Digital Repository Masters Projects Spring 2025 Improving Neonatal Resuscitation Provider Skill Performance Adrianne Murdock Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Murdock, A. 2025. Improving Neonatal Resuscitation Provider Skill Performance. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP Improving Neonatal Resuscitation Provider Skill Performance Project Title by Adrianne Murdock Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY April 15, 2025 Ogden, UT Date Adrianne Murdock BSN, RN April 15, 2025 Student Name, Credentials (electronic signature) Date Jamie Wankier Randles EdD, MSN, RN April 21, 2025 MSN Project Faculty Date (electronic signature) Anne Kendrick, DNP, RN, CNE (electronic signature) DNP, N, CNE MSN Program Director Note: The program director must submit this form and paper. April 22, 2025 Date 1 Improving Neonatal Resuscitation Provider Skill Performance Adrianne Murdock BSN, RN, MSN Student Annie Taylor School of Nursing Weber State University MSN Project 2 Abstract Purpose/Aims: Enhancing the knowledge, skills, and confidence of neonatal resuscitation providers is a crucial aspect of the standardized Neonatal Resuscitation Program (NRP) training. This project aims to address inconsistencies in current NRP training by incorporating sequential skills practice, simulation-based learning, and structured debriefing to improve provider competency and neonatal outcomes. Rationale/Background: Neonatal resuscitation is a high-acuity, low-frequency event requiring providers to demonstrate proficiency in critical life-saving skills. The current training methods for out-of-hospital providers are inconsistent, leading to varying skill and confidence levels. Literature indicated that standardized training, including sequential skills practice, simulationbased learning, and reflective debriefing, improves provider competence, team coordination, and neonatal outcomes. Methods: A structured NRP class format was developed, incorporating sequential skills practice aligned with resuscitation guidelines, simulation scenarios specific to out-of-hospital settings, and structured debriefing. Providers will complete pre- and post-training surveys to assess confidence and skill performance changes. NRP instructors will receive train-the-trainer education to ensure consistent instruction and facilitation of debriefing sessions. Results: Integrating structured training practices improves neonatal outcomes by reducing errors and enhancing timely interventions. Conclusions: By implementing a consistent and structured NRP class, out-of-hospital providers have increased confidence, improved skill retention, and enhanced team communication during neonatal resuscitations. Keywords: neonatal resuscitation, deliberate skills practice, simulation, debriefing, 3 Improving Neonatal Resuscitation Provider Skill Performance Neonatal resuscitation is a critically timed intervention in the immediate moments following a newborn’s birth that demands competent and effective responses from healthcare providers. The Neonatal Resuscitation Program (NRP) is the cognitive and hands-on training that equips healthcare providers with essential skills and knowledge to intervene when newborns fail to transition to extrauterine life independently (Weiner & Zaichkin, 2021). NRP is critical because it helps save newborns' lives by teaching healthcare providers how and when to respond in crucial situations (Weiner & Zaichkin, 2021). Quality NRP education gives providers the skills and confidence to treat patients effectively. Adherence to the NRP algorithm and guidelines, developed with the best neonatal resuscitation information (Aziz et al., 2021), improves patient outcomes and decreases neonatal morbidity and mortality (Nolan et al., 2020). The NRP program's vision (Neonatal Resuscitation Program, n.d.) is to improve neonatal health by having an expert provider at every birth. Emergency Medical Service (EMS) providers who attend out-of-hospital births and do not have additional NRP-trained personnel available to assist during resuscitation must obtain NRP skill competence to prevent a poor neonatal outcome. In the MSN project clinical setting, various instructors teach NRP classes to EMS providers, creating inconsistent course formats. Skills are often taught and practiced out of the order used during the NRP resuscitation guidelines. In addition, simulation experiences are often rushed or do not adequately train participants for complex out-of-hospital resuscitation, and debriefing is not part of the class structure. Structured NRP training, including simulation and debriefing, can affect the quality of resuscitation, which significantly impacts neonatal morbidity and mortality (Asmamaw Bekele et al., 2021). This MSN project will explore current practices and literature to implement a 4 structured and consistent NRP class with improved skills practice (Copple, 2020), simulation (Felton & Cheshire, 2024), and debriefing (Yang & Oh, 2021) to improve provider skill performance and thus improve neonatal outcomes. Statement of Problem Emergency medical services (EMS) provide transport and medical care for patients from the incident scene to the hospital or between healthcare facilities. An EMS transport provider’s job requires all team members, including those primarily caring for adult and pediatric patients, to be Neonatal Resuscitation Program (NRP) providers. For providers who infrequently use delivery room resuscitation skills, the Sequential Practice and Evaluation class format is recommended (NRP Instructor Toolkit, n.d.). Additionally, when out-of-hospital providers engage in NRP training, the simulations and evaluations should be modified to meet the provider's scope of practice and equipment available during transport (Weiner & Zaichkin, 2021). Neonatal resuscitation is a high-acuity, low-occurrence (HALO) situation where certification and competence are not interchangeable (Garvey & Dempsey, 2020). Current practice in a local transport provider setting meets the requirements for certification. However, due to inconsistent delivery, some NRP providers still lack the necessary confidence in their skills to perform competently as a team. Training is significantly associated with providers' knowledge of neonatal resuscitation (Asmamaw Bekele et al., 2021), but after initial training, due to the lack of exposure, provider knowledge, skills, and competency decline (Hwang et al., 2024). NRP provides instructors with the tools and flexibility to design program-specific courses to meet the learners' needs (Copple, 2020). In this MSN project setting, instructors develop and teach various class formats. Each 5 instructor has different teaching capabilities, bringing their own educational and experience biases. During course instruction, team members often do not acquire NRP skills proficiency (Copple, 2020) and have improperly emphasized or missed content (McGlinn & Sundgren, 2022). Therefore, this MSN project aims to implement an enhanced and consistent Sequential Practice and Evaluation NRP process for out-of-hospital providers to improve patient safety and neonatal outcomes by increasing team members' confidence and NRP skills. This project goal will be accomplished by conducting a comprehensive literature review to identify the best practices in NRP class formats and methods for instruction. The literature review will guide the development of a consistent and structured course format to improve provider confidence, patient outcomes, and team performance. Significance of the Project Effective NRP goes beyond certification, instilling provider confidence and competence in infrequently used skills. A consistent and structured NRP provider course can improve providers' skill performance in high-acuity and low-occurrence resuscitations (Copple, 2020; McGlinn & Sundgren, 2022). Training programs must offer consistent content material and delivery format and provide simulation and debriefing opportunities. When NRP course content varies, provider confidence can be affected, team performance suffers, and patient care and safety are jeopardized (Garvey & Dempsey, 2020; Mayer et al., 2022). This MSN project is significant because it addresses critical gaps in training out-ofhospital providers involved in neonatal resuscitation, aligning NRP class certification courses with best practice recommendations, and ensuring that all team members receive consistent course training. This MSN project seeks to empower healthcare teams with improved skill 6 performance for effective resuscitation by establishing a standardized and enhanced Sequential Practice and Evaluation NRP class with simulation and debriefing options. A standardized process and class format allow instructors to follow skills practiced sequentially (Weiner & Zaichkin, 