Simulation Training in Neonatal Resuscitation: Practice Makes Perfect

Laura A Stokowski, RN, MS


July 25, 2006

Editorial Collaboration

Medscape &

Neonatal Resuscitation: Practice Prevents Errors

If it seems as if Kimberly Yaeger and Kristine Boyle are unusually adept at resuscitating a latex baby, well, it's because they've had a lot of practice. Kimberly Yaeger, RN, BSN, MEd(c), and Kristine Boyle, RNC, MSN, NNP, are from the Center for Advanced Pediatric Education (CAPE) at Stanford University, a high-fidelity stimulation training center in Palo Alto, California. These 2 nurses conducted a workshop entitled, "Neonatal Simulation Central," which combined a presentation about the fundamentals of simulation training with actual hands-on experience in a mini-simulation exercise.[1]

Simulation training has its roots in the aerospace industry. Many patient care situations, such as neonatal resuscitation, require technically complex skills and a high level of interdependence among team members -- characteristics that are shared with fields such as aviation. The potential for errors in both fields is significant. An educational approach known as crew resource management, developed by aviation experts, emphasizes the role of human factors in high-stress, high-risk environments.[2]

One of the important benefits of simulation training is the prevention of medical error.[3] In a recent review of root causes of perinatal morbidity and mortality, 72% of errors involved communication issues, 47% involved staff competence, and 40% involved orientation and training issues.[4] Errors arising from these root causes are preventable.

Simulation training is ideally suited to address these deficiencies because it emphasizes teamwork and allows both experienced staff and trainees to learn or improve technical skills in a realistic environment without posing harm to human patients.[3] Any sincere effort to improve the quality of healthcare must entail a shift in the way that clinicians are trained. Rather than emphasizing individual knowledge and skills, healthcare personnel should undergo continual systematic training, rehearsal, performance assessment, and refinement in their practice as members of clinical teams.[5]

The concept underlying simulation training is that learning is facilitated through experience.[6] When medical professionals are immersed in intense, dynamic, complex medical scenarios with colleagues and state-of-the-art technology, they are able to practice and acquire cognitive technical and behavioral skills to manage crises and avoid adverse outcomes. These skills are then transferable to the clinical setting.

Neonatal Resuscitation: Key Behavioral Skills

Yaeger and Boyle outlined the 10 important behavioral skills that lead to success during a simulated (or real) neonatal resuscitation:

  • Know your environment

  • Anticipate and plan

  • Assume the leadership role

  • Communicate effectively

  • Distribute work load optimally

  • Allocate attention wisely

  • Use all available information

  • Use all available resources

  • Call for help early enough

  • Maintain professional behavior

These are the same principles that the aerospace industry incorporates into crew resource management, a program used to teach the behavioral skills necessary to manage emergencies and prevent human error. These behaviors have also been adapted to the training of personnel to manage crises in the field of anesthesia.[6]

Hint: If you are going to be participating in a neonatal simulation scenario, these 10 key principles are also the behaviors that you (and others) will be using to evaluate your performance during the post-scenario debriefing.

The Scenario

A simulation scenario is designed to challenge cognitive, technical, and behavioral skills. The scenario takes place in a high-fidelity simulation environment, which is a controlled environment that replicates the patient care environment and offers audio, visual, and tactile cues. All scenarios are videotaped for later review.

Trainees take on the roles of primary or backup (secondary) responder. A typical scenario lasts 15-20 minutes. Simulator faculty (called "confederates") often take part in the scenarios as well; these individuals may or may not be known to participants before the scenario takes place. Scenarios can be designed to incorporate the algorithms of the Neonatal Resuscitation Program (NRP) (delivery room simulation) or to review the important steps to manage any number of common neonatal emergencies.

Typical neonatal resuscitation scenarios can simulate problems with patients (meconium aspiration, perinatal depression, hemorrhage, congenital anomalies), equipment failure, or interpersonal interactions among members of the delivery room team.[7] Personnel should include all of the professionals and family members typically present at the type of delivery (vaginal, operative). Confederates can take on 1 or more roles to create the complex environmental cues and stressful conditions often present in a real delivery room.[8]

At CAPE, neonatal simulation scenarios are conducted in a realistic, high-fidelity environment. Instructors can remotely alter vital signs on the patient monitors so that participants must assess and respond to changes in heart rate, respiratory rate, blood pressure, central venous pressure, and oxygen saturation. Cosmetics are used to simulate cyanosis, urticaria, and hematomas on neonatal mannequins, and fake body fluids such as blood or meconium add to the realism. Prosthetics are creatively applied to replicate congenital malformations.[3]

A few pointers about participating in scenarios: It's critical to suspend disbelief throughout the experience. You must fully immerse yourself in the scenario and react exactly as you would in an actual emergency. Most participants find this easier than they think it will be because all of the equipment and supplies are real and functioning, and the scenarios are conducted in real time.

While the scenario is going on, think out loud, and do everything just as you would in a real situation (rather than just saying, "I would suction or I would start compressions..."). Work as a team.


Debriefing is a review and facilitated discussion of the videotaped scenario. Debriefing must take place immediately following the scenario and include all participants. Active trainee participation is critical to the effectiveness of debriefing, resulting in deeper processing and better retention of learning than during passive debriefing sessions.[6] At CAPE, debriefings are conducted in a room with multiple video monitors and comfortable seating that is physically separated from the simulated delivery room, avoiding any potential psychological or emotional effects that may linger from being in the simulation room.[7] The goal of debriefing is to examine how closely the participants' performance approached the target and to identify what further learning objectives are required to bridge the gap between performance and goals.[6] The emphasis is on the key behavioral skills, neonatal resuscitation guidelines, and other salient teaching points about each scenario. The debriefings are constructive, reinforcing positive aspects of the performance and pinpointing areas for improvement in a nonjudgmental manner.[3]

Neonatal Resuscitation: The Bottom Line

Although Yaeger and Boyle's workshop on neonatal simulation-based training was necessarily only a very basic introduction, it was an excellent overview and provided some direction for those wishing to start simulation training programs at their own institutions. Simulation training is a methodology that is applicable to all disciplines and is highly effective for multidisciplinary team training. Dedication, time, and a little creativity are all that are required to become skilled in this methodology.[1]

  1. Yaeger K. Boyle K. Neonatal Resuscitation Central. Program of the 9th Annual Neonatal Advanced Practice Nursing Forum; May 31-June 2, 2006; Washington DC.

  2. Agency for Healthcare Research and Quality. Making health care safer: a critical analysis of patient safety practices. Evidence Report/Technology Assessment Number 43. 2001. AHRQ, Rockville, Md. Available at: Accessed July 14, 2006.

  3. Yaeger KA, Halamek LP, Coyle M, et al. High fidelity simulation-based training in neonatal nursing. Adv Neonatal Care. 2004;4:326-331. Available at: Accessed July 14, 2006.

  4. Joint Commission on Accreditation of Healthcare Organizations. Preventing infant death and injury during delivery. Sentinel Event Alert Issue 30. July 21, 2004.

  5. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care. 2004;13:2-10. Abstract

  6. Anderson JM. Introduction to simulation-based training. NeoReviews. 2005;6:411-413.

  7. 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:e45.

  8. Murphy AA, Halamek LP. Simulation-based training in neonatal resuscitation. NeoReviews. 2005;6:489-492.


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