Neonatal Simulation: A Practical Guide [1 ed.] 9781610022606, 9781610022613, 2018942267, 1610022602

Table of contents :
Preface
Application of Learning Theory in Simulation
Scenario Design
Simulation and the Neonatal Resuscitation Program
Mannequins and Task Trainers
Simulation for Neonatal Airway Management
Umbilical Catheter Placement
Simulation for Infant Lumbar Puncture Training
Neonatal Thoracentesis and Chest Tube Placement Simulation
Simulating Neonatal Pericardial Effusion and Cardiac Tamponade
Neonatal Exchange Transfusion
Extracorporeal Membrane Oxygenation Simulation
Extracorporeal Life Support Organization Training and Education
Simulation-Based Education for Parents and Other Home Caregivers of Infants With Technology Dependence
Boot Camps
Simulation in Neonatal Global Health
Virtual Simulation
Telesimulation for Neonatal Resuscitation Education and Training
In Situ Simulation
In Situ Simulations for Testing New Health Care Environments
Communication Skills in Neonatal Simulation
Standardized Patients
Moulage: The Special Effects
Simulation Training for Effective Resuscitation Leadership
Debriefing in Simulation-Based Training in Neonatology: An Outcomes-Based Approach
Blended-Method Debriefing With the PEARLS Debriefing Framework
Co-Debriefing in Neonatal Simulation
The Difficult Debriefing
Rapid-Cycle Deliberate Practice
Simulation Operations
Simulation Research Networks
Simulation-Based Research in Neonatology
History of Neonatal Simulation
Appendix A
Appendix B
Appendix C
Appendix D
Appendix E
Appendix F
Appendix G
Index

Citation preview

Includes 225+ full-color images!

A PRACTICAL GUIDE

Editors: Lamia Soghier, MD, MEd, CHSE, FAAP, and Beverley Robin, MD, MHPE, CHSE, FAAP

D

eveloped by the leading experts in neonatal simulation, this innovative resource delivers neonatal health care professionals and educators essential guidance on designing, developing, and implementing simulation-based neonatal education programs.

This book guides the reader through scenario design, mannequins and task trainers, moulage, simulation techniques, virtual simulations, mannequin adaptations needed to conduct specific simulation procedures, debriefing methods, and more. Step-by-step images guide the reader through how to adapt mannequins to simulate procedures and how to replicate bodily fluids and conditions commonly encountered in newborns. With 225+ color images, as well as plenty of helpful boxes and tables throughout, this book will be useful to both novices and experts.

For other neonatal resources, visit the American Academy of Pediatrics at shop.aap.org. ISBN 978-1-61002-260-6

90000>

Soghier • Robin

More than 30 chapters include • In Situ Simulation • Simulation and the Neonatal Resuscitation Program • Mannequins and Task Trainers • Boot Camps • Debriefing in Simulation-Based Training in Neonatology • Simulation Operations • And more...

Neonatal Simulation A PRACTICAL GUIDE

A PRACTICAL GUIDE

The early chapters cover learning theory, fundamentals of scenario design, and simulation and the Neonatal Resuscitation Program®. The later chapters cover specific applications of simulation in neonatology and debriefing techniques.

Neonatal Simulation

Neonatal Simulation

EDITORS

Lamia Soghier, MD, MEd, CHSE, FAAP

• Beverley Robin, MD, MHPE, CHSE, FAAP

9 781610 022606

AAP

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Neonatal Simulation A PRACTICAL GUIDE

EDITORS

Lamia Soghier, MD, MEd, CHSE, FAAP

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• Beverley Robin, MD, MHPE, CHSE, FAAP

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American Academy of Pediatrics Publishing Staff Mary Lou White, Chief Product and Services Officer/SVP, Membership, Marketing, and Publishing Mark Grimes, Vice President, Publishing Heather Babiar, MS, Senior Editor, Professional/Clinical Publishing Theresa Wiener, Production Manager, Clinical and Professional Publications Amanda Helmholz, Medical Copy Editor Peg Mulcahy, Manager, Art Direction and Production Linda Smessaert, Director, Marketing Published by the American Academy of Pediatrics 345 Park Blvd Itasca, IL 60143 Telephone: 630/626-6000 Facsimile: 847/434-8000 www.aap.org The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of all infants, children, adolescents, and young adults. The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of Pediatrics. Any websites, brand names, products, or manufacturers are mentioned for informational and identification purposes only and do not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication. The persons whose photographs are depicted in this publication are professional models. They have no relation to the issues discussed. Any characters they are portraying are fictional. The publishers have made every effort to trace the copyright holders for borrowed materials. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. This publication has been developed by the American Academy of Pediatrics. The contributors are expert authorities in the field of pediatrics. No commercial involvement of any kind has been solicited or accepted in the development of the content of this publication. Christopher Colby discloses a relationship with InTouch Health. Walter Eppich discloses consultant relationships with Center for Medical Simulation and PAEDSIM eV and editorial board member relationships with Perspectives on Medical Simulation and Advances in Simulation. Jennifer Fang discloses a relationship with InTouch Health. Janene Fuerch discloses relationships with Novonate, Emme, and D-Rev. Chapter 24 is supported in part by the Endowment for the Center for Advanced Pediatric and Perinatal Education. Every effort has been made to ensure that the drug selection and dosages set forth in this publication are in accordance with the current recommendations and practice at the time of publication. It is the responsibility of the health care professional to check the package insert of each drug for any change in indications or dosage and for added warnings and precautions. Every effort is made to keep Neonatal Simulation: A Practical Guide consistent with the most recent advice and information available from the American Academy of Pediatrics. Please visit www.aap.org/errata for an up-to-date list of any applicable errata for this publication. Special discounts are available for bulk purchases of this publication. Email Special Sales at [email protected] for more information. © 2021 American Academy of Pediatrics All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means— electronic, mechanical, photocopying, recording, or otherwise—without prior permission from the publisher (locate title at http://ebooks. aappublications.org and click on © Get permissions; you may also fax the permissions editor at 847/434-8780 or email [email protected]). First edition published 2021. Printed in the United States of America 9-384/0421

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ISBN: 978-1-61002-260-6 eBook: 978-1-61002-261-3 Library of Congress Control Number: 2018942267

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III Editors Lamia Soghier, MD, MEd, CHSE, FAAP Associate Professor of Pediatrics The George Washington University School of Medicine Medical Director, Neonatal Intensive Care Unit Children’s National Health System Washington, DC

Beverley Robin, MD, MHPE, CHSE, FAAP Assistant Professor, Pediatrics Director, Neonatal-Perinatal Medicine Fellowship Program Rush University Medical Center Chicago, IL

Contributors Anne Ades, MD, MSEd Professor of Clinical Pediatrics Perelman School of Medicine at the University of Pennsylvania Attending Neonatologist The Children’s Hospital of Philadelphia Philadelphia, PA Chapter 11. Extracorporeal Membrane Oxygenation Simulation Chapter 14. Boot Camps Catherine Allan, MD, FAAP Medical Director, Cardiac Intensive Care Unit Associate Program Director, Simulator Program Boston Children’s Hospital Boston, MA Chapter 11. Extracorporeal Membrane Oxygenation Simulation Christine Arnold, MS, RNC, CHSE Educator for Pursuing Excellence University of Rochester Medical Center Rochester, NY Chapter 27. The Difficult Debriefing Jennifer Arnold, MD, MSc, FAAP Medical Director, Center for Medical Simulation and Innovative Education Johns Hopkins All Children’s Hospital St Petersburg, FL Chapter 13. Simulation-Based Education for Parents and Other Home Caregivers of Infants With Technology Dependence Michael-Andrew Assaad, MD, FRCPC, FAAP Associate Professor of Pediatrics Division of Neonatology University of Montreal Montreal, Quebec, Canada Chapter 5. Simulation for Neonatal Airway Management Chapter 25. Blended-Method Debriefing With the PEARLS Debriefing Framework Chapter 26. Co-debriefing in Neonatal Simulation Appendix B

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Marc Auerbach, MD, MSc Associate Professor of Pediatrics and Emergency Medicine Yale University School of Medicine New Haven, CT Chapter 7. Simulation for Infant Lumbar Puncture Training Alana Barbato, MD Assistant Professor of Clinical Pediatrics Division of Neonatal-Perinatal Medicine Indiana University School of Medicine Indianapolis, IN Chapter 9. Simulating Neonatal Pericardial Effusion and Cardiac Tamponade G. Jesse Bender, MD NICU Medical Director Mission Health System Asheville, NC Chapter 19. In Situ Simulations for Testing New Health Care Environments Angela D. Blood, MPH, MBA, CHSE-A Director, Curricular Resources Association of American Medical Colleges (AAMC) Washington, DC Chapter 1. Applications of Learning Theory in Simulation Renee D. Boss, MD, MHS Associate Professor, Neonatology and Palliative Care Johns Hopkins University School of Medicine Baltimore, MD Chapter 20. Communication Skills in Neonatal Simulation Steven Brediger, RRT-NPS ECMO Educator Boston Children’s Hospital Boston, MA Chapter 11. Extracorporeal Membrane Oxygenation Simulation Christie J. Bruno, DO Associate Professor of Pediatrics Neonatal-Perinatal Medicine Fellowship Training Program Director Yale New Haven Children’s Hospital New Haven, CT Chapter 10. Neonatal Exchange Transfusion Chapter 14. Boot Camps

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IV

CONTRIBUTORS

Melanie Burke, MRT (R) Simulation Technician, Simulation Lab Health Sciences North Sudbury, Ontario, Canada Chapter 22. Moulage: The Special Effects Sabrina M. Butteris, MD Associate Professor, Department of Pediatrics University of Wisconsin School of Medicine and Public Health American Family Children’s Hospital Madison, WI Chapter 15. Simulation in Neonatal Global Health Bobbi J. Byrne, MD, FAAP Professor of Clinical Pediatrics Division of Neonatal-Perinatal Medicine Indiana University School of Medicine Indianapolis, IN Chapter 8. Neonatal Thoracentesis and Chest Tube Placement Simulation Chapter 9. Simulating Neonatal Pericardial Effusion and Cardiac Tamponade Chapter 18. In Situ Simulation Appendix C Appendix D Douglas M. Campbell, MD, FRCPC Director of NICU, Medical Director of Allan Waters Family Simulation Centre Program Department of Pediatrics University of Toronto St Michael’s Hospital, Unity Health Toronto Toronto, Ontario, Canada Chapter 32. History of Neonatal Simulation Todd Chang, MD, MAcM Associate Director / Research Director, CHLA Las Madrinas Simulation Center Associate Fellowship Director, Division of Emergency Medicine Director of Research & Scholarship, Division of Emergency Medicine Vice Chair, Institutional Review Board Children’s Hospital Los Angeles Associate Professor of Pediatrics/Medical Education Keck School of Medicine University of Southern California Los Angeles, CA Chapter 30. Simulation Research Networks Adam Cheng, MD Professor, Departments of Paediatrics and Emergency Medicine University of Calgary Calgary, Alberta, Canada Chapter 25. Blended-Method Debriefing With the PEARLS Debriefing Framework Chapter 26. Co-debriefing in Neonatal Simulation

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Christopher E. Colby, MD Professor of Pediatrics Mayo Clinic Rochester, MN Chapter 17. Telesimulation for Neonatal Resuscitation Education and Training Rita Dadiz, DO, CHSE, FAAP Associate Director of Pediatrics Director, Neonatal Innovation and Safety Simulation Program Division of Neonatology University of Rochester Medical Center Rochester, NY Chapter 19. In Situ Simulations for Testing New Health Care Environments Chapter 27. The Difficult Debriefing Maria Carmen G. Diaz, MD, FACEP, FAAP Clinical Professor of Pediatrics and Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University Philadelphia, PA Medical Director of Simulation Nemours Institute for Clinical Excellence Attending Physician, Division of Emergency Medicine Nemours/Alfred I. duPont Hospital for Children Wilmington, DE Chapter 13. Simulation-Based Education for Parents and Other Home Caregivers of Infants With Technology Dependence Archana Dhar, MD Associate Professor of Pediatrics UT Southwestern Medical School Medical Director of Transport Division of Pediatric Critical Care Children’s Health Medical Center Dallas, TX Chapter 12. Extracorporeal Life Support Organization Training and Education Walter Eppich, MD, PhD, FSSH Professor and Chair of Simulation Education and Research Royal College of Surgeons of Ireland Dublin, Ireland Chapter 25. Blended-Method Debriefing With the PEARLS Debriefing Framework Chapter 26. Co-debriefing in Neonatal Simulation Jennifer L. Fang, MD, MS, FAAP Assistant Professor of Pediatrics Medical Director, Teleneonatology Division of Neonatal Medicine Mayo Clinic Rochester, MN Chapter 17. Telesimulation for Neonatal Resuscitation Education and Training

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CONTRIBUTORS

Heather M. French, MD, MSEd Associate Professor of Clinical Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA Chapter 23. Simulation Training for Effective Resuscitation Leadership Appendix F Janene H. Fuerch, MD Clinical Assistant Professor of Pediatrics Division of Neonatal and Developmental Medicine Stanford University Palo Alto, CA Chapter 31. Simulation-Based Research in Neonatology Kristen M. Glass, MD Associate Professor of Pediatrics Division of Neonatal-Perinatal Medicine Penn State Health Milton S. Hershey Medical Center Penn State College of Medicine Hershey, PA Chapter 10. Neonatal Exchange Transfusion Megan M. Gray, MD Assistant Professor of Pediatrics Division of Neonatology University of Washington Seattle, WA Chapter 4. Mannequins and Task Trainers Chapter 6. Umbilical Catheter Placement Arika G. Gupta, MD Assistant Professor of Pediatrics Department of Pediatrics Division of Neonatology Northwestern University Feinberg School of Medicine Ann & Robert H. Lurie Children’s Hospital of Chicago Chicago, IL Chapter 25. Blended-Method Debriefing With the PEARLS Debriefing Framework Chapter 26. Co-debriefing in Neonatal Simulation Louis P. Halamek, MD, FAAP Professor Division of Neonatal and Developmental Medicine Department of Pediatrics Stanford University Founding Director, Center for Advanced Pediatric and Perinatal Education (CAPE) Director of Neonatal Resuscitation, Attending Neonatologist Lucile Packard Children’s Hospital Palo Alto, CA Chapter 3. Simulation and the Neonatal Resuscitation Program Chapter 24. Debriefing in Simulation-Based Training in Neonatology: An Outcomes-Based Approach Chapter 31. Simulation-Based Research in Neonatology

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Elizabeth A. Hunt, MD, MPH, PhD Associate Professor Department of Anesthesiology and Critical Care Medicine Johns Hopkins University School of Medicine Director, Johns Hopkins Medicine Simulation Center Baltimore, MD Chapter 28. Rapid-Cycle Deliberate Practice Sarah Isaac, MEd, BHSc, BA Simulation Technician Health Sciences North Sudbury, Ontario, Canada Chapter 22. Moulage: The Special Effects Priti Jani, MD, MPH Assistant Professor of Pediatrics Section of Critical Care Medicine The University of Chicago, Comer Children’s Hospital Chicago, IL Chapter 1. Applications of Learning Theory in Simulation Lindsay Johnston, MD, MEd, CHSE, FAAP Associate Professor of Pediatrics Division of Neonatal-Perinatal Medicine Yale School of Medicine New Haven, CT Chapter 11. Extracorporeal Membrane Oxygenation Simulation Chapter 14. Boot Camps David O. Kessler, MD, MSc Vice Chair of Innovation for the Department of Emergency Medicine Associate Professor Columbia University Vagelos College of Physicians and Surgeons New York, NY Chapter 7. Simulation for Infant Lumbar Puncture Training Suzanne Lortie-Carlyle Manager, Simulation Lab Health Sciences North / Horizon Santé-Nord Sudbury, Ontario, Canada Chapter 22. Moulage: The Special Effects Lisa Mayer, RN, BSN Simulation Educator Riley Maternal and Newborn Health at Indiana University Health Indianapolis, IN Chapter 8. Neonatal Thoracentesis and Chest Tube Placement Simulation Tyler Montroy, A-EMCA, PCP Simulation Technician Health Sciences North Sudbury, Ontario, Canada Chapter 22. Moulage: The Special Effects

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CONTRIBUTORS

Ahmed Moussa, MD, MMed, FRCPC, FAAP Director, Center for Applied Health Sciences Education (CPASS) University of Montreal Associate Professor, Departement of Pediatrics University of Montreal Neonatologist, CHU Sainte-Justine Montreal, Quebec, Canada Chapter 5. Simulation for Neonatal Airway Management Appendix B Allyson Norton, RN Simulation Technician Health Sciences North Sudbury, Ontario, Canada Chapter 22. Moulage: The Special Effects Mark T. Ogino, MD, FAAP Chief Partnership Officer Neonatology Chief, Nemours Delaware Valley Nemours/Alfred I. duPont Hospital for Children Wilmington, DE Clinical Professor of Pediatrics Sidney Kimmel Medical College of Thomas Jefferson University Philadelphia, PA Chapter 12. Extracorporeal Life Support Organization Training and Education Julie S. Perretta, MSEd, RRT-NPS, CHSE-A Assistant Professor Anesthesiology and Critical Care Medicine Johns Hopkins University School of Medicine Director of Education and Innovation Johns Hopkins Medicine Simulation Center Baltimore, MD Chapter 2. Scenario Design Chapter 28. Rapid-Cycle Deliberate Practice Appendix A Appendix G Michael B. Pitt, MD, FAAP Associate Professor of Pediatrics Division of Hospital Pediatrics University of Minnesota Minneapolis, MN Chapter 15. Simulation in Neonatal Global Health Michael Roach, BScN, MN (c) Simulation Educator Health Sciences North Sudbury, Ontario, Canada Chapter 22. Moulage: The Special Effects Shannon Poling, MEHP, RRT-NPS, CHSE Simulation Educator Johns Hopkins Medicine Simulation Center Johns Hopkins University Baltimore, MD Chapter 28. Rapid-Cycle Deliberate Practice

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Beverley Robin, MD, MHPE, CHSE, FAAP Assistant Professor, Pediatrics Director, Neonatal-Perinatal Medicine Fellowship Program Rush University Medical Center Chicago, IL Chapter 2. Scenario Design Chapter 19. In Situ Simulations for Testing New Health Care Environments David L. Rodgers, EdD, EMT-P, NRP, FAHA Manager, Interprofessional Learning and Simulation Penn State Health Milton S. Hershey Medical Center Hershey, PA Chapter 29. Simulation Operations Taylor Sawyer, DO, MEd, CHSE-A Director of Medical Simulation Associate Division Head for Education Division of Neonatology Associate Professor of Pediatrics Department of Pediatrics Division of Neonatology University of Washington School of Medicine, Seattle Children’s Hospital Seattle, WA Chapter 4. Mannequins and Task Trainers Chapter 6. Umbilical Catheter Placement Joo Lee Song, MD Assistant Professor of Clinical Pediatrics Division of Emergency and Transport Medicine Children’s Hospital Los Angeles Department of Pediatrics Keck School of Medicine University of Southern California Los Angeles, CA Chapter 30. Simulation Research Networks Theophil A. Stokes, MD Associate Professor of Pediatrics Uniformed Services University of the Health Sciences Bethesda, MD Chapter 20. Communication Skills in Neonatal Simulation Lillian Su, MD Clinical Associate Professor of Pediatrics Stanford University School of Medicine Medical Director of Simulation, Heart Center Lucile Packard Children’s Hospital Palo Alto, CA Chapter 11. Extracorporeal Membrane Oxygenation Simulation Patricia E. Thomas, PhD, RN, NNP-BC, CNE Clinical Associate Professor College of Nursing University of Texas at Arlington Arlington, TX Chapter 16. Virtual Simulation

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CONTRIBUTORS

Rachel A. Umoren, MB, BCh, MS, FAAP Associate Professor of Pediatrics Division of Neonatology Department of Pediatrics University of Washington Seattle, WA Chapter 4. Mannequins and Task Trainers Chapter 6. Umbilical Catheter Placement Chapter 16. Virtual Simulation Joanne Weinschreider, MS, RN Director of Simulation and Learning Resources School of Nursing Saint John Fisher College Rochester, NY Chapter 27. The Difficult Debriefing Elizabeth A. Wetzel, MD, MS Assistant Professor of Clinical Pediatrics Division of Neonatal-Perinatal Medicine Indiana University School of Medicine Indianapolis, IN Chapter 18. In Situ Simulation Appendix C Appendix D

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Alexander Wood, BScN Simulation Technician, Simulation Lab Health Sciences North Sudbury, Ontario, Canada Chapter 22. Moulage: The Special Effects Nicole K. Yamada, MD, MS, FAAP Clinical Associate Professor Division of Neonatal and Developmental Medicine Stanford University School of Medicine Associate Director, Center for Advanced Pediatric and Perinatal Education (CAPE) Attending Neonatologist Medical Director, Neonatal Critical Care Transport Team Lucile Packard Children’s Hospital Palo Alto, CA Chapter 3. Simulation and the Neonatal Resuscitation Program Marsha E. Yelen, MSN, RN Director of the Standardized Patient Program Rush University Clinical Skills and Simulation Center Chicago, IL Chapter 21. Standardized Patients Appendix E

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To Dr Halamek, founder of neonatal simulation, and to all neonatal health care professionals and the patients who benefit from their care



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XI

Contents Preface ............................................................................................................................................ XIII 1. Applications of Learning Theory in Simulation ........................................................................1 Priti Jani, MD, MPH, and Angela D. Blood, MPH, MBA, CHSE-A

2. Scenario Design .........................................................................................................................17 Julie S. Perretta, MSEd, RRT-NPS, CHSE-A, and Beverley Robin, MD, MHPE, CHSE, FAAP

3. Simulation and the Neonatal Resuscitation Program ............................................................33 Nicole K. Yamada, MD, MS, FAAP, and Louis P. Halamek, MD, FAAP

4. Mannequins and Task Trainers .................................................................................................45 Taylor Sawyer, DO, MEd, CHSE-A, FAAP; Megan M. Gray, MD; and Rachel A. Umoren, MB, BCh, MS, FAAP

5. Simulation for Neonatal Airway Management .......................................................................59 Ahmed Moussa, MD, MMEd, FRCPC, FAAP, and Michael-Andrew Assaad, MD, FRCPC, FAAP

6. Umbilical Catheter Placement..................................................................................................75 Taylor Sawyer, DO, MEd, CHSE-A, FAAP; Megan M. Gray, MD; and Rachel A. Umoren, MB, BCh, MS, FAAP

7. Simulation for Infant Lumbar Puncture Training ...................................................................85 David O. Kessler, MD, MSc, and Marc Auerbach, MD, MSc

8. Neonatal Thoracentesis and Chest Tube Placement Simulation ...........................................95 Lisa Mayer, RN, BSN, and Bobbi J. Byrne, MD, FAAP

9. Simulating Neonatal Pericardial Effusion and Cardiac Tamponade ...................................107 Alana Barbato, MD, and Bobbi J. Byrne, MD, FAAP

10. Neonatal Exchange Transfusion.............................................................................................121 Christie J. Bruno, DO, and Kristen M. Glass, MD

11. Extracorporeal Membrane Oxygenation Simulation ...........................................................127 Lindsay Johnston, MD, MEd, CHSE, FAAP; Anne Ades, MD, MSEd; Lillian Su, MD; Steven Brediger, RRT-NPS; and Catherine Allan, MD, FAAP

12. Extracorporeal Life Support Organization Training and Education ...................................141 Archana Dhar, MD, and Mark T. Ogino, MD, FAAP

13. Simulation-Based Education for Parents and Other Home Caregivers of Infants With Technology Dependence ...............................................................................................147 Jennifer Arnold, MD, MSc, FAAP, and Maria Carmen G. Diaz, MD, FACEP, FAAP

14. Boot Camps ..............................................................................................................................161 Anne Ades, MD, MSEd; Christie J. Bruno, DO; and Lindsay Johnston, MD, MEd, CHSE, FAAP

15. Simulation in Neonatal Global Health ...................................................................................181 Michael B. Pitt, MD, FAAP, and Sabrina M. Butteris, MD

16. Virtual Simulation ...................................................................................................................193 Rachel A. Umoren, MB, BCh, MS, FAAP, and Patricia E. Thomas, PhD, RN, NNP-BC, CNE

