Thursday, June 25, 2015

Expert Modeling to Improve Acquisition of Behavioral and Technical Skills in Resuscitation Training

JoDee Anderson, MD, MEd
Oregon Health Sciences University

Background: Birth asphyxia accounts for approximately 20% of the five million neonatal deaths that occur globally each year. For this reason, the Neonatal Resuscitation Program (NRP) was developed in 1987 to increase success in neonatal resuscitation during the first few critical minutes after birth. Despite the positive impact on neonatal outcome, many of the skills acquired in the traditional NRP training (lecture-based) do not translate well to actual delivery room practice. Video analyses of delivery room resuscitations and root cause analyses of term infant death and disability have identified a lack of expertise in requisite technical, behavioral and cognitive skills contributing to poor outcome. Where traditional NRP training involves a multiple choice examination with passive learning activities, experiential learning theory supports the use of more immersive, realistic learning opportunities to better address the needs of NRP providers. Simulation-based training in this pretext has been shown to be effective in technical behavioral and cognitive skills acquisition and translation. The Neonatal Resuscitation Program has embraced these findings; all NRP training will be simulation-based by 2011. Improving this critical education will involve more than simulating a few resuscitations though; the ideal training paradigm will decrease the amount of real-life experience required to become an expert. Exploring expertise may allow refinement of our educational strategies in resuscitation training. In simulation-based training, learners learn from mistakes (learner modeling) during the facilitated debriefing, which promotes reflection-on-action. While reflection-on-action can change future performance, learning to reflect-in-action may be of equal importance. Reflection-in-action separates the novice from the expert, allows the participant to respond to cues in the environment and make critical decisions based on those cues. Demonstrating expertise involves modeling the expert’s technical and behavioral skills and revealing the internal conversation and critical thinking as the expert responds in the moment to these dynamic cues. When skills such as these are modeled, learners selectively take in information about performing; from these observations a mental image is created that provides a standard of reference for future performance.

Objective: To assess the impact of expert modeling on the acquisition and performance the requisite of technical and behavioral skills in neonatal resuscitation training.

Methods: A video was created using a Delphi process to demonstrate expert technical skills, behaviors, and thought processes during newborn resuscitation. A convenience sample of 31 subjects was enrolled; all participants had completed a simulation-based NRP course prior to the study. Baseline demographics, NRP cognitive test scores, and a subjective measure of confidence were collected. Subjects were randomized by a table of random numbers. The experimental group reviewed the expert model video while the control group practiced megacodes with facilitated debriefing. All participants then individually underwent a videotaped megacode in the simulator. The videos were scored by blinded reviewers to assess technical and behavioral skills. Mean scores were calculated and compared for each group using a two tailed t-test.

Results: There was no significant difference between the groups in age, gender, simulation experience, NRP experience, cognitive knowledge, or confidence. The experimental group scored significantly higher in technical skills than the control group (p<0.001). The experimental group scored significantly higher in behavioral skills than the control group (p<0.001). The Cronbach's alpha was 0.97 and the inter-rater reliability was 0.8 for the behavioral assessment..

Conclusion: The addition of expert modeling to simulation-based neonatal resuscitation training improves acquisition of behavioral and technical skills.