Discussion

We have demonstrated a marked deterioration in both knowledge and skills as early as 3 months following attendance on the NLS course. This is the first time that this phenomenon has been demonstrated after the NLS course and confirms the findings of studies on other resuscitation courses.6 Loss of skills occurred despite recruitment taking place at a regional neonatal centre where candidates have more experience than others from smaller units. The small number of doctors attending the courses meant that comparison of outcomes between professional groups and grades of medical staff could not be meaningfully performed. The NLS courses taking place at Liverpool Women's Hospital are run according to nationally agreed standards,1 with the instructors teaching each aspect of the course in a standard way. This makes it likely that these results are generalisable to other courses and makes it unlikely that there were major differences between any of the 13 courses that candidates had attended, which could have affected the results of the study.

The NLS course has been designed to be educationally optimal through practical simulation experiences aimed at supporting experiential and reflective learning3 and incorporates many facets within the simulation scenarios that facilitate learning.4 Despite this, the study suggests that the ability to demonstrate knowledge and skills at a later date does not seem to be sustained. However, it can not necessarily be inferred that a candidate who did not ‘pass’ the airway test in this study would not be competent at resuscitation in real life. Essentially, they were being tested in a ‘surprise’ simulation—there could be other factors at play in a real resuscitation, not present in the simulated environment, which may result in a different performance in real life. The low-fidelity mannequin used for retesting may have made it more difficult for candidates to suspend disbelief compared to when attending the actual course, and following the ‘airway test’ algorithm might have been more difficult during this ‘one-off’ scenario where they had been taken unprepared from the clinical area compared to when they were ‘zoned-in’ to the simulation on the NLS course.

At 3–5 and 12–14 months post-training, the two main reasons for candidate failure on the airway test were changing the towel and auscultation of the heart rate, especially following the delivery of the inflation breaths. Given that this was a low-fidelity simulation that used dry towels and a mannequin, it is possible that candidates may be more likely in the clinical setting to remember to change a wet and soiled towel for a dry one. In the clinical setting, the assessment of the heart rate is usually made, as it is part of the Apgar scoring and may be more readily vocalised in a clinical setting.

Some studies have suggested that factors, which may ameliorate deterioration in knowledge and particularly skills, might be the provision of regular booster or refresher sessions and focusing on discrete skills as part of a task during training and at follow-up.7–12 On the NLS, all candidates who are unsuccessful on their first attempt are offered constructive feedback and a short booster training session prior to retesting. In our study, we offered candidates who failed on their first attempt a mini booster session immediately following the test. In brief, the airway opening manoeuvres available were discussed and candidates were informed of the reasons for them failing and allowed a brief time for practice prior to retesting. It is possible that this may have assisted in a further number of candidates passing on their second attempt. Frequent booster sessions for the individual may encourage a behavioural change by repetitive reinforcement. However, the effects of booster sessions after the NLS have not been assessed.

The current recommendation set by the UK Resuscitation Council is that health professionals repeat the NLS on a 4 yearly basis. Doctors who change posts every 6 months may be offered a booster training session at each induction at the start of their post, and mandatory NLS in-house training for resuscitation is often offered on an annual basis. Our study showed at 3–5 months and 12–14 months, the majority of candidates who passed the airway test on their first attempt had been exposed to resuscitation training on a 6 monthly basis, effectively receiving booster sessions, and supports the case for their effectiveness. Given this finding and a loss of skills evident after 3–5 months in our study, it therefore might be advantageous for a short refresher resuscitation programme to be offered between episodes of mandatory NLS training. Basing this on the NLS would allow for consistency which might not be present in in-house sessions. There is some evidence from a systematic review that these ‘in-house’ drills might improve clinical practice.10–12

Booster sessions have cost and human resource implications. It is unlikely to be practical to offer 3–6 monthly cycles of booster resuscitation sessions at institutions—rather it might be more feasible to embed aspects of deliberate practice (including resuscitation drills) at staff induction sessions and into daily work. Apart from further simulation sessions, other work has suggested that ‘reinforcement’ in the clinical area, to strengthen behaviour, will also improve competence.13 The results from the study suggest that, as perhaps might be expected, the more resuscitations candidates were exposed to in the clinical area, and the more likely they were to pass the airway test. For those candidates working in small district general hospitals, it is less likely that they will be involved in resuscitations on a regular basis compared to those working in a large regional unit. Staff in smaller units therefore may benefit from more in-house skills and drills sessions. One way of ensuring that the less exposed staff is receiving the skills and drills sessions could be for them to keep a formal record of resuscitations attended after the NLS course. After 6 months, unless a certain threshold number of resuscitations has been attended (eg, 5), a booster session could be offered in-house.

The literature has demonstrated that the use of videoing simulation is increasingly being utilised within medical training14 ,15 and has been used in research studies to assess knowledge and skill retention within the clinical setting.16 This could be used with ‘in-house’ booster sessions to improve their efficacy. Video assessment within the clinical setting may be a useful tool to assess the long-term retention of knowledge and skills. Videoing resuscitations, followed by a critical review of the team's actions, may also assist in acting as a ‘debrief’ for the staff involved. The logistics of this would include obtaining consent from mothers and staff to video them and the babies. As previously mentioned, clinical exposure to resuscitations is variable and depends greatly upon workplace, clinical role and opportunity; video assessment, therefore, may be particularly useful to those not carrying out frequent resuscitations, although there is no evidence to support this at present.

Previous studies have tested confidence at the end of resuscitation training, mostly in the form of a questionnaire or survey and have reported an increase in confidence immediately after.17–22 Our study showed little difference in the confidence scores for the candidates who failed and for those who passed at 3–5 and 12–14 months, suggesting that lack of confidence did not necessarily equate to lack of competence. Also—perhaps more importantly—presence of confidence does not always equate with competence.

In conclusion, skills and knowledge as assessed by low-fidelity simulation deteriorate significantly after the NLS course. It is possible that the structure and programme of the NLS could be redesigned to change education delivery.

The resuscitation theory could be taught as a ‘one-off’ training session, away from the clinical area as it does at present. This could be followed with shorter simulation sessions where each candidate practices and performs an airway test. The use of simulation with individuals working within their own clinical capacity could then be used to enhance the experience. These essentially would be booster sessions within the individual's clinical setting. The sessions would include NLS simulations, be based on a standard teaching package approved by the Resuscitation Council, be delivered by local accredited educators/instructors and occur on a frequent basis (every 4–6 months). These would be formally recognised as part of continuing professional development, the candidate being required to keep an up-to-date portfolio of achievements with each session being signed off by an instructor. This formative process would therefore be candidate-driven and could be more embedded into clinical practice as described above. It could improve resuscitation skills, inform instructors of weaker candidates who may need targeted training and ultimately improve patient safety.

The use of in-house ‘mock’ simulations on a weekly basis might also aid in the retention of knowledge and skills and act as a booster session. In these, healthcare professionals would be able to work and be assessed within their individual sphere of practice.