17. Telesimulation for Neonatal Resuscitation Education and Training ...................................209 Jennifer L. Fang, MD, MS, FAAP, and Christopher E. Colby, MD

18. In Situ Simulation ....................................................................................................................221 Elizabeth A. Wetzel, MD, MS, and Bobbi J. Byrne, MD, FAAP

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XII

CONTENTS

19. In Situ Simulations for Testing New Health Care Environments..........................................237 G. Jesse Bender, MD; Rita Dadiz, DO, CHSE, FAAP; and Beverley Robin, MD, MHPE, CHSE, FAAP

20. Communication Skills in Neonatal Simulation .....................................................................257 Theophil A. Stokes, MD, and Renee D. Boss, MD, MHS

21. Standardized Patients.............................................................................................................271 Marsha E. Yelen, MSN, RN

22. Moulage: The Special Effects ..................................................................................................287 Suzanne Lortie-Carlyle; Melanie Burke, MRT (R); Sarah Isaac, MEd, BHSc, BA; Tyler Montroy, A-EMCA, PCP; Allyson Norton, RN; Michael Roach, BScN, MN (c); and Alexander Wood, BScN

23. Simulation Training for Effective Resuscitation Leadership ................................................313 Heather M. French, MD, MSEd

Introduction to Debriefing ...........................................................................................................329 24. Debriefing in Simulation-Based Training in Neonatology: An Outcomes-Based Approach ..............................................................................................331 Louis P. Halamek, MD, FAAP

25. Blended-Method Debriefing With the PEARLS Debriefing Framework ........................345 Arika G. Gupta, MD; Michael-Andrew Assaad, MD, FRCPC, FAAP; Adam Cheng, MD; and Walter Eppich, MD, PhD

26. Co-debriefing in Neonatal Simulation.............................................................................355 Michael-Andrew Assaad, MD, FRCPC, FAAP; Arika G. Gupta, MD; Walter Eppich, MD, PhD; and Adam Cheng, MD

27. The Difficult Debriefing ....................................................................................................365 Christine Arnold, MS, RNC, CHSE; Joanne Weinschreider, MS, RN; and Rita Dadiz, DO, CHSE, FAAP

28. Rapid-Cycle Deliberate Practice .............................................................................................383 Julie S. Perretta, MSEd, RRT-NPS, CHSE-A; Shannon Poling, MEHP, RRT-NPS, CHSE; and Elizabeth A. Hunt, MD, MPH, PhD

29. Simulation Operations ............................................................................................................397 David L. Rodgers, EdD, EMT-P, NRP, FAHA

30. Simulation Research Networks ..............................................................................................417 Joo Lee Song, MD, and Todd Chang, MD, MAcM

31. Simulation-Based Research in Neonatology.........................................................................425 Janene H. Fuerch, MD, and Louis P. Halamek, MD, FAAP

32. History of Neonatal Simulation..............................................................................................437 Douglas M. Campbell, MD, FRCPC

Appendix A.................................................................................................................................... 453 Appendix B .................................................................................................................................... 456 Appendix C .................................................................................................................................... 458 Appendix D ................................................................................................................................... 463 Appendix E .................................................................................................................................... 467 Appendix F .................................................................................................................................... 472 Appendix G ................................................................................................................................... 475 Index .............................................................................................................................................. 477

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XIII

Preface In 2000, Louis P. Halamek, MD, FAAP, proposed a new approach to teaching neonatal resuscitation that capitalized on existing teaching models and incorporated simulation, such as that used by the military, aerospace, and other high-risk industries. Through “NeoSim”—“hands-on” neonatal resuscitation training and postsimulation debriefing—Dr Halamek brought this new paradigm—simulation-based education—to the field of neonatology. Now, 20 years later, simulation-based education is the mainstay of the Neonatal Resuscitation Program® that teaches thousands of health care professionals in more than 130 countries. Over the years, simulation has been applied to many other aspects of education in neonatology, including procedural skills training, competency assessment, and teamwork and leadership training. In more recent years, simulation in neonatology has further expanded to include testing of new and existing health care environments, educating families on the care of neonates with medical complexities, analyzing new medical devices, and even conducting virtual simulations. The impetus for creating Neonatal Simulation: A Practical Guide was 2-fold. First, we recognized that while there are a variety of published adult and pediatric simulation books, none exist for neonatology. Thus, we wanted to fill this void. Second, we wanted to make the innovative work of the neonatal simulation community easily accessible to health professions educators, simulationists, researchers, and any other groups who can benefit from its content—to enhance learning, patient care, and, ultimately, patient outcomes. The beginning chapters cover learning theory, fundamentals of scenario design, and simulation and the Neonatal Resuscitation Program. The later chapters cover specific applications of simulation in neonatology, and debriefing techniques. Images and appendixes are included, where appropriate, to augment chapters, and central points at the end of each chapter summarize content and offer a quick reference. The book is a culmination of many hours of work by a growing interdisciplinary community of neonatal simulation experts who have shared their insights, research, and experience with us. We thank them immensely for their dedication to the field and their willingness to share. We would especially like to thank the publishing team at the American Academy of Pediatrics; in particular, we thank Alain Park, Barrett Winston, and Heather Babiar, our editors, who believed in this project at its outset and supported us over the span of 3 years. Last, we would like to thank all of you, who care for the tiniest of patients every day; we hope this book will help you teach and learn. Lamia Soghier, MD, MEd, CHSE, FAAP Beverley Robin, MD, MHPE, CHSE, FAAP

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Chapter 1

Applications of Learning Theory in Simulation Priti Jani, MD, MPH, and Angela D. Blood, MPH, MBA, CHSE-A

Objectives In this chapter, you will 1. Define learning theory and characterize its influence on the learner and the clinical environment. 2. Describe the unique context in which theories of adult learning are applied in simulation. 3. Appraise the diverse learning theories and determine their applications in simulation design.

Introduction Adult learners, including neonatal health care professionals, learn in many different ways. No single learning theory explains the entirety of a person’s development through experiencing simulation, whether it is experienced as an instructional method or an assessment method. Considering an educational experience from multiple learning theoretical perspectives may provide more than one explanation or interpretation for how and why learning occurs. Neonatal simulation educators are best served not by an exhaustive review of all learning theories but rather by a review of the most influential and relevant theories that can be applied to simulation. We present multiple learning theories alongside examples of real-life health care scenarios to illustrate how understanding the mechanism of learning can enhance neonatal health care professionals’ skills as simulation educators.

Background Keeping neonatal health care professionals abreast of the latest clinical developments and helping them be able to execute their clinical work to the highest standards are the responsibilities of the profession to patients, families, and the public. With increased emphasis on patient safety, health care education must move away from the “see one, do one, teach one” approach to hands-on, experiential methods, such as simulation, to develop and maintain an excellent clinical workforce and, at the same time, minimize risk to patients.1 Because simulation can closely replicate the clinical environment, its use as a teaching and assessment method is growing considerably. While it is vital that neonatal simulation educators develop skills to design and facilitate simulation curricula, mimicry of the clinical environment is only one of several important components. Successful simulation educators must also understand how and why learning occurs, thereby arming themselves with the knowledge required to optimally and efficiently develop curricula that will positively affect the clinical environment.

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NEONATAL SIMULATION: A PRACTICAL GUIDE

For the purposes of this chapter, the targeted learners are trainees and neonatal health care providers (ie, physicians, nurses, and other health care professionals). Although the fundamental principles of learning and educational theory discussed here are applicable in a variety of settings, it is also important to note that learning theories do not exist in a vacuum. They are informed by and evolve alongside the environment from which they are born. Therefore, the social, political, and cultural contexts of the clinical environment may affect the degree to which a specific theory holds true. Past conceptualizations of learning were dominated by the belief that human behaviors are driven by inner forces, needs, or impulses that are potentially operating below the level of consciousness. Today, we understand that human behavior is influenced by the environment in which it exists. One prominent theory to support this belief is social learning theory, which stresses the roles of observation, modeling, and reinforcement (whether for good or for ill) that affect learning, describing individuals’ behaviors essentially as reactions to stimuli.2 Social learning theory is therefore especially relevant in a clinical work environment such as a neonatal intensive care unit (NICU), where health care professionals are constantly observing each other’s behavior, modeling their behavior in response to their observations, and working toward rewards or avoidance of negative feedback. While largely heterogeneous in their makeup, health care professionals have a common goal of providing excellent patient care. This commonality advantageously positions the neonatal simulation educator because they are not training undifferentiated adult learners, such as those in an undergraduate university program. Rather, neonatal simulation educators are training health care professionals who have defined expectations and similar clinical experiences and common goals.

What Is Learning Theory? Learning theory is the reasoning behind the acquisition and development of knowledge, skills, and attitudes. In this chapter, we define learning or educational theory as not only the acquisition and development of knowledge, skills, and attitudes but also the appropriate application of theory toward the development of curricula. Keeping both acquisition and application in mind is important to be able to ensure the correct use of resources, the intended effect on learners, and the sustainability of the curricula. A lack of any of these factors can degrade curricular sustainability via loss of institutional and learner support. To prevent this, it is important for the simulation educator to have a comprehensive understanding of learning theory; thus, they can better ▶ Describe a problem in the clinical environment from an educational perspective. ▶ Address the needs of learners of different levels (trainees vs practicing health care professionals). ▶ Define goals and learning objectives for an educational activity. ▶ Design educational activities, including the selection of simulation modalities. ▶ Implement educational activities. ▶ Measure the effectiveness of educational activities. To accomplish these goals, medical educators commonly use Kern’s 6-step approach to curriculum development, which includes the following steps3: (1) problem identification and general needs assessment, (2) targeted needs assessment, (3) goals and objectives, (4) educational strategies, (5) implementation, and (6) evaluation and feedback.

Step 1. Problem Identification and General Needs Assessment Problem identification and an associated needs assessment are critical because they provide the foundation and rationale for the curriculum. The needs assessment focuses on the curricular objectives and evaluation plan. Furthermore, it informs the intended impact of a curriculum, taking into account the current educational approach to determine the ideal pathway toward achieving this effect.

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Step 2. Targeted Needs Assessment The targeted needs assessment expands on the general needs assessment by determining the targeted learner group and environment. It takes into account the prior experiences, learning preferences, and proficiencies of the learner group. Similarly, it allows evaluation of the educational environment regarding existing curricula, resources, and barriers.

Step 3. Goals and Objectives A goal is the general educational objective, whereas an objective is specific and measurable. Objectives can pertain to the learner, the process (measures of implementation), or the patient and health care outcomes. Learning objectives should be based on Bloom’s taxonomy4 and can be subdivided into 3 categories: cognitive development (knowledge), affective development (attitude and emotions), and psychomotor skills (manual or physical skills).

Step 4. Educational Strategies It is essential to identify the objectives early during curriculum development. In doing so, the educator can put into play the appropriate educational strategies, taking into account applicable learning theories. For example, if the objective is for the learners to develop competency in umbilical catheter placement, the curriculum might include video review and hands-on skills practice by using a task trainer, drawing on the work of Ericsson’s principles of deliberate practice (discussed in the Deliberate Practice section later in this chapter).5

Step 5. Implementation When developing a simulation-based curriculum, medical educators should carefully consider the approach to implementation so that the resources are used efficiently and effectively to achieve the overarching goals and objectives. In addition, they should consider the necessary institutional and administrative support, essential resources, potential challenges and barriers, and details of curriculum administration.

Step 6. Evaluation and Feedback Program evaluation should be considered by medical educators during the curriculum development phase because it is critical to confirm that the learners achieve the learning objectives. Learner feedback and program evaluation results guide curriculum revisions. After the general needs assessment, the targeted needs assessment, the goals, the objectives, and the learner characteristics are considered, learning theories are applied to develop the educational strategy. Simulation-based medical education (SBME) is advantageous because it provides a surrogate for true experience. It garners the benefit of this experience, while it affords for manipulation of the environment and the experience as needed for effective learning. Two learning theories related to skill acquisition (typically to psychomotor skill acquisition) and applicable to simulation-based training are the Five-Stage Model of Skill Acquisition by Dreyfus6 and the Three Phases of Skill Acquisition outlined by Fitts and Posner.7

Dreyfus Five-Stage Model of Skill Acquisition The Dreyfus model of skill acquisition entails a progression through 5 levels to achieve expertise: novice, advanced beginner, competence, proficiency, and expert/mastery.6

Novice During the novice stage, the learner acquires knowledge about a task, free of context, and learns the rules that guide the actions.6

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Example: During their first Neonatal Resuscitation Program® course, an incoming, first-month pediatrics resident is classified as a novice. They have not rotated in the NICU and have therefore never previously been in this environment, but they are given a set of rules to follow, based on predetermined criteria: a description of the delivery room, when to call for help, steps of and criteria for initiating mask ventilation, and so on.

Advanced Beginner The advanced beginner stage is the period during which the learner begins to gain real-life experience and an understanding of the context and setting. At this stage, from a removed and analytical standpoint, the learner begins to identify “instructional maxims” (guiding principles) for actions.8 Example: One month into the clinical rotation in the NICU, pediatrics residents learn to differentiate oxygen desaturations that require an intervention from those that do not. They do so through pattern recognition; a transient desaturation or one with a poor waveform is likely not clinically significant and can be observed, whereas a sustained desaturation with a good waveform requires prompt intervention.

Competence To achieve competence, the learner must meet the following 3 criteria: (1) engage in abundant experiences, (2) develop emotional attachment to the task at hand, and (3) learn the guidelines that determine actions in variable real-life situations.8 The emotional attachment and associated ownership of decisions made are essential for progression from this competence stage to expert level.6 Example: By the second NICU rotation, pediatrics residents will have had multiple opportunities to provide mask ventilation during neonatal resuscitation. They will experience challenges and errors (eg, an inability to establish a face mask seal, ineffective mask ventilation, provision of mask ventilation at an inappropriate rate) and achieve successes (eg, mask ventilation producing good chest rise and resultant improvement in heart rate and oxygen saturations). From each of these experiences, they will take away insights, opportunities for improvement, and principles for guiding future actions. These understandings of the various paths that can be taken during an oxygen desaturation (eg, equipment use, troubleshooting strategies, and decision-making) will contribute collectively to the development of competence, as will the emotional investment in learning and the recognition of the implications of performing ineffective mask ventilation.

Proficiency When learners reach a level of proficiency, they are able to identify and categorize a problem, as well as to use maxims to determine the appropriate course of action. Experience contributes to situational memory and pattern recognition, which then serve to guide actions.8 Example: Whereas residents in the competence phase recognize a clinically significant oxygen desaturation but are unable to pinpoint the exact cause (while being aware that there are a variety of causes), residents in the proficiency phase identify the cause and use maxims to determine the next path of action; if the cause is persistent apnea, they may choose to place an endotracheal tube, whereas if the cause is chronic lung disease of prematurity, they may choose to initiate noninvasive positive pressure ventilation (PPV).

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Expert/Mastery Experts rely heavily on intuition and memory when performing a task. They have a degree of experience that facilitates an immediate recognition of a problem, as well as the path of action. In comparison to a learner who is proficient, an expert has a greater repository of fine-tuned discriminations for similar situations.6 Example: When an intubated infant with a pneumothorax and indwelling chest tube experiences desaturation with accompanying tachycardia, the nurse begins to ventilate by hand and calls the resident into the room to help. Proficient learners immediately look for chest rise and auscultate the chest. On hearing unilateral breath sounds, they order radiography and request that the nurse provide suctioning. (They also remember prior cases of desaturation that required suctioning and follow the standard algorithms for an intubated patient with desaturation, such as the “DOPE” mnemonic [short for dislodgement, obstruction, pneumothorax, equipment failure]). On entering the room, experts notice the change in vital signs and the unilateral chest rise and they intuitively check the chest tube mechanism for suction. They begin troubleshooting the chest tube mechanism and ask the nurse to set up equipment for possible needle decompression to relieve the reaccumulated pneumothorax.

Fitts and Posner Three Phases of Skill Acquisition Fitts and Posner outline psychomotor skill acquisition in 3 phases: cognitive, associative, and autonomous.7

Cognitive Phase In the initial stage of learning—the cognitive stage—the learner seeks to understand the procedure, experiments with strategies, and performs inconsistently and without fluidity. Example: When learning neonatal endotracheal intubation, beginning pediatrics residents read about the procedure and review the anatomical structure of the neonatal airway and the indications, contraindications, and risks of the procedure. They watch the senior fellow perform the procedure in the NICU. By using a neonatal intubation task trainer, they practice the skill and try various techniques; their performance is clumsy and they are intermittently successful.

Associative Phase During the associative phase, the learner demonstrates the skill more efficiently and with more fluidity, compares the performance with the desired outcome, and makes modifications accordingly; the skill becomes ingrained. Example: Second-year neonatal-perinatal fellows are successful at neonatal endotracheal intubation within the 30-second Neonatal Resuscitation Program guideline for most attempts. When not successful, they analyze their performance to identify strategies to implement during subsequent intubations. The fellow performs the procedure with more ease and fluidity, requiring less concentrated attention than that required during the first year of training.

Autonomous Phase In the final, autonomous phase, performance is fluid and the steps are performed without conscious awareness; cognitive processes become implicit. Example: Attending neonatologists quickly and efficiently complete neonatal endotracheal intubation, without thinking about the individual steps. When asked to explain the procedure, they miss some of the steps because they are “second nature” and performed without conscious awareness.

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Simulation and Team Performance Medical care generally and emergency situations in particular require health care professionals to work collaboratively in interdisciplinary teams, with the goal of providing safe, quality patient care. Like teams in general, health care teams face a number of challenges that include membership fluidity, with changes in team complement between or during clinical events9; inadequate communication, especially traversing professional boundaries10; siloed education, with potential lack of awareness of other team members’ training and skill sets11; and lack of team-specific training.12 However, for effective team performance, teams must establish leadership, use closedloop communication, establish mutual trust, and develop a shared mental model.13 Simulation-based training has been shown to enhance medical team performance.12,14 In the next section, we outline learning theories applied to simulation, particularly to team training.

Adult Learning Theory Knowles’ adult learning theory illustrates a common application of learning theory that applies to learning from experiences in the real world, as well as simulation. Adult learning theory proposes that adults need certain elements for optimal learning. These include self-directed learning, contribution from prior experiences, and problem-solving in real-life contexts. Additionally, readiness and motivation to learn are essential.15 SBME provides neonatal health care providers with the opportunities to apply their prior experiences to problem-solve in contexts that mimic real-life.

Constructivist Learning Theory Other theories demonstrate the parallels to learning between real life and simulation. Constructivist theory postulates that learners use previous knowledge and experiences to construct new knowledge and that the new knowledge is closely tied to the context in which it is constructed. Simulation creates a learning environment that mimics real-life situations, thereby giving meaning and organization to new knowledge acquired and application to real-life situations. Social constructivism highlights that learning is context and culture bound and that social interactions are essential to learning and psychological safety.16 This is especially applicable to postsimulation debriefing, during which discussion of learning points and team-led analysis occur. In line with constructivist theory, simulation culture stresses the importance of a safe environment in which learners can work collaboratively and make mistakes without fear of judgment or reprimand.16

Situated Learning Theory Situated learning theory, a component of social constructivism, emphasizes the interaction between the participants (learners and instructors), the culture, and the environment, highlighting the importance of learning situated in everyday contexts—those in which experiences typically occur.17 Described by Lave and Wenger, situated learning includes communities of practice, wherein group members with shared goals participate in collective learning, binding the group as a social entity.17 Such groups are typically composed of a core group of seasoned members, with a larger proportion of newer, less experienced members. The less experienced members learn through participation in the group, initially peripherally, becoming more experienced and therefore more significant to the functioning of the group over time.17 Example: At the beginning of the rotation, the first-month pediatrics intern watches as the interdisciplinary team resuscitates a neonate in the delivery room. During the following weeks, the intern gradually participates in resuscitations, and, with coaching, provides effective PPV.

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Toward the end of the rotation, the attending physician notices that the intern is no longer reluctant to participate during resuscitations but is eager to stand at the head of the bed and provide PPV, participating as a member of the interdisciplinary team.

Social Cognitive Theory Social cognitive theory, coined by Bandura, is not a single theory but rather a collection of theories holding that learning is shaped by dynamic and reciprocal cognitive, behavioral, and environmental factors.18 Furthermore, learning occurs from observation, not merely through imitation but also through human agency—intentional learning with the goal of changing behaviors. Bandura describes human agency with 4 elements: (1) intentionality (intention to invest in learning), (2) forethought (anticipation of the envisioned goals and outcomes), (3) selfreactiveness (choices made on the basis of perception of difficulty to achieve a specific goal and potential value of the new knowledge), and (4) self-reflectiveness (metacognition, self-awareness, reflection, and self-regulation).19 Example: A team of clinicians participates in a real-life resuscitation event. After the event, they participate in a clinical debriefing. Several opportunities for improvement are identified, regarding role assignments and choreography. These prompt an intentional investment by all to participate in simulation-based resuscitation activities. They recognize that the team will benefit from simulated resuscitations, which will enhance patient care during future resuscitation events. They accept that this process will take time and effort and understand that there is value in participating in simulations to enhance the team’s performance. The self-reflection that occurs during the debriefing and the identification of key gaps and lapses in teamwork translate into the recognition of new approaches to role identification and code choreography during future resuscitations.

Self-efficacy Also described by Bandura, self-efficacy is an individual’s belief in their ability to perform a task or attain a goal, and self-efficacy is fundamental to their actions.20 Not always accurate from a social cognitive theory viewpoint, self-efficacy mediates cognitive advancement in 3 ways: (1) cognitive—self-assessment, preparation, time management, and metacognition; (2) motivational—setting high goals and evaluating achievements; and (3) affective—resilience, coping strategies, and the ability to manage stressors created by challenging situations.21 Self-efficacy is additionally influenced by observing others and receiving feedback and encouragement from others. Collective efficacy refers to the unified ability of a group, which enables group achievement.21 Like selfefficacy, a high level of perceived group efficacy leads to greater motivation, enhanced performance, and better resilience regarding challenges.19 In developing simulation scenarios or sessions for team training, capitalizing on this aspect of human behavior can be advantageous for fostering effective learning (for individuals and teams). Features to consider are (1) using actual team members (as opposed to improvised teams) to allow for group practice and reflection, and, wherever possible, including learners of different levels to allow for role modeling and to permit individual learners to gain insight into their own actions; (2) developing realistic scenarios (based on actual patient events) that appropriately heighten the participants’ physiological responses, with the intent of promoting engagement and enhancing learning; (3) providing an opportunity to observe the feedback of other participants and facilitators during debriefing; (4) getting input and feedback from team members and facilitators during debriefing; and (5) allotting time for repetitive practice or a simple “redo” to provide additional opportunities for individuals and teams to achieve the learning objectives.22

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Experiential Learning Theory Experiential learning theory, proposed by Kolb, highlights experiences (real or simulated) as promoters of learning.23 The assumptions are that learning, based on individual or group experience, is a continual process, with the learner interacting with the environment, and that learning progresses with experiences and reflection on those experiences. Furthermore, experiences are considered in the context of previous experiences. The 4-phase learning cycle includes concrete experience, reflective observation, abstract conceptualization, and active experimentation (Figure 1-1).23

Concrete experience Doing/having an experience

Active experimentation Planning/trying out what you have learned

Perception continuum Processing Processing Kolb’s continuum continuum Learning Cycle

Reflective observation Reflecting/reviewing on the experience

Perception continuum

Abstract conceptualization Concluding/learning from the experience

Figure 1-1. Kolb’s learning cycle. The simulation activity is the concrete experience during which the learners actively participate by “doing.” The subsequent 2 phases—reflective observation and abstract conceptualization—are the hallmarks of postsimulation debriefing. The learners reflect on and analyze the experience, and through abstract conceptualization, they develop new mental representations, modify existing ones, and consider actions for subsequent experiences. In the active experimentation phase, learners apply the knowledge and skills to a new clinical (or simulated) experience, followed by reflection on the experience, thus continuing the iterative learning cycle. The process can begin at any phase of the cycle, and the learner must go through all 4 phases for effective learning to occur. Example: Two pediatrics residents, a nurse, a neonatal-perinatal fellow, and a respiratory therapist participate in a simulated neonatal resuscitation. The neonate has apnea, with poor muscle tone. The team provides PPV but fails to notice that there is no chest rise. The neonate’s heart rate decreases below 60 beats/min, and the fellow initiates chest compressions, coordinated with ventilations. Chaos ensues, and the fellow, who is running the resuscitation, continues chest compressions and orders the administration of epinephrine. The nurses prepare the medication but are unsure of the dose. During the debriefing, the team members reflect on the experience, and the instructor facilitates discussion related (1) to the importance of and the methods for assessing the effectiveness of PPV; (2) to the corrective steps to be initiated when

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PPV is ineffective; (3) to delegation, leadership, and the importance of the leader’s situational awareness; (4) generally to the importance of clear and effective (closed-loop) communication and specifically to medication dosing; and so on. The team has the opportunity to implement the new knowledge and skills in a subsequent simulation (or actual clinical encounter), ideally checking the effectiveness of PPV, providing corrective steps for ineffective PPV, and so forth.

