Journal of Perinatology (2014) 34, 664668

2014 Nature America, Inc. All rights reserved 0743-8346/14

www.nature.com/jp

ORIGINAL ARTICLE
Does simulation booster impact retention of resuscitation
procedural skills and teamwork?
J Bender1,2, K Kennally1, R Shields1 and F Overly2,3

OBJECTIVE: The Neonatal Resuscitation Program (NRP) has transitioned to a simulation-based format. We hypothesized that
immersive simulation differentially impacts similar trainee populations resuscitation knowledge, procedural skill and teamwork
behavior.
STUDY DESIGN: Residents from NICU and non-NICU programs were randomized to either control or a booster simulation
7 to 10 months after NRP. Procedural skill and teamwork behavior instruments were validated. Individual residents resuscitation
performance was assessed at 15 to 18 months. Three reviewers rated videos.
RESULT: Fifty residents were assessed. Inter-rater reliability was good for procedural skills (0.78) and team behavior (0.74)
instruments. The intervention group demonstrated better procedural skills (71.6 versus 64.4) and teamwork behaviors (18.8
versus 16.2). The NICU program demonstrated better teamwork behaviors (18.6 versus 15.5) compared with non-NICU program.
CONCLUSION: A simulation-enhanced booster session 9 months after NRP differentiates procedural skill and teamwork behavior
at 15 months. Deliberate practice with simulation enhances teamwork behaviors additively with residents clinical resuscitation
exposure.
Journal of Perinatology (2014) 34, 664668; doi:10.1038/jp.2014.72; published online 24 April 2014

INTRODUCTION simulation as very effective,18 qualitatively increasing the propor-

The American Academy of Pediatrics recommends that every
hospital-based delivery is attended by a person who is capable
and focused on supporting the baby.1 Approximately 10% of
all newborns will require resuscitation.2 Surveys of practicing
pediatricians have shown that 36 to 81%3,4 perform stabilization
including endotracheal intubation, yet many residents graduate
without prociency in core neonatal resuscitation skills. Guideline
changes and duty hour restrictions have reduced the opportu-
nities to obtain basic resuscitation skills in the current generation
of residents. Clinical practice opportunities for endotracheal
intubation have fallen from 40 per house ofcer in 1994 to fewer
than 15 since 2000.5 Advanced interventions such as chest
compressions or administration of epinephrine are critical when
required, but occur infrequently in 0.08 to 0.12%6,7 of all
newborns. With infrequent opportunity to practice managing
these high acuity events, skills degrade between 3 and 8 months
after training, whereas retraining is typically recommended every
24 months. This deterioration in skills has been demonstrated in
multiple learner populations, including paramedics,8 medical
students,9 family medicine10 and anesthesiologist residents.11,12
Simulation-based educational interventions may augment
retention of resuscitation skills and behaviors. Mock codes may
increase trainees condence with or without improving com-
petence13 or patient outcomes.14,15 Video review can clarify
clinical performance and teamwork behaviors in the delivery
room16,17 as well as in the simulation lab. Neonatal resuscitation
simulation is a mannequin-based simulation designed to leverage
video recording of a mock code with environmental cues suf-
cient to enable trainee immersion, practice and discovery related
to newborn resuscitation. Trainees describe neonatal resuscitation
tion of time spent in active learning, thereby improving
behavioral, technical and critical thinking skills.19 The Neonatal
Resuscitation Program (NRP) has overhauled content and format
between the fth20 and sixth21 edition, shifting from lecture-based
passive learning toward simulation-based active learning. Practi-
cing teamwork is critical for care coordination for a severely
compromised neonate. However, retention of simulation-gained
skills and behaviors had yet to be rigorously evaluated. In this
study, we hypothesize that high-delity simulation booster 7 to 10
months after NRP augments retention of resuscitation knowledge,
procedural skills and teamwork behaviors at 15 to 18 months.
A priori secondary hypotheses include (1) benet from these
simulations is greater among residents with less clinical resuscita-
tion exposure and (2) condence providing resuscitation is
independent of either knowledge or procedural skills.
METHODS
This randomized, controlled educational intervention was approved by
Women and Infants Institutional Review Board.
Sample size
Among the three componentsknowledge, procedural skills and team-
work behaviorspilot data were only available for knowledge on the fth
edition NRP questionnaire. We calculated sample size from an estimated
15 percentage point effect size, based on before and after differences in
NRP knowledge scores. Residents knowledge scores were expected to drift
between the initial NRP course and the nal assessment.10,11 Using alpha
0.05 and 20% non-completion rate, 37 residents give 80% power to detect
15 percentage point difference, 56 residents to detect 10 percentage
points. We selected 56 residents over all study groups, recognizing that

