed, and 73 (52.5%) failed according to the real-time assessment, while 61 (43.8%) passed and 78 (56.1%) failed according to the video assessment. The agreement between the two assessments was 94.9%, with a kappa value of 0.898. Indicating the need for positive pressure ventilation (PPV), 138 (99.3%) did correctly in real-time assessment, while 133 (95.6%) did correctly in video assessment with agreement of 96.4% but low kappa of 0.27. We conclude that the instructors' assessment was excellent and didn't differ from assessments obtained from recorded videos and vice-versa.

Assessing Team Performance in a Longitudinal Neonatal Resuscitation Simulation Training Program: Comparing Validity Evidence to Select the Best Tool

Introduction Neonatal resuscitation is a high-acuity, low-occurrence event that requires ongoing practice by interprofessional teams to maintain proficiency. Simulation provides an ideal platform for team training and evaluation of team performance. Our simulation center supports a longitudinal in situ simulation training program for delivery room teams. In addition to adherence to the Neonatal Resuscitation Program standards, team performance assessment is an essential component of program evaluation and participant feedback. Multiple published teamwork assessment tools exist. Our objective was to select the tool with the best validity evidence for our program's needs. Methods We used Messick's framework to assess the validity of evidence for potential teamwork assessment tools. Four possible tools were identified from the literature: the Mayo High Performance Teamwork Scale (Mayo), Team Performance Observation Tool (TPOT), Clinical Teamwork Scale (CTS), and Team Emergency Assessment Measure (TEAM). Relevant context included team versus individual focus, external evaluator versus self-evaluation, and ease of use (which included efficiency, clarity of interpretation, and overall assessment). Three simulation experts identified consensus anchors for each tool and independently reviewed and scored 10 pre-recorded neonatal resuscitation simulations. Raters assigned each tool a rating according to efficiency, ease of interpretation, and completeness of teamwork assessment. Interrater reliability (IRR) was calculated using intraclass correlation for each tool across the three raters. Average team performance scores for each tool were correlated with neonatal resuscitation adherence scores for each video using Spearman's rank coefficient. Results There was a range of IRR between the tools, with Mayo having the best (single 0.55 and multi 0.78). Each of the three raters ranked Mayo optimally in terms of efficiency (mean 4.66 + 0.577) and ease of use (4+1). However, TPOT and CTS scored highest (mean 4.66 ± 0.577) for overall completeness of teamwork assessment. There was no significant correlation to NRP adherence scores for any teamwork tool. Conclusion Of the four tools assessed, Mayo demonstrated moderate IRR and scored highest for its ease of use and efficiency, though not completeness of assessment. The remaining three tools had poor IRR, which is not an uncommon problem with teamwork assessment tools. Our process emphasizes the fact that assessment tool validity is contextual. Factors such as a relatively narrow (and high) performance distribution and clinical context may have contributed to reliability challenges for tools that offered a more complete teamwork assessment.

Development of neonatal Apgar scoring training program utilizing contactless hand tracking in immersive virtual reality

BACKGROUND

The rapid and accurate assessment of neonatal asphyxia is critical to preventing potentially fatal outcomes. Therefore, nursing students must acquire the skills to assess newborn conditions immediately after birth and implement appropriate interventions. Virtual reality (VR) simulation education has emerged as a promising tool for nursing education, offering repetitive and customizable clinical training while ensuring patient safety and overcoming spatiotemporal limitations.

AIM

This study investigated the effects of a contactless hand-tracking-based immersive VR neonatal Apgar scoring program, adapted from experiential learning theory.

DESIGN

A non-randomized controlled trial with a pre-post-test, quasi-experimental design was conducted.

SETTINGS

The study was conducted at two nursing schools from July to October 2023.

PARTICIPANTS

Participants comprised nursing students holding bachelor's degrees in nursing, with three or four years of experience and successful completion of a neonatal nursing theory course. Additionally, individuals with at least six months of experience working in a neonatal ward or delivery room before enrolling in nursing school were eligible.

METHODS

The participants were divided into three groups: the VR group (n = 27) received contactless hand-tracking-based immersive VR neonatal Apgar scoring training; the simulation group (n = 28) received face-to-face Apgar scoring simulation training; and the control group (n = 26) received instruction on the Apgar scoring criteria. Changes in scores among the VR, simulation, and control groups were statistically compared using ANOVA with SPSS-WIN 27.0.

RESULTS

The VR group exhibited significant improvements in knowledge, learning satisfaction, self-confidence, immersion, and motivation compared to the simulation and control groups. Moreover, satisfaction was significantly higher in the VR group than in the simulation group.

CONCLUSIONS

The hand-tracking-based immersive VR neonatal Apgar scoring program represents an innovative and effective educational tool, prioritizing the privacy and rights of mothers and infants. It can potentially replace traditional delivery-room clinical training, which is observation-based and limited.

A Randomized Controlled Simulation Trial of a Neonatal Resuscitation Digital Game Simulator for Labour and Delivery Room Staff

BACKGROUND

Healthcare providers (HCPs) working in labour and delivery rooms need to undergo regular refresher courses to maintain their neonatal resuscitation skills, which are shown to decline over time. However, due to their irregular schedules and limited time, HCPs encounter difficulties in readily accessing refresher programs. RETAIN is a digital game that simulates a delivery room to facilitate neonatal resuscitation training for HCPs.

OBJECTIVE

This study aims to ascertain whether participants enjoyed the RETAIN digital game simulator and whether it was at least as good as a video lecture at refreshing and maintaining participants' neonatal resuscitation knowledge.

METHODS

In this randomized controlled simulation trial, n = 42 labour and delivery room HCPs were administered a pre-test of neonatal resuscitation knowledge using a manikin. Then, they were randomly assigned to a control or a treatment group. For 20-30 min, participants in the control group watched a neonatal resuscitation lecture video, while those in the treatment group played the RETAIN digital game simulator of neonatal resuscitation scenarios. Then, all participants were administered a post-test identical to the pre-test. Additionally, participants in the treatment group completed a survey of attitudes toward the RETAIN simulator that provided a measure of enjoyment of the RETAIN game simulator. After two months, participants were administered another post-test identical to the pre-test.

