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.

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.

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.

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.

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.

Serious games, a game changer in teaching neonatal resuscitation? A review.

BACKGROUND: Neonatal healthcare professionals require frequent simulation-based education (SBE) to improve their cognitive, psychomotor and communication skills during neonatal resuscitation. However, current SBE approaches are resource-intensive and not routinely offered in all healthcare facilities. Serious games (board and computer based) may be effective and more accessible alternatives. OBJECTIVE: To review the current literature about serious games, and how these games might improve knowledge retention and skills in neonatal healthcare professionals. METHOD: Literature searches of PubMed, Google Scholar, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science and EMBASE databases were performed to identify studies examining serious games in neonatology. All games, such as board games, tabletop games, video games, screen-based simulators, tabletop simulators and virtual reality games were included. RESULTS: Twelve serious games were included in this review (four board games, five video games and three virtual reality games). Overall, knowledge improvement was reported for the RETAIN (REsuscitationTrAINing for healthcare professionals) board game (10% increase in knowledge retention) and The Neonatology Game (4.15 points higher test score compared with control). Serious games are increasingly incorporated into Nursing and Medical School Curriculums to reinforce theoretical and practical learning. CONCLUSIONS: Serious games have the potential to improve healthcare professionals' knowledge, skills and adherence to the resuscitation algorithm and could enhance access to SBE in resource-intensive and resource-limited areas. Future research should examine important clinical outcomes in newborn infants.

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

Background: Each year, over 13 million babies worldwide need help to breathe at birth. While guidelines recommend the Neonatal Resuscitation Program course, medical errors remain common. Frequent simulation training and assessment is needed to address this competence gap; however, alternative approaches are needed to overcome barriers to access. The RETAIN (REsuscitation TrAINing) simulation-based serious game (Retain Labs Medical Inc., Edmonton, AB, Canada) may provide a solution to supplement traditional training. This paper aims to review the available evidence about RETAIN for improving neonatal resuscitation education. Method: Literature searches of PubMed, Google Scholar, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and EMBASE databases were performed to identify studies examining the RETAIN serious game for neonatal resuscitation training. All of the studies describing the RETAIN board game and computer game were included. Results: Three papers and one conference proceeding were identified. Two studies described the RETAIN board game, and two studies described the RETAIN computer game. RETAIN was reported as usable and clinically relevant. RETAIN also improved knowledge of neonatal resuscitation by 12% and functioned as a summative assessment. Further, performance on RETAIN was moderated by players' self-reported mindset. Conclusion: RETAIN can be used for the training and assessment of experienced neonatal resuscitation providers. Further studies are needed to understand the effectiveness of RETAIN to (i) improve other cognitive and non-cognitive skills, (ii) in diverse populations of neonatal resuscitation providers, (iii) in comparison to current standard training approaches, and (iv) in improving clinical outcomes in the delivery room.