1
Department of Pediatrics, Women & Infants' Hospital, Providence, RI, USA; 2Warren Alpert School of Medicine at Brown University, Providence, RI, USA and 3Lifespan Medical
Simulation Center, Rhode Island Hospital, Providence, RI, USA. Correspondence: Dr J Bender, Department of Pediatrics, Women & Infants' Hospital, 101 Dudley St, Providence,
RI 02905, USA.
E-mail: gbender@wihri.org
Received 2 December 2013; revised 7 March 2014; accepted 13 March 2014; published online 24 April 2014

even with this more conservative target the study may be underpowered
to detect procedural skill effects, teamwork behavioral effects or subgroup
comparisons.
Subjects
Investigators recruited all medical school graduates at two Brown
University afliated residency programs (Memorial Hospital of Rhode
Island Family Practice, Hasbro Childrens Hospital categorical Pediatrics)
over two consecutive years. Each resident was followed for 2 years after
experiencing the standard NRP Provider course at the start of residency.
NRP instructors taught the courses in the fth edition format, consisting of
6 to 8 h of standardized lecture intermixed with skills practice and multiple
choice tests, culminating with a mega code covering the entire algorithm.
The two residency programs provided different exposure to clinical
resuscitation events. Pediatric residents spent 2 months in their rst year in
a high volume level III neonatal intensive care unit (NICU) at Women and
Infants Hospital of Rhode Island, including 2 weeks on a busy delivery
service. Annual delivery volume was ~ 9000 deliveries, with a 32% cesarean
section rate and 230 infants born with o 1500 g birth weight. Residents
received consistent mentoring from neonatal nurse practitioners on the
delivery service during day shifts, with frequent independent practice on
night shifts. The curriculum included regular lectures and case review on
delivery room stabilization and management. For this study, these
residents were labeled NICU program.
The Family Practice residents experienced 2 months in a level II nursery.
Typical patient volumes included fewer than 600 deliveries annually, 23%
cesarean section rate and fewer than ve infants with o 1500 g birth
weight. Monthly mock codes with case reviews formed the core of their
resuscitation experience. Given the clear difference in clinical resuscitation
exposure, these residents were labeled Non-NICU program.
Randomization
Computer-generated a priori random assignment selected intervention
residents, stratied within each program to reduce bias from pre-existing
skills. Randomization was revealed to schedule the intervention for half of
the Pediatric residents and half of the Family Practice residents. These
residents had the simulation-enhanced booster 7 to 9 months after the
NRP course. The control arm consisted of the remaining rst year residents
from each program. All residents were assessed with simulation 15 to
18 months after taking the NRP course. Residents in the intervention
arm were exposed to simulation twice, once at the booster and once at
assessment. Residents in the control arm performed routine clinical duties
on the booster days.
Simulation experience
Residents were briefed on the study in an open forum. Condentiality was
emphasized, limiting both participant content sharing and research team
sharing evaluations. Participants signed informed consent. Residents were
scheduled into one of four half-day booster sessions and one of eight half-
day assessment sessions. Each session included residents from NICU and
non-NICU programs, and assessment sessions inter-mixed residents from
intervention and control. Residents were not requested to review NRP or
prepare for simulation.
Simulation exposures were standardized. Each booster simulation was
an emergent cesarean section for fetal heart tone decelerations in a high-
delity simulated operating room. Two minutes after the residents arrival,
a stressed obstetric team handed off a non-vigorous term infant covered
with blood and meconium. Each assessment simulation was a shoulder
dystocia scenario in a chaotic labor room, delivering an unresponsive
neonate requiring resuscitation. Scenarios were designed around the