2021), provide simulations explicitly written for out-of-hospital providers (Garvey & Dempsey, 2020), and offer debriefing for meaningful learning (Yang & Oh, 2021). According to Copple (2020), standardizing course content using training-the-trainer methods and creating gold-standard skill instruction videos can decrease instructor teaching variability and enhance learner confidence. In addition, teams that train consistently have enhanced overall team performance (Lindhard et al., 2021). Simulation enhances NRP certification classes and strengthens teams (Lindhard et al., 2021). Evidence-based research demonstrated that adult learners benefit from well-run simulations in their knowledge and skills as NRP providers (Felton & Cheshire, 2024; Garvey & Dempsey, 2020). Hardie and Lioce (2020) found that NRP simulation as a team improves skills, knowledge, and confidence, is a safe place to practice hands-on essential skills, and enhances skill retention. Debriefing is the most critical stage in simulation-based education, providing instant feedback and learning through self-reflection (Yang & Oh, 2021). Adherence to the guidelines "based on the best available resuscitation science" (Aziz et al., 2021, p. S161) improves neonatal outcomes. Better training prepares providers to deliver high-quality care during critical neonatal emergencies. Quality NRP classes can improve timely and effective interventions, greatly influencing the newborns' quality of care at delivery (Zaichkin et al., 2021). This initiative is pivotal, as improved training directly correlates with enhanced neonatal care, reducing morbidity and mortality rates (Mayer et al., 2022). 7 Ultimately, this MSN project aligns with the NRP Program's vision to ensure that every birth is attended by a knowledgeable and skilled provider, significantly contributing to the health and safety of newborns (Neonatal Resuscitation Program, n.d.). A comprehensive literature review will inform best practices for collaborating to develop a structured Sequential Practice and Evaluation NRP class with simulation and debriefing. Review of the Literature The Neonatal Resuscitation Program (NRP) is an educational framework that teaches healthcare providers the knowledge and skills to intervene in the delicate moments following a newborn's birth and assist with breathing. However, completing the NRP program does not imply competence (Weiner& Zaichkin, 2021). EMS providers who attend out-of-hospital births and are the sole individuals with NRP knowledge need increased skill performance to improve neonatal outcomes (Zaichkin et al., 2021). Enhanced neonatal resuscitation courses improve competence among novice learners (Copple, 2020). However, in this MSN project setting, NRP instructors and classes vary greatly, omitting sequenced practice, simulation, and debriefing. This literature review explored the current literature and best practice guidelines to support enhancing the NRP class structure with sequential skills practice (Weiner& Zaichkin, 2021), simulation in neonatal resuscitation (Garvey & Dempsey, 2020), and meaningful debriefing (Woda et al., 2022) to improve provider competence and skill performance. Framework Standard NRP class formats do not adequately prepare out-of-hospital transport providers to competently and confidently provide neonatal resuscitation. This MSN project aims to restructure the class format to increase provider confidence and foster better team performance to improve neonatal outcomes. The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) 8 model is a simple nurse-driven model that enhances leadership and interdisciplinary collaboration (Melnyk & Fineout-Overhold, 2023). In the JHNEBP three-phase model, the PET process includes a practice question, evidence, and translation, and applies well to operational questions (Melnyk & Fineout-Overhold, 2023). This JHNEBP model provides an excellent outline for this MSN project to assemble an interdisciplinary team, refine the question, gather internal and external evidence, develop recommendations for change, and then translate the findings into a plan. The steps of the model align with this MSN project in the following ways: Practice question: In this step, an area for improvement will be identified and will then guide the formation of an interdisciplinary team and key stakeholders. Evidence: This model step will help evaluate internal evidence, including culture and equipment, external evidence, and a review of NRP standards and clinical evidence for class structure/simulation. Based on this information, recommendations will be developed for changes to class structure and simulation (Hardie & Lioce, 2020), debriefing (McGlinn & Sundgren, 2022), and incorporating innovative teaching methods (Zanno, 2022). Translation: This will guide the creation and implementation of a new class structure and process. The administration of pre- and pre-post-surveys will help evaluate the effectiveness of the new format. Strengths and Limitations The JHNEBP model has various strengths and limitations. The strengths of this model include the user-friendly tools available to assist in each phase of the project (Johns Hopkins Evidence-Based Practice Model, n.d.). Additionally, the model aims to incorporate best practices and the latest research findings into patient care (Welch Medical Library Guides: Nursing Resources: JHNEBP Model Resources, 2021). Using best practice and current research 9 associated with the project goal of aligning current NRP course teaching with the best evidencebased practice. The JHNEBP model also highlights evidence-based practice (EBP) as an interprofessional activity to improve team collaboration and continuous improvement based on feedback (Welch Medical Library Guides: Nursing Resources: JHNEBP Model Resources, 2021). Implementing the JHNEBP model with the provided tools will help improve team collaboration while applying best practices. The JHNEBP model is limited when the evidence to drive practice changes is low. When there is a lack of Level IV and Level V evidence, teams should proceed cautiously and develop a pilot study before implementing a full-scale change. Despite the framework's limitations in incorporating lower levels of evidence, the JHNEBP and its user-friendly tools are available from Johns Hopkins (Johns Hopkins Evidence-Based Practice Model, n.d.). The JHNEBP model is reliable for implementing evidence-based changes in this MSN project. Analysis of Literature Despite advancements in neonatal resuscitation, questions persist regarding the effectiveness of training methods on provider skill performance and competency (Copple, 2020). Training methods and provider skill performance and competency form the foundation of the MSN Project PICOT question: In healthcare providers undergoing NRP training (P), does implementing a structured format with simulation and debriefing (I), compared to standard NRP training, improve skill performance in neonatal resuscitation? This literature review explored the benefits of NRP's sequential practice and evaluation method of practicing skills in the order used in resuscitation and the integration of simulation and debriefing techniques into certification classes. 10 Search Strategies A literature search was conducted using Weber State University Stewart Library's OneSearch, CINAHL, PubMed, Ovid, and Google Scholar to identify current evidence. This literature review included only articles published between 2020 and 2024 to keep information current. The keyword search included NRP, neonatal resuscitation program, simulation, debriefing, teaching methods, best practices, coaching, quality improvement, team building, skill retention, skill performance, and confidence. Various Boolean combinations were created with the abovementioned keywords to create a broader search. Synthesis of the Literature The literature identified three themes regarding NRP education and teaching methods to improve provider skill performance: 1) structured class format and sequential practice of skills, 2) simulation for deliberate practice, and 3) debriefing for meaningful learning. Structured Class Format with Sequential Skills Practice Acquiring and maintaining skills can be difficult within an acute healthcare environment. Solidifying nursing skills requires a structured method based on deliberate skills practice (Johnson et al., 2019). The 8th edition of NRP introduced two different instructor-led learning formats tailored to providers' roles and responsibilities (Zaichkin et al., 2021). The course emphasized role-specific training, ensuring each provider is better equipped to respond effectively during resuscitation. Two different instructor-led learning formats exist, including Sequential Practice and Evaluation and the Comprehensive Skills Test Format, where expert NRP providers may 'test out' by participating in a challenging team resuscitation scenario followed by a debriefing (Zaichkin et al., 2021). 