Neonatal resuscitation: A cross-sectional study measuring the readiness of healthcare personnel

Background: Optimal neonatal resuscitation requires knowledge and experience on the part of healthcare personnel. This study aims to assess the readiness of hospital healthcare personnel to perform neonatal resuscitation. Methods: This was an observational study conducted in May 2021 by distributing questionnaires to nurses, midwives, doctors, and residents to determine the level of knowledge and experience of performing neonatal resuscitation. Questionnaires were adapted from prior validated questionnaires by Jukkala AM and Henly SJ. We conducted the research in four types of hospitals A, B, C, and D, which are defined by the Regulation of the Minister of Health of the Republic of Indonesia. Type A hospitals have the most complete medical services, while type D hospitals have the least medical services. The comparative analysis between participants’ characteristics and the knowledge or experience score was conducted. Results: A total of 123 and 70 participants were included in the knowledge and experience questionnaire analysis, respectively. There was a significant difference (p = 0.013) in knowledge of healthcare personnel between the type A hospital (median 15.00; Interquartile Range [IQR] 15.00–16.00) and type C hospital (median 14.50; IQR 12.25–15.75). In terms of experience, the healthcare personnel of type A (median 85.00; IQR 70.00-101.00) and type B (median 92.00; IQR 81.00-98.00) hospitals had significantly (p =0,026) higher experience scores than the type D (median 42.00; IQR 29.00-75.00) hospital, but we did not find a significant difference between other type of hospitals. Conclusions: In this study, we found that the healthcare personnel from type A and type B hospitals are more experienced than those from type D hospitals in performing neonatal resuscitation. We suggest that a type D hospital should refer the neonate to a type A or type B hospital if there is sufficient time in cases of risk at need for resuscitation.


Background
To decrease the neonatal mortality in developing countries, there is an urgent need to improve the neonatal care. Data from developing countries showed that about 4 million babies die in the neonatal period. 1 Among these developing countries, Indonesia had a mortality rate reaching 12.4 per 1,000 live births in 2019. 2 The optimal strategy for neonatal referral and readiness of the hospital must be assessed and shored up to decrease the neonatal mortality rate in Indonesia. 3,4 The leading causes of neonatal mortality were prematurity, sepsis, and asphyxia. 5-7 These conditions often necessitate neonatal resuscitation. 8,9 Neonatal resuscitation involves a series of procedures performed to prevent the morbidity and mortality associated with a hypoxic-ischemic tissue injury (brain, heart, kidney) and restore spontaneous breathing and adequate cardiac output. 10,11 Appropriate neonatal resuscitation is believed to increase the survival of neonates and reduce the mortality. 12 Neonatal resuscitation service and patient prognosis are strong factors influencing the success of this procedure. Essential equipment must also be readily available for use, whenever needed. 11,13 The healthcare personnel which play important roles on the neonatal resuscitation must be prepared with comprehensive training. 14 Training is expected to increase the capability and confidence of healthcare personnel in performing neonatal resuscitation. 15 To provide optimal services, healthcare personnel must be prepared with both knowledge and experience. [16][17][18] Therefore, the factors that are associated with the knowledge and experience of the healthcare personnel need to be assessed and actions taken, to increase the level of these qualities. This study aims to assess the readiness of hospitals by analyzing the knowledge and experience of healthcare personnel in performing neonatal resuscitation.

Study design and participants
The data in this study was collected in May 2021 by distributing questionnaires to nurses, midwives, doctors, and residents to determine the level of knowledge and experience of the subject regarding neonatal resuscitation. The researchers met the participants at the pediatrics department of each hospital and explained the questionnaire. The participants filled out a statement of consent to be participating in this study. To address one potential source of bias, we invited respondents from all types of hospitals (A-D) to participate in our study.

Data collection
This study was conducted in May 2021. The participants filled out the questionnaire for knowledge and experience measurement. The questionnaire was adapted from the study of Jukkala AM and Henly SJ with permission. 19,20 They developed questionnaires for measuring knowledge and experience in hospital settings. The questionnaires were then translated into Indonesian. The questionnaire was then circulated to 10 nurses to assess its validity and reliability using the bivariate correlation test and Cronbach's alpha reliability test.
The resuscitation knowledge questionnaire contained 25 statements which are true or false questions. The participants chose the answer by marking either "true" or "false" in the corresponding column. The mark for each correct answer was 1 point, and 0 points for each incorrect answer. We obtained the total score of each participant for further analysis.
The resuscitation experience questionnaire contained 23 statements regarding neonatal resuscitation. The participants were asked to choose an answer using a Likert scale from one to five to indicate how frequently they did each job from 'rarely' to 'often'. The data from each subject was then summed for further analysis.