essential steps of NRP. Vignettes were varied to reduce predictability,
changing descriptive elements (for example, gravida, social history) from
resident to resident without altering underlying physiologic corrections.
Residents who moved efciently through the scenario within 15 min were
challenged with a tension pneumothorax, without impacting assessment
score. Interventions were done on a mannequin (Laerdal, SimNewB)
preprogrammed for scenario-specic physiologic responses. One NRP
instructor consistently performed the central support role of newborn
nurse. She was scripted to enable progress without excessive prompting
and mistakes were not corrected during the simulation run.
Each simulation-enhanced booster session started with a 30-min
orientation to simulation. Stated learning objectives were to (1) follow
NRP guidelines and (2) demonstrate effective team leadership. Residents
2014 Nature America, Inc.
Simulation improves procedural skills and teamwork
J Bender et al
665
were coached to resuscitate realistically, request help as necessary, do all
steps and verbalize actions and plans. They were encouraged to explore
the code cart, practice intubation and recognize mannequin cues of
cyanosis, heart rate, breath sounds and movement before the simulation.
Each resident individually managed one scenario for 20 min. The other 2 to
4 residents in each session rotated through educational stations on airway
practice, umbilical venous catheter placement or unrelated Pediatric
Advanced Life Support (PALS) scenarios. Residents did not receive
feedback or observe each others performance until post-simulation22
group debrieng. Portions of each residents run were highlighted during a
75- min round-table intermediate23 level-facilitated discussion. Trained24
debriefers guided residents to explore specic procedural and teamwork
learning objectives. This instructional design provided individual perfor-
mance assessments while optimizing the time allotted for reective
learning during debriengs.25
Validated performance instruments
Performance was evaluated with novel customized instruments. Assessment
scales evaluating procedural skills and team behaviors during simulated
scenarios have been developed17,26,27 and validated with acceptable inter-
rater reliability (kappa 0.42 to 0.59).2830 To improve discrimination of subtle
procedural differences, the existing NRP Megacode Assessment Form20 was
modied to reect specic procedural learning objectives. Iterative
renement (see Supplementary Appendix I) by four NRP instructors resulted
in good concordance between raters (kappa 0.62 to 0.83).
The teamwork behavior instrument was similarly rened from global
team competency scales31,32 and delivery room-specic scales16,33 to t
our scenarios. Supplementary Appendix II describes the development and
validation of the instrument with key behavioral attributes organized into
ve teamwork subscales. The overlapping Venn diagram construct may
complicate interpretation, but clearly benetted rater determination at
assessment. Each subscale was scored as predominantly (1) undermining
behaviors, (2) missed opportunities, (3) neutral, (4) good examples or (5)
consistent outstanding behaviors. The instrument discriminated favorably
between similar performances when two videos were independently
reviewed by four raters.
Data collection
The three domains of assessment were knowledge, procedural skills
and teamwork behaviors. All participants had knowledge determined at
baseline using the NRP questions scored from their initial provider course,
as well as just before assessment using a subset of the same questions.
Residents did not receive feedback on any written components during the
study. Video recordings of simulations were retained for determination of
procedural skills and teamwork behaviors.
Residents evaluated their simulation experience on a 5-point Likert scale
using our routine simulation evaluation form. Residents also self-reported
related experiences that could alter their learning curve during study
simulations. These included familiarity with simulation, proximate certica-
tions, clinical resuscitation events and intubation successes. Each of these