Reflection-in-Action/Reflection-on-Action Described by Schön, reflection-in-action and reflection-on-action are 2 additional principles that are applicable to SBME.24 Reflection-in-action occurs when a person reflects (typically unexpectedly) on their own performance during the performance. Then, as necessary, the individual applies knowledge or skill from previous experiences to modify the current performance. Schön differentiates reflection-in-action from other types of reflective practice because the effects on performance are immediate. Example: The senior neonatal-perinatal fellow, while performing an endotracheal intubation, notices that she cannot visualize the vocal cords because she is not exerting sufficient pressure onto the laryngoscope handle. She modifies her technique and easily passes the endotracheal tube through the neonate’s vocal cords. In contrast, reflection-on-action is the retrospective review and analysis of actions with the goal of enhancing subsequent performance. This is the premise of postsimulation debriefing. Example: During simulation-based procedural skills training, the first-year neonatal-perinatal fellow struggles with endotracheal intubation. Afterward, she reflects on her performance, and together, she and the senior fellow identify strategies for her to implement during subsequent practice.

Deliberate Practice Described by Ericsson, deliberate practice (DP) is the purposeful, repetitive practice of cognitive or psychomotor skills within a specific domain, combined with rigorous skill assessment and feedback that is specific, focused, and ongoing.25 Applied to motivated learners, DP has been demonstrated to enhance performance in a variety of domains.5 As described by McGaghie and Kristopaitis, DP has the following 10 features26: 1. Highly motivated learners who have good concentration 2. Well-delineated learning objectives or tasks 3. Appropriate degree of difficulty 4. Focused, repetitive practice 5. Rigorous and precise educational measurements 6. Immediate, illuminating feedback from instructors, simulators, and other leaders 7. Monitored learning experiences and strategies, error correction, and degree of understanding 8. Refined performance resulting from ongoing DP 9. Assessment to reach mastery performance; equal expected minimal outcomes; potentially varied learning times 10. Advancement to a subsequent task or unit Example: A group of new neonatology nurse practitioners participates in simulation-based endotracheal intubation training. The lead instructor reviews the curricular objectives, outlines the steps, and, on a neonatal mannequin, demonstrates the technique step by step. Thereafter, in groups of 2, each led by an instructor, the learners practice endotracheal intubation on neonatal mannequins. Each learner’s practice provides the opportunity for correction of deficiencies,

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expert tips, and sharing of knowledge that is beneficial to all learners present. The learners continue to practice, receiving ongoing focused feedback from instructors, with additional demonstration by the instructor, as necessary. The learners incorporate instructor feedback as they continue to practice, and they are also encouraged to monitor their own performances. As practice continues, many of the psychomotor skills become automatic. Although the learners initially spent time learning how to connect the laryngoscope blade to the laryngoscope handle, open the mouth, and position the patient, these steps no longer contribute to the cognitive load, and effortful practice focuses on other, more complex aspects of the procedure. Continued practice leads to mastery of the skills of uncomplicated intubation (on a mannequin); however, the duration of training to achieve mastery varies between the learners.

Mastery Learning Mastery learning (ML), first described by Bloom, is a rigorous type of competency-based instruction in which all learners are expected to attain the educational objectives before advancing to the next level of learning.4 ML incorporates features of DP and highlights focused teaching, ongoing practice, and feedback with gradually less coaching, aimed at achieving mastery performance. A key principle is that the time to achieve ML can vary between learners.4 McGaghie and Kristopaitis describe the following 8 features of ML26: 1. Baseline assessment of learners 2. Clear, well-defined learning objectives of progressive difficulty 3. Educational activities (ie, skills practice, study) concentrated on attaining the learning objectives 4. Establishment of a minimum passing mastery standard (MPS) for each educational component 5. Formative evaluation with feedback to assess progress toward the MPS for each educational component 6. Continued practice or study until the MPS is attained 7. Advancement to the next level only when performance meets or exceeds the MPS 8. Uniform outcomes, but time to achieve an MPS can vary between learners Example: Neonatal-perinatal medicine trainees must achieve mastery of the skills of neonatal resuscitation early in their first year of training. Neonatal Resuscitation Program guidelines outline the MPS for the didactic (online test) and e-simulation components, and validated procedural checklists can be used to set an MPS for procedural skills performance. Baseline and ongoing assessment can be accomplished in the simulated environment, where the trainees have the opportunity to engage in DP until mastery is achieved through participation in multiple scenarios and skills stations (with well-defined learning objectives) with increasing levels of difficulty. Achievement of the mastery standard can be evaluated during simulations, by using checklists, or during miniclinical evaluation exercises (individual stations or exercises during which an expert observes and rates the learner).

Zone of Proximal Development Vygotsky’s zone of proximal development (ZPD), initially used in reference to child development, has more recently been applied to learners of all ages and refers to the area that is just beyond the learner’s actual developmental level, representing a challenge that can be attained with assistance.27 This typically includes instructional scaffolding, through which the instructor assists the learner in advancing their ZPD. As the learner progresses, the instructor reduces the support as it becomes unwarranted. Furthermore, the role of social interaction is important. Engaging the learner with learners who are slightly more advanced (further into their own ZPDs) can assist in advancing the learner’s ZPD. This type of near-peer teaching is advantageous to the learners and the peers themselves, who refine their own performances through teaching.28

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Example: Determining a trainee’s ZPD and using near-peer teaching are typical in neonatalperinatal medicine training. When first-year fellows begin their training, the third-year fellows assess the new fellows’ performances. On the basis of their individual experiences, the incoming fellows’ ZPDs vary. The third-year fellows coach the first-year fellows at the bedside and during simulation-based training, thus bringing the newcomers’ skills along in their individual ZPDs and refining their own skills (and teaching) in the process.

Cognitive Load Theory Cognitive load theory (CLT), developed by Sweller in the 1980s, emphasizes that when the amount of material the working memory can process is overloaded, learning becomes compromised.29 This overload occurs because working memory, which is responsible for conscious processing, analysis, and decision-making, temporarily stores and manipulates the material but has very limited capacity and duration for new information.30 Thus, CLT plays an important role in determining the ideal instructional strategies when medical educators are developing scenarios or simulation-based curricula. Total cognitive load refers to the volume of material that the working memory can process at any given time and comprises 3 types of cognitive load: intrinsic, extraneous, and germane.31 Intrinsic cognitive load refers to the inherent complexity of a task or scenario and the learner’s knowledge and level of experience.30 This is an important consideration in developing simulation scenarios so that the task complexity is at the appropriate learner level and not too far into, or beyond, the learner’s ZPD. Example: Immersing a first-year pediatrics resident into a simulation scenario of a neonatal hypoxic arrest secondary to a tension pneumothorax would represent a significant intrinsic cognitive load on the learner, whereas immersing them into a scenario of a neonatal apnea that necessitates mask ventilation would likely be more appropriate. Extraneous cognitive load is the layout, design, and presentation of the educational sessions or simulation. The extraneous cognitive load is determined by instructors (or instructional designers) and can be modified to enhance learning.32 In fact, studies have shown that reducing extraneous cognitive load directly increases learning across a variety of learning contexts and, most notably, for novice learners.33 Thus, a scenario for which superfluous information, redundancy, or insufficient information is provided can increase extraneous cognitive load. Example: A simulation scenario for which the learners (third-year medical students) receive the patient information via a detailed printed patient information sheet and again at the beginning of the scenario from a nurse (simulated participant) via a verbal handoff, with explicit, detailed patient information, would likely represent a high extraneous cognitive load and overwhelm the learners. Additionally, environmental factors may contribute to extraneous cognitive load, in turn affecting learning. For instance, an interdisciplinary neonatal resuscitation scenario conducted in an emergency department would represent an environment that differs significantly from the typical environment in which a neonatal resuscitation occurs. The noises associated with patient care and the patients themselves, as well as the lack of authentic neonatalspecific equipment and poor “crowd control,” would increase the extraneous load, distract the learners (especially those who are novices), and diminish the intended educational experience. Furthermore, because emotions can contribute to extraneous load, when developing simulation sessions, educators should consider the emotional load inherent in the scenario (eg, the death of a patient). Educators should also take into account any role portrayal and the amount or degree of emotional display when incorporating actors (standardized participants), such as those in hybrid simulations, so as not to overwhelm the participants and negatively affect learning.30 Germane cognitive load is a subset of intrinsic load that comprises the learner’s cognitive processing and the amount of working memory devoted to learning a new skill or task and creating schemas. Thus, instructional designers should consider and optimize the germane load, such that the simulation (or other educational exercise) is of appropriate difficulty to challenge the learners, encourage critical thinking, and promote learning.

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When designing scenarios and simulation sessions, educators and instructional designers should consider CLT to create realistic situations that are conducive to and enhance learning.34 First, while chaotic emergency situations can be reflective of the actual clinical environment, educators should consider the cognitive load and thus the potential effect on learning. These types of situations are best suited to advanced learners and teams. For novice learners, providing materials in advance, such as clinical algorithms or procedural checklists given a day or more before the simulations, can decrease the extraneous cognitive load, as can embedding a standardized participant in a health care professional role (eg, a nurse)35 to assist with unfamiliar equipment and suggest adherence to protocols. In keeping with CLT, simulations (or procedural skills training) should be progressive, with learners mastering simple tasks before moving on to those that are more complex and require integration of multiple skills. One should also consider the fidelity of the simulation—the extent to which the simulation replicates “reality,”36 the environment (Does it accurately reflect the clinical environment? Is it too complex for the level of the learners?), the fidelity of the simulation activity (task trainer, mannequin, or standardized participant; Does using a high-technology mannequin aid the learners, or does it provide too high of a cognitive load? Does the standardized participant’s portrayal distract the learners by adding a significant cognitive load?), and the extent to which the task reflects actual clinical practice (ie, What are the learner tasks, and do they align with the learner level of training or experience? Should first-year neonatal-perinatal fellows perform pericardiocentesis, or should training begin with endotracheal intubation and umbilical catheter placement?). Lastly, informing learners that they are expected to perform to the best of their abilities can decrease extraneous cognitive load by removing specific performance-oriented goals.34

Debriefing Essential to effective simulation-based learning is debriefing, which is covered in Chapter 24, Debriefing in Simulation-Based Training in Neonatology: An Outcomes-Based Approach; Chapter 25, Blended-Method Debriefing With the PEARLS Debriefing Framework; Chapter 26, Co-debriefing in Neonatal Simulation; and Chapter 27, The Difficult Debriefing. This vital aspect of learning relies on reflective observation after a tangible experience. Reflection during debriefing is considered an essential feature of SBME and is supported by numerous learning theorists, as outlined in this chapter. Among them is Graham Gibbs, whose reflective cycle focuses on “learning by doing.” Gibb’s model (Figure 1-2), in which there are 6 stages, can be applied to postsimulation debriefing in the following ways37: 1. Description: a simple description of “what happened” 2. Feelings: a description of thoughts and feelings, without analysis 3. Evaluation: a discussion of events, including a review of what was effective and what was not 4. Analysis: making sense of the situation, in comparison with other experiences 5. Conclusion: drawing conclusions from what occurred; take-home learning 6. Action plan: actions for similar future experiences, including what learners will do differently next time

Learning Theory Takeaways Simulation addresses many domains of learning in health care professions education—including the cognitive, psychomotor, and behavioral domains—aimed at preparing health care professionals for providing safe and effective patient care. As exemplified in this chapter, multiple learning theories can aid us in understanding how simulation can promote effective learning. This is illustrated in the best evidence medical education report by Issenberg and others.38 Undertaking an extensive review and synthesis of more than 100 peer-reviewed SBME articles published over a 34-year span, the researchers derived a list of 10 features and uses of simulation as a strategy to support learning, which we summarize below (in italics).

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Description What happened?

Action plan If it arose again, what would you do?

Feelings What were you thinking and feeling?

Conclusion What else could you have done?

Evaluation What was good and what needs improvement? Analysis What sense can you make of the situation?

Figure 1-2. Gibb’s reflective cycle.

Supported by several learning theories (Kolb, experiential learning; Gibbs, learning by doing; and Schön, reflective practice), feedback is the single most important characteristic of SBME for effective learning. Feedback allows learners to self-assess and evaluate their progress toward the acquisition and maintenance of skills. Second to feedback, repetitive practice, backed by the theories of Ericsson (DP) and Bloom (ML), is noted to be a key feature of SBME. Curricular integration of simulation-based activities is additionally an important factor, as is participation in activities with progressive difficulty (eg, DP, ML), as well as clinical variation with the use of multiple learning strategies, as appropriate to the learner level. Intrinsic to SBME, the researchers highlighted a controlled environment in which learners can repetitively practice, reflect, and make mistakes (DP) without negative consequences for themselves or for patients. Individualized learning was also noted to be an important factor; simulation enables complex tasks to be separated into individual components, and as described by Bloom, learners progress through various stages of learning at their own pace, toward the development of expertise and mastery (eg, DP, ML). Finally, delineated outcomes (learning objectives), as appropriate to the learner level, and simulator fidelity— the degree of realism—were also found to be important factors.

Summary While there is a multitude of learning theories, this chapter serves to highlight a sample of those that are most relevant to simulation as an instructional and assessment method. Learning theories have variable applications to simulation-based education and assessment, and while multiple theories might be relevant, the applicability of any given theory depends on a variety of factors that most importantly include the learning objectives, the targeted learners, and the simulation modalities used. It is vital that educators and instructional designers consider applicable learning theories when developing simulation curricula to promote optimal learning.

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Central Points ▶ Adult learning theory proposes that for optimal learning to occur, adult learners need to be motivated to learn, possess self-direction, have prior experiences from which to draw, and problem-solve in real-life contexts. ▶ Constructivist learning theory and social cognitive learning theories emphasize the role of context in learning, thus paralleling real-life learning to learning that occurs during simulations. ▶ Grounded in the learning theories of Kolb (experiential learning), Schön (reflective practice), and Gibbs (learning by doing), feedback is the single most effective characteristic of SBME for learning. ▶ Educators and instructional designers should appraise various learning theories and apply those that are most pertinent to simulation curricula design, to be able to optimize learning outcomes.

References 1. Rodriguez-Paz JM, Kennedy M, Salas E, et al. Beyond “see one, do one, teach one”: toward a different training paradigm. Postgrad Med J. 2009;85(1003):244–249 PMID: 19520875 https://doi.org/10.1136/qshc.2007.023903 2. Bandura A. Social Learning Theory. General Learning Press; 1971. Accessed December 16, 2020. http://www.asecib.ase.ro/ mps/Bandura_SocialLearningTheory.pdf 3. Kern DE, Thomas PA, Hughes MT, eds. Curriculum Development for Medical Education: A Six-Step Approach. 2nd ed. Johns Hopkins University Press; 2009 4. Taxonomy of Educational Objectives: The Classification of Educational Goals. David McKay Co Inc; 1956. Bloom BS, ed. Cognitive Domain; handb 1 5. Ericsson KA, Charness N, Hoffman RR, Feltovich PJ, eds. The Cambridge Handbook of Expertise and Expert Performance. Cambridge University Press; 2006 https://doi.org/10.1017/CBO9780511816796 6. Dreyfus S. The five-stage model of adult skill acquisition. Bull Sci Technol Soc. 2004;24(3):177–181 https://doi.org/10.1177/ 0270467604264992 7. Fitts PM, Posner MI. Human Performance. Brooks/Cole Publishing Co; 1967 8. Peña A. The Dreyfus model of clinical problem-solving skills acquisition: a critical perspective. Med Educ Online. 2010; 15(1):4846 https://doi.org/doi:10.3402/meo.v15i0.4846 9. Tannenbaum SI, Mathieu JE, Salas E, Cohen D. Teams are changing: are research and practice evolving fast enough? Ind Organ Psychol. 2012;5(1):2–24 https://doi.org/10.1111/j.1754-9434.2011.01396.x 10. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(suppl 1):i85–i90 PMID: 15465961 https://doi.org/10.1136/ qshc.2004.010033 11. Galloway SJ. Simulation techniques to bridge the gap between novice and competent healthcare professionals. Online J Issues Nurs. 2009;14(2) 12. Weaver SJ, Lyons R, DiazGranados D, et al. The anatomy of health care team training and the state of practice: a critical review. Acad Med. 2010;85(11):1746–1760 PMID: 20841989 13. Salas E, Sims DE, Burke CS. Is there a “Big Five” in teamwork? Small Group Res. 2005;36(5):555–599 https://doi.org/ 10.1177/1046496405277134 14. Hunt EA, Duval-Arnould JM, Nelson-McMillan KL, et al. Pediatric resident resuscitation skills improve after “rapid cycle deliberate practice” training. Resuscitation. 2014;85(7):945–951 PMID: 24607871 https://doi.org/10.1016/ j.resuscitation.2014.02.025 15. Huang HM. Toward constructivism for adult learners in online learning environments. Br J Educ Technol. 2002;33(1): 27–37 https://doi.org/10.1111/1467-8535.00236 16. Ker J, Bradley P. Simulation in medical education. In: Swanwick T, ed. Understanding Medical Education: Evidence, Theory and Practice. The Association for the Study of Medical Education; 2010:175–192 17. Lave J, Wenger E. Situated Learning: Legitimate Peripheral Participation. Cambridge University Press; 1991 https://doi.org/ 10.1017/CBO9780511815355 18. Bandura A. Social-learning theory of identificatory processes. In: Goslin DA, ed. Handbook of Socialization Theory and Research. Rand McNally; 1969:213–262 19. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 2001;52(1):1–26 PMID: 11148297 https:// doi.org/10.1146/annurev.psych.52.1.1 20. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Prentice Hall; 1986

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21. Chemers MM, Hu LT, Garcia BF. Academic self-efficacy and first year college student performance and adjustment. J Educ Psychol. 2001;93(1):55–64 https://doi.org/10.1037/0022-0663.93.1.55 22. Stocker M, Burmester M, Allen M. Optimisation of simulated team training through the application of learning theories: a debate for a conceptual framework. BMC Med Educ. 2014;14(1):69 PMID: 24694243 https://doi.org/10.1186/14726920-14-69 23. Kolb DA. Experiential Learning: Experience as the Source of Learning and Development. Prentice Hall; 1984 24. Schön DA. The Reflective Practitioner: How Professionals Think in Action. Basic Books Inc; 1983 25. Ericsson KA, Krampe RT, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100(3):363–406 https://doi.org/10.1037/0033-295X.100.3.363 26. McGaghie WC, Kristopaitis T. Deliberate practice and mastery learning: origins of expert medical performance. In: Cleland J, Durning SJ, eds. Researching Medical Education. John Wiley & Sons Ltd; 2015:219–230 27. Vygotsky LS. Mind in Society: The Development of Higher Psychological Processes. Oxford University Press; 1978. Originally published 1930 28. Chauvin SW. Applying educational theory to simulation-based training and assessment in surgery. Surg Clin North Am. 2015;95(4):695–715 PMID: 26210964 https://doi.org/10.1016/j.suc.2015.04.006 29. Sweller J. Cognitive load during problem solving: effects on learning. Cogn Sci. 1988;12(2):257–285 https://doi.org/ 10.1207/s15516709cog1202_4 30. Fraser KL, Ayres P, Sweller J. Cognitive load theory for the design of medical simulations. Simul Healthc. 2015;10(5): 295–307 PMID: 26154251 https://doi.org/10.1097/SIH.0000000000000097 31. van Merriënboer JJG, Kester L, Paas F. Teaching complex rather than simple tasks: balancing intrinsic and germane load to enhance transfer of learning. Appl Cogn Psychol. 2006;20(3):343–352 https://doi.org/10.1002/acp.1250 32. Chandler P, Sweller J. Cognitive load theory and the format of instruction. Cogn Instr. 1991;8(4):293–332 https://doi.org/ 10.1207/s1532690xci0804_2 33. Sweller J. Cognitive load theory: what we learn and how we learn. In: Spector MJ, Lockee BB, Childress MD, eds. Learning, Design, and Technology. Springer; 2016:1–17 https://doi.org/10.1007/978-3-319-17727-4_50-1 34. Reedy GB. Using cognitive load theory to inform simulation design and practice. Clin Simul Nurs. 2015;11(8):355–360 https://doi.org/10.1016/j.ecns.2015.05.004 35. Nestel D, Mobley BL, Hunt EA, Eppich WJ. Confederates in health care simulations: not as simple as it seems. Clin Simul Nurs. 2014;10(12):611–616 https://doi.org/10.1016/j.ecns.2014.09.007 36. Dieckmann P, Gaba D, Rall M. Deepening the theoretical foundations of patient simulation as social practice. Simul Healthc. 2007;2(3):183–193 PMID: 19088622 https://doi.org/10.1097/SIH.0b013e3180f637f5 37. Gibbs G. Learning by Doing: A Guide to Teaching and Learning Methods. Further Education Unit at Oxford Polytechnic; 1988 38. Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27(1):10–28 PMID: 16147767 https://doi. org/10.1080/01421590500046924

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Chapter 2

Scenario Design Julie S. Perretta, MSEd, RRT-NPS, CHSE-A, and Beverley Robin, MD, MHPE, CHSE, FAAP

Objectives In this chapter, you will 1. Recognize the primary components of a simulation scenario. 2. Appreciate that there are a variety of approaches to scenario design. 3. Identify the importance of learning objectives as the foundation of scenario design. 4. Recognize that the learning objectives and cognitive load should align with the learner level. 5. Develop simulation scenarios that resemble clinical situations encountered in the neonatal intensive care unit.

Introduction Scenario design is a foundational skill that should be cultivated by simulation and medical educators. It essentially forms the cornerstone of the learning experience.1 Each scenario-debriefing sequence is a building block in the session. Each session then contributes to the overall curriculum. In the cycle of experiential learning, as applied to simulation-based education, the opportunity to reflect on performance is vital for transfer and retention of learning. Therefore, it is easy to understand why educators place a great deal of emphasis onto postsimulation debriefing. However, thoughtful scenario design provides the milieu for the learners’ “concrete experience.” There are a variety of approaches to scenario design and an even wider variety of scenario design templates; however, most important is that the scenario includes the key components. In this chapter, we review approaches to scenario design; highlight the importance of learning objectives as the foundation of a scenario and present 2 methods for their development; and outline and describe the steps of scenario design and provide practical tips to aid in the development of scenarios pertinent to clinical practice in the neonatal intensive care unit (NICU) environment.

