The RETAIN Simulation-Based Serious Game-A Review of the Literature

Volume-targeted mask ventilation during simulated neonatal resuscitation

OBJECTIVE

Mask positive pressure ventilation (PPV) in the delivery room is routinely delivered with set peak inflation pressures. To aid mask PPV, stand-alone respiratory function monitors (RFMs) have been used in the delivery room, while ventilator-based, volume-targeted ventilation (VTV) is routinely used in the neonatal intensive care unit (NICU).

DESIGN

This is a prospective, randomised, crossover simulation study. Participants were briefly trained to use a neonatal ventilator for volume-targeted mask ventilation (VTV-PPV), then performed mask ventilation on a manikin in a randomised order using VTV-PPV, T-piece PPV or T-piece PPV with RFM visible.

SETTING

In situ in a neonatal resuscitation room within a level 3 NICU.

PARTICIPANTS

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

INTERVENTIONS

Semiautomated, ventilator-based VTV-PPV using two-hand hold versus manual PPV via a T-piece device (T-piece, RFM masked) versus manual PPV with RFM visible using one-hand hold.

MAIN OUTCOME MEASURES

Respiratory characteristics including % mask leak, tidal volume (VT) and peak inflation pressure (PIP).

RESULTS

Thirty-two HCPs (23 (72%) female and 9 (28%) male) participated. The median mask leak was significantly lower with 'VTV-PPV' (11%, IQR 0%-14%) compared with both 'T-piece, RFM visible' (82%, IQR 30%-91%) and 'T-piece, RFM masked' (81%, IQR 47%-91%) (p<0.0001). The median delivered VT was 4.1 mL/kg (IQR 3.9-4.4) with VTV-PPV compared with 2.1 mL/kg (IQR 1.2-9) with T-piece, RFM visible and 1.8 mL/kg (IQR 1.1-5.8) with T-piece, RFM masked (p=0.0496). PIP was also significantly lower with VTV-PPV.

CONCLUSION

During neonatal simulation, VTV-PPV reduced mask leak and allowed for consistent VT delivery compared with T-piece with and without RFM guidance.

Optimizing Digital Tools for the Field of Substance Use and Substance Use Disorders: Backcasting Exercise

BACKGROUND

Substance use trends are complex; they often rapidly evolve and necessitate an intersectional approach in research, service, and policy making. Current and emerging digital tools related to substance use are promising but also create a range of challenges and opportunities.

OBJECTIVE

This paper reports on a backcasting exercise aimed at the development of a roadmap that identifies values, challenges, facilitators, and milestones to achieve optimal use of digital tools in the substance use field by 2030.

METHODS

A backcasting exercise method was adopted, wherein the core elements are identifying key values, challenges, facilitators, milestones, cornerstones and a current, desired, and future scenario. A structured approach was used by means of (1) an Open Science Framework page as a web-based collaborative working space and (2) key stakeholders' collaborative engagement during the 2022 Lisbon Addiction Conference.

RESULTS

The identified key values were digital rights, evidence-based tools, user-friendliness, accessibility and availability, and person-centeredness. The key challenges identified were ethical funding, regulations, commercialization, best practice models, digital literacy, and access or reach. The key facilitators identified were scientific research, interoperable infrastructure and a culture of innovation, expertise, ethical funding, user-friendly designs, and digital rights and regulations. A range of milestones were identified. The overarching identified cornerstones consisted of creating ethical frameworks, increasing access to digital tools, and continuous trend analysis.

CONCLUSIONS

The use of digital tools in the field of substance use is linked to a range of risks and opportunities that need to be managed. The current trajectories of the use of such tools are heavily influenced by large multinational for-profit companies with relatively little involvement of key stakeholders such as people who use drugs, service providers, and researchers. The current funding models are problematic and lack the necessary flexibility associated with best practice business approaches such as lean and agile principles to design and execute customer discovery methods. Accessibility and availability, digital rights, user-friendly design, and person-focused approaches should be at the forefront in the further development of digital tools. Global legislative and technical infrastructures by means of a global action plan and strategy are necessary and should include ethical frameworks, accessibility of digital tools for substance use, and continuous trend analysis as cornerstones.