was measured on a unique scale estimated to discriminate clinical relevance.
Familiarity with simulation-based medical education was scored per
exposure to standardized patients, mannequins, animal models, mock
codes and high-delity simulations (1 to 5). Proximate certications included
NRP, Advanced Cardiac Life Support, or PALS scenarios (scored 1 to 4). The
impact of clinical resuscitation events was scored (1 to 4) by the proximity of
the most recent NICU rotation for never, >6 months, 3 to 6 months, o3
months. Successful endotracheal intubation of a neonate scored (0 to 3) for
never, o4, 4to 7 or >7 intubations.
Condence in resuscitation may both modify the primary outcomes
and be affected by the booster intervention. Condence at the time of
assessment was an average of response scores for the following questions.
How condent are you (1) resuscitating a non-vigorous term baby with
meconium-stained amniotic uid, (2) managing an apneic baby, (3)
intubating a late-preterm baby, (4) managing a cyanotic, spontaneously
breathing newborn and (5) assessing effective bag-mask ventilation.
Participants used a scale 0 to 4, with higher numbers representing an
increased level of condence.
Data analysis
Three raters were standardized on the instruments by separate review of
three videos followed by group feedback. They independently scored each
assessment video recording. They were all NRP instructors; two had been
Journal of Perinatology (2014), 664 668
 Simulation improves procedural skills and teamwork
J Bender et al
666
involved in the simulations 2 years before. Intra-class correlation coef-
cients were determined for reviewer concordance on procedural skills and
teamwork behaviors. Knowledge score was the percent of questions
scored correctly. Procedural skills and teamwork behavior scores were the
sum of procedure elements (maximum 107) and behavior elements
(maximum 25) averaged across three raters, respectively. Outcomes were
compared between intervention and control groups as well as between
NICU and non-NICU program types. Residents related experiences and
condence were compared between intervention and control groups, and
between program types. Pearson correlations were calculated for related
experience versus primary outcomes. Two-tail Students t-tests (P-value
o0.05) were used to compare means for normal distributions; the
Wilcoxon test was used for non-normal distributions. Subgroup analysis
was done to identify populations maximally affected by these specic
simulations. Each analysis compared mean values using two-tailed t-test,
P-value o0.05. Subgroup analysis compared mean knowledge, procedural
and teamwork behavioral scores for intervention versus control groups
among the NICU program and the non-NICU program.
RESULTS
Fifty-eight residents enrolled and were randomized over
2 years. Two withdrew after randomization (Figure 1). Six in the
intervention group were not assessed for reasons unrelated to the
study, primarily resident turnover in the non-NICU program.
Related experiences did not differ between intervention and
control groups (Table 1) while conrming expected differences
between NICU and non-NICU programs. Residents rated the
assessment simulations and debrieng as highly effective on the
simulation evaluation form. The 41 residents (82%) who evaluated
the sessions rated (mean s.d., maximum 5) objectives relevant
(4.9 0.3), simulations realistic (4.7 0.5), debrieng effective
(4.8 0.5) and overall high practice impact (4.7 0.6). Assessment
instruments demonstrated good concordance between reviewers.
Intra-class correlations were 0.779 for procedural skills, and, for
teamwork behaviors, 0.686 for allocating attention, 0.720 for
communicating effectively, 0.729 for leadership role, 0.828 for
distributing workload and 0.724 for professionalism.
The booster occurred at 9 1.9 months after the NRP course,
the assessment at 15.8 1.7 months. Knowledge drifted from
baseline scores (94 3.4%) to 9 months (72 11%, intervention
group) and 15 months (70 11%, all participants). Decline in
knowledge scores was similar between study groups or program
types. At assessment, the intervention group demonstrated better

Resident Enrollment

Enrollment Assessed for eligibility (n=60)

Excluded (n=2)
Not meeting inclusion criteria (n=0)
Declined to participate (n=0)
Other reasons (n=2)

Randomized (n=58)

Baseline

Allocation
Allocated to intervention (n= 29) Allocated to control (n= 29)
Received allocated intervention (n= 27) Received allocated control (n= 29)
Did not receive allocated intervention (n= 2) Did not receive allocated control (n=0)
Booster
NICU program (n= 15) Non-NICU (n= 12) NICU program (n= 16) Non-NICU (n= 13)

Follow-Up
Lost to follow-up (n= 6) Lost to follow-up (n=2)

Discontinued intervention (n= 0) Discontinued intervention (n=0)

Assessment
NICU program (n=14) Non-NICU (n= 9) NICU program (n=16) Non-NICU (n= 11)

Analysis
Analysed (n= 23) Analysed (n= 27)
Excluded from analysis (n= 0) Excluded from analysis (n= 0)

NICU program (n= 14) Non-NICU (n= 9) NICU program (n= 16) Non-NICU (n= 11)

Figure 1. Resident enrollment.

Journal of Perinatology (2014), 664 668 2014 Nature America, Inc.

 Simulation improves procedural skills and teamwork
J Bender et al
667
Table 1. Residents related experiences and condence, by the study group and program type

Potential confounder By study group By program type

Intervention Control P-value NICU Non-NICU P-value

Mean (s.d.) Mean (s.d.) Mean (s.d.) Mean (s.d.)

Proximate certications 2.4 (0.7) 2.6 (0.9) 0.37 2.3 (0.7) 2.9 (0.9) 0.005
Simulation familiarity 2.9 (1.3) 2.5 (1.1) 0.33 3.0 (1.3) 2.2 (0.9) 0.03
Recent NICU exposure 2.5 (1.3) 2.0 (1.1) 0.17 3.0 (0.9) 1.0 (0) o0.001
Intubation successes 0.8 (0.6) 0.6 (0.8) 0.38 0.8 (0.7) 0.3 (0.6) 0.02
Resuscitation condence 2.5 (0.6) 2.2 (0.7) 0.14 2.5 (0.6) 2.0 (0.7) o0.007
Abbreviation: NICU, neonatal intensive care unit.

Table 2. Primary outcomes by study group within program type

Within NICU program Within Non-NICU program MANOVA

(mean (s.d.)) (mean (s.d.))

Outcome Intervention Control Intervention Control Group Program Group by

(n = 14) (n = 16) (n = 9) (n = 11) effect effect program effect

Knowledge % 73 (9) 71 (9) 67 (11.6) 65.2 (15.2) F = 0.03 F = 2.87 F = 0.01

P = 0.57 P = 0.10 P = 0.93
Procedural skills 73.1 (8.4) 66.9 (11.3) 68.9 (11) 61.3 (13.1) F = 6.05 F = 2.67 F = 0.12
P = 0.02 P = 0.11 P = 0.73
Teamwork behaviors 20 (2.6) 17.3 (3.6) 16.8 (1.8) 14.7 (4.3) F = 5.63 F = 10.2 F = 0.56
P = 0.02 P = 0.003 P = 0.46
Abbreviations: F, F-test; MANOVA, multivariate analysis of variance; NICU, neonatal intensive care unit; P, P-value.

procedural skills (71.6 versus 64.4) and teamwork behaviors (18.8
versus 16.2) compared with control. The NICU program demon-
strated better teamwork behaviors (18.6 versus 15.5) compared
with non-NICU program. Subgroup analysis (Table 2) supported
these group and program effects. Procedural skills correlated well
(r = 0.86) with teamwork behaviors. Knowledge scores correlated
weakly with either procedural skills (r = 0.66) or behavior (r = 0.51),
and all correlated poorly (r = 0.28 to 0.55) with related experiences
and condence.
DISCUSSION
Effective resuscitation of the critically ill neonate requires
integrated tiers of knowledge, procedural skills and teamwork
behaviors. Essential NRP procedural skills successfully reach the
neonate given effective knowledge and teamwork. Simulation
may enhance each component.34 This study was done just before
a fundamental transition in sixth edition NRP, shifting learner
contact hours focus from {knowledge and procedure} to
{procedure to teamwork}. Deliberate practice with three simula-
tions within 6 months of NRP may improve performance.35 The
impact of a single booster session on performance or behavior
is less clear. Two studies failed to demonstrate improved NRP
performance with validated instruments immediately following36
or 2 weeks after (Van der Heide (2006)) a single simulation session.
The present study shows that a single simulation-enhanced
booster session 9 months after the initial NRP course measurably
differentiated 15-month procedural skills and teamwork behaviors
from those not receiving the booster. Knowledge drifted equally
in both groups. This did not undermine the intervention groups
superiority with essential procedural skills. While the measured
benets from simulation (+7.2) may be clinically nominal, it was at
least as signicant (+5.5) as more extensive interim clinical
resuscitation exposure.
Teamwork training integrated into the NRP course improves
behaviors in multiple disciplines37 that may persist 6 months after
2 h of simulation-based training.38 This study explored a separate
booster, as neither simulation nor teamwork was integrated into
NRP at the time. We found simulation followed by attention to
teamwork principles during facilitated debrieng to be sufcient
to distinguish behaviors 6 months later. Subgroup analysis
identied independent effects on teamwork behaviors from
simulation and clinical resuscitation exposure. Yet the residents
with the least clinical exposure did not display the best gains from
simulation, refuting our secondary hypothesis. The data support
that deliberate practice has an incremental benet on teamwork
behaviors regardless of source. As observed clinical performance
was outside the study scope, we can only presume that
persistently superior procedural skills and teamwork behaviors in
the simulation arena correlate with patient benet. We remain
skeptical of over-interpreting knowledge or condence scores,
given their poor correlation with either skills or behavioral
competence.
Several study limitations affect interpretation of the results.
Twenty percent attrition by intervention residents introduces
potential selection bias. Rater bias was minimized by reviewing
videos more than 2 years after the simulations. Second, the study
was underpowered for procedural skill or teamwork behaviors,
nding statistically signicant results less than the 15% targeted
difference for knowledge scores. Third, individual resident pro-
cedure and teamwork improvement is not knowable without
baseline measurement. Group outcome comparisons are reason-
able given randomization into equivalent cohorts. The study
groups are balanced (Table 1) with respect to previous NRP and
related certications, simulation familiarity, NICU exposure and
live procedural success with intubation. Fourth, as high versus low
tech simulation was not compared, we can only conclude that
the environment was sufciently immersive. Fifth, alternate

2014 Nature America, Inc. Journal of Perinatology (2014), 664 668

 Simulation improves procedural skills and teamwork
J Bender et al
668
educational approaches were not offered at the time of educa-
tional booster. This confounds the impact of simulation with a
booster effect, limiting conclusions regarding the relative efcacy
of revisiting NRP by another means. Finally, the measured
differences may have resulted from an extra simulation exposure
at intervention. While simulation neophytes march up a steep
learning curve when doing their rst simulation, these residents
had signicant previous exposures. One extra simulation session
would minimally alter their experience.
A growing literature supports the efcacy of simulation as
recommended in the sixth edition NRP. This study uniquely
substantiates the NRP transition in an era when instructors
struggle to adapt ingrained teaching styles to the new simulation-
based format. It describes a differential effect on two similar
populations of a single simulation-based educational booster
customized for high trainee relevance and clinical practice impact.
The results caution against relying on cognitive measures to
project clinical performance or patient outcomes. They provide
insight to the relative contribution of simulation and live clinical
exposure upon each tier of neonatal resuscitation. Customizing
scenarios to the practitioners clinical practices may optimize
learning.
A simulation-enhanced booster session 9 months after NRP
differentiates procedural skills and teamwork behaviors at 15
months. Deliberate practice with simulation enhances teamwork
behaviors additively with residents clinical resuscitation exposure.
Traditional non-simulation-based educational techniques may
have a similar effect.
CONFLICT OF INTEREST
The authors declare no conict of interest.
ACKNOWLEDGEMENTS
We acknowledge the generous contributions of all the residents who participated, as
well as MaryAnn Garrin, Dan Gingras, Beau Abar, Lynne Dansereau, Joe McNamara,
Joe Bliss and Abbot Laptook. This work was supported by Department of Pediatrics,
Women & Infants' Hospital.
REFERENCES
1 American Academy of Pediatrics, American College of Obstetricians and
Gynecologists. In: Gilstrap LC, Oh W (eds). Guidelines for Perinatal Care, 5th edn.
American Academy of Pediatrics: Elk, Grove Village, IL, USA, 2002, 187.
2 American Heart AssociationAmerican Academy of Pediatrics. 2005 American
Heart Association Guidelines for CPR and Emergency Cardiovascular Care of
Pediatric and Neonatal Patients: Neonatal Resuscitation Guidelines. Pediatrics
2006; 147(5): e1029e1038.
3 Falck AJ, Escobedo MB, Baillargeon JG, Villard LG, Gunkel JH. Prociency of
pediatric residents in performing neonatal endotracheal intubation. Pediatrics
2003; 112(6): 12421247.
4 Feigin RD, Drutz JE, Smith EOB, Collins CR. Practice variations by population:
training signicance. Pediatrics 1996; 98(2): 186190.
5 Leone TA, Rich W, Finer NN. Neonatal intubation: success of pediatric trainees.
J Pediatr 2005; 146(5): 638641.
6 Perlman J, Risser R. Cardiopulmonary resuscitation in the delivery room. Asso-
ciated clinical events. Arch Pediatr Adolesc Med 1995; 149(1): 2025.
7 Aziz K, Chadwick M, Downton G, Baker M, Andrews W. The development and
implementation of a multidisciplinary neonatal resuscitation team in a Canadian
perinatal centre. Resuscitation 2005; 66(1): 4551.
8 Patterson M, Moyer M, LeMaster T, Pio B. Effect of a focused paramedic educa-
tional intervention on the acquisition and retention of airway management skills
in the pediatric patient [Abstract]. Soc Pediatr Res 2005; 57: 1874.
9 Curran VR, Aziz K, Oyoung S, Bessel C. Evaluation of the effect of a computerized
training simulator (anakin) on the retention of neonatal resuscitation skills. Teach
Learn Med 2004; 16(2): 157164.
Supplementary Information accompanies the paper on the Journal of Perinatology website (http://www.nature.com/jp)
Journal of Perinatology (2014), 664 668
10 Levitt C, Kaczorowski J, Outerbridge E, Jiminez V, Connoly B, Slapcoff B. Knowl-
edge gained following neonatal resuscitation program courses. Family Med 1996;
28: 403406.
11 Semeraro FSL, Cerchiari EL. Retention of CPR performance in anaesthetists.
Resuscitation 2006; 68(1): 101108.
12 Boet S BB, Naik VN, Siu LW, Riem N, Chandra D, Bould MD, et al. Complex pro-
cedural skills are retained for a minimum of 1 yr after a single high-delity
simulation training session. Br J Anaesth 2011; 107(4): 533539.
13 Madar J. Clinical risk management in newborn and neonatal resuscitation. Semin
Fetal Neonatal Med 2005; 10(1): 4561.
14 Cappelle C, Paul R. Educating residents: the effects of a mock code program.
Resuscitation 1996; 31(2): 107111.
15 Pliego JF W-JH, Rajab MH, Browning JL, Fothergill RE. Ob/Gyn boot camp using
high-delity human simulators: enhancing residents perceived competency,
condence in taking a leadership role, and stress hardiness. Simul Healthcare
2008; 3(2): 8289.
16 Thomas E, Sexton J, Lasky R, Helmreich R, Crandell D, Tyson J. Teamwork and
quality during neonatal care in the delivery room. J Perinatol. 2006; 26: 163169.
17 Carbine D, Finer N, Knodel E, Rich W. Video recording as a means of evaluating
neonatal resuscitation performance. Pediatrics 2000; 106: 654658.
18 Halamek L, Kaegi D, Gaba D, Sowb Y, Smith B, Smith B 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.
19 Murphy A, Halamek L. Educational Perspectives: Simulation-based Training in
Neonatal Resuscitation. NeoReviews 2005; 6(11): e489e492.
20 Short J. Textbook of Neonatal Resuscitation, 5th edn. American Academy of
Pediatrics and American Heart Association: Elk Grove Village, IL, USA, 2006.
21 Kattwinkel J. Textbook of Neonatal Resuscitation, 6th edn. American Academy of
Pediatrics and American Heart Association: Elk Grove Village, IL, USA, 2011.
22 Heukelom JNV, Begaz T, Treat R. Comparison of postsimulation debrieng versus
in-simulation debrieng in medical simulation. Sim Healthcare 2010; 5: 9197.
23 Dismukes R, Smith G. Facilitation and Debrieng in Aviation Training and Opera-
tions . Ashgate: Aldershot; UK, 2000.
24 A New Vision for Pediatric and Perinatal Education at Center for Advanced
Pediatric and Perinatal Education (http://cape.lpch.org/).
25 Fanning RM, Gaba DM. The role of debrieng in simulation-based learning. Simul
Healthcare 2007; 2(2): 115125.
26 Gaba D, Howard S. Assessment of clinical performance during simulated crises
using both technical and behavioral ratings. Anesthesiology 1998; 89(1): 818.
27 Weller J, Bloch M. Evaluation of high delity patient simulator in assessment of
performance of anaesthetists. Br J Anaesth 2003; 90(1): 4347.
28 Van der Heide P, Toledo-Eppinga L, van der Heide M, van der Lee J. Assessment of
neonatal resuscitation skills: a reliable and valid scoring system. Resuscitation
2006; 71: 212221.
29 Adler MD, Trainor JL, Siddall VJ, McGaghie WC. Development and validation of
high delity patient simulator case scenarios for pediatric resident evaluation
[Abstract]. Soc Pediatr Res 2006; 7: 182186.
30 Brett-Fleegler MB, Vinci RJ, Weiner DL, Harris SK, Shih MC, Kleinman ME. A
simulator-based tool that assesses pediatric resident resuscitation competency.
Pediatrics 2008; 121(3): e597e603.
31 Overly F, Sudikoff S, Shapiro M. High delity medical simulation as an assessment
tool for pediatric residents' airway management skills. Pediatr Emerg Care. 2007;
23(1): 1115.
32 Frankel A, Gardner R. Using the Communication and Teamwork Skills (CATS)
Assessment to measure health care team performance. Jt Comm J Qual Patient Saf
2007; 33(9): 549558.
33 Training materials from Center for Advanced Pediatric Education, Palo Alto.
34 Halamek L. The simulated delivery-room environment as the future modality for
acquiring and maintaining skills in fetal and neonatal resuscitation. Semin Fetal
Neonatal Med. 2008; 13: 448453.
35 Sawyer T, Sierocka-Castaneda A, Chan D, Berg B, Lustik M, Thompson M.
Deliberate practice using simulation improves neonatal resuscitation perfor-
mance. Simul Healthcare 2011; 6(6): 327336.
36 Campbell D, Barozzino T, Farrugia M, Sgro M. High-delity simulation in neonatal
resuscitation. Paediatr Child Health 2009; 1(14): 1923.
37 Yaeger KA, Halamek LP, Coyle M, Murphy A, Anderson J, Boyle K et al. High-delity
simulation-based training in neonatal nursing. Adv Neonatal Care 2004; 4(6):
326331.
38 Thomas EJ, Williams AL, Reichman EF, Lasky RE, Crandell S, Taggart WR. Team
Training in the Neonatal Resuscitation Program for Interns: teamwork and quality
of resuscitations. Pediatrics 2010; 125(3): 539546.
2014 Nature America, Inc.