RESULTS

For the primary outcome (neonatal resuscitation performance), an analysis of variance revealed that participants significantly improved their neonatal resuscitation performance over the first two time points, with a significant decline to the third time point, the same pattern of results across conditions, and no differences between conditions. For the secondary outcome (attitudes toward RETAIN), participants in the treatment condition also reported favourable attitudes toward RETAIN.

CONCLUSIONS

Labour and delivery room healthcare providers in both groups (RETAIN simulator or video lecture) significantly improved their neonatal resuscitation performance immediately following the intervention, with no group differences. The findings suggest that participants enjoyed interacting with the RETAIN digital game simulator, which provided a similar boost in performance right after use to the more traditional intervention.

Using Simulation-Based Training to Improve Neonatal Resuscitation Clinical Competency, Confidence, and Comfort Level of NICU Caregivers

BACKGROUND

Approximately 10% of newborns require resuscitation at delivery or during a neonatal intensive care unit (NICU) stay. Neonatal intensive care unit caregivers competent in providing neonatal resuscitation decrease perinatal mortality and improve neonatal outcomes. Infrequency of resuscitation events, lack of repetition, and inexperience leave caregivers feeling un-prepared for emergency situations. There is a need for educational strategies to maintain competency and increase confidence and comfort level.

METHOD

This quality improvement project used a pre-post survey design. Competency was assessed during simulated mock codes using the Creighton Competency Evaluation Instrument. Self-perceived confidence and comfort level were assessed using a pre-post survey.

RESULTS

Descriptive statistics indicated that the average score on the Creighton Competency Evaluation Instrument fell below the targeted minimally competent goal of 80%. Practical significance was noted between the pre-intervention and post-intervention means of both perceived confidence and comfort level.

CONCLUSION

Simulation-based education may increase the competency, confidence, and comfort level of NICU caregivers and should be conducted routinely. Similar projects could be replicated at other institutions to address continuing competency with neonatal resuscitation. [J Contin Educ Nurs. 2024;55(4):175-180.].

The Effects of a Digital Game Simulator versus a Traditional Intervention on Paramedics' Neonatal Resuscitation Performance

Neonatal resuscitation is a skill set that comprises procedures, assessment, decision-making, communication, and teamwork. It is used in an emergency situation in the delivery room with the aim of supporting newborn infants who are not able to begin breathing on their own. Thus, healthcare providers need to refresh their neonatal resuscitation skills periodically, according to the Neonatal Resuscitation Program, to ensure that they can react quickly and effectively in emergency situations. The RETAIN digital game simulator was designed to enable healthcare providers to practice their neonatal resuscitation skills. To evaluate the effectiveness of this game in a laboratory setting, a randomized control trial sampled 42 paramedics who completed a pre-test, were randomly assigned to watch a traditional lecture video on the neonatal resuscitation procedure or to play a novel digital game simulation on the same topic, and then completed a following test. A two-way mixed ANOVA revealed a statistically significant improvement in paramedics' neonatal resuscitation performance over time, which did not differ between conditions. Thus, digital games can provide an enjoyable alternative to traditional practices in refreshing neonatal resuscitation knowledge.

RiNeo MR: A mixed reality simulator for newborn life support training

Neonatal resuscitation is an uncommon, albeit critical task that is more likely to succeed if performed properly and promptly. In this context, simulation is an appropriate way for training and assessing the abilities of all medical staff involved in delivery room care. Recent studies have shown that learning is enhanced if the simulation experience is realistic and engaging. Hence, Virtual Reality can be beneficial for newborn resuscitation training. However, the difficulty of providing realistic haptic interaction limits its use. To overcome this constraint, we have designed RiNeo MR, a simulator for newborn life support training, combining a sensorized manikin to monitor in real time resuscitation skills, with a Virtual Reality application. The system includes a Virtual Reality headset, Leap Motion to track the user's hands, sensorized bag valve mask, and manikin to monitor head and mask positioning, ventilation, and chest compression. RiNeo MR can be used in two modalities: 2D to let the trainee practice resuscitation manoeuvres on the physical manikin, while receiving real time feedback; 3D that allows the user to be immersed in a virtual environment and practice in an hospital-like setting. In the 3D mode, virtual and real manikins are overlapped and communicate in real time. Tests on 16 subjects (11 controls without medical expertise and 5 paediatric residents) demonstrated that the simulator is well tolerated in terms of discomfort. Moreover, the simulator is high rated for user experience and system usability, suggesting that RiNeo MR can be a promising tool to improve newborn life support training. RiNeo MR is a proof of concept of a mixed-reality newborn life support simulator that can be a promising tool to spread newborn resuscitation high-quality training among healthcare providers involved in perinatal medicine.

Mask ventilation using volume-targeted neonatal ventilator for neonatal resuscitation: a randomised cross-over simulation study

OBJECTIVE

To use simulations to compare a novel mask ventilation method using a neonatal ventilator, with mask ventilation using a T-piece resuscitator, to study human factors prior to clinical testing.

DESIGN

Prospective randomised cross-over simulation study. Participants were briefly trained to use a neonatal ventilator for mask ventilation. Each participant was fitted with eye-tracking glasses to record visual attention (VA) and performed two simulated preterm neonatal resuscitations in a randomised sequence.

SETTING

In situ in a neonatal resuscitation room within a Level 3 neonatal intensive care unit.

PARTICIPANTS

Healthcare professionals (HCPs) trained in neonatal resuscitation with experience as team leaders.

INTERVENTIONS

Semiautomated, ventilator-based, volume-targeted positive pressure mask ventilation (VTV-PPV) versus manual mask ventilation via T-piece device (T-piece PPV).

MAIN OUTCOME MEASURES

Subjective workload (Surgical Task Load Index, SURG-TLX), VA, quantitative and qualitative postsimulation survey responses.

RESULTS

Thirty HCPs participated. HCPs reported higher total SURG-TLX scores (43.5/120 vs 33.8/120) and higher scores in mental demand (8.2/20 vs 5.6/20), physical demand (6.6/20 vs 5.1/20), task complexity (8.2/20 vs 6/20) and situational stress (8.3/20 vs 5.9/20) for VTV-PPV. Temporal demand and distraction scores were similar. While participants took longer to complete VTV-PPV simulations, participants dedicated similar a %VA to the mannikin and T-piece gauges or ventilator screen. More participants increased the rate of ventilation during VTV-PPV; other corrective steps were similar. Overall, participants rated VTV-PPV positively. Participants identified potential challenges with physical ergonomics, cognition and teamwork.