11 Sequential practice involves learning and practicing skills or concepts in a specific order that builds upon previous steps. Donoghue et al. (2021) found that deliberate practice, in which learners had a specific goal to achieve, received performance feedback, and had time for repeated practice, improved skill performance. Deliberate practice promoted mastery of learning and improved educational outcomes in life support education (Donoghue et al., 2021). Sequential Practice and Evaluation is recommended for NRP providers who do not often participate in resuscitations. In this format, the instructor guides learners through skill demonstration and practice scenarios until the learner can lead their team correctly through the algorithm and perform skills without coaching (Zaichkin et al., 2021). Practice scenarios build on the skills and knowledge from previous lessons (Zaichkin et al., 2021). Clinicians who do not experience neonatal resuscitation often need enhanced training, focusing on key skills and extra practice to improve their comfort with NRP skills (Copple, 2020). A fragmented approach to practicing technical skills does not reinforce the correct sequence in the NRP algorithm (McGlinn & Sundgren, 2022). Situation cognition, where learning is situated in experience, is emphasized through sequential skills practice (McGlinn & Sundgren, 2022). Hands-on skills should be practiced in the order needed in resuscitation, and scenarios to practice them built on previous knowledge (McGlinn & Sundgren, 2022; Zaichkin et al., 2021). Additionally, Copple (2020) recommended facilitating practice stations with a worksheet based on the lesson reviews in the NRP textbook (Weiner & Zaichkin, 2021) to assist learners in processing new information. McGlinn and Sundgren (2022) improved learner satisfaction by implementing changes to their NRP class format. In addition to skills stations based on the NRP algorithm, multidisciplinary teams worked together throughout the class before working together in 12 simulations. Gold standard videos were created to teach the skills stations, which helped demonstrate the skills, sequencing, communication, and teamwork (McGlinn & Sundgren, 2022). Research showed that instructors who functioned as coaches using NRP content instead of teachers provided standardized instruction and offered corrections to improve the learners' skill performance (McGlinn & Sundgren, 2022). By focusing on hands-on skills practiced in the proper sequence and incorporating team-based scenarios, an enhanced NRP course improved clinician confidence and competence, particularly for those less frequently involved in neonatal resuscitations (Copple, 2020; McGlinn & Sundgren, 2022). Simulation-Based Training Healthcare simulation is a teaching and training technique in which students apply theoretical knowledge and practice skills in a safe environment that promotes critical thinking (Koukorikos et al., 2021). It is used to teach and train healthcare professionals at all levels. Simulation-based education enhanced team spirit and cooperation and increased student selfconfidence and comfort in skill performance (Koukorikos et al., 2021). Wang and Ji (2021) found that simulation-based healthcare education in a realistic setting bridged the gap between theory and practice. Simulation scenarios related to real-life learning supported teamwork as groups encouraged and interacted with team members to creatively problem solve and work together to complete the task (Wang & Ji, 2021). Simulation-based learning, an effective teaching technique, promoted cognitive, affective, and psychomotor skills development through hands-on experiences (Mishra & Trivedi, 2023). Simulation-based training has emerged as a cornerstone in neonatal resuscitation education. It has been consistently shown to improve healthcare providers' skills (Alalhareth & Howarth, 2020), confidence (Felton & Cheshire, 2024), and team performance (Lindhard et al., 13 2021). The 2020 American Heart Association (AHA) guidelines for Neonatal Resuscitation (Aziz et al., 2020) emphasized the importance of simulation-based training for improving neonatal resuscitation skills by practicing essential tasks such as airway management, chest compressions, and medication administration in a controlled environment. Alalhareth and Howarth (2020) concluded that simulation is a safe and controlled environment for the students to practice clinical scenarios that support neonatal skill development, and the more straightforward the simulation training process, the more effective it was in meeting learning objectives. Simulation training promoted a tangible learning methodology and greatly benefited knowledge retention (Alalhareth & Howarth, 2020). Felton and Cheshire (2024) cited the NRP program's shift over the past ten years from a passive lecture-based format to simulation-based learning to enhance skill development and critical thinking. A comprehensive simulation-based NRP training program increased and helped maintain nurses' competency and confidence and improved teamwork (Felton & Cheshire, 2024). Lindhard et al. (2021) found that simulation-based training enhanced team and technical performance in NRP scenarios. Hardie and Lioce (2020) demonstrated the importance of structured formats in simulation training, suggesting that systematic scenario design and facilitation approaches contribute significantly to skill acquisition and retention. Wang and Ji (2021) noted that student engagement in simulation-based education could predict learning outcomes, satisfaction, critical thinking skills, and academic achievement. Research showed that stimulation combined thinking and physical engagement, which resulted in performance engagement (Wang & Ji, 2021). Students demonstrated self-directed learning by preparing to enter and solve problems within the simulation (Wang & Ji, 2021). Teams are also strengthened by the active engagement of peers, who show mutual respect in their interactions to 14 solve complex clinical problems. Wang and Ji (2021) found that the closer the real-life practice to the learning situation, the more positive feedback and encouragement from peers promoted student engagement and learning. In furthering student engagement, the facilitator's role should be to help and guide with 'inquiry' rather than impart knowledge (Wang & Ji, 2021). Garvey and Dempsey (2020) cited the exponential growth of simulation in newborn care, which provided guided experiences that blended theoretical knowledge and practical skills in a risk-free environment. Structured NRP simulation teaches teamwork and allows providers of all experience levels to become familiar with the equipment and remain competent (Garvey & Dempsey, 2020). Garvey and Dempsey (2020) cited multiple benefits of simulation on NRP as innovative ways of improving NRP skills. Learners are motivated to improve through deliberate practice with immediate feedback without the stress of an actual patient needing time-sensitive interventions (Garvey & Dempsey, 2020). Simulation provided an ideal environment for students to gain familiarity with and troubleshoot equipment (Garvey & Dempsey, 2020). In addition to skills performance, simulation improved confidence, knowledge, and teamwork (Garvey & Dempsey, 2020). When team training with simulation is incorporated into NRP, teams communicate more effectively, maintain better workload management, and decrease error rates (Garvey & Dempsey, 2020). Debriefing in Simulation A simulation activity should include three components: a pre-brief, a scenario, and a debrief led by a simulation facilitator (Kuszajewski, 2021). Debriefing is the foundation for effective simulation-based education (Yang & Oh, 2021), as debriefing and feedback are critical for enhancing performance (Garvey & Dempsey, 2020). 