The Neonatal Resuscitation Program Comes of Age
Article Outline
- Simulation and Graduate Medical Education
- Role of Simulation in the Neonatal Resuscitation Program
- A Simulation-Based Neonatal Resuscitation Training Program for Pediatric Trainees
- Conclusions
- Appendix.
- References
- Copyright
NRP, Neonatal Resuscitation Program
The Neonatal Resuscitation Program (NRP), established by the American Academy of Pediatrics and the American Heart Association, is the accepted standard for teaching neonatal resuscitation.1 The initial vision of the NRP was to provide effective intervention for newborns requiring resuscitation by a trained healthcare professional and develop a standardized educational program would promote optimal care in the resuscitation of sick newborns.2 In its short life-span, the NRP has matured with the implementation of best educational practices. From inception in 1985 until 2000, the curriculum was based on anecdotal evidence and scholarly speculations initially developed by champions Catherine Cropley, RN, MN, and Ronald Bloom, MD. In the fourth edition of the NRP in 2000, the first organized review of existing scientific literature took place, aligning the curriculum with evidence-based guidelines.
Now approaching its sixth edition, the NRP continues to be a leader in establishing the best evidenced-based practice for the care of newborns requiring resuscitation in the delivery room by inclusion of simulation-based training into the curriculum. A traditional NRP course consists of a day filled with textbook readings, lectures with accompanying slide presentations and videos, and skills stations at which trainees practice individual technical skills on partial-task trainers (low-tech mannequins and body-part trainers such as intubation heads).3 With studies showing that cognitive and technical skills achieved in such standardized courses are retained for only 6 to 12 months, the goal of a simulation-based training curriculum is to improve sustained learning and skill in the care of newborns requiring resuscitation at the time of delivery.4
Simulation and Graduate Medical Education
Simulation in healthcare is an evolving educational methodology that began >20 years ago in the field of anesthesiology.5, 6 Previously, other high-risk industries, such as aviation and nuclear power, have used simulation to improve safety and minimize risk. Simulation-based research in healthcare continues to show that the use of such methodologies enhances performance in both real-life clinical situations and simulated resuscitations.7 In addition, use of debriefings after real or simulated resuscitations has been found to improve learning, knowledge, and skills.8
Simulation is an educational method by which learning occurs in realistic environments in which healthcare professionals work as a team providing care for patient simulators of variable sophistication using real medical equipment. Most simulated encounters include some type of simulator, a realistic environment, and a post-simulation debriefing session, during which most of the learning occurs. Simulation incorporates adult learning principles in an experiential learning encounter (Table; available at www.jpeds.com). Simulation provides an opportunity to observe and assess learner performance, congruent with the recent transition in graduate medical education standards from an experiential and apprenticeship training model (ie, 3 years of pediatric residency training) to an outcomes-based training model (ie, by the end of a pediatric residency, a learner will be able demonstrate or perform specific tasks or skills).
Despite residency work hour restrictions and time limitations for pediatric and neonatal intensive care rotations, graduate medical education continues to focus on complex competencies and skills such as neonatal resuscitation. A continuing challenge for academic training centers is how to meet the demands of graduate medical education while following Residency Review Committee and Accreditation Council for Graduate Medical Education recommendations that afford less time for mastery of skills. Current training requirements state that the neonatal intensive care curriculum must be designed to teach resuscitation of newborns in the delivery room and that residents must complete the NRP.9 Simulation-based education offers advantages compared with traditional teaching methods in allowing for repetitive and deliberate practice of the skills necessary for managing complex, high-risk, and rare clinical events in an environment that is safe for both patients and trainees. The challenge for pediatric training programs is to support and incorporate simulation-based training curriculum into an already tight residency training schedule.
Role of Simulation in the Neonatal Resuscitation Program
The newest edition of the NRP curriculum not only embraces, but also requires simulation.10 Until now, the paradigm of the NRP has relied on lectures accompanied by skill stations using low-tech mannequins and without a formal debriefing process, thereby only addressing knowledge and technical skills. The incorporation of simulation-based methodology will now address the complex behavioral skills that are essential during resuscitation of the newborn. The NRP has undertaken training instructors in the basics of simulation and debriefing by requiring them to watch a DVD, including segments on how to facilitate effective debriefings and tips for creating scenarios, by January 2012. NRP instructors will now be required to have the knowledge and skills needed to conduct simulation-based training (ie, how to design simulation scenarios and debrief using reflective questions). Additionally, in an effort to shift the focus of instructor-learner interactions in the classroom to simulation-based exercises, the NRP has eliminated the written examination as part of the program, in lieu of and replaced it with an online examination that an individual must complete before attending an NRP course. Highly technical mannequins facilitate simulation methodology, but are not required.
