Edited by: Michael Wagner, Medical University of Vienna, Austria
Reviewed by: Lukas Peter Mileder, Medical University of Graz, Austria; Janneke Dekker, Leiden University, Netherlands
This article was submitted to Neonatology, a section of the journal Frontiers in Pediatrics
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Advanced clinical neonatal nurses are expected to have technical skills including bag-mask ventilation. Previous studies on neonatal bag-mask ventilation skills training focus largely on medical students and/or physicians. The aim of this study was to investigate whether advanced clinical neonatal nursing students’ bag-mask ventilation training with real-time feedback resulted in transfer of bag-mask ventilation performance to a simulated setting without feedback on ventilation.
Students in advanced clinical neonatal nursing practiced bag-mask ventilation on a premature manikin (Premature Anne, Laerdal Medical, Stavanger, Norway) during skills training. A flow sensor (Neo Training, Monivent AB, Gothenburg, Sweden) was placed between the facemask and the self-inflating bag (Laerdal Medical), and visual feedback on mask leak (%), expiratory tidal volume (VT
Mask leakage and ventilation rate was higher, and VT
Skills training with real-time feedback on mask leak, ventilation rate, tidal volume, and inflation pressure did not result in objective or subjective improvements in bag-mask ventilation in a simulated neonatal resuscitation situation. Incorrect VT
When a newborn infant needs stabilization and resuscitation, the advanced clinical neonatal nurse participates in the team. There are three intrinsic elements of human performance in these situations: 1. technical skills; and non-technical, i.e., 2. Cognitive, and 3. behavioral skills. According to the “sociotechnical systems” theory, these elements are to some extent inseparable from each other (
Although, airway management is often the responsibility of physicians and respiratory therapists, the advanced clinical neonatal nurse is expected and required to have the knowledge, technical and non-technical skills, and execute physical and mental tasks, actions, and functions as a part of the resuscitation team. However, studies have shown that even experienced healthcare professionals have problems performing correct bag-mask ventilation (
The International Liaison Committee on Resuscitation recommends programs that include simulation training with feedback from different sources including devices such as respiratory monitoring devices (
Thus, the objective of this study was to investigate whether bag-mask ventilation skills training with real-time feedback on mask leak, delivered tidal volume, ventilation rate, and inflation pressure, enabled students in advanced clinical neonatal nursing to perform high-quality bag-mask ventilation in a simulated neonatal resuscitation scenario.
Students in the master’s degree program normally participate in simulation training every half-term, but due to the Covid pandemic, the first-term simulation training was replaced with an online training case, using a video-recorded simulated scenario. This present project was conducted in the second half-term of the master’s degree program in advanced clinical neonatal nursing. Skills and simulation training took place in the simulation room at Lovisenberg Diaconal University College (LDUC), Oslo, Norway.
The requirement for admission to the master’s degree program is a completed Bachelor’s degree in nursing. Additionally, students must have at least 2 years of full-time postgraduate nursing experience, including minimum 1 year of full-time experience relevant to the program. Norwegian neonatal intensive care units (NICUs) are classified based on the level of medical treatment and neonatal care that they provide (
The project was approved by the head of the faculty at LDUC and the Norwegian Center for Research Data (NSD). All students at the master’s degree program in advanced clinical neonatal nursing received oral information and a written invitation to participate in the study, and the participating students gave their written consent.
The Neo Training system (Monivent AB, Gothenburg, Sweden) is designed to support neonatal ventilation skills training, and improve and maintain manual ventilation skills (
In August 2021, the students at the master’s degree program (
In alignment with the International Nursing Association for Clinical Simulation and Learning (INACSL) (
Lectures were given in advance of the skills training and focused on the guidelines for resuscitation, and theoretical and practical perspectives on neonatal ventilation. The lectures addressed how to place the face mask, definitions of effective ventilation (tidal volume 4–6 ml/kg and rate 30 min–1), and ventilation corrective actions, e.g., establishment and maintenance of open airways, repositioning of the baby’s head to secure a neutral position, and chin-jaw lifts to enlarge the pharynx. The ventilation skills training was organized in two sessions. In the first session, the students practiced bag-mask ventilation on a term manikin (Baby Anne, Laerdal Medical, Stavanger, Norway) to ensure that they managed basic ventilation skills prior to the commencement of the study data acquisition. This manikin has a realistic airway resistance that allows students to learn the important techniques of opening the airways and chin-jaw lifting (
In the second session, i.e., the study baseline session, the students practiced one-by-one on a premature manikin (Premature Anne, Laerdal Medical, Stavanger, Norway). Each student ventilated the manikin for 3 min. During this session, they got visual real-time feedback on ventilation using the Monivent Neo Training system, supplemented by verbal feedback from a trained facilitator.
In October 2021, full-scale simulations were performed in accordance with recommendations from the INACSL with briefing, simulation, debriefing and evaluation (
Testing of the setup with support from Monivent AB revealed no internal air leak in the Premature Anne manikin airways. The target VT
After skills- and simulation training had both been completed, a structured Likert-scale questionnaire was used to investigate the students’ self-perceived competence in bag-mask ventilation before vs. after skills- and simulation training. In the questionnaire, the students also reported in which category NICU they were employed, whether they had performed neonatal ventilation in clinical practice, and the number of years of clinical work experience.
