Outcome of Clinical Simulation on Neonatal Resuscitation in Development of Knowledge and Skill among Baccalaureate Nursing Students at a selected Nursing Institution

Dr. Malarvizhi.G^1*, H. Glory², S. Rajeswari³, Bindu C Vasanthi⁴

¹Vice Principal cum Professor HOD of Pediatric Nursing Department PSG College of Nursing, Avinashi Road, Peelamedu, Coimbatore-641004.

^2,3,4Asst. Professor, Department of Pediatric Nursing, PSG College of Nursing, Avinashi Road, Peelamedu, Coimbatore-641004.

*Corresponding Author Email: malarvizhi2k5@yahoo.co.in

ABSTRACT:

Context: Simulation facilitates learning with practice opportunities with feedback for the students in preparatory programme in health care profession. Objectives: This study examined the effectiveness of Clinical simulation in acquiring knowledge and skill in performing Neonatal Resuscitation among B.Sc. Nursing students. Methods and Materials: With Quasi experimental approach Eighty five students of B.Sc Nursing III year were enrolled by Non Randomized purposive sampling technique. Study was conducted in Simulation Lab, PSG IMSR, Coimbatore. The student’s knowledge was assessed by using questionnaire on Neonatal Resuscitation Programme (NRP). The students were educated on NRP in case scenarios through clinical simulation approach in four groups. After the period of one week the student’s knowledge and Psychomotor skill in performing Neonatal Resuscitation was assessed through questionnaire and Objective Structured Clinical Examination (OSCE) on Neonatal Resuscitation Programme. Results/Findings: The results revealed that half of the nursing students 44 (52%) had inadequate knowledge, forty one nursing students (48%) had moderately adequate knowledge and none of them had adequate knowledge on neonatal resuscitation in pre test. Mean knowledge score at Pre test was 8.83±2.80 and the post test knowledge score was 21.7±2.68. Comparison of pre test and post test Knowledge score on NRP was 12.89±3.92 (t=30.31, p-value=0.0001, p<0.05) and statistically significant difference was found in post test knowledge score. There was a significant increase in post test skill of nursing students on various areas like Basic Life support, newborn not breathing, Positive pressure ventilation and chest compression with calculation and administration of medications. The overall mean post test skill was 21.52±4.21. Moreover, it was found that the nursing students after post test skill reported that they were confident in performing Neonatal resuscitation. Conclusion: This finding demonstrates that the clinical simulation transforms the pedagogy of nursing education from theory and clinical learning to theory, simulation and clinical application.

KEYWORDS: Neonatal Resuscitation Programme, Simulation, Objective Structured Clinical Examination, Case Scenarios, Psychomotor skill.

INTRODUCTION:

A healthy start to life is vital in establishing the foundation of a healthy nation. India has been making considerable progress on the front of child health, and eradication of polio from India is evidence to this effect. During the last two decades, India has witnessed a significant reduction in the quantum of child deaths. It has been estimated that preventable neonatal deaths can be decreased by at least 50% through implementation and scale-up of educational interventions that include neonatal resuscitation and other essential elements of basic newborn care¹.

India contributes to 17.5% of the world’s population and nearly one-fifth of the total live births. Its contribution to the global burden of newborn deaths is higher when compared to that of maternal and under-5 deaths. India contributes to 16% of global maternal death; and 21% of under-5 deaths. When it comes to newborn mortality, the proportion increases to 27%. The commitments in the India Newborn Action Plan (INAP) were developed to align with the global (ENAP) Every Newborn Action Plan. India however aspires to achieve the global ENAP targets by 2030, five years ahead of the global deadline with all the states to individually achieve the targets by the end of 2035.

Neonatal deaths are the biggest contributor to child deaths, an attempt to improve child survival hinges on improving newborn health. Although, the annual burden of neonatal deaths has reduced from 1.35 million in 1990 to 0.76 million in 2012, we still face a huge challenge to reduce further the number of deaths².

Neonatal resuscitation is a key skill that health care providers at health facilities, where deliveries occur, must have. These skills would significantly contribute to reduction of neonatal deaths related to birth asphyxia. This learning has to take place from their beginning of training and course of study in order to equip the knowledge and acquire skill in neonatal resuscitation.