Super Divya, an Interactive Digital Storytelling Instructional Comic Series to Sustain Facilitation Skills of Labor and Delivery Nurse Mentors in Bihar, India-A Pilot Study

To improve the quality of intrapartum care in public health facilities of Bihar, India, a statewide quality improvement program was implemented. Nurses participated in simulation sessions to improve their clinical, teamwork, and communication skills. Nurse mentors, tasked with facilitating these sessions, received training in best practices. To support the mentors in the on-going facilitation of these trainings, we developed a digital, interactive, comic series starring “Super Divya”, a simulation facilitation superhero. The objective of these modules was to reinforce key concepts of simulation facilitation in a less formal and more engaging way than traditional didactic lessons. This virtual platform offers the flexibility to watch modules frequently and at preferred times. This pilot study involved 205 simulation educators who were sent one module at a time. Shortly before sending the first module, nurses completed a baseline knowledge survey, followed by brief surveys after each module to assess change in knowledge. Significant improvements in knowledge were observed across individual scores from baseline to post-survey. A majority found Super Divya modules to be acceptable and feasible to use as a learning tool. However, a few abstract concepts in the modules were not well-understood, suggesting that more needs to be done to communicate their core meaning of these concepts.

Theoretical knowledge and skill retention 3 and 6 months after a European Newborn Life Support provider course

INTRODUCTION

The European Resuscitation Council Newborn Life Support Course (ERC- NLS) aims at training healthcare professionals, involved in perinatal care, in order to intervene efficiently and promptly to assist transition or resuscitate neonates who require help at birth. However, limited data exists for the retention of the theoretical knowledge and practical skills provided by the course. This study aims to evaluate the degree of knowledge and skill retention 3 and 6 months after the ERC-NLS provider course.

METHODS

This is a prospective study. Theoretical knowledge was evaluated using the ERC-approved NLS written test (50 True/False questions). Evaluation of technical skills included performance, on an Advanced Life Support neonatal maniquin (LAERDAL), of airway management, ventilation and support of circulation (21 detailed skills). The effect of certain factors on theoretical skill retention was also evaluated.

RESULTS

One hundred and sixteen (n = 116) participants were initially recruited in the study (12 males and 104 females). Theoretical knowledge was evaluated in 113 participants (3 participants missed follow-up appointments) and technical skills in 80 participants. The mean score for theoretical knowledge was 86.24% ± 5.3, 80.88% ± 7.43 and 80.04% ± 7.04 at baseline, at 3 and 6 months, respectively. This difference was significant among the three time points (baseline vs 3 months: p < 0.001; baseline vs 6 months: p < 0.001; 3 month's vs 6 months: p = 0.034). Although gender did not have an effect, doctors and participants of higher education yielded higher score of success. Regarding technical skills, 9 skills showed a continuous decline of performance from baseline to 6 months, while no difference existed for 12 skills.

CONCLUSIONS

Healthcare professionals after the NLS provider course retain satisfactory levels of theoretical knowledge and technical skills even at 6 months post-training, although, there is a decline compared to baseline. Further research is needed in order to establish the proper time and type of refreshment course in order to improve outcomes.

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.

Health Care Providers' Performance, Mindset, and Attitudes Toward a Neonatal Resuscitation Computer-Based Simulator: Empirical Study

BACKGROUND

Neonatal resuscitation involves a complex sequence of actions to establish an infant's cardiorespiratory function at birth. Many of these responses, which identify the best action sequence in each situation, are taught as part of the recurrent Neonatal Resuscitation Program training, but they have a low incidence in practice, which leaves health care providers (HCPs) less prepared to respond appropriately and efficiently when they do occur. Computer-based simulators are increasingly used to complement traditional training in medical education, especially in the COVID-19 pandemic era of mass transition to digital education. However, it is not known how learners' attitudes toward computer-based learning and assessment environments influence their performance.

OBJECTIVE

This study explores the relation between HCPs' attitudes toward a computer-based simulator and their performance in the computer-based simulator, RETAIN (REsuscitation TrAINing), to uncover the predictors of performance in computer-based simulation environments for neonatal resuscitation.