15 The International Nursing Association for Clinical Simulation and Learning (INACSL) standards (INACSL Standards Committee et al., 2021) emphasized the role of planned and structured debriefing in creating a supportive learning environment where students can identify strengths, address knowledge gaps, and improve teamwork and communication. The debriefing process should use a theoretical method (Woda et al., 2022) and include one or more techniques: feedback, debriefing, or guided reflection (INACSL Standards Committee et al., 2021). Regardless of the strategy, the facilitator should maintain a physical and physiologically safe environment to encourage discussion, provide feedback, and promote reflective thinking and problem-solving (Kuszajewski, 2021). Yang and Oh (2020) found that both the Gather-Analyze-Summarize (GAS) and the Debriefing for Meaning for Learning (DML) methods were effective in neonatal-based simulations, and debriefing was more effective when learners led it. Both models mentioned are learner-centered and foster students' recognition of limitations and gaps in their clinical knowledge and skills (Yang & Oh, 2021). Kuszajewski (2021) stressed the importance of a structured, collaborative, and reflective debriefing process. Debriefing is feedback in which communication is learner-centered, bidirectional, and interactive (Kuszajewski, 2021). Kuszajewski (2021) emphasized that debriefing should have three phases: reaction, understanding/analysis, and summary. In the reactive phase, students express their initial emotions. In the understanding/analysis phase, the facilitator explored the learner's thought process while guiding the discussion to align it with learning objectives (Kuszajewski, 2021). To promote learner involvement, the facilitator should not lecture but guide the discussion through open-ended questions and active listening 16 (Kuszajewski, 2021). The summary phase included takeaway points congruent with learning objectives (Kuszajewski, 2021). Kuszajewski (2021) described facilitating debriefing as an 'art and science' that required training to develop quality debriefing skills. Facilitating and debriefing a simulation also required training, and skills were promoted through training-the-trainer programs (Woda et al., 2022). Hardie and Lioce (2020) found six essential elements for facilitator development. The Hardie and Lioce (2020) elements included 1) being able to create a safe and positive learning environment, 2) being able to blend practice and theory, 3) being able to serve as a role model, 4) having a passion for teaching, 5) having flexibility and adaptability, and 6) human-centered approach. Woda et al. (2022) also suggested using a debriefing worksheet and setting debriefing questions while facilitators learned a debriefing method. Concerning neonatal resuscitation simulations, Garvey and Dempsey (2020) found that video-assisted and oral feedback enhanced debriefing and improved teamwork and skills retention. A safe environment with appropriate feedback facilitated open discussion, and reflective thinking reinforced knowledge and skills (INACSL Standards Committee et al., 2021). McGlinn and Sundgren (2022) highlighted how enhanced debriefing strategies improved learner satisfaction and educational outcomes in NRP training, reinforced learning objectives, and translated simulation experiences into improved clinical practice. The reflective and structured approach to debriefing in simulation-based education enhanced teamwork, skill retention (Garvey & Dempsey, 2020), and learner satisfaction (McGlinn & Sundgren, 2022). Summary of Literature Review Findings and Application to the Project The literature review revealed that although the NRP certification program is based on evidence-based practice, many researchers felt it was not sufficiently implemented to create and 17 maintain competent NRP providers (Asmamaw Bekele et al., 2021; Copple, 2020; Felton & Cheshire, 2024; Hwang et al., 2024; McGlinn & Sundgren, 2022). Three themes that improved skill performance were identified: sequential skills practice, simulation, and debriefing. To enhance NRP skills performance and confidence, Copple (2020) recommended deliberate skills practice in sequential order (McGlinn & Sundgren, 2022). Hardie and Lioce (2020) emphasized that structured formats in simulation training, with scenario design and facilitation, contributed significantly to skill acquisition and retention. The hands-on approach of simulation training enhanced skill performance through deliberate practice in a safe and non-threatening environment (Garvey & Dempsey, 2020), which prepared providers to respond effectively to emergencies with greater confidence and competence (Felton & Cheshire, 2024). In addition, peer support, feedback, and facilitator coaching fostered student engagement (Wang & Ji, 2021). These training methods significantly strengthened healthcare teams by emphasizing collaboration and communication within realistic simulations (Garvey & Dempsey, 2020). A formal and structured debriefing (INACSL Standards Committee et al., 2021; Kuszajewski, 2021) with trained facilitators (Hardie & Lioce, 2020) enhanced learner performance, development, and improvement of skills (Garvey & Dempsey, 2020). The findings from the literature review highlighted the importance of offering sequential skills practice, structured simulation, and debriefing to increase skill performance in out-of-hospital NRP providers. Project Plan and Implementation This MSN project aims to implement an enhanced and consistent Sequential Practice and Evaluation NRP class, including simulation and debriefing for out-of-hospital EMS providers to improve patient safety and neonatal outcomes by increasing team members' confidence and NRP 18 skills. This project's goal will be accomplished by collaborating with essential stakeholders to review the evidence from the literature and develop a consistent and structured NRP class format to improve neonatal outcomes and patient safety by increasing team members' NRP skills and confidence. Plan and Implementation Process The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model will be used as the framework for this MSN project to address the PICOT question: In healthcare providers undergoing NRP training, does implementing a structured format with simulation and debriefing, compared to standard NRP training, improve skill performance in neonatal resuscitation? The JHNEBP three-phase model includes a practice question, evidence, and translation, strengthening interdisciplinary collaboration (Melnyk & Fineout-Overhold, 2023). The implementation of this project will consist of interdisciplinary collaboration from the program director, educators, clinical manager, NICU Medical Director, NRP instructors, and the MSN project coordinator. The first step in this project will be to meet with the program director, clinical manager, medical director, and educators during the monthly admin meeting to present internal evidence, including unit culture and equipment, and external evidence found in the literature review, including a review of NRP standards and evidence-based recommendations for consistent class structure with simulation and debriefing. This discussion will highlight the three themes identified that improved provider confidence and skill performance in NRP, including sequential skills practice (see Copple, 2020; McGlinn & Sundgren, 2022), simulation (see Hardie & Lioce, 2020), and debriefing (see Garvey & Dempsey, 2020). This method strengthened healthcare 19 teams (Garvey & Dempsey, 2020) and prepared healthcare providers to handle emergencies with increased competence and confidence (Felton & Cheshire, 2024). Upon approval, the MSN project coordinator and educators will meet with the NRP instructors to present the identified practice question and the evidence-based recommendations from the literature review. The discussion will highlight that NRP program completion does not ensure competence (see Weiner& Zaichkin, 2021), and EMS providers, who are often the only NRP-certified attendants at out-of-hospital births, need increased skill and knowledge to improve neonatal outcomes (Zaichkin et al., 2021). This meeting will be an open discussion identifying individual and cultural barriers and resistance to change. As facilitating and debriefing a scenario requires skills and training, this meeting will also include a train-the-trainer component for facilitator skill development in simulation and debriefing (see Hardie &Lioce, 2020; Woda et al., 2022). Team collaboration helps create better results than working alone due to a common goal supported by mutual engagement and shared resources (Zampronga et al., 2021). When “the exchange of best practices and the creation of new knowledge for an improved professional activity” supports those involved in clinical teaching, they recognize areas for improvement and become mutually committed (Zampronga et al., 2021, p. 4). Thus, the NRP instructors will collaborate with the project coordinator, using their collective wisdom, knowledge, and experience, to create a consistent and structured NRP class format for out-of-hospital providers. Consistent with the three themes from the literature, including a structured class format with sequential skills practice and simulation with debriefing, instructors will contribute to developing the course format and content, including review questions and gold-standard videos for skills demonstration. Additionally, other instructors will contribute to writing an out-of-hospital 20 simulation that has learning points comparable to the Comprehensive Skills