Basic Newborn resuscitation skills includes initial steps such as drying, suctioning, positioning and tactile stimulation and assisted ventilation using bag and mask and advanced resuscitation skills includes use of endotracheal intubation and chest compression and use of medication. Neonatal Resuscitation which involves life of newborn. It is difficult for B.Sc Nursing III year students to get direct hands on skill in performing NRP in babies.

Researchers recognize the need for greater objectivity in measuring competence, using structured multi-faceted measures of several factors instead of simple observation of students’ implementation of the nursing process³.

Entry-level nursing students often fear entering a patient’s room. Worrying they could harm a patient, dreading being unprepared for the particulars of clinical situations, and feeling uncertain of how to communicate with patients and families, new students experience initial jitters, compromising their self confidence and calling into question their competence⁴.

Simulation facilitates learning with practice opportunities with feedback for the students in preparatory programme in health care profession. Simulation takes active role in simulating reality experiences to students to learn and acquire skills in neonatal resuscitation. Hence a quasi experimental study was planned and conducted to assess the UG students knowledge and skill on Neonatal Resuscitation using simulated scenarios.

MATERIALS AND METHODS:

Quasi experimental one group pretest and post test design was used to assess the knowledge and skill of nursing students in performing Neonatal Resuscitation through Clinical Simulation in the simulation lab. Non Randomized purposive sampling technique was adapted to select eighty five students of B.Sc Nursing III year who are learning pediatric nursing and willing to participate in the study as participants. The present study was undertaken in Simulation Lab, PSG IMSR, Coimbatore. The study was conducted from January to May 2015 in four batches. The student’s knowledge was assessed by using questionnaire on Neonatal Resuscitation Programme. The students were educated on Neonatal Resuscitation programme in case scenarios After the period of one week the student’s knowledge and skill in performing Neonatal Resuscitation was assessed through simulated clinical scenarios by administering questionnaire and check list on Neonatal Resuscitation Programme. Psychomotor skill on neonatal resuscitation was checked through Objective structured clinical examination OSCE, in this prepared procedural stations the investigator checked the skills with the help of check list on resuscitation. On the 7^th day post test was conducted, provided knowledge based questionnaire to the students and Skill was checked through OSCE. The study was approved by IHEC and informed consent was obtained from all the students’ participant of the study.

Case Scenarios:

The Neonatal Resuscitation was demonstrated to the students through case scenario which was performed through Medium fidelity simulators. There were four case scenarios:

Case scenario: 1 - Basic Life support:

A 28 year old primi gravida is admitted to the Labor room in active labor. Her membranes ruptured 2 hrs back on the way to the hospital. Female attendant with the woman says that the amniotic fluid was clear. In the labor room the obstetrician notices that the cervix dilates progressively and after 4 hrs a baby girl is born vaginally by vertex presentation. On assessing, the baby is active and crying⁵.

The expected responses of the students are to initiate routine care such as dry the baby, provide warmth, open air way, cut the umbilical cord in 1-2 mts and ongoing evaluation.

Case scenario: 2 clearing Airway:

A 34 year old multi-parous woman is admitted to the labor room in early labor. After some time the membranes rupture to reveal a meconium stained amniotic fluid. The obstetrician looks at the fetal heart rate. She decides to allow a vaginal delivery. Immediately after birth, the baby is observed to have minimal breathing efforts and poor tone⁵.

The students need to demonstrate their skill in clearing the airway by using large suction catheter and tracheal suctioning by meconium aspirator.

Case scenario: 3 Positive Pressure Ventilation:

A 25 years old primi gravida with non progress of labor delivers a male baby at term gestation. The baby is limp, not breathing and has a large caput. There is no meconium staining of liquor. The cord is cut immediately and the baby is placed under a radiant warmer. The nurse dries the baby with pre-warmed sheets and then removes the wet linen. The baby is then placed in a sniffing position to keep the airway open. A quick suction is done on the mouth followed by the suction of nose. The head is repositioned and brief stimulation done by flicking the sole of the baby. The baby is still not breathing after these initial steps. The resuscitation team takes a decision to initiate positive pressure ventilation⁵.