Background As defined by Harrington and Simon, a simulation scenario is “an artificial representation of a real-world event to achieve educational goals through experiential learning.”2 In general, scenarios in health care simulation include goals and objectives, a description of the clinical situation, room setup, mannequins, props and equipment, moulage, mannequin operation, faculty and technician instructions, and, where applicable, directions for standardized, or simulated, participants (SPs), also referred to as embedded participants.3 Because simulation scenarios create the structure of the learning experience, on which the debriefing hinges, careful consideration should be paid to the scenario design process. While there are a variety of approaches to scenario design, the specific method used is unimportant, provided that all the necessary components are included. A well-developed scenario is one that has

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all the key details outlined, is evidence based, elicits the desired outcomes or learner responses,4 allows learners to carry away key pearls, and is easily replicated by the same or different instructors. Phrampus outlines 4 core steps of scenario design addressed in a specified order.5 The first step is identifying a topic, a curricular gap, or the need for team training, typically through a needs assessment. The second step— identifying the learners—is an important consideration because the learning objectives must be appropriate for the level of the targeted learners. For example, the learning objectives and thus the complexity of the scenario should be more advanced for neonatal-perinatal medicine fellows than for pediatrics residents. There may also be a variety of interprofessional learners—for example, physicians, nurses, pharmacists, and respiratory therapists (RTs)—potentially necessitating objectives for each learner group and common objectives for the learners functioning as a team. The third step of scenario design is developing learning objectives. This step requires careful consideration because the learning objectives outline specifically what the learners should achieve through participation in the simulation. These can be primary or secondary, with primary objectives being relatively broad (eg, core competencies, adherence to algorithms such as the Neonatal Resuscitation Program® [NRP®] algorithm) and secondary objectives being more specific (eg, psychomotor skills such as endotracheal intubation, behavioral skills such as team communication).6 The fourth core step is determining how to assess that the learning objectives have been met. This may include assessment instruments such as checklists or rating scales. Generally, the scenario should include a facilitator or debriefer guide that provides pertinent details about conducting the scenario and instructions on using the assessment instruments, so that their focus is geared toward ensuring that the objectives are achieved. Phrampus stresses that when the 4 core steps have been completed, the scenario designer should turn their focus to the description of the clinical situation and the other scenario components, such as mannequins, props, and equipment. Robertson and Bradley propose a “backward design” approach to scenario development.7 With the backward design approach to curriculum design, developed by Wiggins and McTighe,8 the curriculum designer begins with the end goal in mind and works “backward” to reach the goal. By using this approach, the scenario developer or curriculum designer begins with the desired results. What are the goals of the scenario? What should the learners know at the conclusion of the simulation session? What are the scenario (and curricular) priorities? The second step of the backward design approach, much like Phrampus’s fourth step, focuses on the evidence that the learners have achieved the learning objectives and thus the desired outcome. This step requires the scenario designer (or curriculum developer) to consider the assessment methods before designing the specific scenario (or curriculum) components. The third step of the backward design approach is developing the actual scenario and thus the learning activity. What activities will facilitate the learners achieving the desired cognitive, technical, or behavioral skills? How will the scenario provide the learners with the opportunity to demonstrate the desired skills? In this third step, the scenario designer begins by setting the stage. What is the scenario setting (NICU, emergency department [ED], or other clinical environment)? What are the patient’s gestational age and sex? What is their clinical presentation? Is a parent or family member (SP) included? The next step—“storyboarding”—involves outlining a graphic representation of the sequence of events in the scenario.2 Storyboarding typically includes 2 phases, the first of which is a creative phase: the scenario designer outlines general ideas that support the overall objectives of the scenario. In the second phase, the scenario designer reviews and prioritizes the ideas, creates the specific flow of the scenario, determines the actions the learners should take, and considers possible alternatives, ensuring that there is no (or an appropriate amount of) redundancy9 in the sequence of events and expected learner responses. The process of storyboarding is typically facilitated by a scenario design template. Guidelines for scenario design have been shared by different specialty organizations,7,10,11 and many simulation programs have created scenario design templates (see the Additional Resources section later in this chapter). Although templates typically include the same basic sections, they can follow different formats. The template sections typically include

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1. 2. 3. 4. 5. 6.

19

Course Planning and Logistics Goals and Learning Objectives Patient Information Resources and Equipment Scenario Progression Debriefing and Evaluation

A template that incorporates all these components has been provided in Appendix A, and the following sections constitute a step-by-step guide to help you through designing your own simulation scenario.

Course Planning and Logistics Before developing a simulation scenario, it is necessary to understand why the content is important and to identify the learners’ needs. These are accomplished by conducting a needs assessment. The results of the needs assessment are what instructors use to guide the development of an overarching goal or broad objective for the simulation, which then directs designers in the development of scenario-specific objectives.12 Scenarios are typically developed to achieve several goals, which can include enhancing education or training, achieving performance improvement or quality improvement (eg, identifying latent safety threats in new and existing health care environments, testing new equipment, and testing new workflows), assessing trainees, or pursuing research purposes. Usually, the reason for developing a scenario is the identification of a new clinical standard, a gap in clinician performance, or a change in patient outcomes that requires an educational intervention. Scenario designers should make all efforts to identify these elements, which are essential for accurate scenario development. Example: A community hospital has identified a 30% increase in precipitous deliveries of preterm neonates in the ED. As part of a multitiered approach to ensuring patient safety, the entire ED clinical staff is required to complete the neonatal resuscitation course, with a focus on delivery of a preterm neonate. Scenario designers have flexibility with and can repetitively modify (as necessary) completed scenarios intended to educate, test new health care environments, and improve quality. However, to maintain standardization, they should adhere to more stringent guidelines and cannot modify completed scenarios designed for research purposes or high-stakes assessment.13 Each scenario should include information related to the learners and scenario logistics. These include 1. Scenario duration 2. Learner population (ie, discipline, training level) 3. Learner group size 4. Precourse work (ie, prereading, video review, prerequisite skills) During the scenario design phase, it is important to determine the learner group size early on, as this will dictate the number of resources (including instructors and equipment) that needs to be procured. Additionally, the learner level(s) (ie, novice vs beginner vs expert) and learner discipline(s) should be carefully considered. For example, a pulmonary hypertensive crisis scenario based in the NICU and designed to incorporate a multidisciplinary team of learners at various levels could have objectives for each member group (eg, registered nurses, physicians, RTs, pediatrics residents) and common objectives for the team, whereas a resuscitation focused in the delivery room may be designed for only 1 to 2 individuals and have fewer or more focused objectives.

Developing Goals and Learning Objectives Learning objectives—the most important element of any scenario—form the foundation of the scenario and frame the desired learner outcome or performance. Learning objectives are statements of learner performance that

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should be clear and relevant, appropriately aimed at the learner level, and written with specific detail to allow them to be directly measured. Each simulation scenario should have several learning objectives6,14,15 that clearly support the scenario’s overall goal. Some authors advocate for having behavioral (eg, communication), cognitive, and psychomotor learning objectives for each scenario.6 Bloom’s taxonomy, often used for developing learning objectives, is a hierarchical list of observable actions (and accompanying teaching strategies) that begins with basic domains of learning (eg, knowledge, comprehension) and progressively outlines higher cognitive domains of learning, such as application, analysis, synthesis, and evaluation. It is these higher cognitive domains of learning that simulation scenarios target.16 It is important to remember that learning objectives for which the basic domains of learning are the focus are best achieved via means other than simulation scenarios (eg, demonstration and return demonstration for handwashing, task trainers for practicing endotracheal intubation). Learning objectives also guide the debriefing; the instructor should ensure that the learners achieve the learning objectives developed during the scenario design phase. In addition to primary and secondary objectives, scenarios can have tertiary objectives. Tertiary objectives stem from unanticipated learner events or actions during the scenario (eg, unanticipated but important learner mistakes, or tremendous teamwork).17 The instructor watching the scenario can note these objectives while the scenario is playing out and, depending on the nature of the objectives and the available time, can discuss them during the debriefing. The learners should achieve the primary objectives, and these objectives should be prioritized by the instructor during the debriefing. If learners consistently fail to meet the objectives, the scenario should be reviewed to determine if there is a scenario flaw (eg, unrealistic cues) or if the scenario, in its current state, is designed for different objectives. The scenario should then be revised accordingly. There are several strategies for designing learning objectives.18 One of the best known is the strategy that uses the “SMART” acronym (short for specific, measurable, achievable, realistic, time based).19 For example, the learner will be able to place an endotracheal tube within 30 seconds for a preterm neonate who experiences decompensation and requires an alternative airway during a delivery room scenario. In this example, the learning objective is specific to the resuscitation of a preterm neonate and describes the situation in which the endotracheal tube will be placed. Achievement of performance within the appropriate time frame can easily be measured with observation. This is both realistic (pertains to real-life delivery situations) and achievable (the mannequin can be intubated). Additionally, the objective is time based and confined to 30 seconds. Another method for designing learning objectives is the “ABCD” method (short for audience, behavior, condition, degree).20 This method describes the 4 components of a learning objective. The A defines who participates in the learning activity—for example, first-year medical students and preclinical nursing students. B describes what the learners will be expected to do and includes an action verb—for example, “draws up the correct dose and concentration of epinephrine.” C describes what conditions the learner will encounter while they are participating in the simulation activity—for example, “an unstable neonate experiences supraventricular tachycardia and requires synchronized cardioversion.” D identifies how well the learners will be expected to perform to meet the learning objective, such as “perform all steps of the NRP algorithm in the correct sequence and with the correct timing.” Examples of each of the ABCD objectives and their association with the SMART objectives for the ED neonatal resuscitation scenario can be found in Table 2-1. Here is an example of objectives designed by using the ABCD method. 1. After the recognition of unstable supraventricular tachycardia, the neonatology provider will immediately administer the correct dose of adenosine to a neonate who has not responded to vagal maneuvers. 2. During the resuscitation of a neonate with Pierre Robin sequence who experiences airway obstruction and decompensation in the delivery room, the neonatology provider will immediately place a laryngeal mask airway to ensure airway patency.

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Table 2-1. Sample Learning Objectives for the ED Neonatal Resuscitation Scenario Objective 1

Audience ED nurses

Behavior Adjust the ambient temperature of the room before delivery.

Condition On being notified of a preterm delivery

Degree Change the room temperature (to 25°C–27°C [77°F –80.6°F]) before delivery.

SMART Specific  Measurable  Achievable  Realistic  Time based 

2

Neonatal resuscitation team

Place the preterm neonate into a resealable, food-grade polyethylene bag.

On delivery of the preterm neonate

Immediately

Specific  Measurable  Achievable  Realistic  Time based 

Abbreviation: ED, emergency department.

Patient Information The Patient Information section includes a general description of patient information, followed by the important background information learners will need to know, such as the patient’s name, sex, presenting problem, and physical examination and pertinent laboratory or radiological findings. This section is intended to provide learners with a limited amount of pertinent information they will need to start critically appraising the clinical situation. It is by no means an exhaustive rundown of what will transpire, and it should not give away the scenario. As noted by Alinier, it provides the starting point for the inquiry thread; when they have received this information, learners should start asking questions to elicit more details needed for them to be able to perform the correct management.3 The information provided should be sufficiently concise to paint a realistic picture but not overwhelm the learners or the instructor(s). Medical history pertinent to the scenario (eg, preeclampsia, multiple miscarriages) and, where applicable, pertinent social history should also be included in this section. Real-life patient events and information from patients’ medical records can be modified and used to develop this portion of the scenario.21 In fact, basing scenarios on actual patient events is recommended because this increases the likelihood that the scenario will accurately depict real-life clinical events.3,22 Relevant medical record information; laboratory tests; radiological findings; pictures of rashes, craniofacial anomalies, or other physical findings; and electrocardiographic or fetal heart tracings can be collected and deidentified. This information, intended for the learners, should be attached to the scenario outline and made available to the instructors or facilitators before the scenario starts. It is prudent to ensure that details of actual cases are altered to ensure that patient privacy is not compromised. Color-coding the medical records, test results, and other sources of information that correspond to each scenario makes it easier to sort items during cleanup, after the scenario has run, and helps prevent them from becoming mixed up with sources from other scenarios.3 Box 2-1 provides a sample description of the patient information outlined for the ED neonatal resuscitation scenario. When designing a scenario, one should include how the learners will access the patient information—via paper or electronic medical record or verbally from the instructor or SP (eg, in the role of a paramedic or nurse). This should be as close as possible to the clinical experience in the specific institution. Some centers have the ability to develop simulated electronic patient medical records. If this is an option, one should ensure that the patient name matches the scenario and that during the scenario, a computer is available for learners to access the information.

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Box 2-1. Sample Patient Information for the ED Neonatal Resuscitation Scenario Patient name: B.B. Carlin Gestational age: 26 weeks 2 days’ gestation Sex: male Weight: unknown Clinical setting: ED, critical care room Chief issue: preterm delivery Maternal history: A 24-year-old mother arrives at the ED with significant abdominal pain while on vacation. Contractions began approximately 3 h ago. She is followed up by an obstetric practice in her home state. She denies having any significant medical history, and no abnormalities were identified during the 20-wk US examination. On arrival, she is noted to have 8- to 9-cm cervical dilation, and delivery is imminent. She is estimated to be at 26 weeks 2 days’ gestation, according to first trimester US results. Medications: prenatal vitamins Laboratory findings: none available Imaging findings: unavailable Abbreviations: ED, emergency department; US, ultrasonographic.

Resources and Equipment When designing a scenario, instructors should consider the resources (personnel, space, SPs, moulage, and time) and equipment (mannequins, durable medical equipment, and supplies) required for each scenario. Scenario templates generally include a detailed section that lists these. We suggest starting a first-draft list of resources and adding to it as the scenario is built. The ideal time to finalize the equipment list is when all the other components of the scenario have been completed. It is important to remember that, to the extent possible, equipment and supplies (eg, a radiant warmer bed, endotracheal tubes, monitors) used in the scenario should resemble the actual equipment used in the clinical environment. One should avoid the temptation of using outdated equipment that does not represent current practice, as this may result in the learners not achieving the appropriate skills. It may be necessary to include equipment (eg, an endotracheal tube) that is appropriately sized for the mannequin(s) that will be used. Most manufacturers provide a list of the appropriately sized equipment that fits the mannequin (eg, endotracheal tube size); simulation centers typically have this information readily available. The learning objectives dictate the simulator selection, as well as the moulage and inclusion (or not) of an SP. Well-developed learning objectives help determine the features and capabilities necessary in a mannequin. For instance, a scenario that requires learners to resuscitate a preterm neonate delivered after a placental abruption, including placement of the neonate into a food-grade polyethylene bag, and endotracheal intubation also requires a mannequin of the appropriate size, capable of accommodating endotracheal intubation and positive pressure ventilation. If a mannequin that meets the scenario specifications is unavailable, the scenario should be adapted to minimize the risk of negative learning. Negative learning23 occurs when a learner develops poor habits or shortcuts because of the inadequacy or lack of realism of the simulation and then transfers these actions (or lack thereof) to real-life situations24—for example, not putting on gloves (universal precautions) during a simulated delivery and then forgetting to do this in real life, or being informed that the mannequin is a “preterm infant” and, at the same time, being asked to perform endotracheal intubation on a full-term–sized mannequin with a 3.5-cm endotracheal tube (an appropriate size for a full-term but not a preterm infant). When choosing the mannequin, equipment, moulage, props, and SP (and their role), one must consider factors that contribute directly to achievement of the learning objectives, recognizing that the goal is to enhance realism to the extent possible, without distracting the learners.

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Because there will likely be wide variability in the availability of resources, one may consider developing a “hierarchy” of resource needs; this allows instructors to quickly differentiate items that are essential for achievement of the learning objectives from those that are more general and may not ultimately be necessary. When designing a scenario, one should consider where the simulation will take place—in the simulation center, in the actual clinical environment (in situ), or in another location. This should be noted on the scenario template. When a session is conducted in the simulation center, instructors should schedule the session and review the scenario and necessary equipment, mannequins, moulage, and props with the simulation technologists or simulation educators to ensure that the supplies will be available when needed. The type and number of instructors or simulation educators and their roles should be indicated on the scenario design sheet, and these facilitators should be scheduled and notified in advance. If additional instructors, such as experts with specific skills (eg, extracorporeal membrane oxygenation experts, specialists) are needed, that should be indicated on the scenario template as well. When designing the scenario, one should consider who will operate the mannequin (Is it logical for the instructor to operate the mannequin, or is it more prudent for a simulation technologist or an additional instructor to do this, so that the instructor can pay adequate attention to the learners during the scenario?). Consideration of the complexity of the scenario (basic newborn resuscitation vs advanced resuscitation necessitating chest compressions), learner level (medical students vs neonatal-perinatal fellows), and learner complement (small team vs large interprofessional team) can help guide this decision. Additional instructor needs should be noted in this section. The moulage and props should be listed, with details, as necessary (eg, “meconium placed onto the blanket,” “omphalocele attached to the mannequin abdomen”). Additionally, the SP role and script should be included; some scenario design templates have a separate section for these. For in situ simulations, the scenario template should indicate the clinical environment in which the simulation will occur (eg, the NICU) and the specific location (eg, the specific procedure room). Because in situ simulations require special attention to details so as not to affect patient care, pertinent details and supporting documents should be included (eg, signs or verbal notification scripts to inform parents or visitors that the simulation will occur, notifications for administrators and charge nurses, “no-go” criteria for canceling the simulation if the clinical area is busy)25 (see Chapter 18, In Situ Simulation). An example snapshot of equipment for the ED neonatal resuscitation scenario is provided in Box 2-2. There are a variety of approaches to medication use in simulation-based education. When designing scenarios, educators should consider whether they will use expired medications or typical vials filled with water or saline. These are discussed in more detail in Chapter 18, In Situ Simulation. However, it is important that educators assess the risks and benefits of each approach and indicate the selected approach on the scenario template.

Clinical Details and Scenario Progression The clinical aspects of the scenario need to be carefully orchestrated so that they are plausible, engage the learners in a meaningful way, and enable them to achieve the desired learning outcomes. It is important to carefully outline the clinical details (eg, vital signs, clinical presentation) and the expected clinical progression. Learner cues are typically provided via the mannequin (eg, cyanosis, tachypnea) or environment (eg, NICU, labor and delivery unit).26 However, in light of mannequin limitations, depending on the scenario, the instructor may need to provide verbal cues27 (eg, “the patient’s capillary refill time is delayed”) to enhance realism and promote the learners’ grasp of the clinical situation.28 These should be considered during the scenario design phase and included in the scenario template, as appropriate. When developing the scenario progression, the scenario designer should consider the learners’ potential responses and determine how the mannequin (and, if applicable, the SP) will respond to each of the potential clinical interventions or actions. There are 2 approaches to mannequin vital sign and physiological parameter changes—preprogramming and making vital signs/physiological parameter changes “on the fly” (manually) by using tablets or phone apps. Scenarios can be preprogrammed so that they can be advanced automatically, or they can be programmed in segments that can be advanced manually after learners complete the appropriate interventions or actions. The

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Box 2-2. A Sample List of Equipment Needed for the ED Neonatal Resuscitation Scenario • • • • • • • • • • • • • • • • • • • • • • • •

Food-grade polyethylene bag Radiant warmer bed with adjustable temperature setting Room with adjustable thermostat Preterm (or full-term) neonatal mannequin Blankets Neonate hat Bulb syringe Air-oxygen blender Positive pressure ventilation device Preterm- and full-term–sized masks 8.0F feeding tube and 20-mL syringe Laryngoscope handle Laryngoscope blades (sizes 00, 0, and 1) with bright light Endotracheal tubes (sizes 2.5F, 3.0F, and 3.5F) Stylet CO2 detector Laryngeal mask airway (size 1) and 5-mL syringe Epinephrine (0.1 mg/mL) Normal saline solution Stethoscope Electrocardiographic monitor and leads Pulse oximeter monitor and sensor Supplies for administering medications and placing an emergency UVC Chemically activated warming pad

Abbreviations: CO2, carbon dioxide; ED, emergency department; UVC, umbilical venous catheter.

advantage of using preprogrammed scenarios is that they are time bound. If the instructor does not require the vital signs to change throughout the scenario duration or the scenario will progress regardless of learner actions, it may be prudent to preprogram the mannequin. If the instructor desires more control and flexibility, the vital signs and physiological changes can be manually controlled. This approach requires the progression details to be carefully outlined in the scenario template, typically in table format or as a flowchart. This approach allows the mannequin operator (instructors or simulation technologists) to advance the scenario on the basis of learner actions and responses. Mannequin preprogramming requires more time up front but enables the instructor to more closely observe the participants during the simulation, and, when applicable, control audiovisual equipment.3 The “on the fly” approach requires the mannequin controller to clearly visualize the learner actions to be able to manipulate the mannequin to respond appropriately. This can become a challenge if the mannequin controller’s view is obscured (eg, by a learner), if the action is very subtle, or if communication between the learners is not audible to the controller. One approach to overcome this is for the mannequin controller to communicate with an SP (eg, in the role of nurse or paramedic) by using a commercially available earpiece and 2-way communication device or wireless system3,29 or simply through gestures or signals. These “what if ” issues should be discussed during scenario planning and pilot testing (see the Pilot Testing section later in this chapter), and details should be included in the scenario template. Some simulation centers offer “train-the-trainer” programs to familiarize instructors with scenario design methodology and equipment and mannequin setup and operation. Take advantage of these if they are available! When designing the clinical portion of the scenario, one should consider the following questions: ▶ How does the scenario start? ▶ What makes the scenario move forward? ▶ How does the scenario end?

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How Does the Scenario Start? The first step in designing the clinical aspects of the scenario is to decide on the patient’s initial state: vital signs, muscle tone, vocalizations, skin color, and other physiological parameters. Additionally, the mannequin presenting position should be considered. For example, the mannequin would likely be in a radiant warmer bed for a neonatal resuscitation scenario, whereas for a NICU in situ scenario, the mannequin might be in the mother’s (SP’s) arms. A neonatal resuscitation scenario might include the following aspects: ▶ Vital signs: heart rate (HR), respiratory rate, blood pressure, or oxygen saturations ▶ Patient tone: decreased tone ▶ Movement: no movement or some movement ▶ Vocalizations: crying, grunting, or none ▶ Color: pink or cyanosis Table 2-2 presents a sample overview of a patient’s state for the ED neonatal resuscitation scenario.

Table 2-2. Sample Patient State for the ED Neonatal Resuscitation Scenario

State Initial

Heart rate, beats/ min 88

Respiratory rate, breaths/min 5

Blood pressure, mm Hg 44/20

SpO2, % 75

Tone Limp

Movement None

Vocalizations None

Color Cyanosis

Abbreviations: ED, emergency department; SpO2, oxygen saturation measured with pulse oximetry.

It is also important to determine the number of participants who will be present in the initial phase30 and whether the scenario calls for additional participants who are “on standby” and will be called in at a later point. This information should be noted in the scenario template. The approach of staggering participants’ arrivals supports communication practice around handoffs and changes in team complement.3

What Makes the Scenario Move Forward? Once the initial state has been determined, the next step is to identify the ideal and alternative intervention(s). This is best accomplished by brainstorming all likely options, some of which may not be clinically plausible (but might be performed by the learners). Thereafter, the scenario designer should consider which of the interventions (ideal or not) would require a change in the patient’s state. Here is an example series of ideal intervention steps for the ED neonatal resuscitation scenario. 1. Immediately after delivery, the preterm neonate is placed into a food-grade polyethylene bag. 2. The neonate is stimulated. 3. The neonate’s mouth and nose are suctioned. 4. The electrocardiographic leads are placed onto the neonate’s chest. 5. The pulse oximeter sensor is placed onto the neonate’s right wrist or hand, and the sensor is connected to the pulse oximeter monitor. Once the appropriate monitoring equipment is placed onto the mannequin, the controller can begin to display the patient’s vital signs on the cardiorespiratory monitor. 6. Positive pressure ventilation is initiated. Depending on the scenario, there may be more than one correct course of action. It is also common for several interventions to be implemented simultaneously; thus, the scenario interventions may not be linear. For each of the potential learner actions, the scenario developer should answer the following questions:

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Is the intervention… ▶ …correct or incorrect? ▶ …essential or nonessential to the case progression? ▶ …likely to change the patient’s vital signs? For ease of visualization, the vital sign and physiological changes can be outlined in a flowchart format, like the NRP algorithm. An example progression of the patient’s state for the ED neonatal resuscitation scenario is shown in Table 2-3.

Table 2-3. A Sample Progression of the Patient’s State for the ED Neonatal Resuscitation Scenario Heart rate, beats/ min

State Initial

88

Respiratory rate, breaths/ min

Blood pressure, mm Hg

SpO2, %

Tone

Movement

Vocalization

Color

5

44/20

75

Limp

None

None

Cyanosis

Without effective PPV

55

5

44/20

52

Limp

None

None

Cyanosis

With 30 s of effective PPV

110

15

Unchanged

≥75

Mild tone

None

Weak cry

Acrocyanosis

Abbreviations: ED, emergency department; PPV, positive pressure ventilation; SpO2, oxygen saturation measured with pulse oximetry.