To shed light on the results, a
We tested for differences in the fraction of correct ventilations (VT
Data were registered from the 10 students who performed bag-mask ventilation both in the skills training and during simulation. These students had median (IQR) years of clinical experience of 7 (4–11) years, ranging from 3 to 16 years. One student worked in a category 3a NICU, two students in a category 3b NICU, and seven students in a category 3c NICU. Except for the student from the 3a NICU and one student from a 3c NICU, all students reported having performed neonatal ventilation in clinical practice. Eight students answered the
We analyzed 4.166 ventilations, 876 during skills training and 3.290 during simulation.
In the skills training, 52% of ventilations had a higher than recommended VT
Box plots all students combined of
Box plots individual students, skills training and simulation combined of
Spaghetti plots individual students of
The results of questionnaire 1 are presented in
Bar chart of students’ self-assessed skills in
In previous studies, results from real-time feedback have either been masked or made visible to the participants during ventilation (
Our results are in agreement with Gomo et al. (
Despite our students’
It is the responsibility of both the individual healthcare professional, educational institutions and the NICU leadership that knowledge of and skills in providing safe and effective ventilation are repeatedly trained and tested. The results from this study contrast with studies that found that training with real-time feedback improved ventilation performance (
Anderson et al. (
Our participants were adult learners and had a median (IQR) year of clinical experience of 7 (4–11) years, but only 8 out of 10 reported to have performed neonatal ventilation in clinical practice. According to Mumma et al. (
Except for the student from 3a NICU and one student from a 3c NICU, all students reported having performed neonatal ventilation in clinical practice. In clinical practice, nurses must be properly trained in the early identification of clinical deterioration (
Having an unfamiliar role in the simulated setting may contribute to participant stress. Lizotte et al. (
All 10 students had the same lecture and skills training 8 weeks before the simulation, and all of them were experienced nurses working in relatively high-acuity level 3 NICUs. However, some individual differences will naturally appear in a group. These characteristics can be understood as non-technical skills and may have contributed to the differences in performance. The students in this study confirmed that simulation training is a stressful situation but stated that they became more focused on the tasks and managed to stay calm even though they were stressed. Non-technical skills include cognitive and social skills that complement technical skills (
Eye-tracking was used to measure visual attention, and Monivent provided real-time feedback in a recent randomized simulation study (
A strength of this study is that it contributes to filling a knowledge gap in our understanding of neonatal ventilation skills in nurses, as opposed to medical students and physicians. The study was a collaborative effort between the nursing and medical profession, and between higher education and clinical practice. Limitations include a low number of participants. Despite the low number of participants, the study indicates that human factors need more attention in the education of advanced clinical neonatal nurses. All the students had experience with simulation training in clinical practice before the start of the master’s degree program, but it is a limitation that this study did not include a baseline simulation, the reason for which has been explained in the methods section. The equipment we used, i.e., the self-inflating bag and mask, may not have been the best when a T-piece is often the device used in the clinical field. In further studies, the participants should be allowed to choose the resuscitation device they are most familiar with. The manikin was checked for an internal air leak, but it is still possible that this may have occurred undergoing ventilations.
Despite these limitations, we believe that our study provides useful learning points for educational contexts and clinical practice.
For students in the master’s degree program in advanced clinical neonatal nursing, skills training with real-time feedback on mask leakage, tidal volume, ventilation rate, and inflation pressure did not result in high-quality bag-mask ventilation in a stressful simulated scenario. The objective measures agreed with the students’ own perceptions that their skills had not improved after the skills- and simulation training. In future studies, it would be of interest to try to distinguish individual differences influencing stress management in the performance of bag-mask ventilation in simulated neonatal resuscitation. It would also be interesting to investigate if more frequent training before simulation, and both blinded and visible real-time feedback training would improve the simulation results.
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
The studies involving human participants were reviewed and approved by the Norwegian Center for Research Data (NSD)–reference number 890517. The patients/participants provided their written informed consent to participate in this study.
IR performed the data collection. IR and AS conceptualized the study and analyzed and interpreted the data. IR and A-KJ drafted the initial version of the manuscript. HA and AR contributed to the conceptualizing, data analysis, and interpretation. All authors participated in critical revision of the manuscript for important intellectual content, approved the final manuscript as submitted, and agreed to be accountable for all aspects of the work.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
This work was supported by Lovisenberg Diaconal University College. The funding was used for simulation instructor training, planning of the study, and dissemination of the results (conference attendance and publication fees).
We thank the students for participating in the study. We also acknowledge Hilde Jacobsen RN, MScN for facilitating the skills training and Susan Henriette Kaaber RN, MScN for facilitating the simulation training.
expiratory tidal volume
neonatal intensive care unit
Lovisenberg Diaconal University College
interquartile range
cardiopulmonary resuscitation.