Tests in the NRP 8th edition (see Weiner & Zaichkin, 2021), as a systematic scenario design contributes significantly to skill acquisition and retention (see Hardie & Lioce, 2020). The remaining instructors will contribute to the debriefing process and develop set questions to use while the debriefing method is being learned (see Woda et al., 2022). The NRP instructors, program educators, and MSN project coordinator will meet again to distribute their portion of the class development and present their course content. With the feedback and suggestions from the group, the class format, gold-standard videos, simulation scenarios, and debriefing questions will be revised. The NRP instructors, program educators, program director, medical director, clinical manager, and MSN project coordinator will meet for a mock NRP class for out-of-hospital EMS providers. Instructors will be able to experience the structure and consistent flow of the class, take turns managing skills stations, and facilitate simulation and debriefing. A debriefing of the simulation and class structure will allow all stakeholders to provide feedback. A survey will be emailed to class participants two weeks before attending the structured NRP provider class to evaluate previous class offerings and their confidence in the NRP algorithm and skills. Before attending the in-person class, participants must complete the quarterly RQI and eLearning module for Advanced NRP providers. Additionally, completing the pre-survey will be their entry ticket to the class. A follow-up survey will be sent by email after completion of the NRP class, evaluating the new class structure and their confidence in the NRP algorithm and skills. A reminder email will be sent to participants in two weeks to improve the data capture for class improvement. 21 After the structured out-of-hospital EMS provider NRP classes, the MSN project coordinator will review and compile survey data. During a monthly staff meeting, the project coordinator will present the data gathered to all stakeholders, including class participants. Instructors and program educators will provide feedback on their experience in the process and class changes, and implement feedback from instructors and students to continuously improve the NRP class. Interdisciplinary Team The healthcare professionals contributing to this MSN project are the Program Manager, the Clinical Manager, program educators, the NICU Medical Director, NRP instructors, NRP advanced providers, simulation specialists, and the MSN project coordinator. These healthcare professionals desire improved patient safety and outcomes through evidence-based quality improvement. Program Director and Clinical Manager The support of the Program Director and the Clinical Manager is crucial to the implementation and success of this MSN project. They are the program's top leadership, and their support and buy-in will impact the team's attitude toward implementing this change. They must approve the time and budget for NRP instructors to rework the class structure, attend trainthe-trainer events and meetings, and approve additional implementation expenses. Program Educators This program's educators are stakeholders in all the staff education requirements and competencies. Hospital and program standards and requirements drive education. The program educators are committed to implementing best practices and improving the skills and confidence 22 of staff members to provide safe patient care that improves patient outcomes. The educators are mentors who can assist with implementation and leadership support. NICU Medical Director The program's NICU Medical Director is a valuable resource for guiding NRP instructors in transferring resuscitation knowledge to out-of-hospital care. Her expertise in neonatal resuscitation, NRP guidelines, and algorithms will significantly benefit the success of this project. NRP Instructors There are currently seven NRP instructors: respiratory therapists, NICU nurses, L&D nurses, and a neonatal nurse practitioner (NNP). They have extensive knowledge in neonatal resuscitation and are all invested in improving their coworkers' NRP knowledge and skills to improve their confidence and skills and provide better neonatal outcomes at resuscitations. They each bring unique teaching skills and talents that, when shared, will benefit each other and the class restructure. NRP providers The NRP providers in the project setting are EMS providers, who will likely be the only NRP-certified providers at an out-of-hospital birth. This MSN project aims to improve their confidence and skills through deliberate skills practice, providing a simulation environment where they can practice and receive immediate feedback, and reinforcing learning through meaningful debriefing. The NRP providers have the most to gain through the successful implementation of this project. Certified Simulation Facilitator 23 A certified simulation facilitator can provide simulation facilitation in a train-the-trainer class. Facilitator development involves teaching valuable simulation/debriefing methods to create a positive human-centered learning environment, role modeling practice, and theory (Hardie & Lioce, 2020). Facilitators are valuable in fostering the continued professional development of NRP instructors. Project Coordinator The project coordinator supervises the project from its proposal through its implementation and conclusion. They are responsible for creating the deliverables, facilitating interdisciplinary meetings, and following through with stakeholders. The project coordinator will present the pre- and post-survey data to the stakeholders at a staff meeting. Description and Development of Project Deliverables Six deliverables will be used in the implementation of this MSN project. The six deliverables include 1) a PowerPoint presentation for stakeholders, 2) a PowerPoint Train-theTrainer presentation for NRP instructors, 3) a pre-and post-NRP class knowledge and confidence survey for NRP Providers, 4) a pre-and post-NRP class knowledge and confidence survey for NRP Instructors 5) a revised NRP class agenda, and 6) simulation debriefing questions. This section will discuss the six deliverables and their application to the success of this MSN project. PowerPoint Presentation for Stakeholders The first deliverable is a PowerPoint presentation (Appendix A) to gain approval from stakeholders, including the Program Director, Clinical Manager, program educators, and the NICU medical director. The PowerPoint highlights the three themes found in the literature and presents evidence-based practice recommendations for a revised NRP class for out-of-hospital 24 providers. This deliverable aims to gain support and buy-in from essential stakeholders who will approve the project's implementation. Train the Trainer PowerPoint Presentation for NRP Instructors The second deliverable is a PowerPoint presentation (Appendix B) for the NRP class instructors. The presentation highlights the three themes found in the literature. It presents evidence-based recommendations for revising the NRP class structure for out-of-hospital providers, including a consistent format, sequential skills practice, simulation, and debriefing. It also includes train-the-trainer elements to educate the instructors to become effective simulation and debriefing facilitators. This deliverable aims to gain the support and buy-in from the instructors to collaborate with the project coordinator to revise the NRP class format. Pre and Post-Survey of the NRP Providers' Confidence in NRP Knowledge and Skills The third deliverable is a pre- and post-NRP class survey (Appendix C) regarding the NRP providers' confidence in implementing NRP knowledge and skills. In addition to rating their confidence, they will also rate their confidence in their partners' ability to implement NRP knowledge and skills. Hardie and Lioce (2020) found that NRP simulation as a team improves skills, knowledge, and confidence. The survey will be collected anonymously through a Google form emailed to them with the class instructions. In addition to e-learning, the pre-survey will be required as an entry ticket for the instructor-led class. After completing the class, the post-survey will also be administered via a Google form emailed to the participants. The pre- and postsurveys will measure the success and implementation of the class changes from the participants' perspective. Pre- and Post-Survey of the NRP Instructors’ Confidence in Teaching NRP Knowledge and Skills 25 The fourth deliverable is a pre- and post-new class implementation Survey for NRP instructors (Appendix D) regarding their confidence in teaching NRP knowledge and skills. In addition to rating their confidence in teaching, they also rate the students’ knowledge and