The scenario designer should consider whether the vital signs and physiological parameters should change in a linear fashion or whether they should change at various times, based on the sequence of interventions. When the appropriate sequence of interventions and their associated vital sign and physiological changes have been determined, the next step is to predict the inappropriate interventions learners might perform when they are “off track.” The scenario designer should also consider how the instructor might move learners back to the correct interventions during the scenario. For example, the vital signs can be manipulated to provide the learners with cues to prompt an alternate intervention, or an SP (eg, in the role of a nurse) can provide a natural verbal prompt to change the learners’ path. Example 1: If the learners provide continuous positive airway pressure (instead of positive pressure ventilation) when the mannequin denotes apnea: The HR drops to 75 beats/min, cyanosis displays, and O2 saturations are 85%. Example 2: If the learners are unsuccessful at endotracheal intubation: An SP, in the role of senior physician, enters the room and performs endotracheal intubation; the scenario then continues. Example 3: If the learners do not discontinue chest compressions when the HR is above 60 beats/min: The SP (nurse) says, “The heart rate is now above 60 beats per minute.” Scenario designers should consider the amount of time it typically takes for test results to return and for medication to be delivered, and they should build these response times into the scenario. Sometimes, instructors are tempted to run the scenario in a “time-warped” fashion, in light of time constraints31; however, this may be an unrealistic representation of the learners’ real-life experience and may thus reinforce negative learning. However, if time warping is used, it may be prudent for the instructor to notify the learners during the prebriefing that test results and medications may be immediately available to them but that this immediacy is unrealistic and was incorporated into the simulation in this manner only in the interest of time.

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How Does the Scenario End? Scenario duration is typically approximately 10 to 20 minutes, depending on the number of learning objectives, the case complexity, and the number of decision points.6,30 Ideally, the scenario should end when the learners have successfully achieved the learning objectives. However, this may not always be the case. There might be instances in which time limits are a component of the learning objectives. Instructors can use the following scenario termination strategies: ▶ Time limited: Scenario is based on performance guidelines (eg, the NRP algorithm), with additional time allotted on the basis of the learner level (to accommodate for a learning curve, such as one for medical students vs one for neonatal-perinatal medicine fellows). ▶ Patient status: Scenario ends when the patient’s vital signs and physiological parameters reach a specific range or before an intervention that occurs late in the scenario and is unrelated to the learning objectives. The scenario termination method should be clearly noted in the scenario template. For example, the scenario ends when any of the following criteria are met: ▶ X minutes have passed. ▶ The learners have successfully performed endotracheal intubation. ▶ One minute of chest compressions has been performed for an HR sustained below 60 beats/min.

Additional Revisions When the Scenario Progression section has been developed, the scenario designer should create a summary of the scenario, captured in a few sentences, as an overview. This is typically included in a subsection termed “General Scenario Description.” In addition, when the Scenario Progression section has been completed, it is also important to review the equipment section to determine whether items will need to be added. Also, one should again consider whether the mannequin selected for the case will still meet the learning needs. Solutions to overcoming mannequin or environmental limitations may need to be considered. Examples for the ED neonatal resuscitation scenario include 1. The training room does not have an adjustable thermostat. Option 1: Print and laminate a thermostat with an arrow that can be moved to the desired temperature; tape it to the wall for learners to access during the scenario. Option 2: Obtain a decommissioned thermostat interface and temporarily mount it to the wall before the scenario. 2. The mannequin does not have the capability to denote cyanosis. Option 1: Apply moulage techniques (such as makeup) to create cyanosis (which remains on throughout the scenario). (See Chapter 22, Moulage: The Special Effects.) Option 2: Verbalize the neonate’s color. (Note: For both of these options, during the prebriefing, the learners should be notified how cyanosis will be conveyed.)

Debriefing and Evaluation Postsimulation debriefing should be guided by the scenario goals and learning objectives. Specific debriefing techniques are detailed in Chapter 24, Debriefing in Simulation-Based Training in Neonatology: An OutcomesBased Approach; Chapter 25, Blended-Method Debriefing With the PEARLS Debriefing Framework; Chapter 26, Co-debriefing in Neonatal Simulation; and Chapter 27, The Difficult Debriefing. To assist in organizing the debriefing, it can be helpful for the instructor to have a checklist of correct actions,

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with an associated feedback script. While the learners participate in the scenario, the instructor can use the checklist to document learners’ performance (eg, to document that a task was done correctly, not done, or done incorrectly). The checklist can then be used to guide feedback during debriefing. An example checklist of actions for the ED neonatal resuscitation scenario is provided in Table 2-4.

Table 2-4. A Sample Checklist of Actions for the ED Neonatal Resuscitation Scenario Correct action Increase the room temperature in anticipation of a preterm birth.

Done

Not done

Done incorrectly

Notes

Good: The team did this immediately after they were informed about the pending delivery. The NRP recommends increasing the room temperature to 23°C–25°C [73.4°F –77°F].32

✓

Place the pulse oximeter onto the neonate’s right hand or wrist. Provide 30 s of effective PPV.

Feedback

Indications for pulse oximeter use. Preductal location.

✓

✓

Poor chest rise

Importance of assessing chest rise

“MR SOPA” not performed

How to assess the effectiveness of PPV

Abbreviations: ED, emergency department; NRP, Neonatal Resuscitation Program; PPV, positive pressure ventilation; MR SOPA, mask readjustment, repositioning the airway, suctioning the nose then mouth, pressure increase, and alternative airway.

Additional Notes Scenario design templates typically include a section for additional notes that instructors can use when running the scenario or at a later time. This can include tips on setup (what worked and what did not), notable debriefing points, and notable cues or props that did or did not enhance the scenario. This information can be used to refine the scenario or develop other scenarios.

Standardized, or Simulated, Participants, Also Known As “Embedded Participants” SPs, also known as embedded participants, are individuals who, during the course of the clinical scenario, can (a) provide assistance in locating or troubleshooting equipment; (b) provide support for learners in the form of offering “available help,” such as being “the nurse in charge”; (c) provide clinical cues that the mannequin cannot provide, such as its temperature or capillary refill time; and (d) enhance realism by portraying a family member, as appropriate.33 SPs who contribute by providing clinical, technical, or mannequin information can be members of the simulation or clinical team. The roles should be indicated on the scenario template and assigned and reviewed with the representative person before the simulation. Ideally, the role of nonclinical personnel, such as family members, should be portrayed by actors who are scripted and trained in the role (see Chapter 21, Standardized Patients). Some scenario templates include a subsection for the SP role and script. If not, an SP-specific template can be used. When used appropriately, SPs enhance realism, provide additional information, and redirect learners. In NICU and delivery room simulations, SPs can portray staff members (eg, operating room nurse, anesthesiologist), family members, or consultants. When SPs are incorporated into a scenario, they should assume a single role and they should not switch to portray a different role during the same scenario, because switching can result in the learners becoming confused. It is advisable, particularly if the scenario is being used for research purposes, that the SP role be well scripted and rehearsed before the session.34

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Distractors Distractors, much like they sound, are elements introduced into the scenario to draw the learners’ attention away from the current task. They are typically directly or indirectly related to the clinical scenario and add an additional layer of complexity. Distractors vary in nature, scope, and range. For example, an SP can be scripted into the role of an angry parent who becomes loud at the patient’s bedside or a nurse or consultant who disagrees with the team’s diagnosis and management plan. Incorporating a malfunctioning piece of equipment or an incorrect medication type or dose can also serve as a distractor.13 The purpose of these types of distractors is to mimic the actual clinical environment and to challenge the learners. Distractors should be built into the scenario and aimed at meeting (not distracting from) the learning objectives. Because distractors can significantly increase the learner cognitive load, when deciding whether to incorporate distractors, scenario designers should carefully consider the learner level. Furthermore, when SPs are incorporated into the scenario, their responses and complexity should be calibrated to the learner level.13 For example, a distraught, angry father incorporated into a neonatal resuscitation scenario would likely represent a significant cognitive load for a beginning neonatal-perinatal fellow whose primary focus is recalling the steps of the NRP algorithm, whereas a third-year, finishing fellow will have mastered the steps of resuscitation and would be better equipped to respond to the angry father. As an additional example, the scenario includes resuscitating an infant who just experienced an unintended endotracheal extubation while they were lying on their mother’s chest during kangaroo care. To the experienced clinical team, this scenario is realistic and likely to occur in the NICU. The physicians and nurses must resuscitate the infant and handle the distressed parent, who is now guilt-ridden and shocked by the event. The scenario objectives may include determining optimal parent communication strategies during active crises, eliciting additional personnel (eg, social worker, RTs), and delineating roles (Who will perform endotracheal intubation? Who will talk with the mother?). However, adding these distractors to a simple endotracheal extubation scenario would be unsuitable for novice trainees, who may become overwhelmed and quickly lose track of the primary objective of performing endotracheal intubation. During scenario pilot testing, instructors may discover that the distractor is likely to increase the learners’ cognitive load excessively or that the distractor modifies the environment significantly (eg, the angry father is too loud, and the learners can’t hear other team members).

Pilot Testing Ideally, scenarios should be evidence based and validated through peer review and pilot testing.6 To ensure that the scenario runs smoothly, is realistic, and includes all necessary components and that all required resources are available and appropriate, pilot testing should occur with participants who represent the intended learner group,35 who are ideally naïve to the scenario and will not participate in the actual simulation session. Postparticipation debriefing with the representative group enables scenario designers to explore their experience and assess their responses36 so that the scenario designer can make informed scenario revisions and anticipate some of the learners’ potential responses to the scenario.

Summary Scenarios are the foundation of experiential learning in simulation-based education and therefore warrant a focused and organized, step-by-step approach to their design. Learning objectives, the cornerstone of a scenario, should be developed with the learner level, learner complement, and desired outcomes in mind. A scenario template should be used to guide scenario development, and the details should be carefully and clearly outlined to serve as a blueprint to guide instructors.

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Central Points ▶ While there are a variety of approaches to scenario design and many available scenario templates, scenarios typically include the scenario name and duration, learner discipline and level, learning objectives, clinical information and progression, and required resources. ▶ The learning objectives are the most important element of a scenario; scenario designers should develop the learning objectives by focusing on the learners and the desired outcomes, while aligning the cognitive load with the learner level. ▶ Resources such as personnel, space, time, and equipment (mannequins and durable medical equipment) are important considerations in designing scenarios. ▶ To promote realism, scenarios should be based on actual patient cases (without identifiers) and pilot tested with a representative group of learners.

Additional Resources Additional examples of scenario templates include ▶ The scenario design template in Appendix A ▶ The National League for Nursing “Simulation Design Template,” available at www.gvsu.edu/cms4/asset/ 890FA567-BE74-A168-6DBE725A35EBA90F/nln_interprofessional_simulation_design_template.docx ▶ The National League for Nursing “Simulation Design Template,” available at http://www.nln.org/sirc/ sirc-resources/sirc-tools-and-tips#simtemplate ▶ The Stanford Medicine Center for Immersive and Simulation-based Learning “Scenario Template,” available at https://cisl.stanford.edu/content/dam/sm/cisl/documents/Design%20a%20Program/ILC%20Scenario%20 Template%202015-DRAFT-2.pdf ▶ The University of Washington Center for Health Sciences Interprofessional Education, Research, and Practice “Simulation Scenario Development Template,” available at https://collaborate.uw.edu/wp-content/ uploads/2020/08/ScenarioDevelopmentTemplate_2017_02_23_LB.pdf ▶ The “TEACH Sim” template from Benishek LE, Lazzara EH, Gaught WL, Arcaro LL, Okuda Y, Salas E. The Template of Events for Applied and Critical Healthcare Simulation (TEACH Sim): a tool for systematic simulation scenario design. Simul Healthc. 2015;10(1):21–30 ▶ The Duke University Anesthesiology “Simulation Case Development Tool” from Benishek LE, Lazzara EH, Gaught WL, Arcaro LL, Okuda Y, Salas E. The Template of Events for Applied and Critical Healthcare Simulation (TEACH Sim): a tool for systematic simulation scenario design. Simul Healthc. 2015;10(1):21–30

References 1. Terrett L, Cardinal P, Landriault A, Cheng A, Clarke M. Simulation Scenario Development Worksheet (Simulation Educator Training: Course Material). Royal College of Physicians and Surgeons of Canada; 2012 2. Harrington DW, Simon LV. Designing a simulation scenario. In: StatPearls. StatPearls Publishing; 2019. Accessed December 16, 2020. https://europepmc.org/books/NBK547670 3. Alinier G. Developing high-fidelity health care simulation scenarios: a guide for educators and professionals. Simul Gaming. 2011;42(1):9–26 https://doi.org/10.1177/1046878109355683 4. Seropian MA, Brown K, Gavilanes JS, Driggers B. Simulation: not just a manikin. J Nurs Educ. 2004;43(4):164–169 5. Phrampus PE. The first four steps of healthcare simulation scenario design. Simulating Healthcare blog. July 23, 2018. Accessed December 16, 2020. https://simulatinghealthcare.net/2018/07/23/the-first-four-steps-of-healthcare-simulationscenario-design 6. Waxman KT. The development of evidence-based clinical simulation scenarios: guidelines for nurse educators. J Nurs Educ. 2010;49(1):29–35 PMID: 19810672 https://doi.org/10.3928/01484834-20090916-07

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Accessed December 16, 2020. https://www.nursingsimulation.org/article/S18761399%2816% 2930126-8/fulltext 13. Huffman J, McNeil G, Bismilla Z, Lai A. Essentials of scenario building for simulation-based education simulation pearls. In: Grant VJ, Cheng A, eds. Comprehensive Healthcare Simulation: Pediatrics. Springer; 2016:19–29 https://doi. org/10.1007/978-3-319-24187-6_2 14. Huffman JL, McNeil G, Lai A. Essentials of scenario building for simulation-based education. Semantic Scholar. Accessed December 16, 2020. https://www.semanticscholar.org/paper/Essentials-of-Scenario-Building-for-Simulation-HuffmanMcNeil/83a9a63c98756310157aeedbfce908cfe1d9cd5a 15. Benishek LE, Lazzara EH, Gaught WL, Arcaro LL, Okuda Y, Salas E. The Template of Events for Applied and Critical Healthcare Simulation (TEACH Sim): a tool for systematic simulation scenario design. Simul Healthc. 2015;10(1):21–30 PMID: 25514586 https://doi.org/10.1097/SIH.0000000000000058 16. Condensed version of the taxonomy of educational objectives. In: Taxonomy of Educational Objectives: The Classification of Educational Goals. Longman; 1984:201–207. Bloom BS, ed. Cognitive Domain; handb 1 17. Ziv A, Ben-David S, Ziv M. Simulation based medical education: an opportunity to learn from errors. Med Teach. 2005; 27(3):193–199 PMID: 16011941 https://doi.org/10.1080/01421590500126718 18. Chatterjee D, Corral J. How to write well-defined learning objectives. J Educ Perioper Med. 2017;19(4):E610 PMID: 29766034 19. Doran GT. There’s a S.M.A.R.T. way to write management’s goals and objectives. Manage Rev. 1981;70(11):35–36 20. Hodell C. ISD From the Ground Up: A No-nonsense Approach to Instructional Design. 4th ed. ATD Press; 2016:85–112 21. Murray WB. Simulators in critical care education: educational aspects and building scenarios. In: Dunn WF, ed. Simulators in Critical Care and Beyond. Society for Critical Care Medicine; 2004:29–32 22. Black SA, Nestel DF, Horrocks EJ, et al. Evaluation of a framework for case development and simulated patient training for complex procedures. Simul Healthc. 2006;1(2):66–71 PMID: 19088579 https://doi.org/10.1097/01.SIH.0000244446. 13047.3f 23. Baily L. Dr. Kenneth Gilpin shares why sometimes we can do more harm than good through medical simulation. HealthySimulation.com. Published July 2, 2015. Accessed June 15, 2020. https://www.healthysimulation.com/7532/ dr-kenneth-gilpin-shares-why-sometimes-we-can-do-more-harm-than-good-through-medical-simulation 24. Weller JM, Nestel D, Marshall SD, Brooks PM, Conn JJ. Simulation in clinical teaching and learning. Med J Aust. 2012;196(9):594 PMID: 22621154 https://doi.org/10.5694/mja10.11474 25. Bajaj K, Minors A, Walker K, Meguerdichian M, Patterson M. “No-go considerations” for in situ simulation safety. Simul Healthc. 2018;13(3):221–224 PMID: 29621037 https://doi.org/10.1097/SIH.0000000000000301 26. Paige JB, Morin KH. 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Colman N, Doughty C, Arnold J, et al. Simulation-based clinical systems testing for healthcare spaces: from intake through implementation. Adv Simul (Lond). 2019;4:19 PMID: 31388455 https://doi.org/10.1186/s41077-019-0108-7

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32. Resuscitation and stabilization of babies born preterm. In: Weiner GM, ed. Textbook of Neonatal Resuscitation. 7th ed. American Academy of Pediatrics; 2016:225–242 33. Lopreiato JO. Healthcare Simulation Dictionary. Agency for Healthcare Research and Quality; 2016. AHRQ publication 16(17)-0043. Accessed December 16, 2020. https://www.ahrq.gov/sites/default/files/publications/files/sim-dictionary_0.pdf 34. Lewis KL, Bohnert CA, Gammon WL, et al. The Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP). Adv Simul (Lond). 2017;2:10 PMID: 29450011 https://doi.org/10.1186/s41077-017-0043-4 35. O’Brien JE, Hagler D, Thompson MS. Designing simulation scenarios to support performance assessment validity. J Contin Educ Nurs. 2015;46(11):492–498 PMID: 26509401 https://doi.org/10.3928/00220124-20151020-01 36. Downing SM, Haladyna TM. Validity and its threats. In: Downing S, Yudkowsky R, eds. Assessment in Health Professions Education. Routledge; 2009:21–56 https://doi.org/10.4324/9780203880135

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Chapter 3

Simulation and the Neonatal Resuscitation Program® Nicole K. Yamada, MD, MS, FAAP, and Louis P. Halamek, MD, FAAP

Objectives In this chapter, you will 1. Review the origins of the Neonatal Resuscitation Program (NRP®). 2. Describe the incorporation of simulation into the NRP curriculum. 3. Analyze the effect of simulation on changing the educational paradigm of the NRP. 4. Demonstrate how the NRP collaborated with industry to drive patient simulator development and design. 5. Assess the current state of simulation in the NRP.

Introduction The Neonatal Resuscitation Program (NRP) was established by the American Academy of Pediatrics (AAP) in 1987 in response to a national initiative to standardize the care of newborns. The key objectives of the program were to base clinical practice recommendations on the best available evidence and to provide instruction for clinicians on the different types of skills necessary for successful neonatal resuscitation.1,2 In its early years, the NRP followed a traditional paradigm of didactic education through textbook and lecture-based learning coupled with the practice of technical skills on suitable task trainers. This paradigm has evolved significantly since those early years, as the need for more comprehensive team training became apparent, with a focus on the behavioral skills necessary to perform under the intense time pressure of resuscitation. In this chapter, we review the origins of the NRP, describe the incorporation of simulation into the NRP, analyze how simulation changed the traditional paradigm of education and training in the NRP, and demonstrate how the NRP collaborated with industry to drive simulator development and design. Finally, we assess the current state of simulation in the NRP curriculum.

Origins of the NRP The field of neonatology has its genesis in the 1960s, when some pediatricians began to specialize in the care of neonates. However, a focus on the status of the newborn in the delivery room began even earlier, in the early 1950s, with Virginia Apgar’s work.3 Nevertheless, it was not until nearly 30 years later, in the 1980s, that the need for a consistent approach in caring for neonates became a clinical focus. At that time, the AAP Committee on Fetus and Newborn and the AAP Section of Perinatal Pediatrics declared that training in neonatal resuscitation

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was a national priority.1 The subsequent creation of the Resuscitation of the Newborn Task Force resulted in the national goal of having at least 1 professional trained in neonatal resuscitation at every delivery. In 1987, this initiative became the NRP.1 Neonatal resuscitation is a dynamic and complex task. To promptly recognize, successfully resuscitate, and effectively stabilize a neonate in distress, health care professionals must have knowledge of fetal and neonatal physiology; proficiency in technical skills, such as endotracheal intubation and umbilical vessel catheterization; and the ability to manage the technological, pharmacological, and human resources available in the delivery room.4 At its core, the NRP was developed to disseminate standardized clinical guidelines and facilitate acquisition of the content knowledge and technical skills necessary to resuscitate a newborn. However, the scope of this program extends beyond these basic goals to also ensure that clinical practice recommendations are based on the best available evidence; to recognize the cognitive, technical, and behavioral skills necessary for successful neonatal resuscitation; and to appropriately prepare instructors and regionalize training.1

Incorporation of Simulation Into the NRP Simulation was formally introduced into the NRP in 2010, following recommendations from the International Liaison Committee on Resuscitation (ILCOR). After a review of the science on educational techniques for knowledge and skill acquisition and assessment, ILCOR recognized simulation as a methodology that should be used in resuscitation education. ILCOR also recommended that briefings and debriefings be implemented for both simulation-based learning activities and clinical care of actual patients. In response to the scientific evidence and these recommendations, the AAP and the American Heart Association moved to incorporate simulation, briefing, and debriefing into the NRP.5

Why Simulation? The traditional model of health care education and training consists of 3 main components: reading of the literature, observation of others with more experience in the field, and hands-on experience during a defined period in preparation for independent practice.4 Despite its long-standing history, this educational method fails to adequately meet the learning needs of adult health care professionals. Research has shown that adult learners are independent, self-directed, internally motivated, and eager to learn because of the social and professional roles they fill in their daily lives. They seek immediate applications for knowledge gained, and as they accumulate experience, it serves as a foundation and resource for their ongoing intellectual development.6 Additionally, optimal acquisition and retention of knowledge and skills by adults have been shown to be achieved through active participation, rather than passive observation.7 As a result, the needs of adult learners are better met through experiential learning, such as those experiences available in simulated environments.8 Simulation-based training immerses trainees in realistic situations populated with enough key visual, auditory, and tactile cues to prompt trainees to respond as they would in real life. Simulation-based training has been used for decades in industries outside of health care that are characterized by a similar high risk to human life, including aerospace, commercial aviation, the military, and the nuclear power industry. Simulation was first used in medicine in the 1980s for training in the management of critically ill patients in the operating room.9,10 Simulation-based training in neonatal resuscitation was originally developed at Stanford University in 1995, where it was well received by trainees and was shown to effectively recreate the conditions encountered in the delivery room.4 In addition to better meeting the needs of adult learners, simulation-based training has a number of advantages over traditional educational methods: it is a more efficient learning method for trainees, and it is safer for patients.1,2,4,6,8 Simulation also reduces the costs associated with gaining clinical experience by offering an alternative to the expensive patient care environment as the only location for clinical training, and it allows for the

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recycling and reuse of supplies and devices that would normally require disposal if they were used on real patients. In terms of learning efficiency, trainees can engage in simulation-based training at scheduled intervals and experience multiple clinical scenarios within a relatively brief period, rather than having to rely on the random chance of gaining adequate clinical exposure during a prescribed observation period. In doing so, trainees can gain experience with any number of highly realistic clinical situations, including rare but potentially devastating events. Another benefit of simulation is that the degree of difficulty of simulated clinical experiences can be scaled to meet the needs of trainees—be they novices, experts, or learners somewhere in between. Trainees are also allowed to experience the natural evolution of mistakes, without the need for intervention by senior faculty, while avoiding all risk of patient harm or medical liability. Furthermore, simulation provides opportunities for trainees to learn how to cope with mistakes and failures, so that they can manage them appropriately when they occur during the care of real patients.