REVISED Amendments from Version 1
The latest version of this manuscript provided changes to the abstract, limitations, and conclusions of the study. The study's limitations are more explicitly stated, particularly those related to the small number of respondents and the presence of interactions between variables. Some explanations are added to clarify the table. Revision also involves copyediting of the manuscript to enhance reader understanding. The author acknowledges the suggestions by the reviewers in improving this journal.
Any further responses from the reviewers can be found at the end of the article According to the American Academy of Pediatrics (AAP), 22 work units in neonatal care are divided into four levels, namely level 1 to level 4. Level 1 units stabilizes the condition of term infants with physiologically stable conditions. Level 2 work units are responsible for stabilizing the premature infants and term infants who are physiologically ill. Level 3, it is necessary to carry out continuous infant stabilization and observation. Level 4 meet all three level capabilities, plus have experience caring for the most complex and critically ill newborns. 22 However, in this study we only have three level of NICU. Level 1 consisted of the emergency room, baby room, or neonate room; Level 2 consisted of a perinatology room; and Level 3 consisted of a Neonatal Intensive Care Unit (NICU).

Statistical analysis
We provide tables for each answered question for the knowledge and experience questionnaire. For analysis, we use the average of the total knowledge and experience scores for the comparative analysis. The continuous data was presented as median and interquartile range (IQR). The Mann-Whitney U test and Kruskal-Wallis test were used to compare differences of total knowledge or experiences score between the groups for each factor. The Kruskal-Wallis test was used for the multi-categorical data. The Mann-Whitney U test was used for the two-categorical data and the post-hoc analysis. Statistically significant was considered using two-sided α less than 0.05. Statistical analysis was done using the IBM SPSS software (version 23, RRID:SCR_016479).

Study participant characteristics
The characteristics of the participants in the study are shown in Table 1. 47 Total 123 respondent fill the knowledge questionnaire and 70 respondent fill the experience questionnaire. The respondents of knowledge questionnaire mostly worked at type A hospitals (64.2%) and were mostly aged below 30 years. Only one participant was educated in master's degree and doctoral degree. The participating professions in this study were midwives (37.4%) and nurses (33.3%) and also dominated by women (91.1%). Most of the employees were contract workers, which consists of midwives, nurses, and general practitioners. For the experience questionnaire, the participants mostly worked at type A hospitals (48.6%). Most of the participant's professions were nurses (45.7%) and the participants were predominantly females (85.7%). Most of the participants had bachelor's degrees (60%) and the permanent worker (40%) was the most common type of worker.
In both questionnaires, the profession may confound education, work experience, employment status, and unit level. Most of the residents were bachelor degree, below 5 years experience, were students, and on the neonatal care level 3. Most general practitioners have bachelor degrees, below 5 years experience, were contract workers, and on the neonatal care level 1. Most midwives have associate degrees, below 1 years experience, were contract workers, and on the neonatal care level 1. For nurses, they distribute well in variables. Table 2 showed the answers to the knowledge questionnaire. The highest number participants chose incorrect on the statement about chest compression initiation and positive pressure ventilation (87%). Statements about the number of heart rates in infants, infant diagnosis of primary or secondary apnea, the timing of oxygen administration, and the purpose of determining the Apgar score were also considered difficult questions by many participants.

Knowledge questionnaire
We found a significant difference (p = 0.007) between male (median 17.00; IQR 15.00-18.00) and female (median 15.00; IQR 14.00-16.00) participants as shown in Table 3. The education and type of professional role were important factors on participants knowledge. The students (which was the same population as residents) (

Experience questionnaire
The responses to the experience questionnaire were shown in Table 4. Most participants rarely performed pulse examinations of the umbilical cord (40%). The study also revealed that several participants rarely perform endotracheal suctioning (35.7%), umbilical catheterization (34.3%), took blood through an umbilical vein catheter (47.1%), and  administer drugs/fluids through an umbilical catheter (35.7%). Most participants were also not experienced in interpreting the results of neonatal' blood gases (27/70; 38.6%) as shown in Table 4. Table 5 shows the comparison between risk factors of each group in terms off resuscitation experience. The type of hospital was associated with the experience of the medical profession (p = 0.026) with type B having the highest experience. In the post-hoc analysis, we know that there are non-significant differences between type A hospital and type B hospitals (p = 0.618). The significant differences for the experience of the healthcare personnel are between A and D hospitals (p = 0.014) and between B and D hospitals (0.007).
We also found asignificant difference (p = 0.022) between the age groups, seemingly the older participants had more experience on neonatal resuscitation. Profession type also played an important role in neonatal resuscitation (p = 0.002). The nurses had the highest experience score (median 89.50; IQR 78.75-96.00) and the general practitioners have the lowest experience score (median 42.00; IQR 30.00-66.00). Longer work experience tended to be associated with a higher experience score (p = 0.006) and the second unit level was the unit level with the lowest experience score compared to the first and third level (p = 0.003).