METHODS

Participants were 50 neonatal HCPs (45 females, 4 males, 1 not reported; 16 respiratory therapists, 33 registered nurses and nurse practitioners, and 1 physician) affiliated with a large university hospital. Participants completed a demographic presurvey before playing the game and an attitudinal postsurvey after completing the RETAIN game. Participants' survey responses were collected to measure attitudes toward the computer-based simulator, among other factors. Knowledge on neonatal resuscitation was assessed in each round of the game through increasingly difficult neonatal resuscitation scenarios. This study investigated the moderating role of mindset on the association between the perceived benefits of understanding the terminology used in the computer-based simulator, RETAIN, and their performance on the neonatal resuscitation tasks covered by RETAIN.

RESULTS

The results revealed that mindset moderated the relation between participants' perceived terminology used in RETAIN and their actual performance in the game (F3,44=4.56, R2=0.24, adjusted R2=0.19; P=.007; estimate=-1.19, SE=0.38, t44=-3.12, 95% CI -1.96 to -0.42; P=.003). Specifically, participants who perceived the terminology useful also performed better but only when endorsing more of a growth mindset; they also performed worse when endorsing more of a fixed mindset. Most participants reported that they enjoyed playing the game. The more the HCPs agreed that the terminology in the tutorial and in the game was accessible, the better they performed in the game, but only when they reported endorsing a growth mindset exceeding the average mindset of all the participants (F3,44=6.31, R2=0.30, adjusted R2=0.25; P=.001; estimate=-1.21, SE=0.38, t44=-3.16, 95% CI -1.99 to -0.44; P=.003).

CONCLUSIONS

Mindset moderates the strength of the relationship between HCPs' perception of the role that the terminology employed in a game simulator has on their performance and their actual performance in a computer-based simulator designed for neonatal resuscitation training. Implications of this research include the design and development of interactive learning environments that can support HCPs in performing better on neonatal resuscitation tasks.

Using the RETAIN Tabletop Simulator as a Summative Assessment Tool for Neonatal Resuscitation Healthcare Professionals: A Pilot Study

Background: Frequent and objective summative assessment of neonatal healthcare providers is important to ensure high-quality care to patients during neonatal resuscitation. Currently, neonatal resuscitation providers are only individually assessed using an at-home online multiple-choice questionnaire. While simulation-based assessment is preferred, resource constraints limit its widespread uptake. An alternative approach to simulation-based summative assessment is needed. Simulation-based serious games may provide a solution. Objective: The aim of this study was to examine if individual performance on the RETAIN (REsuscitation TrAINing for healthcare professionals) tabletop simulator can be used as a summative assessment of neonatal resuscitation providers, regardless of their prior board game experience. Method: Neonatal healthcare providers were recruited from a tertiary perinatal center to complete a (1) demographic pre-survey, (2) neonatal resuscitation scenario using an open-answer written pre-test, (3) neonatal resuscitation scenario using the RETAIN tabletop simulator, and (4) post-survey measuring usage and attitudes toward board games. Multiple linear regression analyses using the Johnson-Neyman technique were conducted in R to probe the moderation effect of years of board game on the relationship between pre-test and game performance. Results: Twenty Neonatal Resuscitation Program-trained healthcare providers (nurses, nurse practitioners, respiratory therapists, and fellows) were recruited for this study (n = 19 females). Participants' mean (standard deviation) pre-test score was 8.35 (1.81) out of a total 16 possible points (52%) and a score of 18 (4.41) out of a total of 40 possible points (45%) using RETAIN. Overall board game experience was 22.5 (12.6) years. Finally, years of board game moderated significantly the relation between the pre-test and game performance (B = -0.13, SE = 0.05, beta = -0.48, t = -2.77, p < 0.05; 95% CI [-0.24, -0.03]). Thus, participants' performance on the two tests (written and simulator) was significantly positively associated, but only for those who reported fewer than 21.5 years of board game experience. Conclusion: This study reports the preliminary results of a pilot study, indicating that the RETAIN tabletop simulator could be used as a simulation-based summative assessment, an enjoyable, low-cost alternative to traditional assessment approaches. RETAIN offers a solution to the need for more frequent and continued assessment of neonatal resuscitation providers.