Changing the Paradigm Despite its advantages, integrating simulation-based training into the NRP faced both cultural and logistic challenges. Like many educational programs that preceded it, the NRP was built on a foundation of textbooks and lectures. It had been successfully delivered to millions of trainees by tens of thousands of instructors in the United States and was extremely popular among trainees and instructors alike. However, acquiring and recalling content knowledge and competence in technical skills alone are insufficient for delivering optimal patient care, when the activity requires working effectively as a team under intense time pressure. Behavioral skills such as communicating effectively, leading, and anticipating and planning for next steps are vital during crises such as newborn resuscitation. Through the development of simulation-based training in neonatal resuscitation at Stanford University in the mid-1990s, a number of innovations in training were created, including an emphasis on integrating cognitive, technical, and behavioral skills; technical performance debriefing; and building new, more sophisticated technologies that facilitated the provision of realistic patient and environmental cues. The value of a focus on improving behavioral skills and team training was highlighted in the 2004 Sentinel Event Alert on preventing perinatal death and injury, in which The Joint Commission reported that ineffective communication contributed to nearly 75% of the cases of neonatal mortality and severe neonatal morbidity reported during that year.11 In the same report, The Joint Commission recommended risk reduction strategies that included team training, debriefings to evaluate team performance, and using effective and standardized communication. Recommendations such as these provided the impetus to change the paradigm of education and training in neonatal resuscitation. The NRP had been in existence for nearly 2 decades when the move to integrate simulation-based training occurred. The key strategies for execution were based on the goals of making the changes easily adoptable, uniform, and distributable on a national level. These strategies led to a phased implementation through which instructors were prepared first, followed by distribution of the newly formatted curriculum to trainees. For both groups, culture change was key. Most NRP instructors were accustomed to the traditional educational paradigm in which they were responsible for giving lectures and scoring examinations. Initial fears and uncertainties of instructors about simulation were deconstructed by de-emphasizing the technological aspects of the methodology and demystifying the concepts of debriefing. The Instructor Manual for Neonatal Resuscitation was extensively revised so that it became a comprehensive self-study tool for instructors that included new chapters on simulation and debriefing, as well as an appendix of resources for scenario design and debriefing tools.12 An additional instructor resource, the NRP Instructor DVD: An Interactive Tool for Facilitation of Simulation-based Learning, was created to serve as a repository of learning resources for use by instructors in preparation for and during training programs. Video exemplars were provided to clearly illustrate the basics of scenario design and debriefing, including common pitfalls. Among the key points for instructors (Box 3-1) were 2 overarching principles for successful simulation-based training: (a) the quality of a scenario is independent of the technology used and (b) the quality of a debriefing is most

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dependent on the ability of the instructor to facilitate discussion among the learners. In other words, good scenarios can be run with simple technology and still fulfill the learning objectives, and adults learn best when allowed to actively reflect on their performance.13,14 Box 3-1. Key Points for Instructors of Simulation-Based Training • • • • •

Set clear expectations for learners, even before they arrive to the training program. Tailor the training to meet the needs of the learners. Facilitate but do not dominate learning, either during the scenario or at the debriefing. When debriefing, do not lecture. It is not about you; it is about your learners and how they care for their patients.

New expectations were also set for trainees, as they were required to move from being passive learners in lectures to becoming active participants in simulation-based training who were willing to make—and learn from— mistakes. The focus of the curriculum shifted to using simulation to practice and apply the content knowledge and technical skills that were already acquired through other methods. Thus, one of the most significant changes was the removal of content knowledge review from the training program agenda. Instead, trainees were expected to review the Textbook of Neonatal Resuscitation and complete a content knowledge evaluation through an online examination before attending an NRP hands-on training course. The basics of technical skills were reviewed in the textbook so that they could then be practiced and evaluated at skills stations in an expeditious fashion during the course (termed a “flipped classroom” approach). Finally, the emphasis of training was placed onto actively participating in realistic simulated scenarios during which learners are challenged to incorporate cognitive, technical, and behavioral skills, followed by debriefings facilitated by NRP instructors. These simulated clinical scenarios are tailored to challenge learners at all levels of proficiency (Box 3-2), and debriefings are deliberately focused on individual performance, how that performance affects performance of the team, and how team performance influences patient outcome. Box 3-2. Key Points for Learners in Simulation-Based Training • Come prepared to the training program; content knowledge and technical skills should be reviewed before arrival at the training program. • Behave in scenarios as you do in real life. • Be willing to make mistakes and learn from them. • Maintain confidentiality of performance and content. • It is not about you; it is about your patients.

With the adoption of simulation-based training, the NRP set a new standard for training in neonatal resuscitation, as well as resuscitation training within the Pediatric Advanced Life Support (or “PALS”), Advanced Cardiac Life Support (or “ACLS”), and Advanced Pediatric Life Support (or “APLS”) programs.15 The emphasis on active learning by participants, realistic simulations, and objective debriefings in the NRP follows the example set by other industries in which the risk to human life is high.

Driving Simulator Development and Design With the development of simulation-based training for neonatal resuscitation, it became apparent that there was a need for a realistic neonatal patient simulator that could accurately represent the physiological alterations intrinsic to the neonate in distress. Most human neonatal simulators available in the 1990s and early 2000s had low anatomical fidelity and little to no capability to represent important physiological cues, including spontaneous respirations, generation of heart tones, movement of or alteration in muscle tone, or change in skin color. Given that heart rate, respiratory activity, and skin color are all major cues that determine the need for initiating, escalating, and terminating resuscitative measures in caring for neonates, the unavailability of all 3 of these cues in a newborn mannequin made effective simulation-based training difficult. In 2005, driven by this lack of a realistic

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neonatal patient simulator, the NRP Steering Committee created, vetted, and published a list of desired features in a request for proposal (RFP) to the patient simulator industry to foster the creation of a realistic human neonatal patient simulator.1 By publishing an RFP, the NRP was able to make certain that all potential manufacturers had access to the minimum requirements necessary for a neonatal patient simulator that met the NRP learning objectives. This was the first time that developing a highly realistic patient simulator was driven by a professional body rather than the internal marketing objectives of industry. In this RFP, the NRP made the distinction between “necessary” features and “useful” features on the basis of NRP learning objectives. Features deemed “necessary” were to be inherent to the base platform of the simulator, whereas features considered “useful” were to be incorporated only if development time was short and the cost relatively low. Through this approach, the NRP ensured that the focus remained on creating a patient simulator that met the needs of its eventual users in a cost-effective manner, rather than an expensive and technologically complex device that could be difficult to use and therefore have limited application (Tables 3-1 and 3-2).

Table 3-1. Desired Features for a Full-term Neonatal Patient Simulator Feature

Variables Necessary features (inherent in a standard platform)

Heart tones

Minimum of 3 rates (0, 50, 150 beats/min) Fixed intensity (loud)

Breath sounds

Minimum of 4 spontaneous RRs (0, 30, 60, 100 breaths/min) Fixed intensity (loud) Fixed laterality (present on both right and left sides)

Chest rise

Passive, in response to positive pressure airflow into lungs

Airway and lungs

Allows transmission of positive pressure airflow delivered by BMV or intubation with an ETT Allows for intubation with an ETT Useful features (considered an upgrade or addition to the base platform)

Heart tones

Variable rate of 0–300 beats/min Variable intensity, from soft to loud Spontaneous generation of electrocardiographic signals Cardiac dysrhythmias

Breath sounds

Variable spontaneous RR of 0–120 breaths/min Variable intensity, from soft to loud Variable laterality (differential transmission to right and left sides)

Chest rise

Moves in synchrony with spontaneous breaths

Airway

Reservoir for simulated meconium Patent nares connected to posterior pharynx Nares that can be occluded Palpable cricothyroid membrane that can be incised

Color change

Lips with a capacity to turn from blue to red (continued)

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Table 3-1 (continued) Useful features (continued) Feature Vascular features

Variables Palpable pulses at the umbilicus and brachial artery Patent umbilical vein to allow cannulation Reservoir for simulated blood at the end of the umbilical vein Patent umbilical artery to allow cannulation Reservoir for simulated blood at the end of the umbilical artery

Esophagus

Connected to the stomach Allows passage of a suction catheter Can be occluded

Prostheses

Gastroschisis (abdomen) Omphalocele (abdomen) Myelomeningocele (posterior thorax) Polydactyly (hands) Bilateral flank masses (lateral abdomen) Nasopharyngeal teratoma (mouth) Cleft lip and/or palate (mouth) Edema (thorax and abdomen) Cystic hygroma (neck) Different skin tones Miscellaneous features

Upper-airway noise

Audible stridor, in synchrony with inspirations Audible grunting, in synchrony with exhalations

Chest wall allowing for incision and placement of tube into pleural space

Reservoir for air, to simulate pneumothorax

Chest wall allowing for incision and placement of tube into pericardium

Reservoir for fluid, to simulate pericardial effusion

Abdominal wall allowing for incision and placement of tube into peritoneum

Reservoir for fluid, to simulate ascites

Spontaneous movement

With articulation at multiple joints: head, neck, shoulders, elbows, wrists, waist, hips, knees, and ankles

Reservoir for fluid, to simulate pleural effusion

Abbreviations: BMV, bag-mask ventilation; ETT, endotracheal tube; RR, respiratory rate. Adapted from American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee. Desired Features for Industry for the Development of a Realistic Neonatal Human Patient Simulator. American Academy of Pediatrics; 2005.

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Table 3-2. Desired Features for a Preterm Neonatal Patient Simulator Feature

Variables Necessary features (inherent in a standard platform)

Anthropometric features

Physical features consistent with a preterm neonate (eg, relatively large head in comparison to size of the body) Weight, length, and head circumference at the 50th percentile for gestational age

Portability

Realistic simulation of the delivery of a human neonate requires that the simulator be carried from the mother’s bed to the radiant warmer for resuscitation.

Heart tones

Minimum of 5 rates (0, 30, 60, 90, 150 beats/min) Fixed intensity (loud) May originate from a device (eg, stethoscope) external to the simulator

Breath sounds

Minimum of 4 spontaneous RRs (0, 30, 60, 100 breaths/min) Fixed intensity (loud) Fixed laterality (present on both right and left sides) May originate from a device (eg, stethoscope) external to the simulator

Thorax

Chest rise is passive, in response to positive pressure airflow into the lungs. Provides a realistic degree of resistance during chest compressions

Airway and lungs

Allows transmission of positive pressure airflow delivered by BMV or intubation with an ETT Allows for intubation with an ETT Allows for placement of nasal prongs

Vascular features

Patent umbilical vein to allow cannulation Reservoir for simulated blood at the end of the umbilical vein Patent umbilical artery to allow cannulation Reservoir for simulated blood at the end of the umbilical artery Useful features (considered an upgrade or addition to the base platform)

Heart tones

Variable rate of 0–300 beats/min Variable intensity, from soft to loud Spontaneous generation of electrocardiographic signals Cardiac dysrhythmias

Breath sounds

Variable spontaneous RR of 0–120 breaths/min Variable intensity, from soft to loud Variable laterality (differential transmission to right and left sides)

Thorax

Chest rise is active, moving in synchrony with spontaneous breaths.

Airway

Trachea that can be occluded Mainstem bronchus that can be occluded Nares that can be occluded Patent nares connected to the posterior pharynx (continued)

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Table 3-2 (continued) Useful features (continued) Feature

Variables

Color change

Lips, tongue, and/or central thorax with a capacity to turn from blue to red

Vascular features

Palpable pulses at the umbilicus and brachial artery

Esophagus

Connected to the stomach Allows passage of a suction catheter Can be occluded

Prostheses

Edema (thorax and abdomen) Different skin tones Miscellaneous features

Upper-airway noise

Audible stridor, in synchrony with inspirations; adjustable volume Audible grunting, in synchrony with exhalations; adjustable volume Audible crying, in synchrony with exhalations; adjustable volume

Chest wall allowing for incision and placement of tube into pleural space

Reservoir for air, to simulate pneumothorax

Chest wall allowing for incision and placement of tube into pericardium

Reservoir for fluid, to simulate pericardial effusion

Abdominal wall allowing for incision and placement of tube into peritoneum

Reservoir for fluid, to simulate ascites

Spontaneous movement

With articulation at multiple joints: head, neck, shoulders, elbows, wrists, waist, hips, knees, and ankles

Reservoir for fluid, to simulate pleural effusion

Additional useful features Responses of the simulator to interventions

Realistic and based on physiological models housed within the simulator or in an external device, such as a handheld or laptop computer

Provision of objective feedback

Strategically placed sensors to not only drive the physiological models but also provide feedback (and a downloadable performance record) to the trainee key sensors; can be used to measure parameters such as airflow, air pressure and oxygen concentration in the airway and lungs, rate of ventilation, rate and depth of chest compressions, position of ETT in the trachea or esophagus, position of umbilical catheters in the umbilical arteries and vein, pressure in the pleural space, presence of chest tubes in the pleural space, presence of foreign material in the proximal airway, and similar variables

Abbreviations: BMV, bag-mask ventilation; ETT, endotracheal tube; RR, respiratory rate. Adapted from American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee. Desired Features for Industry for the Development of a Realistic Preterm Neonatal Human Patient Simulator. American Academy of Pediatrics; 2013.

The success of the potential professional business relationship between the NRP and the company that would seek to develop the next neonatal patient simulator depended on clarity by both parties regarding their distinct responsibilities. The primary responsibility of the NRP was to define the specific learning objectives and relevant features that the patient simulator should have. The company was expected to bring technical expertise, as well as the flexibility to work with a professional body whose primary focus was on education rather than profit. Both the NRP and the prospective partners had to demonstrate openness to continuing dialogue that challenged assumptions by either party and led to creative and cost-effective solutions. Direct involvement of engineers and other technical and educational design experts early in the development process was vital to an efficient and

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productive partnership. The goal of the NRP was to select a company that respected the program’s educational approach, understood its organizational mission, exhibited a commitment to learning innovation, and shared its vision for the end product. As a result, the vetting process to find this partner was intentionally lengthy to ensure consistency in philosophy, approach, and application within all levels of the organization over time. After careful review, in 2006 the AAP formally partnered with Laerdal (Stavanger, Norway) to build the world’s first sophisticated full-term neonatal patient simulator; the SimNewB became available in 2008. In 2015, the SimNewB was joined by Premature Anne, a sophisticated preterm neonatal patient simulator, also designed on the basis of the NRP learning objectives. However, these are only 2 models; there are many other commercially available neonatal mannequins on the market.

Current State of Simulation in the NRP Built on a solid foundation of methodology and technology specifically driven by NRP learning objectives, the use of simulation-based training within the NRP continues to grow. To date, the simulation-based curriculum has been taught by more than 22,000 NRP instructors to more than 1.1 million NRP providers. With more than 10,000 new NRP instructors trained since the implementation of the simulation-based curriculum, the NRP continues to evolve and adapt to the needs of health care professionals who care for neonates in the United States and the world. The NRP continues to evolve for instructors as well with the addition of the Instructor Mentor role in recognition of the coaching and practice needed for NRP instructors to become facile with simulation and debriefing. In addition, the NRP Instructor DVD has been retired and replaced by the NRP Instructor Toolkit, an online resource with written, video, and webinar content that covers topics such as facilitating simulation, debriefing techniques, and coaching new debriefers.16 Through its continued evolution, the NRP remains relevant to professionals from multiple disciplines, at all levels of experience. With the revision of clinical guidelines and concomitant curriculum updates, the NRP strives to include new and robust learning opportunities for health care professionals while also challenging instructors to shift from the role of teachers attempting to drill knowledge into trainees to that of facilitators fostering acquisition of skills by learners.2,17

Summary Since its introduction into neonatal-perinatal medicine in the 1990s and its formal integration into the NRP in 2010, simulation has become a key component of learning for all health care professionals charged with newborn resuscitation. Over nearly 3 decades, this shift in training methodology has led to the evolution of trainee learning from a passive activity to an active process that engages and acknowledges trainees as adult learners, whose knowledge and skill acquisition is facilitated by instructors. Successful simulation-based training depends on scenarios that fulfill the defined learning objectives of the curriculum, learners who behave in simulation as they would in real life, and opportunities for learners to reflect on their performance through facilitated debriefings. The key to the sustained value of simulation-based training in the NRP and throughout health care is the understanding and expectation that errors will and should occur during training. It can be argued that we learn best from our mistakes, and simulation provides an opportunity for that learning to occur without injuries to real patients. High-stakes simulation-based training should be embraced as the standard in preparing for and assessing performance in the real clinical environment.18 By continuing to push both learners and their instructors to take advantage of these learning opportunities, we can continue to improve the care of newborns in the United States and around the world.

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Central Points ▶ The NRP was developed to disseminate clinical guidelines and facilitate acquisition of the content knowledge and technical skills necessary to resuscitate a newborn in a standardized fashion. However, the scope of this program has grown beyond these initial goals. ▶ The traditional paradigm of health care education and training that consists primarily of didactics and observational learning is insufficient to fully meet the comprehensive needs of health care professionals. Simulationbased training can effectively overcome many of these limitations. ▶ The emphasis on experiencing, managing, and debriefing performance failures, in addition to successes, has revolutionized how training in neonatal resuscitation is delivered to millions of health care professionals in the United States. ▶ By using learning objectives to define technological features, the NRP was able to work with industry to drive the development and design of human patient simulators that meet the needs of end users in a cost-effective manner. ▶ The model of simulation-based training adopted by the NRP continues to evolve to better achieve the learning objectives of its trainees and serves as an example for other training programs in pediatric and adult resuscitation.

References 1. Halamek LP. The genesis, adaptation, and evolution of the Neonatal Resuscitation Program. NeoReviews. 2008;9(4): e142–e149 https://doi.org/10.1542/neo.9-4-e142 2. Ades A, Lee HC. Update on simulation for the Neonatal Resuscitation Program. Semin Perinatol. 2016;40(7):447–454 PMID:27823817 https://doi.org/10.1053/j.semperi.2016.08.005 3. Philip AG. The evolution of neonatology. Pediatr Res. 2005;58(4):799–815 PMID:15718376 https://doi.org/10.1203/01. PDR.0000151693.46655.66 4. Halamek LP, Kaegi DM, Gaba DM, et al. Time for a new paradigm in pediatric medical education: teaching neonatal resuscitation in a simulated delivery room environment. Pediatrics. 2000;106(4):e45 PMID:11015540 https://doi. org/10.1542/peds.106.4.e45 5. Perlman JM, Wyllie J, Kattwinkel J, et al; Neonatal Resuscitation Chapter Collaborators. Part 11: neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010;122(16)(suppl 2):S516–S538 PMID:20956259 https://doi.org/10.1161/ CIRCULATIONAHA.110.971127 6. Murphy AA, Halamek LP. Simulation-based training in neonatal resuscitation. NeoReviews. 2005;6(11):e489–e494 https://doi.org/10.1542/neo.6-11-e489 7. Slamecka NJ, Graf P. The generation effect: delineation of a phenomenon. J Exp Psychol Hum Learn. 1978;4(6):592–604 https://doi.org/10.1037/0278-7393.4.6.592 8. Arnold J. The Neonatal Resuscitation Program comes of age. J Pediatr. 2011;159(3):357–358.e1 PMID:21846521 https://doi.org/10.1016/j.jpeds.2011.05.053 9. Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment: re-creating the operating room for research and training. Anesthesiology. 1988;69(3):387–394 PMID:3415018 https://doi.org/10.1097/00000542-198809000-00017 10. Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med. 1992;63(9):763–770 PMID:1524531 11. The Joint Commission. Preventing infant death and injury during delivery. Sentinel Event Alert. 2004;30. Published July 21, 2004. Accessed December 16, 2020. http://www.jointcommission.org/assets/1/18/SEA_30.pdf 12. Zaichkin J, ed. Weiner G, Major C, associate eds. Instructor Manual for Neonatal Resuscitation. American Academy of Pediatrics and American Heart Association; 2011 13. Roberts NK, Williams RG, Kim MJ, Dunnington GL. The briefing, intraoperative teaching, debriefing model for teaching in the operating room. J Am Coll Surg. 2009;208(2):299–303 PMID:19228544 https://doi.org/10.1016/j.jamcollsurg.2008.10.024

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14. Amin HJ, Aziz K, Halamek LP, Beran TN. Simulation-based learning combined with debriefing: trainers satisfaction with a new approach to training the trainers to teach neonatal resuscitation. BMC Res Notes. 2013;6(1):251 PMID:23827017 https://doi.org/10.1186/1756-0500-6-251 15. Cheng A, Rodgers DL, van der Jagt É, Eppich W, O’Donnell J. Evolution of the Pediatric Advanced Life Support course: enhanced learning with a new debriefing tool and Web-based module for Pediatric Advanced Life Support instructors. Pediatr Crit Care Med. 2012;13(5):589–595 PMID:22596070 https://doi.org/10.1097/PCC.0b013e3182417709 16. Sawyer T, Ades A, Ernst K, Colby C. Simulation and the Neonatal Resuscitation Program 7th edition curriculum. NeoReviews. 2016;17(8):e447–e453 17. Halamek LP. Simulation in neonatal-perinatal medicine. In: Martin RJ, Fanaroff AA, Walsh MC, eds. Fanaroff & Martin’s Neonatal-Perinatal Medicine. Elsevier Inc; 2015:89–97 18. Halamek LP. Simulation and debriefing in neonatology 2016: mission incomplete. Semin Perinatol. 2016;40(7):489–493 PMID:27810117 https://doi.org/10.1053/j.semperi.2016.08.010

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Chapter 4

Mannequins and Task Trainers Taylor Sawyer, DO, MEd, CHSE-A, FAAP; Megan M. Gray, MD; and Rachel A. Umoren, MB, BCh, MS, FAAP

Objectives In this chapter, you will 1. Recognize that simulation modalities should be selected on the basis of the desired learning outcomes. 2. Describe various types of mannequins and task trainers. 3. Compare the benefits and limitations of various neonatal task trainers and mannequins. 4. Differentiate simulator technology from simulator fidelity. 5. Recognize unmet needs and future directions for neonatal task trainers and mannequins.

Introduction Simulation is a frequently used educational medium for neonatal education and training.1,2 The 7 major simulation modalities include (a) task trainers, (b) mannequins, (c) computer-based systems, (d) virtual reality, (e) haptic systems, (f) standardized (simulated) patients, and (g) animal models. Generally, task trainers and mannequins are the most commonly used simulation modalities in simulation-based education. In this chapter, we review the use of task trainers and mannequins in simulation-based neonatal education, compare and contrast commercially available neonatal task trainers and mannequins, differentiate simulator technology and simulator fidelity, and examine the concept of functional task alignment. We conclude with an analysis of future directions in neonatal task trainers and mannequins.

Background Simulation is the primary instructional method used to train health care professionals in neonatal resuscitation and neonatal procedural skills, as well as behavioral and teamwork skills that are critical to newborn care. The simulation modality selected should align with the desired learning outcomes or competency domains, which fall into 3 general skill areas: cognitive, technical, and behavioral. Selection of the mannequin or task trainer starts after the learning objectives have been determined. The learning objectives drive the decision of which task trainer or mannequin should be used, including the choice between high technology and low technology. The mannequin or task trainer should be the appropriate size and dimensions for the scenario, such as a preterm neonatal mannequin for a scenario involving a neonate born at 28 weeks of gestational age, and should provide learners with the appropriate cues to enable them to advance through the scenario—ideally without additional instructor input. Additionally, a “dress rehearsal” should be performed before the session to determine whether the selected mannequin provides the appropriate feedback and is suitable to meet the learning objectives. In this sense, the process

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is an iterative one that requires planning. Instructors should also consider creating a backup plan, if the equipment is unavailable or does not function in the desired way on the day of the simulation. Task trainers are partial-body (eg, head, arm) or whole-body simulators used for training in specific technical procedures (Table 4-1) and are thus used during simulation experiences that focus on acquiring and maintaining cognitive and technical skills. Task trainers allow learners to repetitively practice a procedural skill by replicating specific actions required to perform a procedure in the actual clinical environment, without posing a risk to actual patients. For example, during neonatal-perinatal medicine training “boot camps,” incoming trainees learn and practice neonatal intubation, chest tube insertion, and exchange transfusions before starting clinical rotations.3 Similarly, experienced providers can practice and maintain their skills, especially for procedures such as pericardiocentesis and electro-cardioversion, which are rarely performed during clinical care.4

Table 4-1. Neonatal Airway Task Trainers Task trainer

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Representation

Price, $ (U.S. dollar)*

Gestational age

Description and features

Neonatal Intubation Trainer (Laerdal Medical)

600

Preterm newborn (34 weeks of gestation)

Intubation with 3.0F ETT. Size 1 LMA. Neonatal head attached to base with removable cover. No chest cavity. Has plastic bags for lungs.

Newborn Airway Management Skills Trainer (Gaumard Scientific)

600

Full-term newborn

Intubation with 3.5F ETT. Size 1 LMA. Soft neck with cricoid cartilage. Chest rises during ventilation. Nasal passage permits placement of nasopharyngeal tube.

Infant Airway Management Trainer (Laerdal Medical)

800

1-month-old newborn

Intubation with 3.5F or 4.0F ETT. Size 1 or 1.5 LMA. Neonatal head attached to base. No chest cavity. Has plastic bags for lungs.

Newborn Airway Trainer (SynDaver Labs)

1,500

Preterm newborn (30 weeks of gestation)

Intubation with 3.0F ETT. Size 1 LMA. Neonatal head and neck without base. No chest cavity or lungs. Composed of SynTissue synthetic tissues made from salt, water, and fiber. Requires storage in fluid.