CONCLUSION

Using a neonatal ventilator to perform volume-targeted PPV is feasible, but human factors need to be considered.

Enhancing residents' neonatal resuscitation competency through team-based simulation training: an intervention educational study

BACKGROUND

Neonatal resuscitation training in a simulated delivery room environment is a new paradigm in pediatric medical education. The purpose of this research is to highlight team-based simulation as an effective method of teaching neonatal resuscitation to senior pediatric residents.

METHODS

In an intervention educational study, we evaluated the impact of team-based simulation training in the development of neonatal resuscitation. A team consisting of a three-person group of senior pediatric residents performed neonatal resuscitation on a low-fidelity newborn simulator based on the stated scenario. Video-based structured debriefing was performed and followed by the second cycle of scenario and debriefing to evaluate the feasibility of conducting team-based simulation training in a lesser-resourced environment. Evaluation criteria included megacode scores which is a simulation performance checklist, pre-and post-test scores to evaluate residents' knowledge and confidence, the survey checklist as a previously developed questionnaire assessing residents' satisfaction, and debriefing from live and videotaped performances. Four months after the end of the training course, we measured the behavioral changes of the residents by conducting an OSCE test to evaluate post-training knowledge retention. Mean ± SD was calculated for megacode, satisfaction (survey checklist), and OSCE scores. Pre- and post-program gains were statistically compared. The first three levels of Kirkpatrick's training effectiveness model were used to evaluate the progress of the program.

RESULTS

Twenty-one senior residents participated in the team-based simulation. The mean ± SD of the megacode score was 35.6 ± 2.2. The mean ± SD of the overall satisfaction score for the evaluation of the first level of the Kirkpatrick model was 96.3 ± 3.7. For the evaluation of the second level of the Kirkpatrick model, the pre-posttest gain in overall confidence score had a statistically significant difference (P = 0.001). All residents obtained a passing grade in OSCE as an evaluation of the third level.

CONCLUSIONS

Team-based simulation training in neonatal resuscitation improves the knowledge, skills, and performance of pediatric residents and has a positive effect on their self-confidence and leadership skills. There is still a need to investigate the transfer of learning and abilities to real-life practice, and further research on cost-effectiveness and impact on patient outcomes is warranted.

Improved neonatal outcomes by multidisciplinary simulation-a contemporary practice in the demonstration area of China

Background

Simulation-based training improves neonatal resuscitation and decreases perinatal mortality in low- and middle-income countries. Interdisciplinary in-situ simulation may promote quality care in neonatal resuscitation. However, there is limited information regarding the effect of multidisciplinary in-situ simulation training (MIST) on neonatal outcomes. We aimed to investigate the impact of MIST on neonatal resuscitation in reducing the incidence of neonatal asphyxia and related morbidities.

Methods

Weekly MIST on neonatal resuscitation has been conducted through neonatal and obstetrical collaboration at the University of Hong Kong-Shenzhen Hospital, China, since 2019. Each simulation was facilitated by two instructors and performed by three health care providers from obstetric and neonatal intensive care units, followed by a debriefing of the participants and several designated observers. The incidence of neonatal asphyxia, severe asphyxia, hypoxic-ischemic encephalopathy (HIE), and meconium aspiration syndrome (MAS) before (2017-2018) and after (2019-2020) the commencement of weekly MIST were analyzed.

Results

There were 81 simulation cases including the resuscitation of preterm neonates of different gestational ages, perinatal distress, meconium-stained amniotic fluid, and congenital heart disease with 1,503 participant counts (225 active participants). The respective incidence of neonatal asphyxia, severe asphyxia, HIE, and MAS decreased significantly after MIST (0.64%, 0.06%, 0.01%, and 0.09% vs. 0.84%, 0.14%, 0.10%, and 0.19%, respectively, all P < 0.05).

Conclusions

Weekly MIST on neonatal resuscitation decreased the incidence of neonatal asphyxia, severe asphyxia, HIE, and MAS. Implementation of regular resuscitation simulation training is feasible and may improve the quality of neonatal resuscitation with better neonatal outcomes in low- and middle-income countries.

European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update

Respiratory distress syndrome (RDS) care pathways evolve slowly as new evidence emerges. We report the sixth version of "European Guidelines for the Management of RDS" by a panel of experienced European neonatologists and an expert perinatal obstetrician based on available literature up to end of 2022. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, appropriate maternal transfer to a perinatal centre, and appropriate and timely use of antenatal steroids. Evidence-based lung-protective management includes initiation of non-invasive respiratory support from birth, judicious use of oxygen, early surfactant administration, caffeine therapy, and avoidance of intubation and mechanical ventilation where possible. Methods of ongoing non-invasive respiratory support have been further refined and may help reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation by targeted use of postnatal corticosteroids remains essential. The general care of infants with RDS is also reviewed, including emphasis on appropriate cardiovascular support and judicious use of antibiotics as being important determinants of best outcome. We would like to dedicate this guideline to the memory of Professor Henry Halliday who died on November 12, 2022.These updated guidelines contain evidence from recent Cochrane reviews and medical literature since 2019. Strength of evidence supporting recommendations has been evaluated using the GRADE system. There are changes to some of the previous recommendations as well as some changes to the strength of evidence supporting recommendations that have not changed. This guideline has been endorsed by the European Society for Paediatric Research (ESPR) and the Union of European Neonatal and Perinatal Societies (UENPS).

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

BACKGROUND

Teamwork during neonatal resuscitation is essential. Situations arise quickly and unexpectedly and are highly stressful, requiring pediatric registered nurses (pRN) to respond effectively and in a structured manner. In Sweden, pRNs work in all pediatric settings including the neonatal intensive care unit. The experience and actions of pRNs are seldom explored, and studies within this area could develop and improve strategies for neonatal resuscitation situations.

PURPOSE

To describe pRNs' experiences and actions during neonatal resuscitation.

METHODS

A qualitative interview study based on the critical incident technique was performed. Sixteen pRNs from 4 neonatal intensive care units in Sweden were interviewed.