Simulation-based training focuses more on behavioral and teamwork skills than on individual technical skills and provides the opportunity for multidisciplinary teams to train together. Until now, healthcare professionals have trained in silos: nurses in nursing school, physicians in medical school. However, when a patient deteriorates, healthcare providers are expected to work well as a successful resuscitation team, although they have not had an opportunity to practice working together. Both the Institute of Medicine and the Joint Commission have reported that medical errors result more often from deficiencies in teamwork, leadership, and communication, rather than technical or cognitive deficiencies.11, 12 Simulation-based NRP will provide the opportunity for multidisciplinary healthcare teams to practice and improve these critical skills in a safe environment for learners and patients.
A Simulation-Based Neonatal Resuscitation Training Program for Pediatric Trainees
At Texas Children’s Hospital, our goal has been to develop a simulation-based NRP that is practical, sustainable, and meets Accreditation Council for Graduate Medical Education training requirements. Traditionally, at our institution, like most, the NRP was offered once a year in the summer for all new pediatric interns. Interns spent 1 day in a classroom, where lectures and technical skills were practiced in skill stations on low-tech mannequins. Our challenge was to develop a simulation-based training NRP that would provide an opportunity for residents, nurses, and other providers to participate in multidisciplinary simulation training in neonatal resuscitation.
One of the greatest challenges in developing a simulation-based curriculum is the increased instructor resources needed. Not only do instructors need to acquire a new skill set (ie, how to conduct and debrief simulation scenarios), but also the instructor to student ratio is higher than in traditional classroom lecturing. Additionally, most simulation facilities are not able to accommodate a large group of learners at one time. Despite these challenges, simulation is clearly the future of medical education.
To meet our goal of implementing a simulation-based NRP program at Texas Children’s Hospital, we had to develop an alternative plan. After meeting with stakeholders, a plan was developed to offer a simulation-based NRP 2 to 4 times monthly for 12 learners per class, with a minimum of 3 instructors per class. With this new format, pediatric interns were assigned on the first Friday of their first rotation in either the newborn nursery or neonatal intensive care unit to a class combined with nurses and other allied healthcare providers. Faculty agreed to cover for the residents during their 4-hour training sessions. Each session includes a 30-minute introduction to simulation and the mannequins, a 1-hour technical skills session in which learners practice bag-mask ventilation, cardiopulmonary resuscitation, endotracheal intubation, and emergent umbilical line placement with low-tech task trainers, and 2.5 hours of participation in simulation scenarios with structured debriefing sessions incorporating video review. Pediatric interns now learn alongside new and seasoned neonatal healthcare providers in groups of 3 to 6 persons. All NRP instructors are trained to teach NRP, as well as simulation educational methodology in a 2-day training program developed at our simulation center.
Conclusions
The NRP’s inclusion of simulation-based methodology is a pioneering example of how a large, international educational program can incorporate simulation-based techniques despite perceived obstacles and challenges. As pediatric post-graduate training programs and other institutions meet this new requirement for NRP training, a greater understanding of how to implement simulation-based curricula could lead to further simulation-based training programs in other areas of healthcare to improve education and patient care. The NRP is coming of age by keeping up with best educational practice and the ever-changing demands of medical education.
Appendix.
Table. Adult learning principles and simulation correlations
| Adult learning principle | Simulation curriculum correlate |
|---|---|
| • Adults prefer to apply what they learn soon after learning it | • Simulation provides immediate, hands-on practice |
| • Adults prefer learning concepts and principles | • Online modules and examinations present concepts before simulation |
| • Adults learn better at their own pace | • Simulation provides repetitive and deliberate practice educational opportunities |
| • Adults like to help set their own learning objectives | • Learner-focused debriefings allow for reflection on personal objectives |
| • Adults like to receive immediate feedback | • Debriefing, ideally with video review, of simulation scenarios is real-time, immediate, and learner focused |
References
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- . Collaborative off-line reflection: a way to develop skill in action science and action inquiry. In: Reason P, Bradbury H editor. Handbook of action research. Thousand Oaks, California: Sage; 2001;p. 405–412
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- . To err is human: building a safer health system. 1st ed.. Washington, DC: National Academy Press; 2000;
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PII: S0022-3476(11)00568-3
doi:10.1016/j.jpeds.2011.05.053
© 2011 Mosby, Inc. All rights reserved.