The students are expected to position the baby, apply the face mask with EC technique and to provide ventilation if HR does not improve and if there is no chest rise perform the corrective steps.

Case scenario: 4 Chest Compressions:

A primi gravida woman with term pregnancy is admitted in labor with poor fetal movements. The obstetric team notified the pediatric team to be in the delivery room. The radiant warmer was turned on and resuscitation equipment checked. The woman delivered a limp and apneic baby, who was immediately transferred by the resuscitation team to the radiant warmer. The baby was dried, properly positioned, suctioned and stimulated by flicking the soles. But, 30 seconds after birth the baby was still limp, apneic and cyanotic. One member of the team initiates positive pressure ventilation with bag and mask using room air. Another member checked the heart rate by palpating the umbilical cord for pulse. After 5 inflations the baby had a heart rate below 60 bpm. The care provider performing PPV looked for chest rise. There was no chest rise, so the care provider checked the mask for its seal, the head for its proper position, checked if the airway was clear, and then again checked that the chest was rising with each breath. Despite these steps, after 30 seconds of effective ventilation the baby’s heart rate was below 60 bpm. Now, what is the step need to be performed?⁵

The students are expected to identify the site of chest compression and co-ordinate chest compression with ventilation if HR not improves after 1 minute assist in ET intubation and able to calculate and prepare the drugs and fluids for the baby.

Scoring:

The skill of the students in resuscitating newborn with case scenarios were observed and assessed through OSCE with checklist. The interpretation of score was made as: Done carry 2 marks, partially done carry 1 mark and not done carry 0 no mark.

RESULTS:

Participants:

The final sample (N = 85students) consisted of predominantly females (n = 76, 84 %) males (n = 9, 11%) with a mean age of 19 years (SD = 1.5). Table 1 summarizes the Demographic data for the overall sample.

Table 1: Student Participant Demographics (n = 85)

Characteristic		Mean ± SD	Frequency and percentage
Age		19 ± 1.5
Gender	Male	1.106 ± 0.31	9 (11%)
	female		76 (84%)

The results of the study revealed that in pre test, 44 nursing students (52%) had inadequate knowledge, forty one nursing students (48%) had moderately adequate knowledge and none of them had adequate knowledge in the aspects of Initial support and management, Air way and Breathing, chest compression, endotracheal intubation, drugs and fluids in resuscitating newborn, whereas in post test almost 83 (98%) had adequate knowledge on the same.

Table 3: Comparison of Area wise pre and post practice score of nursing students on NRP (n=85)

Practice areas		Pretest Mean			Post test mean
Initial steps and routine care –Normal newborn Resuscitation		±SD	Standard Variance s²	95% of Confidence Interval range	± SD	Standard Variance s²	95% of Confidence Interval range
	Done	-	-	-	82±2.25	5.06	77.78-86.61
	Partially done	13.8 ±6.32	13.65	1.4-26	4±1.4	2	1.22-6.77
	Not done	71.2±6.9	48.62	57.5-84.8	-	-	-
Resuscitating newborn not breathing – Meconium stained amniotic fluid	Done	-	-	-	82.5±2.32	5.38	77.95-87.04
	Partially done	11.6±5.8	34.26	0.12-23	3.5±1.90	3.61	-1.15-7.30
	Not done	73.4±5.8	34.26	61.92-84.87	-	-	-
Resuscitating Newborn With Positive Pressure Ventilation- Apneic Newborn with Heart rate ˂ 100	Done	-	-	-	82±2.19	4.80	77.84-86.44
	Partially done	6.71±6.7	44.90	-6.41-19.84	3.3±1.96	3.86	-0.52-7.18
	Not done	78±6.7	44.90	65.15-91.41	-	-	-
Resuscitating Newborn With Chest Compression With Medication Limp Newborn with Heart rate ˂ 60	Done	-	-	-	82±2.19	4.80	77.84-86.44
	Partially done	5.5±7.0	51.28	-8.46-19.60	3.3±1.96	3.86	-0.52-7.18
	Not done	79.42±7.16	51.28	65.39-93.46	-	-	-