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Table 4-1 (continued) Task trainer

Representation

Price, $ (U.S. dollar)*

Gestational age

Description and features

AirSim Baby X (TruCorp)

2,000

Full-term, 6-month infant

Intubation with 3.5F or 4.0F ETT. Size 1 LMA. Neonatal head attached to base. No chest cavity. Has plastic balloons for lungs.

AirSim Pierre Robin X (TruCorp)

2,000

Full-term, 6-month infant with Pierre Robin sequence

Intubation with 3.5F or 4.0F ETT. Size 1 LMA. Neonatal head attached to base. No chest cavity. Has plastic bags for lungs.

Abbreviations: ETT, endotracheal tube; LMA, laryngeal mask airway. * Prices reflect manufacturer quotes and advertised prices collected by the authors, rounded to the nearest $100 U.S. dollar. Actual prices may vary.

Mannequins, also referred to as human patient simulators, are whole-body simulators with varying degrees of interactivity (Table 4-2). They include features such as representations of heartbeat, respirations, and neurological tone, and they may be computerized or manually manipulated (eg, the NeoNatalie mannequin [Laerdal Medical] used during the Helping Babies Breathe course). Mannequins are generally used for simulation learning experiences that focus on cognitive and behavioral learning objectives that require the health care team to work collaboratively to care for the patient (mannequin) as they would in the actual clinical environment. Examples include interprofessional teamwork training in neonatal resuscitation and neonatal intensive care unit urgent care drills.5 Although neonatal mannequins are primarily used for team training, they can also be used to practice technical skills, such as endotracheal intubation, umbilical catheterization, needle thoracentesis, and intraosseous (IO) needle insertion (Table 4-2). Alternatively, educators can use both a mannequin and a task trainer during a scenario, particularly when a mannequin does not have capabilities for a specific procedure. In such experiences, the mannequin simulates the patient, and the task trainer is placed into the field to enable learners to perform the procedure. Additionally, the use of a task trainer within mannequin simulation capitalizes on the benefits of multiple learners practicing the skill on the less expensive task trainer, for which worn or damaged parts can be replaced fairly easily and without significant cost, while still using the more realistic features of the mannequin. Combining a task trainer and a mannequin thus allows teams to practice cognitive, technical, and behavioral skills within a single session.6

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Technological level

Price, $ (U.S. dollar)*

Gestational age

Premie HAL S108.100 (Gaumard Scientific)

Low

1,500

24 wk

Premature Anne Task Trainer (Laerdal Medical)

Low

Newborn Anne (Laerdal Medical)

Low

Mannequin

Representation

2,500

25 wk

Size (weight and length)

Features

Medical procedures

590 g, 31.75 cm

Inflatable lungs

Endotracheal intubation (2.5F ETT)

Manual brachial, femoral, and umbilical pulses via squeeze bulb

Umbilical catheterization

750 g, 30.5 cm

Inflatable lungs

Endotracheal intubation (2.5F ETT)

IV catheter placement

Umbilical catheterization IV catheter placement (dry ports only)

2,200

Full-term newborn

3.5 kg, 51 cm

Inflatable lungs

Endotracheal intubation (3.5F ETT)

Manual umbilical pulse via squeeze bulb

Umbilical catheterization Needle thoracentesis (midaxillary line) IO access

Premature Anne, Standard (Laerdal Medical)

Moderate

8,500

25 wk

750 g, 30.5 cm

Inflatable lungs

Endotracheal intubation (2.5F ETT)

Heart sounds, breath sounds, vocal sounds, cyanosis

Umbilical catheterization IV catheter placement (dry ports only)

NEONATAL SIMULATION: A PRACTICAL GUIDE

Table 4-2. Mannequins

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Premie HAL S3009 (Gaumard Scientific)

High

16,000

30 wk

1.3 kg, 40 cm

Cyanosis

Endotracheal intubation (2.5F ETT)

Breath sounds

Umbilical catheterization

Heart sounds

IO access

Chest movement, manual umbilical pulse via squeeze bulb

IV catheter placement

Vocal sounds Umbilical, brachial, and femoral pulses Newborn HAL (Gaumard Scientific)

High

19,000

Full-term newborn

2.3 kg, 53 cm

Cyanosis

Endotracheal intubation (3.0F ETT)

Breath sounds

Umbilical catheterization

Heart sounds, chest movement

IO access

Umbilical and brachial pulses, tone

IV catheter placement

Vocal sounds Seizure Tetherless/battery operated SimNewB (Laerdal Medical)

High

24,000

Full-term newborn

3.5 kg, 51 cm

Endotracheal intubation (3.5F ETT)

Breath sounds

Umbilical catheterization

Heart sounds, chest movement Umbilical and brachial pulses, tone

Needle thoracentesis (midaxillary line)

Vocal sounds

IO access

Seizure

IV catheter placement

Tetherless/battery operated (continued)

CHAPTER 4. MANNEQUINS AND TASK TRAINERS

Cyanosis

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Mannequin Newborn Tory (Gaumard Scientific)

Representation

Technological level

Price, $ (U.S. dollar)*

High

22,000

Gestational age

Size (weight and length)

Full-term newborn

2.7 kg, 53 cm

Features

Medical procedures

Cyanosis

Endotracheal intubation (3.5F ETT)

Breath sounds

Umbilical catheterization

Heart sounds

Needle thoracentesis

Chest movement

IO access

Umbilical, femoral, and brachial pulses Vocal sounds Seizure Tetherless/battery operated NENASim (Medical X)

High

23,000

Newborn

4.6 kg, 55 cm

Cyanosis

Endotracheal intubation (3.5F ETT)

Breathing

Peripheral IV access

Heart sounds

IO access

Chest movement Vocal sounds Femoral pulses Head and eyes movement Bulging fontanelle Tetherless/battery operated

NEONATAL SIMULATION: A PRACTICAL GUIDE

Table 4-2 (continued)

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Super Tory (Gaumard Scientific)

Very high

40,000

Full-term newborn

3.6 kg, 53 cm

Cyanosis

Endotracheal intubation (3.5F ETT)

Capillary refill

Umbilical catheterization

Breath sounds

Peripheral IV access in hand or scalp

Heart sounds Chest movement

Midaxillary line sites for needle decompression and chest tube

Umbilical, brachial, and femoral pulses

IO access

Vocal sounds Seizure Programmable airway and lung functions, including lung compliance, bronchi resistance, and respiratory effort that triggers ventilator Tetherless/battery operated Paul (SIMCharacters)

Very high

55,000

27 wk

1 kg, 35 cm

Cyanosis

Endotracheal intubation (2.5F ETT)

Breathing

Umbilical catheterization

Heart sounds

Peripheral IV access

Chest movement Umbilical, femoral, and brachial pulses Vocal sounds Seizure

Tetherless/battery operated Abbreviations: ETT, endotracheal tube; IO, intraosseous; IV, intravenous. * Prices reflect manufacturer quotes received by the authors in June 2018, rounded to the nearest $100 U.S. dollar. Actual prices may vary. Prices may reflect both the mannequins and the required peripheral devices (eg, control module or laptop, compressors). Additional options (eg, display monitors, simulation scenario packages, on-site instructions) and extended warranties can be purchased at additional cost.

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Abdominal distention to simulate necrotizing enterocolitis

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Neonatal Task Trainers Neonatal task trainers are designed for practicing common neonatal procedures, such as endotracheal intubation, peripheral intravenous (IV) catheter insertion, and umbilical catheter placement. There are a variety of commercially available neonatal task trainers. However, because not all neonatal procedural training needs have been met by these commercially available task trainers, educators occasionally create custom, innovative task trainers or rely on animal models to meet their specific needs. Specific types of neonatal task trainers are reviewed as follows.

Airway Trainers The 2 primary types of neonatal airway trainers used for mask ventilation are head-only and head and upper torso trainers, additionally designed for laryngeal mask airway placement and endotracheal intubation. Head-only airway task trainers have a head, a mouth, a tongue, a pharynx, vocal cords, and tracheas of variable lengths. Head and upper torso airway task trainers have the same features, but they also include a chest cavity and simulated lungs. Task trainers are designed to closely resemble the anatomical airway of a neonate, with a large occiput, no teeth, and a relatively mobile mandible. The head is designed to allow flexion and extension, but most neonatal airway task trainers have limited side-to-side or rotational motion. Several sizes of commercially available airway task trainers simulate a full-term infant, a preterm infant, and difficult airway types. The benefits of airway task trainers lie in a lower cost, compared to the cost of whole-body mannequins; the ease with which worn or broken components can be replaced; and their compact size, which allows for easy storage and transport. Potential drawbacks include the limited scope beyond airway skills training, the inability to change the airway difficulty level (mono-configuration), the lack of secretions, and the rubbery texture that fails to mimic the tissues of a real patient. Additionally, a primary drawback to head-only task trainers is the inability to visualize chest rise with positive pressure ventilation, which is a key visual cue of effective ventilation. Examples of airway task trainers and an overview of their key features are outlined in Table 4-1.

Vascular Access Trainers Vascular access trainers include venous, arterial, and IO access models. Most vascular access trainers are standalone limbs (arm or leg), and the vessels are typically narrow-caliber rubber tubing, which can be filled with artificial blood and accessed with a needle or an IV catheter. The “skin” is typically replaceable thin rubber or silicone that provides a realistic feel during puncture with a needle. Once vascular access is achieved, the trainer provides user feedback and confirmation of placement within the vessel, which is evidenced by the return of artificial blood into the needle or IV catheter (Figures 4-1 and 4-2). Vascular access task trainers are used to practice peripheral and central IV catheter insertion.

IO Access Trainers IO access trainers typically include a hollow plastic tibia that can be filled with artificial blood. An IO needle can be inserted into the chamber to achieve access and simulate blood and/or marrow aspiration (Figures 4-3 and 4-4). Successful IO needle insertion will result in the return of blood into the needle and syringe. Replaceable Figure 4-1. The Life/form Infant IV Arm from Nasco. parts can be replaced once the “skin” and artificial bone become worn from excessive punctures. These types of task trainers have the advantage of providing a more accurate representation of the size, look, and feel of a lower extremity of a newborn or an infant and can be reused several times, unlike food-based trainers, such as poultry drumsticks.

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Figure 4-2. The Nita Newborn from Laerdal Medical.

Figure 4-4. The Life/form Intraosseous Simulator from Nasco. Trainer (A) and trainer with additional tibia bones (B) are shown. Figure 4-3. The Laerdal Intraosseous Trainer from Laerdal Medical.

Lumbar Puncture Trainers Infant lumbar puncture (LP) trainers include partial-body or whole-body models. The trainers simulate infants curled into an appropriate position for LP, with palpable hip and spinal landmarks. The trainers incorporate rubber tubing to emulate the subarachnoid space that can be filled with fluid (water) to simulate spinal fluid. When the spinal needle is placed correctly and advanced through the “skin” into the intervertebral space, it penetrates the rubber tubing, and spinal fluid flows into the spinal needle. The fluid can be collected by the operator. The trainers also allow practice in sterile technique with sterile equipment, such as gloves, drapes, and skin cleansers. Examples of infant LP trainers are shown in Figures 4-5, 4-6, 4-7, and 4-8.

Umbilical Catheter Trainers Umbilical catheter trainers are used to practice the placement of umbilical venous catheters and/or umbilical arterial catheters. A variety of these task trainers are commercially available (Figures 4-9 and 4-10). These are typically low-technology whole-body mannequins with an integrated umbilical cord; however, most hightechnology mannequins also include an umbilicus (see Table 4-2). An alternative to simulated umbilical catheter trainers is the use of preserved human umbilical cords. Umbilical cords can be collected, stored in a saline solution for a short period, and subsequently cut into 7- to 10-cm segments. A plastic, disposable infant feeding

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Figure 4-8. The Pediatric Lumbar Puncture Simulator from Limbs & Things.

Figure 4-5. The LumbarPunctureBaby from Simulab.

Figure 4-9. The Baby Umbi from Laerdal Medical.

Figure 4-6. The Life/form Pediatric Lumbar Puncture Simulator from Nasco.

Figure 4-10. Paul, the preterm infant simulator from SIMCharacters.

Figure 4-7. The Baby Stap from Laerdal Medical.

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bottle is filled with artificial blood, and a regular bottle nipple cut across the top is placed onto the bottle. The cut umbilical cord is then partially fed through the bottle nipple, as shown in Figure 4-11. The handling of human tissue in the simulation laboratory presents a unique challenge in ensuring that proper infection control procedures are followed, from acquisition to use and disposal of human waste. Learners should be provided with proper protective equipment during these sessions, and all areas should be cleaned and disinfected thoroughly afterward.

Miscellaneous and Custom-made Trainers Several other types of task trainers are commercially available, for tasks such as circumcision performance and congenital hip dislocation assessment (Figures 4-12 and 4-13). The paucity of neonatal-sized task trainers for less common neonatal procedures has created an ever-growing market for the development of additional task trainers. Thus, some educators and researchers create their own models to fulfill this unmet need. It is anticipated that in the future, many more neonatal task trainers will be available as manufacturers respond to the growing demand for more realistic models.

Figure 4-11. An umbilical cord simulator can be created by placing a preserved length of human umbilical cord into a baby bottle. Umbilical cords can be collected and stored in a saline solution for a short period. Then they can be cut into 7- to 10-cm segments and partially fed through a bottle nipple, which is cut across the top and placed onto a plastic, disposable infant feeding bottle. The bottle is filled with artificial blood.

Neonatal Mannequins Neonatal mannequins are whole-body representations of a newborn or young infant. A variety of neonatal mannequins are commercially available, and they span a wide range of gestational ages and sizes. The number and types of commercially available mannequins continue to increase. Most neonatal mannequins provide a platform to practice cardiopulmonary resuscitation, including airway management, heart rate or pulse detection, and chest compressions, and several mannequins accommodate emergency venous access via the umbilical vein and/or IO route. Mannequins are categorized as “low technology” or “high technology” according to their degree of computerization and mechanization. Mannequin technology is discussed in more detail in the next section. Whereas task trainers are best suited for technical skills training, whole-body mannequins are best suited for the practice of team training and behavioral skills. Whole-body neonatal mannequins are most commonly used in neonatal resuscitation training that has become

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Figure 4-12. The Infant Circumcision Trainer from Life/form.

Figure 4-13. The Baby Hippy from Laerdal Medical.

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the standard method for the Neonatal Resuscitation Program®.7 Table 4-2 outlines examples of commercially available neonatal mannequins, with an overview of the features of each.

Simulator Technology and Simulator Fidelity Most modern whole-body simulators incorporate a high degree of technology. This technology includes microprocessors to enable computer-controlled functions, motors and solenoids to simulate limb movement, air compressors to simulate lung inflation, blue LED lighting to simulate cyanosis, and microphones to mimic crying and airway sounds, such as grunting. The goal of incorporating this degree of technology is to make the simulator appear more lifelike, via visual and auditory cues. The level of resemblance of a simulator to an actual human is encompassed in the concept of “fidelity.” Fidelity is traditionally divided into 2 theoretical constructs: structural fidelity and functional fidelity.8–10 Structural fidelity is the degree to which a simulator mimics the physical appearance of a human and includes characteristics such as appearance, feel, and auditory cues. Functional fidelity relates to what the simulator does, the degree to which the simulator captures the simulated task, the ways in which a simulator reacts to user actions, and the feedback it provides. Structural fidelity is important for developing technical skills, whereas functional fidelity is important for developing cognitive skills.10 When the simulator is used to practice fine motor skills, it should lead to accurate reproduction of the movements actually needed in the clinical care setting. This way, “negative transfer” is avoided—that is, skills learned incorrectly during simulation and transferred to actual clinical care.11 While simulator technology and fidelity are related, a simulator can have a high level of technology and a low level of fidelity or, conversely, a low level of technology and a high level of fidelity. In some instances, fidelity is sacrificed to be able to enhance the technology. For example, including the necessary electronic equipment to demonstrate tongue edema and laryngospasm might require a mannequin head that is larger than a human infant head. Such design features enhance the technology of the mannequin, at the expense of structural fidelity. Recently, educators and investigators have expressed concerns regarding the structural and functional fidelity of commercially available neonatal whole-body simulators.12,13 There is a need for future investigations to align simulator fidelity with the functions and/or tasks necessary for neonatal training.6

Future Directions and Unmet Needs Gaps exist between commercially available neonatal mannequins and task trainers and the needs of neonatal educators and simulation researchers. Current neonatal simulators, for example, are unable to simulate laryngospasm. Unlike their adult counterparts, neonatal simulators do not simulate different types of subtle seizures, and none currently provide automated feedback to learners. Because these needs are unmet by commercially available simulators, neonatal educators have devised creative ways to develop task trainers to practice specific procedures (see Chapter 8, Neonatal Thoracentesis and Chest Tube Placement Simulation, and Chapter 9, Simulating Neonatal Pericardial Effusion and Cardiac Tamponade). Many innovative models for chest tube insertion and practice of other key neonatal procedures have been developed; however, only a small portion of this work has been published.14–17 In the near future, neonatal task trainers and mannequins that have improved technology and fidelity should become commercially available in a greater number and variety.

Summary The informed choice of simulation modality can greatly enhance the quality of a simulated scenario and further learning outcomes. Simulation modalities vary in their utility, fidelity, benefits, limitations, availability, and cost. Instructors should carefully consider their choice on the basis of desired learning outcomes for each session and

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availability of simulators at each site. In this chapter, a number of commercial neonatal task trainers and mannequins have been reviewed to aid instructors in their choice. However, the paucity of models that meet the complete needs of neonatal educators and simulation programs necessitates the development of newer mannequins or task trainers. Throughout this book, other innovative models that address specific procedures or types of simulations are presented.

Central Points ▶ Task trainers and mannequins are the most commonly used types of simulators in neonatal care. ▶ When designing programs for education or research, educators and researchers should carefully consider the type of simulation modality used, to ensure that the simulation experience is optimized and that the research or learning outcomes are achieved. ▶ Although a large variety of neonatal task trainers and mannequins are available, each has its own benefits and limitations. These should be investigated and considered when educators and researchers are choosing between the different models. ▶ Simulator technology refers to the amount of electrical equipment and technical sophistication included in a simulator, while simulator fidelity refers to how closely the simulator mimics a human in form and function. Balancing the higher cost associated with high-fidelity and high-technology simulators with the level of fidelity and technology needed for a specific simulation is important. Not every simulation requires a high level of fidelity and/or a high level of technology to be successful. ▶ There are many unmet needs in modality design. These have spurred the innovation and development of “homemade” neonatal task trainers to fulfill unmet needs. As the number of commercially available neonatal task trainers and mannequins continues to grow, educators are encouraged to pursue innovative solutions to tailor neonatal simulators to their local needs.

References 1. Mileder LP, Urlesberger B, Szyld EG, Roehr CC, Schmölzer GM. Simulation-based neonatal and infant resuscitation teaching: a systematic review of randomized controlled trials. Klin Padiatr. 2014;226(05):259–267 PMID:25153910 https://doi.org/10.1055/s-0034-1372621 2. Rakshasbhuvankar AA, Patole SK. Benefits of simulation based training for neonatal resuscitation education: a systematic review. Resuscitation. 2014;85(10):1320–1323 PMID:25046744 https://doi.org/10.1016/j.resuscitation.2014.07.005 3. Sawyer T, French H, Soghier L, et al. Boot camps for neonatal-perinatal medicine fellows. NeoReviews. 2014;15(2):e46–e55 https://doi.org/10.1542/neo.15-2-e46 4. Sawyer T, Strandjord T. Simulation-based procedural skills maintenance training for neonatal-perinatal medicine faculty. Cureus. 2014;6(4):e173 https://doi.org/10.7759/cureus.173 5. Sawyer T, Laubach VA, Hudak J, Yamamura K, Pocrnich A. Improvements in teamwork during neonatal resuscitation after interprofessional TeamSTEPPS training. Neonatal Netw. 2013;32(1):26–33 PMID:23318204 https://doi. org/10.1891/0730-0832.32.1.26 6. Sawyer T, Leonard D, Sierocka-Castaneda A, Chan D, Thompson M. Correlations between technical skills and behavioral skills in simulated neonatal resuscitations. J Perinatol. 2014;34(10):781–786 PMID:24831522 https://doi.org/10.1038/ jp.2014.93 7. Sawyer T, Ades A, Ernst K, Colby C. Simulation and the Neonatal Resuscitation Program 7th edition curriculum. NeoReviews. 2016;17(8):e447–e453 8. Hamstra SJ, Brydges R, Hatala R, Zendejas B, Cook DA. Reconsidering fidelity in simulation-based training. Acad Med. 2014;89(3):387–392 PMID:24448038 https://doi.org/10.1097/ACM.0000000000000130 9. Maran NJ, Glavin RJ. Low- to high-fidelity simulation—a continuum of medical education? Med Educ. 2003; 37(suppl 1):22–28 PMID:14641635 https://doi.org/10.1046/j.1365-2923.37.s1.9.x 10. Curtis MT, DiazGranados D, Feldman M. Judicious use of simulation technology in continuing medical education. J Contin Educ Health Prof. 2012;32(4):255–260 PMID:23280528 https://doi.org/10.1002/chp.21153

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11. Gagné RM. Training devices and simulators: some research issues. Am Psychol. 1954;9(3):95–107 https://doi.org/10.1037/ h0062991 12. Sawyer T, Strandjord TP, Johnson K, Low D. Neonatal airway simulators, how good are they? a comparative study of physical and functional fidelity. J Perinatol. 2016;36(2):151–156 PMID:26583944 https://doi.org/10.1038/jp.2015.161 13. Gray MM, Delaney H, Umoren R, Strandjord TP, Sawyer T. Accuracy of the nasal-tragus length measurement for correct endotracheal tube placement in a cohort of neonatal resuscitation simulators. J Perinatol. 2017;37(8):975–978 https://doi. org/10.1038/jp.2017.63 14. Rosen O, Campbell D, Bruno C, Gabelman L, Goffman D, Angert R. Low-cost, easy-to-assemble neonatal procedural trainers: chest tube, pericardiocentesis, and exchange transfusion. MedEdPORTAL. 2014;10:9787 https://doi.org/10.15766/ mep_2374-8265.9787 15. Jayaram A, Walton D. Board 522—technology innovations abstract multi-purpose use of a novel gel protected insert for neonatal high fidelity simulation and for “fluid removal” task trainers (submission #1147). Simul Healthc. 2013;8(6):620 https://doi.org/10.1097/01.SIH.0000441720.09266.cf 16. Rosen O, Angert RM. Gastroschisis simulation model: pre-surgical management technical report. Cureus. 2017;9(3):e1109 PMID:28439484 https://doi.org/10.7759/cureus.1109 17. Soni NB, Cox A, McLeod E, Patel A, Harrison C. G23(P) education and training using an innovatively adapted manikin: simple, affordable, feasible and effective (SAFE). Arch Dis Child. 2013;98:A16

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Chapter 5

Simulation for Neonatal Airway Management Ahmed Moussa, MD, MMEd, FRCPC, FAAP, and Michael-Andrew Assaad, MD, FRCPC, FAAP

Objectives In this chapter, you will 1. Identify neonatal airway management, including mask ventilation, endotracheal intubation, and laryngeal mask airway, as core competencies for neonatal health care professionals. 2. Recognize the benefits of simulation for training in neonatal mask ventilation, laryngeal mask airway placement, neonatal endotracheal intubation, and difficult airway management. 3. Compare commercially available airway task trainers and mannequins. 4. Describe the cognitive and psychomotor skills models required for neonatal airway management. 5. Discuss the various considerations for developing airway skills training sessions and creating realistic simulated scenarios that incorporate neonatal airway management. 6. Design a simulation-based neonatal airway lesson plan, including considerations for the difficult airway.

Introduction One in 10 newborns requires resuscitation immediately after birth.1 Neonatal health care professionals must therefore be proficient in the advanced skills of airway management, including mask ventilation (MV), endotracheal intubation (EI), and laryngeal mask airway (LMA) placement. In this chapter, we review cognitive and psychomotor skill acquisition as it pertains to neonatal airway management, discuss the steps of designing a simulation-based session for airway management, and present an example of a simulation-based lesson plan for neonatal EI, MV, and LMA placement that bridges the notions of simulation-based education to real-life airway training and includes assessment of airway management skills.