abilities to perform the skills associated with the NRP algorithm effectively. The survey will be collected anonymously through a Google form emailed to them before the Train-the-Trainer PowerPoint presentation. After implementing and teaching the new course format, the postsurvey will be administered via a Google form and emailed to the instructors. The pre- and postsurveys will measure the success and implementation of the class changes from the instructors’ perspective. Revised Class Agenda The fifth deliverable is a revised NRP class agenda (Appendix E) that follows the 8th edition NRP-suggested Sequential Learning and Evaluation format for providers who do not often use their resuscitation skills (see Zaichkin et al., 2021). To enhance NRP skills performance and confidence, Copple (2020) recommended deliberate skills practice in sequential order needed in resuscitation. The NRP instructors will create this deliverable that designs the class to demonstrate and then practice the skills in order of resuscitation using gold-standard videos, time for deliberate practice, team simulations that build on previous knowledge (see Zaichkin et al., 2021), and debriefing. Debriefing Questions The sixth deliverable is post-simulation debriefing questions (Appendix F). The facilitator should not lecture but guide the discussion through active listening and open-ended questions from the three phases of debriefing: reaction, understanding/analysis, and summary (see Kuszajewski, 2021). McGlinn and Sundgren (2022) highlighted how enhanced debriefing 26 strategies improved learner satisfaction and educational outcomes in NRP training, reinforced learning objectives, and translated simulation experiences into improved clinical practice. The NRP instructors will create this deliverable to ensure consistency in the debriefing phase of the simulation. Timeline The timeline for this project is four months (Appendix G). During this time, stakeholders will approve the project, instructors will make class revisions, and the new class process will be implemented. In week one, during the monthly admin meeting, the project coordinator will give a presentation to approving stakeholders, including the program director, the clinical manager, the medical director, and educators. Upon project approval, the pre-survey will be sent to instructors. In week two, the MSN project coordinator and educators will meet with the NRP instructors to present the evidence-based recommendations for class revision, including a structured class format with sequential skills practice and simulation with debriefing. Instructors will be divided into small groups to work on 1) developing course format and content, creating review questions, and identifying gold-standard videos for skills demonstration, 2) writing an out-of-hospital simulation, or 3) developing set questions to use while facilitating the debriefing. In weeks three to five, instructors will work on revising course content. In week 6, instructors will present their revised course content to other instructor groups, program educators, and project coordinators. In weeks 7-8, with the feedback and suggestions from the group, the new class format will be reviewed by all instructors. In week 9, the NRP instructors, program educators, program director, medical director, clinical manager, and MSN project coordinator will meet for a mock NRP class. The instructors will implement facilitation skills learned in the train-the-trainer class and practice the structure 27 and consistent flow of the class. They will take turns managing skills stations and facilitating simulation and debriefing. During week ten, the project manager and program educators will make revisions and implement feedback received during the mock class. A pre-survey email will be sent to NRP provider class participants, which will be their entry ticket to class. In weeks 1216, NRP Instructors will teach NRP with the new class format. After attending the class, a postclass survey will be emailed to participants. The instructor post-survey will be sent after all the NRP classes have been completed. The MSN project coordinator will review and compile survey data and present it to all stakeholders at a monthly staff meeting, including class participants. This MSN project aims to improve neonatal outcomes and patient safety by increasing team members' NRP skills and confidence. This project's goal will be accomplished by collaborating with essential stakeholders to apply evidence-based improvements to develop and implement a consistent and structured NRP class format that includes sequential practice with deliberate skills practice, simulation, and debriefing for meaningful learning. Project Evaluation Program evaluation is the “systematic gathering or generating and analyzing data about projects to answer what, who, when, and how questions that can improve projects” (Rode et al., 2022, p. 416). This MSN project will be evaluated at three main points, beginning when first assessed to determine if the project aligns with the organization's goals and outcomes, continually throughout the project, and again at the end of project implementation. The MSN project will include formative and summative assessment methods to determine whether the enhanced and structured NRP class agenda changes effectively meet the project's goal of improving the NRP providers' knowledge and confidence in their skills. The formative evaluation will contain ongoing discussions with program educators, NRP instructors, and 28 providers to gather insights and make real-time improvements. Instructors will observe participants during simulations and provide immediate feedback to enhance skill acquisition. Structured debriefing sessions will allow participants to reflect on their experiences, reinforcing learning objectives and identifying areas for improvement. The project coordinator will complete the summative evaluation process by comparing the feedback from the NRP providers' pre- and post-surveys and the NRP instructors' pre- and post-surveys. Participants will complete surveys before and after the training to measure changes in confidence, knowledge, and perceived competency in neonatal resuscitation skills. As evaluated by the survey, the project lead will analyze the four reported perspectives: 1) NRP providers' self-confidence, 2) confidence in team members, 3) the instructors' confidence in teaching the NRP skills, and 4) their confidence in their students. A positive trend in confidence in the post-surveys will reflect successful project implementation. The project coordinator will analyze and review the survey information and share the results with all the participating stakeholders at a monthly staff meeting. Evaluating the data will be an ongoing process to improve the NRP class and the providers' skill level and confidence. The project coordinator and instructors will make changes to the project based on the results and feedback from the survey. Ethical Considerations Ethical project management enhances decision-making, long-term sustainability, and a motivated, unified team. Upholding ethical principles is essential for success in project management (Kronos Group, 2024). This MSN project is committed to upholding ethical standards and social responsibility by ensuring non-discriminatory practices, promoting participant autonomy, and safeguarding privacy and confidentiality. Participation in the study, including pre- and post-surveys, will be voluntary. The training program will be designed to be 29 inclusive, ensuring that all NRP providers receive equal access to high-quality education. All survey responses and performance evaluations will be collected and stored anonymously, with collected data securely stored and accessible only to authorized personnel for analysis and improvement. The project team will maintain transparency in reporting findings and ensure that any modifications to training procedures are evidence-based and aligned with best practices. The primary objective is to enhance neonatal resuscitation skills to improve neonatal outcomes. By fostering a supportive and educational training environment, the project minimizes risks to participants. Through these ethical considerations, this initiative promotes a responsible, equitable, and pragmatic approach to enhancing neonatal resuscitation training for out-ofhospital providers, ultimately leading to improved patient care and safety. Due to the project's implementation in the workplace, the MSN project coordinator will maintain neutrality and avoid personal bias. Personal bias in a project can look like judgment and favoritism. Being self-aware of possible bias and stay self-reflective throughout the project are strategies that can reduce personal bias (Switalski, 2022). The project manager can