Table 3: Shows that the students were able to resuscitate the initial steps of normal newborn in post test (=82 ± 2.25), whereas in pretest they were unable to resuscitate the normal newborn with initial routine care (=71.2 ± 6.9). There was significant improvement in post test skill of resuscitating newborn not breathing (Post test skill=82.5± 2.32; Preset skill =11.6±5.8). The students practice score in resuscitating newborn with positive pressure ventilation was improved after simulation training on NRP than the pre test (Post test skill=82.5± 2.19; Pretest skill =6.71 ±6.7). Students were unaware of how to perform chest compression, calculation of dosage and administration of medication while resuscitating newborn in pretest (=5.5±7.0). Simulation and training had brought major changes in students to perform the resuscitation of newborn with chest compression and medications (=82 ±2.19).

Table 4: Correlation of the mean post test scores of knowledge with skill of nursing students on Neonatal resuscitation (n=85)

Knowledge & Skill on NRP

Mean±SD

Correlation

r value

Sig.

(2-tailed)

Post test Knowledge

21.72 ± 2.67

0.117

0.287

Post test skill

21.51 ±4 .21

(P<0.01)

Table 4: explains that there was a weak correlation found between knowledge and skill of nursing students on neonatal resuscitation the mean knowledge of nursing students doesn’t strongly correlate with the change in the skill of nursing students. (r=0.117, P<0.01)

DISCUSSION:

The present study findings shows that half of the nursing students 44 (52%) had inadequate knowledge on Neonatal Resuscitation Programme on pretest whereas in post test almost 83 (98%) had adequate knowledge on the same. The result of the above findings was in consistent with the study of Bambini. B etal, on outcome of clinical simulation on novice nursing students⁶.

There was statistically significant difference was found in post test knowledge score on Neonatal Resuscitation Programme. (t=30.31, p<0.0001) The results of the above findings demonstrated similarity with an experimental study on effectiveness of intermediate- fidelity simulation training technology in Undergraduate nursing education in United Kingdom, Mean difference was statistically significant (p< 0.01)⁷ There was a significant increase in post test skill of nursing students on various areas like Basic Life support, newborn not breathing, Positive pressure ventilation and chest compression with calculation and administration of medications. The overall mean post test skill was 21.52±4.21. The findings are consistent with the study conducted by Nanthini Subbiah, et al (2012) to assess the educational intervention on NRP among Nursing Personnel; their findings revealed that in post test (20.6± 6.05) all aspects of neonatal resuscitation practice nurses improved their practice after administration of educational intervention⁸.

The findings show that simulated learning in a clinical skills laboratory is reported to increase student confidence and prepares students for real clinical setting, however, this acquisition of skill is often achieved at different rates by different students. A standardized approach to simulated learning in nursing education and the development of further holistic clinical scenarios which are linked to related theory and lectures, would offer measurable learning outcomes to meet professional and regulatory requirements. Therefore, further evaluation of the current learning methods within simulation may offer appraisal of the preparation of students for clinical practice, to ensure that students are offered quality-learning opportunities that are flexible and responsive to both their needs and the demands of the Health Care Services^9.

The current study was limited by the relatively small group of the sample and did not compare of simulation method with traditional method of training students in NRP.

This study supports the use of simulation in an undergraduate nursing curriculum and suggests this instructional modality provides students with knowledge and skill gains and challenges them with memorable experiential learning that they can apply to clinical practice. Gregory A and colleagues reported preservice education in nursing has enhanced the nursing skills in patient care¹⁰. Hence, pre service education to students in NRP will strengthen their neonatal care in view of reducing the Mortality and morbidity rates after their graduation In India various neonatal organizations has initiated to NRP to strengthen neonatal care in a view to reduce neonatal mortality1.¹¹ It has also been envisioned and integrated in the pre-service curriculum of nursing to teach NRP using various clinical scenarios to together to improve the knowledge and competency in NRP to enhance the Survival of at-risk and sick newborns in India. In this view the study has enhanced the skills of nursing students in NRP using simulation technique.

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2. Sample Registration system (SRS) Statistical Reports (2000-12): Office of registrar general of India

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Received on 25.02.2017 Modified on 18.04.2017

Asian J. Nur. Edu. and Research.2017; 7(3): 417-422.

DOI: 10.5958/2349-2996.2017.00083.0