Simulation-Based Summative Assessment of Neonatal Resuscitation Providers Using the RETAIN Serious Board Game-A Pilot Study

Background: Each year, 13-26 million newborn babies require help to breathe at birth. Healthcare professionals (HCPs) who provide neonatal resuscitative care must be frequently evaluated to maintain and improve the quality of healthcare delivered. While simulation-based competence assessment is preferred, resource constraints hinder uptake. We aimed to examine if the RETAIN simulation-based boardgame can be used to assess HCPs' neonatal resuscitation knowledge. Method: Twenty neonatal HCPs (19 females) from the Royal Alexandra Hospital (Edmonton, Canada) were recruited. First, they completed an open-answer written test of one neonatal resuscitation scenario. Then, they completed one neonatal resuscitation scenario of difficulty comparable to that of the open-answer written test, but this time using the RETAIN board game. In the RETAIN board game (https://playretain.com, RETAIN Labs Medical Inc, Edmonton, Canada), players perform simulated neonatal resuscitation scenarios based on real-life cases, using action cards, and equipment pieces. Sessions were video-recorded and scored using Neonatal Resuscitation Program 2015 guidelines. Data are reported as mean (standard deviation) for normally distributed continuous variables, and as median (interquartile range) for non-normal continuous variables. Results: Participants consisted of the following HCPs: 8 nurses, 4 respiratory therapists, 4 nurse practitioners, and 4 neonatal fellows with median (IQR) 10.5(3-17) years of clinical experience. Overall mean (SD) Open-answer test and Game Performance was 8.6(2.1) out of 16 possible points (53%) and 29(3.2) out of 40 possible points (74%), respectively. Out of the 10 actions shared between the open-answer test and game scenario, performance on the open-answer test was mean (SD) 7.2(1.3) (72%) and game performance was mean (SD) 8.8(1.4) (88%) (V = 17, p < 0.01). Conclusion: RETAIN may provide an enjoyable and standardized alternative toward summative assessment of neonatal resuscitation providers. RETAIN may be used to improve more frequent and ubiquitous uptake of simulation-based competence assessment in healthcare settings.

Unsupervised Machine Learning Algorithms Examine Healthcare Providers' Perceptions and Longitudinal Performance in a Digital Neonatal Resuscitation Simulator

Background: Frequent simulation-based education is recommended to improve health outcomes during neonatal resuscitation but is often inaccessible due to time, resource, and personnel requirements. Digital simulation presents a potential alternative; however, its effectiveness and reception by healthcare professionals (HCPs) remains largely unexplored. Objectives: This study explores HCPs' attitudes toward a digital simulator, technology, and mindset to elucidate their effects on neonatal resuscitation performance in simulation-based assessments. Methods: The study was conducted from April to August 2019 with 2-month (June-October 2019) and 5-month (September 2019-January 2020) follow-up at a tertiary perinatal center in Edmonton, Canada. Of 300 available neonatal HCPs, 50 participated. Participants completed a demographic survey, a pretest, two practice scenarios using the RETAIN neonatal resuscitation digital simulation, a posttest, and an attitudinal survey (100% response rate). Participants repeated the posttest scenario in 2 months (86% response rate) and completed another posttest scenario using a low-fidelity, tabletop simulator (80% response rate) 5 months after the initial study intervention. Participants' survey responses were collected to measure attitudes toward digital simulation and technology. Knowledge was assessed at baseline (pretest), acquisition (posttest), retention (2-month posttest), and transfer (5-month posttest). Results: Fifty neonatal HCPs participated in this study (44 females and 6 males; 27 nurses, 3 nurse practitioners, 14 respiratory therapists, and 6 doctors). Most participants reported technology in medical education as useful and beneficial. Three attitudinal clusters were identified by a hierarchical clustering algorithm based on survey responses. Although participants exhibited diverse attitudinal paths, they all improved neonatal resuscitation performance after using the digital simulator and successfully transferred their knowledge to a new medium. Conclusions: Digital simulation improved HCPs' neonatal resuscitation performance. Medical education may benefit by incorporating technology during simulation training.

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.