RESULTS

Critical situations were divided into 306 experiences and 271 actions. pRNs' experiences were divided into 2 categories: individual- and team-focused experiences. Critical situations were managed by individual- or team-focused actions.

Development and use of an infant resuscitation performance tool (Infa-RePT) to improve team performance

BACKGROUND

Measurement of neonatal team resuscitation performance is critical to identify opportunities for improvement and to target education. An effective tool to measure team performance during infant resuscitations is lacking.

METHODS

We developed an in-hospital infant resuscitation performance tool (Infa-RePT) using the modified Delphi method. We employed a QI framework and targeted interventions, including the use of role responsibility checklists, mock codes, and an educational video. We tracked Infa-RePT scores, mock code team attendance, and confidence surveys. Our specific aim was to improve Infa-RePT score from a baseline of 7.4 to <5 (lower is better) over a 26-month period.

RESULTS

Twenty-five elements reached >80% consensus as essential components to include on the Infa-RePT. Independent observation showed 86% concordance on checklist items. Simulation (n = 26) and unit-based code (n = 10) Infa-RePT scores showed significant improvement after project start from 7.4 to 4.2 (p < 0.01) with special cause variation noted on control chart analysis. No significant difference was observed between simulations and in-unit codes. Staff confidence self-reports improved over the study period.

CONCLUSIONS

Use of a novel scoring tool can help monitor team progress over time and identify areas for improvement. Focused interventions can improve resuscitation team performance.

IMPACT

We developed and used a novel, comprehensive measurement tool for team infant resuscitation performance in both simulation and in-unit settings. Using QI methodology, team performance improved after the enhancement of a mock code simulation program. Review of team performance scores can highlight key areas to target interventions and monitor progress over time.

Effects of simulation-based education for neonatal resuscitation on medical students' technical and non-technical skills

Simulation is a learner-centered practice that helps develop and maintain knowledge, skills, and competencies. This study evaluated the effect of neonatal resuscitation simulation-based education for medical students in the fifth year (part of the regular clinical clerkship program) on the perceived performance of their technical and non-technical skills. In addition, we analyzed the difference between instructor's and learners' evaluations of technical skills after the simulation. A one-group pretest-posttest design was adopted. The simulation-based education of the neonatal resuscitation program (NRP) was conducted for 40 medical students from July to November 2020 at a medical school in South Korea. The simulation-based education comprised 5 minutes of pre-briefing, 10 minutes of running the simulation, and 30 minutes of debriefing (using a recorded video). The perceived performance of students' technical and non-technical skills before and after the simulation was compared by collecting and analyzing the pre- and post-questionnaires. The perceived performance of technical (p = .001) and non-technical skills (p < .001) was found to have significantly increased after the simulation. Particularly, the performance of technical skills, such as diagnostic (p = .007) and therapeutic actions (p < .001) and non-technical skills, such as leadership (p < .001), teamwork (p = .001), and task management (p = .020) improved significantly. There was no significant difference in the evaluations of the technical performance of the instructor and learners after the simulation (p = .953). Simulation-based education can improve technical skills, such as diagnostic and therapeutic actions for neonatal resuscitation. It is also effective in enhancing non-technical skills, such as leadership, teamwork, and task management. Further, after the simulation-based education, students can fully self-evaluate through objective reflection and improve their clinical competency.

Instruments to evaluate non-technical skills during high fidelity simulation: A systematic review

Introduction

High Fidelity Simulations (HFS) are increasingly used to develop Non-Technical Skills (NTS) in healthcare providers, medical and nursing students. Instruments to measure NTS are needed to evaluate the healthcare providers' (HCPs) performance during HFS. The aim of this systematic review is to describe the domains, items, characteristics and psychometric properties of instruments devised to evaluate the NTS of HCPs during HFS.

Methods

A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Studies were retrieved from PubMed, Cinahl, Web of Science, Cochrane Library, ProQuest and PubPsych. Studies evaluating the measurement properties of instruments used to assess NTS during HFS training were included. Pairs of independent reviewers determined the eligibility, extracted and evaluated the data. Risk of bias and appraisal of the methodological quality of the studies was assessed using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist, and the quality of the evidence with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

Results

A total of 3,953 articles were screened. A total of 110 reports were assessed for eligibility and 26 studies were included. Studies were conducted in Europe/United Kingdom (n = 13; 50%), North America/Australia (n = 12; 46%) and Thailand (n = 1; 4%). The NTS instruments reported in this review included from 1 to 14 domains (median of 4, Q1 = 3.75, Q3 = 5) and from 3 to 63 items (median of 15, Q1 = 10, Q3 = 19.75). Out of 19 NTS assessment instruments for HFS, the Team Emergency Assessment Measure (TEAM) can be recommended for use to assess NTS. All the other instruments require further research to assess their quality in order to be recommended for use during HFS training. Eight NTS instruments had a positive overall rating of their content validity with at least a moderate quality of evidence.

Conclusion

Among a large variety of published instruments, TEAM can be recommended for use to assess NTS during HFS. Evidence is still limited on essential aspects of validity and reliability of all the other NTS instruments included in this review. Further research is warranted to establish their performance in order to be reliably used for HFS.

Reduction of Central-line-Associated Bloodstream Infections in a Tertiary Neonatal Intensive Care Unit through Simulation Education

Introduction

Critically ill neonates and those with complex medical conditions frequently require the use of central venous lines. Unfortunately, central line-associated bloodstream infections (CLABSIs) result in significant morbidity and mortality, and the cost and increased length of stay burden the healthcare system. Previous studies have demonstrated that standardized care bundles can decrease CLABSI rates, but achieving sustained improvement has proven difficult.

Methods

All patients admitted to the Neonatal Intensive Care Unit between 2014 and 2020 who had a CVL were included in this study. First, we recorded all CLABSI events and total CVL days according to defined criteria. Then, in late 2016, we instituted simulation-based nursing training for CVL care.

Results

Job Instruction Sheets were initially introduced to Neonatal Intensive Care Unit nursing staff simultaneously with one-on-one teaching sessions between instructors and bedside nurses. Intermittent performance audits and re-education for identified deficiencies did not improve the CLABSI rate per 1000 line days. After instituting simulation-based CVL training in 2016, there was a decreased rate of CLABSI events per 1000 line days sustained over time (x = 0.692).

Conclusions

Standardized care bundles and Hospital-acquired Condition interactor audits were insufficient to reduce the CLABSI rate. However, combining care bundles and education with simulation-based training significantly decreased CLABSI rates. One-on-one intensive training and continued ongoing monitoring were critical to producing a sustained reduction. This experience demonstrates that supervised, interactive education combined with simulation can significantly impact patient outcomes.

State-of-the art training in neonatal resuscitation

Healthcare training has traditionally emphasized acquisition and recall of vast amounts of content knowledge; however, delivering care during resuscitation of neonates requires much more than content knowledge. As the science of resuscitation has progressed, so have the methodologies and technologies used to train healthcare professionals in the cognitive, technical and behavioral skills necessary for effective resuscitation. Simulation of clinical scenarios, debriefing, virtual reality, augmented reality and audiovisual recordings of resuscitations of human neonates are increasingly being used in an effort to improve human and system performance during this life-saving intervention. In the same manner, as evidence has accumulated to support the guidelines for neonatal resuscitation so, too, has affirmation of training methodologies and technologies. This guarantees that training in neonatal resuscitation will continue to evolve to meet the needs of healthcare professionals charged with caring for newborns at one of the most vulnerable times in their lives.

Using Mobile Virtual Reality Simulation to Prepare for In-Person Helping Babies Breathe Training: Secondary Analysis of a Randomized Controlled Trial (the eHBB/mHBS Trial)

BACKGROUND

Neonatal mortality accounts for approximately 46% of global under-5 child mortality. The widespread access to mobile devices in low- and middle-income countries has enabled innovations, such as mobile virtual reality (VR), to be leveraged in simulation education for health care workers.

OBJECTIVE

This study explores the feasibility and educational efficacy of using mobile VR for the precourse preparation of health care professionals in neonatal resuscitation training.

METHODS

Health care professionals in obstetrics and newborn care units at 20 secondary and tertiary health care facilities in Lagos, Nigeria, and Busia, Western Kenya, who had not received training in Helping Babies Breathe (HBB) within the past 1 year were randomized to access the electronic HBB VR simulation and digitized HBB Provider's Guide (VR group) or the digitized HBB Provider's Guide only (control group). A sample size of 91 participants per group was calculated based on the main study protocol that was previously published. Participants were directed to use the electronic HBB VR simulation and digitized HBB Provider's Guide or the digitized HBB Provider's Guide alone for a minimum of 20 minutes. HBB knowledge and skills assessments were then conducted, which were immediately followed by a standard, in-person HBB training course that was led by study staff and used standard HBB evaluation tools and the Neonatalie Live manikin (Laerdal Medical).

RESULTS

A total of 179 nurses and midwives participated (VR group: n=91; control group: n=88). The overall performance scores on the knowledge check (P=.29), bag and mask ventilation skills check (P=.34), and Objective Structured Clinical Examination A checklist (P=.43) were similar between groups, with low overall pass rates (6/178, 3.4% of participants). During the Objective Structured Clinical Examination A test, participants in the VR group performed better on the critical step of positioning the head and clearing the airway (VR group: 77/90, 86%; control group: 57/88, 65%; P=.002). The median percentage of ventilations that were performed via head tilt, as recorded by the Neonatalie Live manikin, was also numerically higher in the VR group (75%, IQR 9%-98%) than in the control group (62%, IQR 13%-97%), though not statistically significantly different (P=.35). Participants in the control group performed better on the identifying a helper and reviewing the emergency plan step (VR group: 7/90, 8%; control group: 16/88, 18%; P=.045) and the washing hands step (VR group: 20/90, 22%; control group: 32/88, 36%; P=.048).

CONCLUSIONS

The use of digital interventions, such as mobile VR simulations, may be a viable approach to precourse preparation in neonatal resuscitation training for health care professionals in low- and middle-income countries.

Simulation-Based Neonatal Resuscitation Education for Undergraduate Anesthesia Students: A Pre- and Post-Evaluation of Knowledge and Clinical Skills

Background. Nearly one in five hundred babies unexpectedly need resuscitation at birth, and the need for resuscitation is often unpredictable. A large majority of these deaths occur in low-resource settings and are preventable. Appropriate resuscitation techniques are crucial to the survival of newborn infants. Therefore, producing skilled health professionals in teaching institutions is mandatory to perform this activity. Objective. The study aimed a pre- and post-evaluation of knowledge and clinical skills performance of anesthesia students completing simulation-based neonatal resuscitation training at a Teaching Referral Hospital. Methods. A pre-post-intervention study was conducted on undergraduate final-year anesthesia students at Comprehensive and Specialized Teaching Referral Hospital, Ethiopia. We used a validated checklist to follow the students’ performance (American Heart Association, 2005, and Ogunlesi et al., 2012). The data were collected through this checklist. The collected data were analyzed with statistical package for social sciences (SPSS) version 20. Categorical variables were analyzed with chi-square test, and a $p$ -value <0.05 was considered as statistically significant. Results. A total of 51 students participated in the study. Twenty of them were females. The pre-intervention knowledge of the respondents about aspects of evaluation for neonatal resuscitation was 90.2%, and post-intervention was 94.1%; the knowledge of the respondents about aspects of appropriate actions at pre- and post-interventions was 73.4% and 83.1%, respectively. Conclusions and recommendations: This study showed that there was improvement of post-interventions knowledge and clinical skills of undergraduate anesthesia students for both aspects of evaluation and appropriate actions for neonatal resuscitation. We recommend that students who attached clinical anesthesia practice should take at least simulation-based training at skill laboratories timely.

Neonatal simulation training decreases the incidence of chest compressions in term newborns

AIM OF THE STUDY

To determine the effectiveness of a multidimensional neonatal simulation-based medical education training programme on direct and indirect patient outcome parameters.

METHODS

This was a retrospective analytical study with a historical control group in a level II neonatal care unit (1,700 births per year). A multidimensional interdisciplinary training programme on neonatal resuscitation was implemented in 2015; pre-training (2012-2014) and post-training (2015-2019) eras were compared in terms of mortality (direct outcome) and the received intervention level immediately after birth (indirect outcome). Intervention levels were defined as follows: A) short-term non-invasive ventilation, B) prolonged non-invasive ventilation (>5 inflation breaths), C) chest compressions.

RESULTS

Of 13,950 neonates born during the study period, 826 full-term newborns received one of the three intervention levels for adaptation after birth. A total of 284 (34.4%) patients received short-term non-invasive ventilation (A), 477 (57.8%) had prolonged ventilation (B), and 65 (7.9%) chest compressions (C), respectively. Comparing the pre- and post-training eras, there was no significant reduction in mortality, and no significant changes were found in groups A or B. However, the risk for chest compressions (group C) decreased significantly from 0.91% in the pre-training era to 0.20% in the post-training era (p < 0.001).

CONCLUSION

Although there was no significant effect on neonatal mortality, regular interdisciplinary simulation training decreased the number of administered chest compressions immediately after birth. Further studies are needed to test indirect outcome-related parameters, such as frequency of chest compressions as a measure of effectiveness and impact of medical training.

Silent voices of the midwives: factors that influence midwives' achievement of successful neonatal resuscitation in sub-Saharan Africa: a narrative inquiry

BACKGROUND

In Tanzania, birth asphyxia is a leading cause of neonatal death. The aim of this study was to identify factors that influence successful neonatal resuscitation to inform clinical practice and reduce the incidence of very early neonatal death (death within 24 h of delivery).

METHODS

This was a qualitative narrative inquiry study utilizing the 32 consolidated criteria for reporting qualitative research (COREQ). Audio-recorded, semistructured, individual interviews with midwives were conducted. Thematic analysis was applied to identify themes.

RESULTS

Thematic analysis of the midwives' responses revealed three factors that influence successful resuscitation: 1. Hands-on training ("HOT") with clinical support during live emergency neonatal resuscitation events, which decreases fear and enables the transfer of clinical skills; 2. Unequivocal commitment to the Golden Minute® and the mindset of the midwife; and. 3. Strategies that reduce barriers. Immediately after birth, live resuscitation can commence at the mother's bedside, with actively guided clinical instruction. Confidence and mastery of resuscitation competencies are reinforced as the physiological changes in neonates are immediately visible with bag and mask ventilation. The proclivity to perform suction initially delays ventilation, and suction is rarely clinically indicated. Keeping skilled midwives in labor wards is important and impacts clinical practice. The midwives interviewed articulated a mindset of unequivocal commitment to the baby for one Golden Minute®. Heavy workload, frequent staff rotation and lack of clean working equipment were other barriers identified that are worthy of future research.

CONCLUSIONS

Training in resuscitation skills in a simulated environment alone is not enough to change clinical practice. Active guidance of "HOT" real-life emergency resuscitation events builds confidence, as the visible signs of successful resuscitation impact the midwife's beliefs and behaviors. Furthermore, a focused commitment by midwives working together to reduce birth asphyxia-related deaths builds hope and collective self-efficacy.

Neonatal Simulation Program: A 5 Years Educational Journey From Qatar

We describe the process of implementation, adaptation, expansion and some related clinical intuitional impacts of the neonatal simulation program since its launch in 2016 in a non-simulation neonatal unit. The team has developed 6 types of curricula: 1 full-day course and 5 half-day workshops. A total of 35 free of charge simulation courses/workshops were conducted, 32 in Qatar and 3 abroad with a total of 799 diverse participants. There was a steady increase in the overall success rate of PICC insertion from 81.7% (309/378) to 97.6% (439/450) across 3 years (P < 0.0001). The first attempt PICC insertion success rate has been also increased from 57.7% (218/378) to 66.9% (301/450) across 3 years. The mean duration of PICC insertion has been improved from 39.7 ± 25 to 34.9 ± 12.4 min after implementing the program (P = 0.33). The mean duration of the LISA catheter insertion at the beginning of the workshop was 23.5 ± 15.9 compared to 12.1 ± 8.5 s at the end of the workshop (P = 0.001). When it came to clinical practise in real patients by the same participants, the overall LISA catheter insertion success rate was 100% and the first attempt success rate was 80.4%. The mean duration of LISA catheter insertion in real patients was 26.9 ± 13.9 s compared to the end of the workshop (P = 0.001). The mean duration of the endotracheal intubation at the beginning of the workshop was 12.5 ± 9.2 compared to 4.2 ± 3.8 s at the end of the workshop (P = 0.001). In real patients, the first-attempt intubation success rate has been improved from 37/139 (26.6%) in the first year to 141/187 (75.5%) in the second year after the program implementation (P = 0.001). The mean duration of successful endotracheal intubation attempts has been improved from 39.1 ± 52.4 to 20.1 ± 9.9 s (P = 0.78). As per the participants, the skills learned in the program sessions help in protecting neonates from potential harm and improve the overall neonatal outcome. Implementing a neonatal simulation program is a promising and feasible idea. Our experience can be generalised and replicated in other neonatal care institutions.

Simulation-Based Training in High-Quality Cardiopulmonary Resuscitation Among Neonatal Intensive Care Unit Providers

INTRODUCTION

American Heart Association guidelines recommend the use of feedback devices for CPR provider resuscitation training. There is paucity of published literature regarding the utility of these devices especially in neonates and infants. We sought to evaluate if simulation-based education and debriefing using a CPR feedback device would improve CPR performance on an infant manikin in a cohort of NICU nurses as evaluated by CPR feedback device.

METHODS

We conducted a prospective, observational simulation study to assess the quality of chest compressions by NICU nurses before and after debriefing using CPR quality data captured by an accelerometer-based device. Chest compression (CC) depth, rate, recoil, CC fraction and nursing confidence level related to performing a high-quality CPR were compared before and after debriefing using paired t-test and Wilcoxon rank sum test.

RESULTS

A total of 62 NICU nurses participated in the study and all of them were Neonatal Resuscitation Program (NRP) certified. There was a significant improvement in CC depth and CC fraction [mean + SD values = 0.79 in + 0.17 (pre-debrief), 0.86 in + 0.21 (post-debrief) (p = 0.034) and 56.8% + 17.7 (pre-debrief), 70.8% + 18.4 (post-debrief) (0.0014), respectively]. There was no difference in CC rate (p = 0.36) and recoil (p = 0.25) between pre and post structured debriefing. The confidence level of nurses in all CPR dynamics (appropriate CC rate, CC depth, team communication, minimizing interruption in CC and coordinating CC with ventilation) was significantly higher after simulation and structured debriefing. All the nurses used 3:1 compression: ventilation ratio of NRP despite the patient being a 4 month old premature baby in the NICU.

CONCLUSIONS

Simulation training and debriefing of NICU nurses using CPR feedback device improved their chest compression quality on an infant mannequin and their confidence level for performing high-quality CPR. NICU providers tend to use NRP protocol of 3:1 compression: ventilation ratio during CPR in the NICU irrespective of age of the infant.

Anatomic accuracy, physiologic characteristics, and fidelity of very low birth weight infant airway simulators

BACKGROUND

Medical simulation training requires realistic simulators with high fidelity. This prospective multi-center study investigated anatomic precision, physiologic characteristics, and fidelity of four commercially available very low birth weight infant simulators.

METHODS

We measured airway angles and distances in the simulators Premature AirwayPaul (SIMCharacters), Premature Anne (Laerdal Medical), Premie HAL S2209 (Gaumard), and Preterm Baby (Lifecast Body Simulation) using computer tomography and compared these to human cadavers of premature stillbirths. The simulators' physiologic characteristics were tested, and highly experienced experts rated their physical and functional fidelity.

RESULTS

The airway angles corresponded to those of the reference cadavers in three simulators. The nasal inlet to glottis distance and the mouth aperture to glottis distance were only accurate in one simulator. All simulators had airway resistances up to 20 times higher and compliances up to 19 times lower than published reference values. Fifty-six highly experienced experts gave three simulators (Premature AirwayPaul: 5.1 ± 1.0, Premature Anne 4.9 ± 1.1, Preterm Baby 5.0 ± 1.0) good overall ratings and one simulator (Premie HAL S2209: 2.8 ± 1.0) an unfavorable rating.

CONCLUSION

The simulator physiology deviated significantly from preterm infants' reference values concerning resistance and compliance, potentially promoting a wrong ventilation technique.

IMPACT

Very low birth weight infant simulators showed physiological properties far deviating from corresponding patient reference values. Only ventilation with very high peak pressure achieved tidal volumes in the simulators, as aimed at in very low birth weight infants, potentially promoting a wrong ventilation technique. Compared to very low birth weight infant cadavers, most tested simulators accurately reproduced the anatomic angular relationships, but their airway dimensions were relatively too large for the represented body. The more professional experience the experts had, the lower they rated the very low birth weight infant simulators.

Simulation in neonatal care: towards a change in traditional training?

Simulation has traditionally been used in neonatal medicine for educational purposes which include training of novice learners, maintaining competency of health care providers, and training of multidisciplinary teams to handle crisis situations such as neonatal resuscitation. Current guidelines recommend the use of simulation as an education tool in neonatal practice. The place of simulation-based education has gradually expanded, including in limited resource settings, and is starting to show its impact on improving patient outcomes on a global basis. Over the past years, simulation has become a cornerstone in clinical settings with the goal of establishing high quality, safe, reliable systems. The aim of this review is to describe neonatal simulation training as an effective tool to improve quality of care and patient outcomes, and to encourage the use of simulation-based training in the neonatal intensive care unit (NICU) for not only education, but equally for team building, risk management and quality improvement.

CONCLUSION

Simulation is a promising tool to improve patient safety, team performance, and ultimately patient outcomes, but scarcity of data on clinically relevant outcomes makes it difficult to estimate its real impact. The integration of simulation into the clinical reality with a goal of establishing high quality, safe, reliable, and robust systems to improve patient safety and patient outcomes in neonatology must be a priority.

WHAT IS KNOWN

• Simulation-based education has traditionally focused on procedural and technical skills. • Simulation-based training is effective in teaching non-technical skills such as communication, leadership, and teamwork, and is recommended in neonatal resuscitation.

WHAT IS NEW

• There is emerging evidence for the impact of simulation-based training on patient outcomes in neonatal care, but data on clinically relevant outcomes are scarce. • Simulation is a promising tool for establishing high quality, safe, reliable, and robust systems to improve patient safety and patient outcomes.

Utilizing High-fidelity Simulators in Improving Trainee Confidence and Competency in Code Management

Simulation training is central in preparing practitioners for code management that is free from patient harm.¹ The purpose of this study was to determine if using a high-fidelity simulator in pediatric code education would improve trainee confidence and competency compared with the use of a traditional mannequin in the same setting.

Can parental simulation improve neonatal CPR performance? A pilot study

Basic life support training and instruction is recommended for parents of premature infants discharged from the hospital. In order to assess the short-term efficacy of basic life support simulation, in addition to the institutional training, a prospective single-blinded randomized interventional study was performed. The study group received, besides the institutional training, an additional simulation training. The control group had only traditional training. A test assessment was followed approximately a week later and evaluated by two investigators. Fifty parents participated. Nineteen (38%) were in the study group. The study group showed a significant improvement in all the parameters assessed.Conclusion: The addition of a simulation encounter before discharge may improve short-term parental performance of basic life support. What is Known: • Parents of newborns at risk receive institutional training in basic life support. • The retention of knowledge from this training is a point of concern for parents. What is New: • A single simulation encounter for parents improved resuscitation performance. • Simulation for parents may be an important and useful tool to improve the efficacy of basic life support training.

Investigating the effect of neonatal resuscitation simulation using a competency-based approach on knowledge, skill, and self-confidence of midwifery students using objective structured clinical examination (OSCE)

Background

First-day neonate death has the highest rate in infant mortality. Using modern educational methods such as simulation and competency can be effective in improving learners' performance and subsequently their confidence.

Material and Method

This study was a quasi-experimental intervention on 80 midwifery students of semester 3, 4, and 5 undergraduate degrees. Eighty-six students registered after the researcher's explanations. The learners were randomly assigned into two groups while they were receiving routine midwifery education according to the midwifery curriculum. The learners in the intervention group (in seven groups) received a 7-hour session about neonate resuscitation. The theory session was conducted using PowerPoint presentation, lecture, video, and pictures. The practical session was conducted using simulation with manikins of skill laboratory. The skill practice continued until the learners achieved competency (performing 90% of resuscitation steps). The learners were assessed before, immediately, and 6 weeks after training using questionnaires and a checklist. The data were analyzed using SPSS, descriptive, and inferential statistics.

Results

The knowledge, skill, and self-confidence scores increased significantly immediately after the training (P < 0.001), from 5.05 ± 2.07 (out of 12) to 10.17 ± 1.31, 18.90 ± 3.14 to 68.45 ± 2.05, and 1.50 ± 0.55 to 2.02 ± 0.57, respectively. The changes were retained 6 weeks after the training. These changes were not observed in the control group.

Conclusion

Competency-based, simulation-based, and objective structured clinical examination (OSCE) were effective in students learning to manage initial neonatal resuscitation in the skills' lab, and this increase was retained 6 weeks after the training.

From simulation room to clinical practice: Postgraduate neonatal nursing students' transfer of learning from in-situ resuscitation simulation with interprofessional team to clinical practice

The purpose of this study was to investigate how postgraduate neonatal nursing students transfer learning from in-situ resuscitation simulation with interprofessional teams to clinical practice. It is essential that healthcare professionals involved in stabilization and resuscitation of newborns master technical (e.g.bag-mask ventilation) and non-technical skills (e.g. teamwork and communication). Simulation plays an important role in education as it allows healthcare professionals safe practicing of skills and teamwork under direct supervision. Debriefing is a central component. Eighteen postgraduate neonatal nursing students participated in in-situ simulation with interprofessional team. Subsequently, five students were interviewed individually. A qualitative content analysis was performed. Three descriptive categories were identified, representing the manifest content:'Non-technical skills','Task management in an acute situation', and 'Learning through reflection'. The interviewees highlighted a deeper understanding of the collaboration and mutual dependency in the team after in-situ simulation. One latent content was identified: "Trust and competence in a relational collaboration". It is challenging to choose the best suited learning activities for learning different subject matters, like skills and competencies needed in clinical neonatal resuscitation.Despite this being a small study, the findings can be transferred to similar educational contexts.

Digital Simulation Improves, Maintains, and Helps Transfer Health-Care Providers' Neonatal Resuscitation Knowledge

Purpose: To safely care for their newborn patients, health-care professionals (HCP) must undergo frequent training to improve and maintain neonatal resuscitation knowledge and skills. However, the current approach to neonatal resuscitation simulation training is time and resource-intensive, and often inaccessible. Digital neonatal resuscitation simulation may present a convenient alternative for more frequent training. Method: Fifty neonatal HCPs participated in the study (44 female; 27 nurses, 3 nurse practitioners, 14 respiratory therapists, 6 doctors). This study was conducted at a tertiary perinatal center in Edmonton, Canada from April-August 2019, with 2-month (June-October 2019) and 5-month (September 2019-January 2020) follow-up. Neonatal HCPs were recruited by volunteer sampling to complete a demographic survey, pre-test (baseline knowledge), two digital simulation scenarios (intervention), and post-test (knowledge acquisition). Two months later, participants repeated the post-test (knowledge retention). Five months after the initial intervention, participants completed a post-test using a table-top simulation (knowledge transfer). Longitudinal analyses were used to compare participants' performance over time. Results: Overall the proportion of correct performance increased: 21/50 (42%) passed the pre-test, 39/50 (78%) the post-test, 30/43 (70%) the 2-month post-test, and 32/40 (80%) the 5-month post-test. GLMM and GEE analyses revealed that performance on all post-tests was significantly better than the performance on the pre-test. Therefore, training with the RETAIN digital simulation effectively improves, maintains, and transfers HCPs' neonatal resuscitation knowledge. Conclusions: Digital simulation improved, maintained, and helped transfer HCPs' neonatal resuscitation knowledge over time. Digital simulation presents a promising approach for frequent neonatal resuscitation training, particularly for distance-learning applications.

Mindset Moderates Healthcare Providers' Longitudinal Performance in a Digital Neonatal Resuscitation Simulator

Background: Simulation education can benefit healthcare providers (HCPs) by providing opportunities to practice complex neonatal-resuscitation tasks in low-stake environments. To our knowledge, no study investigated the role of growth mindset on longitudinal performance on neonatal resuscitation before and after simulation-based training. Objectives: This study examines whether 1) the RETAIN digital/table-top simulators facilitate HCPs' neonatal resuscitation knowledge gain, retention, and transfer and 2) growth mindset moderates HCPs' longitudinal performance in neonatal resuscitation. Methods: Participants were n = 50 HCPs in a tertiary perinatal center in Edmonton, Canada. This longitudinal study was conducted in three stages including 1) a pretest and a mindset survey, immediately followed by a posttest using the RETAIN digital simulator from April to August 2019; 2) a 2-month delayed posttest using the same RETAIN neonatal resuscitation digital simulator from June to October 2019; and 3) a 5-month delayed posttest using the low-fidelity table-top neonatal resuscitation digital simulator from September 2019 to January 2020. Three General Linear Mixed Model (GLMM) repeated-measure analyses investigated HCPs' performance on neonatal resuscitation over time and the moderating effect of growth mindset on the association between test time points and task performance. Results: Compared with their pretest performance, HCPs effectively improved their neonatal resuscitation knowledge after the RETAIN digital simulation-based training on the immediate posttest (Est = 1.88, p < 0.05), retained their knowledge on the 2-month delayed posttest (Est = 1.36, p < 0.05), and transferred their knowledge to the table-top simulator after 5 months (Est = 2.01, p < 0.05). Although growth mindset did not moderate the performance gain from the pretest to the immediate posttest, it moderated the relationship between HCPs' pretest and long-term knowledge retention (i.e., the interaction effect of mindset and the 2-month posttest was significant: Est = 0.97, p < 0.05). The more they endorsed a growth mindset, the better the HCPs performed on the posttest, but only when they were tested after 2 months. Conclusions: Digital simulators for neonatal resuscitation training can effectively facilitate HCPs' knowledge gain, maintenance, and transfer. Besides, growth mindset shows a positive moderating effect on the longitudinal performance improvement in simulation-based training. Future research can be conducted to implement growth-mindset interventions promoting more effective delivery of technology-enhanced, simulation-based training and assessment.