navigate personal bias during implementation and evaluation with a discovery mindset. Being open to a discovery mindset opens one up to new ideas, inclusion, and improved teamwork when considering new and untried project solutions (Switalski, 2022). Discussion This project's structured approach to neonatal resuscitation training has the potential to improve provider competency and neonatal outcomes. Traditional class formats do not adequately prepare out-of-hospital NRP providers to confidently and competently provide neonatal resuscitation. This MSN project aimed to improve neonatal outcomes by increasing provider competence and team collaboration through an enhanced and restructured class format 30 (see Copple, 2020). The current literature and best practice guidelines supported enhancing the NRP class structure with sequential skills practice (Weiner& Zaichkin, 2021), simulation in neonatal resuscitation (Garvey & Dempsey, 2020), and meaningful debriefing (Woda et al., 2022) to improve provider competence and skill performance. The evaluation process's findings will contribute to refining training methodologies, ensuring that all out-of-hospital NRP providers are adequately prepared for neonatal emergencies. Evidence-Based Solutions for Dissemination Information will be disseminated in various ways to maximize the impact of this project. The project coordinator will present PowerPoint presentations (Appendix A & B) to stakeholders and instructors, using evidence-based information from a literature review that will drive the class format changes. Pre- and post-survey data will be analyzed and presented to all stakeholders, including NRP providers, at a staff meeting. The project coordinator will also develop and deliver a poster presentation from the MSN research and project to the Weber State University Annie Taylor Dee School of Nursing faculty and peers. Finally, if this project is successful, publication in a peer-reviewed nursing or emergency medicine journal will be pursued by the project coordinator to reach a wider audience and contribute to the body of knowledge in neonatal resuscitation education. Significance to Advanced Nursing Practice This project is crucial in advancing nursing practice by promoting standardized, highquality neonatal resuscitation training. The structured training format enhances provider confidence and competency, reducing the likelihood of errors during neonatal emergencies. Research indicates that structured simulation-based training improves skill retention and team performance (Felton & Cheshire, 2024). Additionally, incorporating debriefing enhances 31 reflective learning, leading to more effective interventions (Yang & Oh, 2021). Implementing this training model will support ongoing professional development in neonatal resuscitation, strengthening interdisciplinary collaboration in emergency response settings. Implications This MSN project has identified strengths and challenges related to its implementation. Its strengths include integrating evidence-based educational strategies, adhering to algorithms, and emphasizing real-world application through simulation. This MSN project is significant because it addresses critical gaps in teacher variability and out-of-hospital NRP providers’ training by aligning NRP class certification courses with best practice recommendations and ensuring that all team members receive consistent course training. This MSN project empowers and strengthens healthcare teams with improved skill performance in high-acuity and low-occurrence resuscitations (Copple, 2020; Lindhard et al., 202; McGlinn & Sundgren, 2022). Standardized course content decreased instructor teaching variability and enhanced learner confidence (Copple, 2020). Through an enhanced and standardized class format, instructors directed sequential skills practice (Weiner & Zaichkin, 2021), provided out-of-hospital focused simulations (Garvey & Dempsey, 2020), and debriefed for meaningful learning (Yang & Oh, 2021). However, challenges such as varying instructor teaching styles, workplace class culture, and resistance to change must be addressed. To mitigate these challenges, the engagement of stakeholders, instructor input, and collaboration in developing the new class format will be vital. The project's long-term impact will be assessed through follow-up surveys and continued data collection, ensuring the training remains practical and relevant to providers’ needs. This MSN project improves training to reduce neonatal morbidity and mortality by aligning with the NRP 32 Program's vision to ensure that every birth is attended by a knowledgeable and skilled provider, significantly contributing to the health and safety of newborns (see Mayer et al., 2022; Neonatal Resuscitation Program, n.d.). Recommendations Recommendations to improve the class format for out-of-hospital NRP providers could have significant and long-lasting impacts on the outcomes of effective resuscitations for newborns. Adherence to the guidelines "based on the best available resuscitation science" (Aziz et al., 2021, p. S161) improves neonatal outcomes. Better training improves the high-quality and timely interventions during neonatal emergencies and directly correlates with enhanced neonatal care, reducing morbidity and mortality rates (Mayer et al., 2022; Zaichkin et al., 2021). Future improvements to the project could involve expanding the structured training format to additional healthcare settings, including rural and underserved areas where EMS providers may have limited access to neonatal resuscitation training. A structured class format with deliberate skills practice, simulation, and debriefing may be incorporated into an additional HALO event training. Further research is needed to explore the long-term effects of structured neonatal resuscitation education on patient outcomes. Integrating more advanced simulation technologies and virtual learning modules could enhance accessibility and reinforce learning. Conclusion Implementing a structured neonatal resuscitation training program represents a significant advancement in improving provider competency and patient outcomes. Combining sequential skills practice, simulation-based learning, and structured debriefing creates a comprehensive educational approach that aligns with best practices in neonatal resuscitation. Through effective dissemination, ongoing evaluation, and refinement, this project has the potential to contribute 33 meaningfully to nursing education and emergency neonatal care. The project findings underscore the importance of standardization and continuous improvement in healthcare training programs, ensuring that neonatal resuscitation providers are well-equipped to deliver life-saving interventions. 34 References Alalhareth, N., & Howarth, M. (2020). The effectiveness of simulation training on nursing students’ neonatal resuscitation skills: A systematic review. 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Simulation-based outreach program improves rural hospitals' team confidence in neonatal resuscitation. Cureus, 14(9), 1–8. https://doi.org/10.7759/cureus.28670 Zamprogna, K., Backes, V., Menegaz, J., Silva, G., Oliveira, M., Fraga, F., & Tristão, F. (2021). Prática docente assistencial: Compartilhamento de ações para o ensino na atenção primária em saúde. Revista de Enfermagem Referência, V Série(Nº5). https://doi.org/10.12707/rv20080 39 Appendix A PowerPoint Presentation for Stakeholders 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 Appendix B Train the Trainer Presentation for Instructors 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 Appendix C Revised NRP Class Pre/Post Survey Date ______________________ What is your role? RN Paramedic RT How long have you been an NRP provider? New provider <2 years 3-5 years 5-10 years >10 years 1= not confident, 2= somewhat confident, 3= neutral, 4= mostly confident, 5= very confident How confident are you in your NRP skills and ability to effectively resuscitate a newborn? 1 2 3 4 5 How confident are you in providing CPAP for a newborn? 1 2 3 4 5 How confident are you in your partners’ ability to provide CPAP for a newborn? 1 2 3 4 5 How confident are you in providing PPV for a newborn? 1 2 3 4 5 How confident are you in your partners’ ability to provide PPV for a newborn? 1 2 3 4 5 How confident are you in providing chest compressions for a newborn? 1 2 3 4 5 How confident are you in your partners’ ability to provide chest compressions for a newborn? 1 2 3 4 5 How confident are you in providing epinephrine for a newborn? 1 2 3 4 5 How confident are you in your partners’ ability to provide epinephrine for a newborn? 1 2 3 4 5 How confident are you in obtaining emergency IV, IO or UV access for a newborn? 1 2 3 4 5 84 How confident are you in your partners’ ability to obtain emergency IV, IO, or UV access for a newborn? 1 2 3 4 5 How confident are you in running a full neonatal resuscitation (full code)? 1 2 3 4 5 How confident are you in your partners’ ability to run a full neonatal resuscitation (full code)? 1 2 3 4 5 2025 Revised NRP Class Pre Survey: https://forms.gle/HXRS7SrAp9FoVTr68 2025 Revised NRP Class Post Survey: https://forms.gle/1LwfWcGwQmQ6p4Gy7 85 Appendix D Revised NRP Class Pre/Post Instructor Survey Date ______________________ In addition to being an NRP instructor, what are your credentials? RN RT How long have you been an NRP Instructor? New Instructor <2 years 3-5 years 5-10 years >10 years 1= not confident, 2= somewhat confident, 3= neutral, 4= mostly confident, 5= very confident How confident are you in your ability to teach NRP skills to effectively resuscitate a newborn? 1 2 3 4 5 How confident are you in explaining/demonstrating CPAP for a newborn? 1 2 3 4 5 How confident are you in your students' ability to provide CPAP for a newborn? 1 2 3 4 5 How confident are you in explaining/demonstrating PPV for a newborn? 1 2 3 4 5 How confident are you in your students’ ability to provide PPV for a newborn? 1 2 3 4 5 How confident are you in explaining/demonstrating chest compressions for a newborn? 1 2 3 4 5 How confident are you in your students’ ability to provide chest compressions for a newborn? 1 2 3 4 5 How confident are you in explaining/demonstrating giving epinephrine to a newborn? 1 2 3 4 5 How confident are you in your students’ ability to provide epinephrine for a newborn? 1 2 3 4 5 86 How confident are you in obtaining explaining/demonstrating emergency IV, IO or UV access for a newborn? 1 2 3 4 5 How confident are you in your students’ ability to obtain emergency IV, IO, or UV access for a newborn? 1 2 3 4 5 How confident are you in explaining/demonstrating a full neonatal resuscitation (full code)? 1 2 3 4 5 How confident are you in your students’ ability to run a full neonatal resuscitation (full code)? 1 2 3 4 5 How confident are you in facilitating a neonatal resuscitation simulation? 1 2 3 4 5 How confident are you in facilitating a debrief? 1 2 3 4 5 2025 Revised NRP Class Pre Instructor Survey: https://forms.gle/4LeL41nt33ekEYFYA 2025 Revised NRP Class Post Instructor Survey: https://forms.gle/Cf9dvRhAVHxE1xE86 87 Appendix E NRP Agenda for Out-of-Hospital Advanced Providers • • • Introductions of the providers and instructors Roster Confirm all participants have completed the online portion of the advanced provider endorsement “We are not here to prove ourselves but to improve ourselves.” Nikole Ihler Review of NRP Key Behavioral Skills • Know your Environment • Use available information • Anticipate and plan • Clearly identify a team leader • Communicate effectively • Delegate the workload optimally • Allocate attention wisely • Use available resources • Call for additional help when needed • Maintain professional behavior Review of Equipment (in emergency delivery kit) • Neo T • Warming measures (neo help/bag, warming blankets, blue towels, hat) • Cord clamps • Bulb syringe Introduction to Simulation Environment • Safe learning environment (ensure both physical and psychological safety) • Suspend disbelief “Tell me, and I forget, teach me, and I may remember; involve me, and I learn.” Benjamin Franklin 88 Positive Pressure Ventilation Knowledge Check Questions: What are the indications to start positive pressure ventilation (PPV) • Baby is not breathing OR is gasping OR HR <100 When should PPV be discontinued? • HR is continuously over 100 with sustained spontaneous breathing What are the recommended pressure settings to start PPV? • PIP 20-25 cm H20, PEEP 5 cm H20 What is the most important indicator of successful PPV? • An increasing HR What are the MR SOPA corrective steps? • Mask adjustment • Reposition the head • Suction the mouth and nose • Open the mouth (consider turning up oxygen) • Pressure increase (5-10 cm H20 increments) to max 40 cm H20 • Alternative airway (endotracheal tube or laryngeal mask) Show 9 min Video on PPV (includes MR SOPA steps) 89 What is CPAP and when is it administered? • Continuous positive airway pressure to keep a spontaneously breathing baby's lungs open • When a baby has labored breathing or low oxygen saturations and HR >100 Show 3 min video on CPAP Review Skills: Set up NeoT with oxygen tank and practice giving PPV Demonstrate walking through MR SOPA steps and administration of CPAP 90 Endotracheal Intubation (Identify the newborn that requires intubation) Knowledge Check Questions: Indications for endotracheal intubation during resuscitation? • HR <100 with PPV, chest compressions, prolonged PPV How do you determine the size of ET tube for various gestational age/weights? • Table 5-1 <1 kg/28 wks = 2.5, 1-2 kg/28-34= 3.0, >2kg/>34 weeks = 3.5 2 strategies to determine the depth of insertion of ET tube? • NTL Nasal septum to ear tragus + 1cm, gestational age Table 5-4 Primary indicators that determine the correct insertion of the ET tube • Increasing HR, color change of CO2 detector, bilateral BS, chest movement with PPV Indications for an obstructed airway? (Condition not improving with a confirmed ET tube) • Tracheal aspirator What four problems could cause a baby’s condition to worsen after endotracheal intubation? D: Displaced ET tube O: Obstructed ET Tube P: Pneumothorax E: Equipment failure Review Skills: Identify and assemble intubation supplies (tube size charts) • Practice or assist with intubation, securing, and suctioning Practice Scenarios: (pg. 151-156) • Term Newborn with risk factors requires intubation • 37-week gestation requires intubation and tracheal aspiration 91 Chest Compressions Knowledge Check Questions: Indications for beginning chest compressions? • Heart rate remains less than 60 bpm When should HR be re-checked? • After 60 seconds of coordinated chest compressions and ventilation When can chest compressions be discontinued? • HR 60 bpm or greater Show: 3 min video on chest compressions Review Skills: Hand position (two thumbs, lower 1/3 of the sternum), Rate (90/min), depth 1/3 AP diameter coordinated with ventilation one-and-two-and-three-and breath-and Practice Scenario: (pg. 175-177) 92 Medications Knowledge Check Questions: Indications for epinephrine during resuscitation? • HR < 60 after 30 sec of PPV and an additional 60 sec of chest compressions and PPV Concentration: 0.1 mg/ml epinephrine= 1mg/10 ml • Dosage & Route ET 0.1mg/kg (1ml/kg) • IV (preferred) or IO= 0.02mg/kg 0.2ml (.2ml/kg followed by3 ml flush) When to expect an increase in HR? • HR should increase by approx. 1 min, can be repeated q 3-5 min If the HR does not respond? What clinical conditions might be considered? • Hypovolemia and tension pneumothorax Signs and Symptoms of Shock in a newborn? Indicating a need for a volume expander? • Pale, delayed capillary refill, weak pulses • Not responding to the steps of resuscitation and signs of shock or history of acute blood loss Fluid, route, and how fast? • NS, 10 ml/kg over 5-10 minutes IV/IO (use caution with preterm newborns < 32 weeks) Review Skills: Draw up Epinephrine using 3 way stop cock Practice giving IV epinephrine using closed-loop communication Draw up NS for volume administration Practice Scenario: (pg. 208-211) Comprehensive Skills Test NRP 8th edition * Plan to update scenario to reflect and out of hospital scenario Debrief (see debriefing questions) References: Nrp instructor toolkit. (n.d.). Neonatal Resuscitation Program. Retrieved September 20, 2024, from https://nrplearningplatform.com/instructor-toolkit/page-layout1/two-recommendedprovider-course-formats Zaichkin, J., Kamath-Rayne, B. D., & Weiner, G. (2021). The Nrp 8th edition: Innovation in education. Advances in Neonatal Care, 21(4), 322–332. https://doi.org/10.1097/anc.0000000000000884 93 Appendix F NRP Simulation and Class Debriefing Reaction How did you feel about your overall performance? What aspects of the scenario did you feel most comfortable managing? What aspects of the scenario presented the most challenges? Understanding/Analysis Were there instances where you deviated from NRP guidelines? How did you assess the infant's response to interventions through the resuscitation process? How did you feel about team communication and coordination during the resuscitation? How did you feel about your NRP Skills? How confident are you in your ability to provide effective resuscitation? What areas still need to be strengthened? Summary What is your takeaway from the simulation today? What have you learned that you will add to your practice? How could this simulation experience be improved? How could this scenario be modified to better reflect real-life resuscitation situations? Is there anything else you would like to discuss? 94 Appendix G NRP Class Revision Timeline