Background Respiratory compromise is the most common presentation of newborns as they transition to the extrauterine environment. These neonates require MV, and a small proportion additionally require advanced resuscitation that includes EI or LMA placement. Ineffective airway management can lead to clinical decompensation and serious lung injury.2,3 Accrediting bodies require that pediatrics residents and neonatal-perinatal fellows achieve competency in MV and EI.4,5 However, acquiring these skills can be challenging.

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MV with an airway mask is a skill that necessitates a significant amount of dexterity, requiring attention to hand placement, mask position, jaw manipulation, and application of downward pressure, while one is avoiding placing pressure on the soft tissues of the neck. Simulation-based training using mannequins provides the opportunity to practice these skills as a whole or as part of a sequence (“MR SOPA,” or mask readjustment, repositioning the airway, suctioning the mouth then nose, opening the mouth, pressure increase, and alternative airway).1,6 A similar argument for simulation has been supported by the literature for LMA placement and neonatal EI.7,8 Beyond these critical skills, simulation can also be used to familiarize the higher-level learner with difficult airway situations.9 Achieving and maintaining competency in EI is important because improper technique can result in airway or esophageal trauma, and prolonged attempts can lead to deoxygenation, increased systolic blood pressure, and increased intracranial pressure.10 However, the reported success rate for pediatrics residents’ neonatal EI is consistently low—between 33% and 63%11,12—likely because of a combination of factors that includes restricted work hours, more midlevel providers, increased use of noninvasive ventilation, changes in clinical practice, and fewer opportunities to intubate very-low-birth-weight neonates.13 The LMA forms a low-pressure, airtight seal against the glottis, allowing pressure from the ventilation device to be transmitted into the trachea. The LMA is an alternative approach to MV and EI, especially in patients with a “difficult” airway (eg, patients with a congenital abnormality of the upper airway, patients in which EI is difficult). The LMA requires minimal experience and training for successful insertion; however, practicing neonatal health care professionals have limited training and experience with this device.14 The above challenges with MV, EI, and LMA insertion have made simulation an attractive option for acquisition and maintenance of these important skills. Multiple studies have demonstrated the effectiveness of simulation for airway training.15–17 Mileder and colleagues found that paramedics demonstrated significantly less face mask leak (during simulated MV) after simulation-based training.18 Van Vonderen and colleagues similarly showed the benefits of simulation-based training for decreasing peak pressures and minimizing mask leak for MV performed by inexperienced health care professionals.19 Finally, Schilleman and others demonstrated that simulation-based training significantly decreased face mask leak during simulated MV and that neonatal health care professionals’ improved performance was sustained 3 weeks after training.20

Commercially Available Airway Task Trainers A variety of commercially available task trainers (Table 5-1) and low- and high-technology mannequins (Figure 5-1) can be used for airway training. These simulators provide variable degrees of physical fidelity and functional fidelity—the degree to which the simulator imitates the physical characteristics of the patient and the degree to which it depicts the skills performed in the actual task, respectively.21 Sawyer and colleagues compared commercially available airway simulators (task trainers and mannequins) and found a wide variation in the physical and function fidelity.22 Maran and Glavin highlighted that simulator costs increase with increasing physical fidelity.21 The models highlighted in Table 5-1 provide learners with the opportunity to perform MV and place an endotracheal tube (ETT), LMA, or oral airway. Correct placement and ventilation can be determined by visible inflation of the plastic bag or balloon in task trainers and by inflation of the plastic lungs, which results in chest rise in mannequins. To date, none of the available neonatal airway models have the capacity to measure the appropriate ventilation volume. To give learner feedback, instructors often rely on seeing a visible chest rise or monitoring internal sensors on high-technology mannequins to verify that the “lungs” are receiving an adequate volume of air. Some computerized models can provide instructors with the ability to assess correct tube placement remotely on the laptop screen, essentially by showing equal ventilation of both lungs when the tube is placed correctly versus right or left main bronchus intubations. Only one of the models depicts a difficult airway (Pierre Robin sequence), and most neonatal models do not provide instructors with the ability to adjust the glottic opening to simulate laryngospasm or stenosis. Grades of difficulty can be attained only by varying the size of the

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Figure 5-1. Photographs of the simulators and task trainers evaluated in the study. (1A) Premature Anne (Laerdal Medical). (1B) Premature Anne airway. (2A) Premie Blue (Gaumard Scientific). (2B) Premie Blue airway. (3A) Newborn Anne (Laerdal Medical). (3B) Newborn Anne airway. (4A) Newborn HAL (Gaumard Scientific). (4B) Newborn HAL airway. (5A) SimNewB (Laerdal Medical). (5B) SimNewB airway. (6A) Newborn Airway Trainer (Syndaver Labs). (6B) Newborn Airway Trainer airway. (7A) Neonatal Intubation Trainer (Laerdal Medical). (7B) Neonatal Intubation Trainer airway. (8A) AirSim Baby (TrueCorp). (8B) AirSim Baby airway. Reproduced from the Journal of Perinatology.22

Table 5-1. Task Trainers and Mannequins With Mask Ventilation, Endotracheal Tube, Laryngeal Mask Airway, or Oral Airway Capabilities Name (company)

Simulator type

Age

Supported procedures and features

Neonatal Intubation Trainer (Laerdal Medical)

Task trainer

Preterm newborn (34 weeks’ gestation)

MV with plastic bags for lungs, oral and nasal intubation, LMA size 1 insertion

Premature Anne (Laerdal Medical)

Mannequin

Preterm newborn (25 weeks’ gestation)

MV with visible chest rise and audible breath sounds, oral and nasal intubation

Newborn Anne (Laerdal Medical)

Mannequin

Full-term newborn

MV with visible chest rise and audible breath sounds, oral and nasal intubation, LMA size 1 insertion

NeoNatalie (Laerdal Medical)

Mannequin

Full-term newborn

MV with visible chest rise and audible breath sounds

SimNewB (Laerdal Medical)

Mannequin

Full-term newborn

MV with visible chest rise and audible breath sounds, oral and nasal intubation, LMA size 1 insertion

Newborn PEDI (Gaumard Scientific)

Mannequin

Full-term newborn

MV with visible chest rise and audible breath sounds, oral and nasal intubation, LMA size 1 insertion

Newborn Airway Management Skills Trainer (Gaumard Scientific)

Mannequin

Full-term newborn

MV with visible chest rise and audible breath sounds, oral and nasal intubation, LMA size 1 insertion

Premie Hal S2209 (Gaumard Scientific)

Mannequin

Preterm newborn (30 weeks’ gestation)

MV with visible chest rise and audible breath sounds, oral and nasal intubation (continued)

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Table 5-1 (continued) Name (company)

Simulator type

Age

Supported procedures and features

Premie Blue S108 (Gaumard Scientific)

Mannequin

Preterm newborn (28 weeks’ gestation)

MV with visible chest rise and audible breath sounds, oral and nasal intubation

Premie Hal S108.100 (Gaumard Scientific)

Mannequin

Preterm newborn (24 weeks’ gestation)

MV with visible chest rise and audible breath sounds, oral and nasal intubation

Newborn Tory S2210 and Super Tory S2220 (Gaumard Scientific)

Mannequin

Full-term newborn

MV with visible chest rise and audible breath sounds, oral and nasal intubation, LMA size 1 insertion

Newborn PEDI S109 (Gaumard Scientific)

Mannequin

Full-term newborn

MV with visible chest rise and audible breath sounds, oral and nasal intubation, LMA size 1 insertion

Newborn HAL S3010 (Gaumard Scientific)

Mannequin

Full-term newborn

MV with visible chest rise and audible breath sounds, oral and nasal intubation, LMA size 1 insertion

PEDI Blue S320.101.250 (Gaumard Scientific)

Mannequin

Full-term newborn

MV with visible chest rise and audible breath sounds, oral and nasal intubation, LMA size 1 insertion

CAE BabySIM (CAE Healthcare)

Mannequin

Full-term newborn

MV with visible chest rise and audible breath sounds, oral and nasal intubation, LMA size 1 insertion

AirSim Baby X (TruCorp)

Task trainer

Full-term newborn

MV with plastic bags for lungs, oral and nasal intubation, LMA size 1 insertion

AirSim Pierre Robin X (TruCorp)

Task trainer

Full-term newborn

Difficult airway simulator, MV with plastic bags for lungs, oral and nasal intubation, LMA size 1 insertion

Newborn Airway Trainer (SynDaver Labs)

Task trainer

Full-term newborn

MV with plastic bags for lungs, oral and nasal intubation, LMA size 1 insertion

Paul (SIMCharacters)

Mannequin

Preterm newborn (27 weeks’ gestation)

MV with visible chest rise and audible breath sounds, oral and nasal intubation

SMART Resuscitation Mask Leak Trainer

Task trainer

Full-term newborn, preterm newborn

MV with visible chest rise, real-time feedback (lung pressure, flow rate, inspired/expired volumes, and percentage mask leak)

Abbreviations: LMA, laryngeal mask airway; MV, mask ventilation.

airway simulator or placing supplements to simulate difficult intubations (eg, subglottic stenosis can be simulated by placing a marble into the trachea or placing a rubber band around the trachea at a distance close to the vocal cords). Most of the currently available task trainers and mannequins are also not well suited to LMA placement, as the tongue is large, the mouth cannot accommodate the LMA, and the setup requires a substantial amount of lubrication because of the excessive friction that can occur when one is placing the LMA into the mannequin. Furthermore, the LMA often does not bounce back after inflation of the cuff (as is the case in an actual patient), and it can easily be dislodged with a small tug. Virtual reality EI training models that develop these psychomotor skills are being researched and developed. Virtual reality training has the additional advantage of providing a variety of airway models that are dynamic in nature, as opposed to a static, physical model that loses its effectiveness once the learner has successfully accomplished intubation. Additionally, virtual models can be programmed with objective parameters that can aid in learner evaluation, a characteristic that is currently unavailable for physical neonatal simulators.

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Cognitive and Psychomotor Skill Acquisition in Neonatal Airway Management Acquisition of neonatal intubation skills follows the same sequence and uses the same models and theories described by educators and cognitive psychologists for general psychomotor skill acquisition. Skill acquisition has classically been divided into cognitive, developmental, and automation phases.23 During the cognitive phase, the learner breaks the procedure down into discrete steps and attempts to master each portion of the task separately. Instructors who are observing learners may notice that their motion appears erratic or clumsy. During the developmental phase, the learner has mastered the steps, particularly in managing a normal airway, but may still need to think about certain aspects of the procedure; moreover, any difficult situation would add burden. Instructors observing the learner notice that there is ease of motion, but the instructor still needs to intervene. Finally, during the automation phase, the learner has fluid motion and is able to handle difficult situations easily and cope with external stimuli that require divided attention. We typically consider these phases to be sequential, but learners may bounce between all 3 phases for a given procedure. For example, a less experienced clinician who is proficient in the intubation of full-term newborns may be unskilled in the intubation of extremely low birth weight infants and may require further cognitive and psychomotor skills development. Ultimately, a learner will progress from rigid adherence to rules (as a novice does) to intuitive decision-making at the expert level, as described by Dreyfus and Dreyfus.24 When deconstructing neonatal airway and skills training in a lesson plan for novices, instructors must consider all 3 of Gagné’s learning outcomes: intellectual skills, cognitive strategies, and motor skills.23 From an intellectual standpoint, learners will be expected to learn the anatomy (discrimination), indications, contraindications, and immediate complications of the procedure (concept learning and rules). Learners will also benefit from developing cognitive strategies, as every airway procedure can be different, and the learner will be expected to actively problem-solve. This cognitive schema has been previously described for other procedures, such as percutaneous chest tube insertion.25,26 In addition, in a published skill acquisition model, motor skills are clearly delineated into cognitive and psychomotor components.27 Many of these models (Gagné, Simpson, and Dreyfus and Dreyfus) require the instructor to pay close attention to the type of learner attending the sessions and the ultimate objective of the training. For example, novice students learning the fundamentals of intubation would require step-by-step guided instruction on the mannequin after a demonstration of the steps (see Appendix B), while an experienced provider would likely benefit from intubation of a difficult airway mannequin with added cognitive load, such as a loud environment or an anxious simulated parent. Simulation is most useful for the practice and assessment of airway management skills,28,29 specifically through the use of deliberate practice (DP), which involves defined objectives, supervised learning, and assessment of performance and feedback.30 These elements are highlighted in the Debriefing During Neonatal Airway Scenarios section later in this chapter. DP has consistently been proven to refine procedural performance, including airway management.30,31 Procedural acquisition and maintenance in neonatal airway management (eg, MV, EI, LMA placement) vary greatly between learners.12 This finding implies that some learners may need more practice than others to become proficient. In addition, any competency established for any given task will not be a static phenomenon and will depend greatly on the experience level of the learner. For example, one intubation per year may maintain competence for the expert practitioner, but refreshers every 6 weeks may be needed for the novice learner.29 This finding highlights the need for ongoing practice, which simulation can handily address in any training program for all neonatal airway management skills. Finally, difficult airway situations, in addition to standard psychomotor skills training, will need to integrate teaching of crisis resource management skills, such as leadership and communication. Fortunately, such skills can be taught by using role-playing, modeling, and simulation, as we discuss in the following paragraphs.

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Designing a Simulation-Based Session for Airway Training Designing simulation-based airway training sessions that achieve the stated learner objectives requires careful planning and attention. Essential steps are detailed in the following paragraphs.

Identifying Learners’ Needs The first step in designing simulation-based airway skills training is to assess the learners’ baseline knowledge and skill and design sessions that cater to the learners’ needs. For example, medical student training would focus on equipment setup and step-by-step instruction, while pediatrics residents would receive advanced training in placing the ETT into a normal airway. Conversely, training for neonatology fellows may focus on managing difficult airways. This step enables instructors to identify performance gaps, tailor the training to the learners’ specific needs, rectify actions performed incorrectly, and avoid unnecessary repetition. Instructors can glean much of this information from learner portfolios, direct observation, logbooks, and institutional procedure databases. Additionally, at the beginning of the simulation-based session, open-ended questions can serve as an icebreaker to allow learners to describe their backgrounds and experiences and to elicit information about their procedural knowledge and skill. Another useful tool to identify learners’ needs is the pretest,32 which enables instructors to gauge learners’ strengths and weaknesses and stimulates learners’ prior recall. The instructor can also have learners perform a simulated skill demonstration to aid in identifying learners’ needs related to airway management, such as MV, LMA insertion, and EI. Use of a validated checklist and silent observation of the learner may aid in identifying gaps and learner level.

Defining the Appropriate Environment When planning airway management simulation-based training, instructors should choose the learning environment that will maximize learners’ needs. Possibilities include the simulation center, teaching in situ (in the neonatal intensive care unit [NICU] or the delivery room), or training in any available classroom or conference room.33,34 The simulation center allows for the most control of a simulation session. Performing airway training in the simulation center tends to decrease the cognitive load of learners, because they are typically relieved of their clinical duties. This environment is usually less distracting, because learners attend to learning, and they attend only to learning. Additionally, performing airway training in the simulation center typically allows more time for prebriefing and debriefing. Moreover, training sessions can be video-recorded, and learners can be provided with live, real-time feedback. Video recordings can provide instructors with a myriad of external information, including the presence of necessary equipment, preparedness, sequence of events, use of sedatives, posture of the learner, turning the temperature of the radiant warmer too high or too low, hunching over the patient, rocking the laryngoscope on the infant’s gums, using too much force, and lack of chest rise from a failed intubation. Finally, additional equipment is easily accessible in the simulation center, allowing learners to practice airway skills on various anatomical models, as well as different airway devices, as needed. The simulation center is a suitable environment for the novice or advanced beginner to learn and practice the basic procedural skills of neonatal MV, EI, and LMA insertion. Furthermore, because the environment is well controlled, the simulation center is ideal for assessing learner performance. The in situ environment is unique in that it tests care processes (see Chapter 18, In Situ Simulation). Thus, it is an ideal environment for advanced airway training for the expert learner, especially difficult airway situations, as knowledge of the working environment and interprofessional teamwork are key objectives. It is also the preferred environment for critical incident analysis of difficult airway situations. For example, in the NICU, after multiple failed intubations that ultimately led to a pneumothorax event and unintended patient harm, an in situ reproduction of the same event may allow for robust incident analysis. Although nonideal because of lack of realism and the risk of lack of learner buy-in, a classroom or conference room can be used for simulation-based airway skills training. Importantly, studies have shown that learners can

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still gain knowledge and skill, despite the environment lacking realism.35 In our experience, the classroom or conference room environment should be reserved for short refresher or “just-in-time” training and paired with a rapid debriefing technique, such as “gather-analyze-summarize”36 or the plus-delta method (a learner-driven, instructor-prompted description of learner behaviors: favorable [plus] and those that the team might have changed [delta]).

Content of the Simulation Session The simulation training session may concentrate on a specific airway management skill or have airway management integrated into the simulation scenario. The learning objectives of the session will likely differ, and the sessions will be oriented toward different levels of learners, on the basis of their needs.

Airway Management With Task Trainers Training on task trainers is usually oriented toward novice learners, involving skill deconstruction, practice, and repetition, aimed at specific cognitive and procedural skill acquisition. Before the procedure, emphasis should be placed on the equipment, the skills needed to prepare the patient, and the sedation sequence (as appropriate). Attention should be paid to postinsertion verification of tube position, taping, and rate of ventilation. These skills are often overlooked during simulation training, but their absence can quickly become detrimental to patient care, such as a trainee who successfully places the ETT in an actual patient but, in their excitement, lets go of the ETT and the patient becomes extubated; this is a misstep necessitating a reintubation procedure to be performed. Similarly, the learner who becomes excited by successfully intubating the patient may proceed to provide ventilation at a very high rate, thus inducing hypercarbia. Alternatively, they may place the tube in too far, causing a pneumothorax. During simulation-based training, once an error is detected, the learner should be given a chance to repeat the procedure from the beginning, with close attention paid to the error. In this sense, a rapid-cycle DP approach (see Chapter 28, Rapid-Cycle Deliberate Practice) could be used. Although ideal for novice learners, simulation-based training by using task trainers can also be used by experienced health care professionals for additional practice and by those needing to maintain procedural proficiency.

Airway Management During Simulation Scenarios Compared to skills training by using task trainers, simulation scenarios have higher-level learning objectives and usually focus on nontechnical aspects of performance, such as teamwork and crisis resource management. In addition, neonatal simulation scenarios induce anticipatory and participatory stress,37 both intentional and secondary to the environment. First, the need for MV, EI, or LMA placement is not in the learners’ control. The task is urgent or emergent, and there is typically a team and/or an instructor watching the learner perform. Cues such as audible monitor alarms, ambient NICU noise, and/or unstable vital signs represent stress during simulation scenarios. As stated previously, these cues enhance realism and promote learner buy-in. However, simulation scenarios that require learners to perform EI typically require involvement of a multidisciplinary team and human resources. Examples of these simulation scenarios include a difficult airway, situations in which the neonate can be ventilated with mask ventilation but cannot be intubated because of an airway anomaly or subglottic stenosis, or sudden decompensation due to a mediastinal mass or tension pneumothorax that will require a multidisciplinary team approach, including summoning a consultant (eg, anesthesiologist or otorhinolaryngologist).

Preparing for Simulation-Based Airway Training Preparing the Learners The “flipped classroom” model,38 in which learners review the steps of airway management and complete assigned reading or conduct video review before attending hands-on training, is the most efficient method for simulationbased training (Table 5-2). Resources may include online instructional videos; printed materials, such as

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Table 5-2. Available Didactic Tools for Airway Management Mask ventilation Printed materials

Instructional videos

Textbook of Neonatal Resuscitation39

NRP App42 Other videos: www.youtube. com/watch?v=JZNHaQK5fCs www.youtube.com/ watch?v=DTYUm0YYeaw

Laryngeal mask airway insertion Textbook of Neonatal Resuscitation39

NRP LMA insertion video43 Other video:

Endotracheal intubation Atlas of Procedures in Neonatology40

Institutional difficult airway algorithms

Textbook of Neonatal Resuscitation39

“Pediatric Difficult Airway Guidelines” (no neonatalspecific available guideline)41

OPENPediatrics video44 :

Difficult airway devices demonstration videos

www.youtube.com/ watch?v=lGTaA_UdIXw

www.youtube.com/ watch?v=fZ7wIE2KaWM

Other video:

www.youtube.com/ watch?v=H58wr1Qczaw

Difficult airway management

www.youtube.com/ watch?v=r_3klctVUoI

www.youtube.com/ watch?v=S5WdVnhtono Educational apps

NRP App42

Unavailable

Unavailable

The Difficult Airway App45 (adult and pediatric)

Assessment tools

Ongoing development46

Ongoing development14

INSPIRE procedural checklist47

Unavailable

Abbreviations: INSPIRE, International Network for Simulation-based Pediatric Innovation, Research, & Education; LMA, laryngeal mask airway; NRP, Neonatal Resuscitation Program.

procedural manuals and textbooks; and assessment tools. Many of the resources are also available in applications for smartphones and tablets. These typically cover indications and contraindications, airway anatomical structure, necessary equipment, procedural steps, potential complications, and common pitfalls. Teaching novice learners the correct terminology for the anatomical landmarks is of utmost importance during all phases of learning. This will aid the learners in applying the correct maneuvers during real clinical encounters, such as distinguishing the epiglottis from the vocal cords or the glottis. In this sense, instructors will have a handle on how to assist learners during real clinical encounters. This should also be discussed in the prebriefing before real patient intubations.

Selecting Simulation Equipment for Training Before training, instructors should gather and, where necessary, assemble equipment, including task trainers and mannequins (see Tables 5-1 and 5-3). Instructors should select the type of simulation modality on the basis of the learners’ needs and the desired learning outcomes. For example, a task trainer or basic mannequin would be appropriate for training pediatrics residents in neonatal EI, whereas a preterm infant–sized mannequin or more advanced airway task trainer would better meet the needs of neonatal-perinatal medicine fellows. Similarly, one might consider an advanced mannequin for simulation scenarios that focus on teamwork, communication, EI, and other procedures. It is also recommended that different models be available during training to provide as much variability for learners as possible. Mastery of one airway model often does not translate into success on other models or in real clinical environments. In fact, licensing bodies describe the need for at least 10 different simulation sessions for reliably assessing transfer of skill in structured clinical examinations.48 Other methods to increase difficulty include providing equipment of inappropriate size, such as a mask or a laryngoscope blade that is too large or too small, to determine whether the learner detects the problem; however, this should be applied only once learners have mastered basic intubation, so as not to add unnecessary cognitive load, particularly with novices. Learners should also be encouraged to experiment with different head positions, shoulder roll versus no shoulder roll, cricoid pressure versus no cricoid pressure, and depth of tube insertion. This experimentation allows

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Table 5-3. Equipment for Airway Training Activity

Equipment

Mask ventilation

• • • • • • • •

Anesthesia flow-inflating bag, self-inflating bag, or T-piece resuscitator Suction Stethoscope Oxygen and air source Blender and flow meter Neonatal face masks of various sizes Electrocardiographic leads and pulse oximeter probe Oral pharyngeal airway of various sizes

Endotracheal intubation

• • • • • • • • • • • •

Anesthesia flow-inflating bag, self-inflating bag, or T-piece resuscitator Suction Stethoscope Oxygen and air source Laryngoscope handle Laryngoscope blades (sizes 00, 0, 1) ETTs (sizes 2.5F, 3.0F, 3.5F) Stylet for oral intubation (optional) CO2 detector Tape Magill forceps for nasal intubation (optional) Blender and flow meter

Laryngeal mask airway placement

• • • • • • •

Anesthesia flow-inflating bag, self-inflating bag, or T-piece resuscitator Suction Stethoscope Oxygen and air source Blender and flow meter LMA (sizes 1 and 1.5) Syringe (5-mL)

Difficult airway management

• • • • • • • • • •

Anesthesia flow-inflating bag, self-inflating bag, or T-piece resuscitator Suction Stethoscope Oxygen and air source CO2 detector Tape Blender and flow meter LMA (sizes 1 and 1.5) ETT (size 2.0F) Video laryngoscope, such as – Airtraq (Teleflex) and blade sizes 0 (infant, gray) and 1 (pediatric, magenta) – C-MAC video laryngoscope (Storz) and blades sizes 0 and 1 – GlideScope video laryngoscope (GVL, Verathon) and blade sizes 0 (patient weight: