EHBB: A randomised controlled trial of virtual reality or video for neonatal resuscitation refresher training in healthcare workers in resource-scarce settings

BMJ Open, Volume 11, No. 8, Year 2021

Interpretação

Objective To assess the impact of mobile virtual reality (VR) simulations using electronic Helping Babies Breathe (eHBB) or video for the maintenance of neonatal resuscitation skills in healthcare workers in resource-scarce settings. Design Randomised controlled trial with 6-month follow-up (2018-2020). Setting Secondary and tertiary healthcare facilities. Participants 274 nurses and midwives assigned to labour and delivery, operating room and newborn care units were recruited from 20 healthcare facilities in Nigeria and Kenya and randomised to one of three groups: VR (eHBB+digital guide), video (video+digital guide) or control (digital guide only) groups before an in-person HBB course. Intervention(s) eHBB VR simulation or neonatal resuscitation video. Main outcome(s) Healthcare worker neonatal resuscitation skills using standardised checklists in a simulated setting at 1 month, 3 months and 6 months. Results Neonatal resuscitation skills pass rates were similar among the groups at 6-month follow-up for bag-and-mask ventilation (BMV) skills check (VR 28%, video 25%, control 22%, p=0.71), objective structured clinical examination (OSCE) A (VR 76%, video 76%, control 72%, p=0.78) and OSCE B (VR 62%, video 60%, control 49%, p=0.18). Relative to the immediate postcourse assessments, there was greater retention of BMV skills at 6 months in the VR group (-15% VR, p=0.10; -21% video, p<0.01, -27% control, p=0.001). OSCE B pass rates in the VR group were numerically higher at 3 months (+4%, p=0.64) and 6 months (+3%, p=0.74) and lower in the video (-21% at 3 months, p<0.001; -14% at 6 months, p=0.066) and control groups (-7% at 3 months, p=0.43; -14% at 6 months, p=0.10). On follow-up survey, 95% (n=65) of respondents in the VR group and 98% (n=82) in the video group would use their assigned intervention again. Conclusion eHBB VR training was highly acceptable to healthcare workers in low-income to middle-income countries and may provide additional support for neonatal resuscitation skills retention compared with other digital interventions. The study was conducted in Lagos, Nigeria and Busia, Western Kenya. Twelve healthcare facilities (nine secondary and three tertiary) were located in Nigeria while eight facilities were located in Kenya. The healthcare facilities were located in urban and semi-urban areas and all have maternal and newborn services with newborn bed capacity ranging from 2 to 80 beds and delivery and neonatal unit staffing capacity from 7 to 124 nurses (see online supplemental file 1). bmjopen-2020-048506supp001.pdf Study participants consisted of nurses and nurse-midwives assigned to labour and delivery, operating room and newborn care units. Site coordinators or research assistants requested contact numbers, units and wards of potential participants from head nurses at identified facilities. Research assistants contacted individuals to determine eligibility and obtained consent (see online supplemental file 2). bmjopen-2020-048506supp002.pdf Nurses and midwives who participate in deliveries and who provide neonatal resuscitation to inborn or outborn infants and provide study consent. Those who had attended a neonatal resuscitation training course in the 1 year preceding the study; individuals who did not provide neonatal resuscitation as part of their duties or would be unavailable or unwilling to participate in follow-up study activities throughout the 6-month postinitial training period. Study IDs generated for each country site were randomly assigned via a computer-generated algorithm to the VR, video and control groups by a US-based study coordinator. Participants were enrolled and assigned a study ID before the HBB course by local study coordinators. Each participant received an Android study phone, preloaded with permission-based access linked to their study ID, via the mobile Helping Babies Survive powered by District Health Information System (DHIS2) app (mHBS/DHIS2), to the participant’s assigned digital intervention. The data analysis team was blinded to the study assignments. The HBB provider course (second edition)27 was taught by study HBB master trainers as 1 day, 8-hour long sessions from December 2018 to August 2019. A 30 min orientation was provided on use of the mHBS/DHIS2 app, including how to access the assigned digital intervention. All participants had access to a digitised HBB provider manual through the mHBS/DHIS2 app. The VR group in addition accessed the eHBB VR simulations which consisted of three interactive three-dimensional simulation scenarios representing care of a newborn requiring routine care, some resuscitation and prolonged resuscitation with positive pressure ventilation. The features of eHBB VR have been previously described and the application is available for free download.26 28 The neonatal resuscitation video used by the video group featured preparation for delivery and the resuscitation of a newborn requiring positive pressure ventilation.29 None of the interventions required internet for use. A total of 274 HCWs participated in the in-person HBB training. Standardised knowledge and skills assessments were conducted by trained research assistants. The HBB knowledge check (15 of 18 multiple-choice questions, ≥80% required to pass) and bag-and-mask ventilation skill check (BMV; 14 of 14 items required to pass) were conducted precourse and postcourse along with the objective structured clinical examination (OSCE) A checklist on preparation for delivery and initial steps of resuscitation (9 out of 12 items and 3 required items to pass). In addition, the postcourse assessment included the OSCE B checklist on prolonged newborn resuscitation (17 out of 23 items and 6 required items to pass). HBB checklists are available for free download from the American Academy of Pediatrics.30 A demographic survey was completed (figure 1). Study diagram. BMV, bag-and-mask ventilation; HBB, helping babies breathe; LDHF, low-dose high frequency; VR, virtual reality. Following the course, participants were encouraged to use their assigned digital intervention weekly and to engage in standard bag-and-mask skills practice with a manikin at the HBB practice corner set up at their facility. Post-course assessments were repeated at 1, 3, and 6 months after the class. A follow-up survey was completed. Data were collected in person by study staff who had completed a HBB second edition master trainer course by experienced HBB master trainers. Staff used the mHBS/DHIS2 tracker app for offline data collection.26 The mHBS tracker app contained digitised HBB knowledge check, BMV skill check and OSCE A and OSCE B checklist and was used by the participants to report their HBB corner practice. The mHBS trainer app separately tracked educational interventions access and use. To standardise data collection and feedback to study participants, an enhanced neonatal simulator, called NeoNatalie Live (Laerdal Medical) was used for BMV. Compared with the low-fidelity NeoNatalie simulators used for HBB training (including the HBB practice corners in this study), NeoNatalie Live manikin can be programmed to simulate key physiological parameters, such as variable rates of lung stiffness and heart rate and provides auditory and visual cues, in the form of ‘crying’ and increased heart rate when the end-user provides BMV.31 In addition, brief automated feedback for the end-user is provided using a Bluetooth-connected tablet device at the end of the assessment as ‘well done’ or ‘needs improvement’ based on bag and mask performance. The use of the NeoNatalie Live manikin software enabled the correlation of observer collected metrics with manikin collected data. The automated feedback provided by Neonatalie Live was the only feedback provided following each assessment.31 Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research. We hypothesised that there will be at least a 20% difference in the proportion of subjects who pass OSCE B at the 6-month evaluation between the VR group or video group and the control group. A sample size of 83 subjects per group would provide 80% power to detect a difference in pass rates between groups if the true pass rates were 85% and 65%, respectively, based on a two-sided α=0.05. The required total sample size for the three groups (VR, video and control) was 249. We recruited 274 participants total to allow for 10% dropout over the 6-month follow-up period. An intention-to-treat analysis was performed, where participants were grouped according to their randomly allocated experimental group (VR, video or control) regardless of their actual exposure. Fisher’s exact test was used to test for any differences in pass rates among the three groups for each of the study evaluations: BMV skills assessment, and standardised simulations of routine care and initial resuscitation (OSCE A) and prolonged resuscitation (OSCE B). Post hoc pairwise comparisons and comparisons between demographic groups were also performed using Fisher’s exact test. Within-group comparisons of evaluation results between timepoints were performed using the sign test. Participant exposure to the interventions (time in the mHBS trainer app) and self-reported clinical activity during the follow-up period were compared between experimental groups using the Kruskal-Wallis test and Wilcoxon rank-sum test. All statistical calculations were conducted with the statistical computing language R (V.4.0.0; R Foundation for Statistical Computing, Vienna, Austria). Throughout, two-sided tests were used, with statistical significance defined as p<0.05.

AI Digest

Study Justification:

– The study aimed to assess the impact of mobile virtual reality (VR) simulations or video for the maintenance of neonatal resuscitation skills in healthcare workers in resource-scarce settings.
– The use of VR and video interventions can provide additional support for neonatal resuscitation skills retention compared to other digital interventions.
– The study focused on healthcare workers in low-income to middle-income countries, where access to traditional training methods may be limited.

Study Highlights:

– The study included 274 nurses and midwives from 20 healthcare facilities in Nigeria and Kenya.
– Participants were randomly assigned to one of three groups: VR (eHBB+digital guide), video (video+digital guide), or control (digital guide only) groups.
– The main outcomes measured were healthcare worker neonatal resuscitation skills using standardized checklists in a simulated setting at 1 month, 3 months, and 6 months.
– The results showed that neonatal resuscitation skills pass rates were similar among the groups at the 6-month follow-up.
– However, there was greater retention of bag-and-mask ventilation skills at 6 months in the VR group compared to the video and control groups.
– On follow-up survey, the VR and video interventions were highly acceptable to healthcare workers, with a high percentage indicating they would use their assigned intervention again.

Recommendations:

– The study recommends the use of eHBB VR training as a valuable tool for neonatal resuscitation skills retention in resource-scarce settings.
– Healthcare facilities should consider incorporating VR or video interventions into their training programs to enhance healthcare worker skills and improve patient outcomes.
– Further research and evaluation are needed to explore the long-term impact and cost-effectiveness of VR and video interventions in neonatal resuscitation training.

Key Role Players:

– Healthcare workers: Nurses and midwives who participate in deliveries and provide neonatal resuscitation.
– Site coordinators or research assistants: Responsible for recruiting participants and coordinating study activities.
– Head nurses: Provide contact information and ward assignments of potential participants.
– Study coordinators: Randomly assign participants to intervention groups and oversee the study.
– HBB master trainers: Teach the HBB provider course and provide training to study staff.
– Research assistants: Conduct standardized knowledge and skills assessments and collect data.
– Data analysis team: Analyze the collected data and provide statistical analysis.

Cost Items for Planning Recommendations:

– VR equipment: Cost of acquiring and maintaining virtual reality equipment for training purposes.
– Video production: Cost of producing high-quality neonatal resuscitation videos for training.
– Training materials: Cost of developing and distributing digital guides and manuals.
– Staff training: Cost of training study staff and healthcare workers on the use of VR and video interventions.
– Facility setup: Cost of setting up HBB practice corners and providing necessary equipment.
– Data collection and analysis: Cost of collecting and analyzing data, including the use of mobile apps and software.
– Research coordination: Cost of coordinating the study, including recruitment, logistics, and communication.
– Evaluation and monitoring: Cost of evaluating the impact and effectiveness of the interventions and monitoring participant progress.
Please note that the provided cost items are general categories and not actual cost estimates. The actual costs will depend on various factors such as the specific equipment and resources required, location, and implementation strategy.

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design is a randomized controlled trial with a 6-month follow-up, which adds to the strength of the evidence. The study was conducted in multiple healthcare facilities in Nigeria and Kenya, which increases the generalizability of the findings. The main outcome measures were assessed using standardized checklists in a simulated setting. The results showed similar pass rates for neonatal resuscitation skills among the VR, video, and control groups at the 6-month follow-up. However, there was greater retention of bag-and-mask ventilation skills in the VR group compared to the video and control groups. The VR group also had numerically higher pass rates in the objective structured clinical examination (OSCE) B at 3 and 6 months. The study concludes that eHBB VR training was highly acceptable and may provide additional support for neonatal resuscitation skills retention. To improve the strength of the evidence, future studies could consider increasing the sample size and including a control group that does not receive any digital intervention.

Resumo

The study was conducted in Lagos, Nigeria and Busia, Western Kenya. Twelve healthcare facilities (nine secondary and three tertiary) were located in Nigeria while eight facilities were located in Kenya. The healthcare facilities were located in urban and semi-urban areas and all have maternal and newborn services with newborn bed capacity ranging from 2 to 80 beds and delivery and neonatal unit staffing capacity from 7 to 124 nurses (see online supplemental file 1). bmjopen-2020-048506supp001.pdf Study participants consisted of nurses and nurse-midwives assigned to labour and delivery, operating room and newborn care units. Site coordinators or research assistants requested contact numbers, units and wards of potential participants from head nurses at identified facilities. Research assistants contacted individuals to determine eligibility and obtained consent (see online supplemental file 2). bmjopen-2020-048506supp002.pdf Nurses and midwives who participate in deliveries and who provide neonatal resuscitation to inborn or outborn infants and provide study consent. Those who had attended a neonatal resuscitation training course in the 1 year preceding the study; individuals who did not provide neonatal resuscitation as part of their duties or would be unavailable or unwilling to participate in follow-up study activities throughout the 6-month postinitial training period. Study IDs generated for each country site were randomly assigned via a computer-generated algorithm to the VR, video and control groups by a US-based study coordinator. Participants were enrolled and assigned a study ID before the HBB course by local study coordinators. Each participant received an Android study phone, preloaded with permission-based access linked to their study ID, via the mobile Helping Babies Survive powered by District Health Information System (DHIS2) app (mHBS/DHIS2), to the participant’s assigned digital intervention. The data analysis team was blinded to the study assignments. The HBB provider course (second edition)27 was taught by study HBB master trainers as 1 day, 8-hour long sessions from December 2018 to August 2019. A 30 min orientation was provided on use of the mHBS/DHIS2 app, including how to access the assigned digital intervention. All participants had access to a digitised HBB provider manual through the mHBS/DHIS2 app. The VR group in addition accessed the eHBB VR simulations which consisted of three interactive three-dimensional simulation scenarios representing care of a newborn requiring routine care, some resuscitation and prolonged resuscitation with positive pressure ventilation. The features of eHBB VR have been previously described and the application is available for free download.26 28 The neonatal resuscitation video used by the video group featured preparation for delivery and the resuscitation of a newborn requiring positive pressure ventilation.29 None of the interventions required internet for use. A total of 274 HCWs participated in the in-person HBB training. Standardised knowledge and skills assessments were conducted by trained research assistants. The HBB knowledge check (15 of 18 multiple-choice questions, ≥80% required to pass) and bag-and-mask ventilation skill check (BMV; 14 of 14 items required to pass) were conducted precourse and postcourse along with the objective structured clinical examination (OSCE) A checklist on preparation for delivery and initial steps of resuscitation (9 out of 12 items and 3 required items to pass). In addition, the postcourse assessment included the OSCE B checklist on prolonged newborn resuscitation (17 out of 23 items and 6 required items to pass). HBB checklists are available for free download from the American Academy of Pediatrics.30 A demographic survey was completed (figure 1). Study diagram. BMV, bag-and-mask ventilation; HBB, helping babies breathe; LDHF, low-dose high frequency; VR, virtual reality. Following the course, participants were encouraged to use their assigned digital intervention weekly and to engage in standard bag-and-mask skills practice with a manikin at the HBB practice corner set up at their facility. Post-course assessments were repeated at 1, 3, and 6 months after the class. A follow-up survey was completed. Data were collected in person by study staff who had completed a HBB second edition master trainer course by experienced HBB master trainers. Staff used the mHBS/DHIS2 tracker app for offline data collection.26 The mHBS tracker app contained digitised HBB knowledge check, BMV skill check and OSCE A and OSCE B checklist and was used by the participants to report their HBB corner practice. The mHBS trainer app separately tracked educational interventions access and use. To standardise data collection and feedback to study participants, an enhanced neonatal simulator, called NeoNatalie Live (Laerdal Medical) was used for BMV. Compared with the low-fidelity NeoNatalie simulators used for HBB training (including the HBB practice corners in this study), NeoNatalie Live manikin can be programmed to simulate key physiological parameters, such as variable rates of lung stiffness and heart rate and provides auditory and visual cues, in the form of ‘crying’ and increased heart rate when the end-user provides BMV.31 In addition, brief automated feedback for the end-user is provided using a Bluetooth-connected tablet device at the end of the assessment as ‘well done’ or ‘needs improvement’ based on bag and mask performance. The use of the NeoNatalie Live manikin software enabled the correlation of observer collected metrics with manikin collected data. The automated feedback provided by Neonatalie Live was the only feedback provided following each assessment.31 Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research. We hypothesised that there will be at least a 20% difference in the proportion of subjects who pass OSCE B at the 6-month evaluation between the VR group or video group and the control group. A sample size of 83 subjects per group would provide 80% power to detect a difference in pass rates between groups if the true pass rates were 85% and 65%, respectively, based on a two-sided α=0.05. The required total sample size for the three groups (VR, video and control) was 249. We recruited 274 participants total to allow for 10% dropout over the 6-month follow-up period. An intention-to-treat analysis was performed, where participants were grouped according to their randomly allocated experimental group (VR, video or control) regardless of their actual exposure. Fisher’s exact test was used to test for any differences in pass rates among the three groups for each of the study evaluations: BMV skills assessment, and standardised simulations of routine care and initial resuscitation (OSCE A) and prolonged resuscitation (OSCE B). Post hoc pairwise comparisons and comparisons between demographic groups were also performed using Fisher’s exact test. Within-group comparisons of evaluation results between timepoints were performed using the sign test. Participant exposure to the interventions (time in the mHBS trainer app) and self-reported clinical activity during the follow-up period were compared between experimental groups using the Kruskal-Wallis test and Wilcoxon rank-sum test. All statistical calculations were conducted with the statistical computing language R (V.4.0.0; R Foundation for Statistical Computing, Vienna, Austria). Throughout, two-sided tests were used, with statistical significance defined as p<0.05.

Materiais

Inovações

The study conducted a randomized controlled trial to assess the impact of mobile virtual reality (VR) simulations using electronic Helping Babies Breathe (eHBB) or video for the maintenance of neonatal resuscitation skills in healthcare workers in resource-scarce settings. The participants included 274 nurses and midwives assigned to labor and delivery, operating room, and newborn care units in healthcare facilities in Nigeria and Kenya. The interventions included eHBB VR simulation or neonatal resuscitation video. The main outcomes measured were healthcare worker neonatal resuscitation skills using standardized checklists in a simulated setting at 1 month, 3 months, and 6 months. The results showed that eHBB VR training was highly acceptable to healthcare workers in low-income to middle-income countries and may provide additional support for neonatal resuscitation skills retention compared with other digital interventions. The study was conducted in Lagos, Nigeria, and Busia, Western Kenya, with healthcare facilities located in urban and semi-urban areas.

AI Innovations Description

The recommendation from the study is to use mobile virtual reality (VR) simulations or video for the maintenance of neonatal resuscitation skills in healthcare workers in resource-scarce settings. The study found that eHBB VR training was highly acceptable to healthcare workers in low-income to middle-income countries and may provide additional support for neonatal resuscitation skills retention compared with other digital interventions. The VR group showed greater retention of bag-and-mask ventilation (BMV) skills at 6 months compared to the video and control groups. The VR group also had higher pass rates in the objective structured clinical examination (OSCE) B checklist on prolonged newborn resuscitation at 3 months and 6 months compared to the video and control groups. The study suggests that eHBB VR training can be an innovative solution to improve access to maternal health by enhancing the skills of healthcare workers in resource-scarce settings.

AI Innovations Methodology

The study titled “EHBB: A randomised controlled trial of virtual reality or video for neonatal resuscitation refresher training in healthcare workers in resource-scarce settings” aimed to assess the impact of mobile virtual reality (VR) simulations using electronic Helping Babies Breathe (eHBB) or video for the maintenance of neonatal resuscitation skills in healthcare workers in resource-scarce settings.

The methodology of the study involved a randomized controlled trial with a 6-month follow-up period. The study was conducted in Lagos, Nigeria, and Busia, Western Kenya, with a total of 274 nurses and midwives assigned to labor and delivery, operating room, and newborn care units recruited from 20 healthcare facilities. The participants were randomly assigned to one of three groups: VR (eHBB+digital guide), video (video+digital guide), or control (digital guide only) groups before an in-person Helping Babies Breathe (HBB) course.

The interventions included eHBB VR simulation or neonatal resuscitation video. The main outcomes measured were healthcare worker neonatal resuscitation skills using standardized checklists in a simulated setting at 1 month, 3 months, and 6 months. The study also included follow-up surveys to assess the acceptability of the interventions.

The results showed that neonatal resuscitation skills pass rates were similar among the groups at the 6-month follow-up. However, there was greater retention of bag-and-mask ventilation (BMV) skills at 6 months in the VR group compared to the video and control groups. The pass rates for the objective structured clinical examination (OSCE) B checklist on prolonged newborn resuscitation were numerically higher in the VR group at 3 months and 6 months compared to the video and control groups.

The study used a computer-generated algorithm to randomly assign participants to the intervention groups. Data collection was conducted through in-person assessments, follow-up surveys, and the use of mobile apps for data collection and intervention access. Statistical analyses were performed using Fisher’s exact test and other appropriate tests.

In conclusion, the study found that eHBB VR training was highly acceptable to healthcare workers in low-income to middle-income countries and may provide additional support for neonatal resuscitation skills retention compared to other digital interventions. The methodology employed in the study allowed for rigorous evaluation of the impact of VR and video interventions on improving access to maternal health in resource-scarce settings.

Autores & Coautores

Statistics:

Citations: 8

Authors: 16

Identifiers:

DOI: 10.1136/bmjopen-2020-048506

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Workforce

Study Countries:

Kenya, Multi-Countries, Nigeria

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory, randomised-control-trial

Study Approach:

Quantitative

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