Discussion
A high level of knowledge and experience of neonatal care is the key to the success of any resuscitation team. 12,15,20 Our study evaluated the knowledge and experience of the health care provider in tertiary hospitals in Indonesia. We found the readiness of healthcare personnel was associated with the type of hospital. We found that medical personnel in the Type A hospital have better knowledge that those in Type C hospital. In terms of experience, the type A and type B hospitals had more experienced healthcare personnel than the type D hospitals. This study also reveals several factors that influence knowledge and experience. Hence, this study may be used as a reference for developing neonatal resuscitation guidelines or policies.
Neonatal resuscitation requires skill of being, which is a product of knowledge and experience. The training of neonatal resuscitation team must be conducted in sufficient depth and refreshed frequently to ensure the ongoing capability and readiness of healthcare personnel. 11,23 The availability of tools is also an important factor of hospital readiness to perform this procedure. 13 Type A or type B hospitals had more qualified facilities to perform the neonatal resuscitation. This is the reason why type A and type B hospitals have better experience in performing neonatal resuscitation than type D hospitals. This also indicates that neonatal resuscitation should ideally be performed at type A or type B hospitals since they are more ready to perform the procedure.
Residents have the highest knowledge score among the professions. The students group also have the highest knowledge score, since they mostly consist of residents. Knowledge of neonatal resuscitation is a competency that must be mastered by residents during their education as a prospective specialist. 24,25 Residents have the responsibility to plan treatment according to the patient's condition. Even with supervision, residents are actually expected to have extensive knowledge about the causes, diagnosis, prognosis, complication, and management of neonates. 26,27 We found that nurses have the best experience scores among other types of professions. Nursing is a profession that is directly involved in providing services to the patients. 16,28,29 In the tertiary hospitals, where there are very large numbers of patients, doctors are often more involved in planning patient management. In this study, almost all general practitioners are young doctors, who just registered as the intern doctors. That may be the reason for their lack of experience. However, the right strategy needs to be implemented to improve the experience for general practitioners, since they will help in handling the newborns. 30 Previous studies have reported the relation between the age and the experience in neonatal resuscitation. 18 Experience will be gained after several times doing and practicing the procedure. 31,32 This is also the reason why work experience has a significant relation to the experience score. Experienced practitioners were found to be more confident in performing procedures on neonatal. 33,34 We found a significant difference between unit level and the total experience score. Higher unit levels have higher total experience scores. This is because at the level 1 unit, the baby being treated is a normal baby, while the higher level of care is related to more complications suffered by the babies. 22,35 The more difficult procedure may not be conducted at the unit level 1 and level 2, whereas such procedure are often performed at unit level 3. 22 However, we did not find any difference in knowledge between the three unit levels. Although most of the treatment capacity in the level 1 unit is for normal babies, knowledge of signs of severity and early treatment is important at all levels. 36 Additional training with skill demonstrations and scenarios using mannequins have been proven to increase the level of knowledge of nurses, doctors, resident doctors, and specialists in Northern Nigeria. 19 To increase personal experience, healthcare practitioners need to practice each step of resuscitation. 37 Routine training may be an important indicator in determining the hospital's readiness to conduct the neonatal resuscitation. 38 Training including various steps of neonatal resuscitation, especially palpating umbilical cord pulse, endotracheal suctioning, endotracheal intubation, umbilical catheter placement, taking blood through an umbilical vein catheter, administering drugs/fluids through an umbilical catheter, and interpreting neonatal blood gas results, must be a priority and requires more intense training since most of the research subjects in this study rarely performed them. 39,40 Endotracheal intubation in neonates is rarely done because of the high level of difficulty and high risk of an adverse event for the procedure. 40,41 There is need of more time practicing and training to do endotracheal intubation. 38,41 The placement of an umbilical catheter, blood collection, and administration of drugs through the umbilical vein are rarely done, possibly because of the potential to be risk factors of sepsis. 42,43 More practice with evaluation are needed to increase the healthcare personnel confidence in doing the neonatal resuscitation. [44][45][46] Research strengths and limitations These findings may provide additional information to the guidelines of healthcare personnel training and qualifications. Nevertheless, several limitations exist in our study. First, the number of research subjects was reduced by the COVID-19 pandemic. We did consecutive sampling rather than random sampling which is more applicable for short time study. This low response rate may have biased the results. However, the participants joined this research voluntarily and were provided brief explanations to ensure comprehension of the questionnaire as an effort to decrease the bias. Second, we did not assess how many times the participants have joined the neonatal resuscitation training. Previous training is likely to be associated with the knowledge and experience score of the participants. Third, there is interaction between variables that may confound each other (i.e. profession with education, work experience, employee status, and care level). However, because of this collinearity, we cannot perform the multivariate analysis to distinguish the effect of each variable.

Conclusion
The success of neonatal resuscitation is influenced by the readiness of the hospital, which can be assessed through indicators such as level of knowledge and experience of the healthcare personnel working at the hospital. In this study, we found that healthcare personnel from type A and type B hospitals were more experienced in conducting neonatal resuscitation than those from type D hospitals. We suggest that a type D hospital or other primary care should refer the neonate to a type A or type B hospital if there is sufficient time in cases of risk at need for resuscitation. Finally, larger observational studies with multicenter approaches should be conducted to substantiate our findings. We confirm that the questions from that paper are suitable and relevant to our research aim. We also have added the discussion regarding the specific point of the questionnaire (in example : the lack of skill on endotracheal intubation) to enrich our discussion. Response: Thank you for your valuable comment. In our country, there is a need for neonatal resuscitation certificates to become a neonatal intensive care unit health provider. They will get the training to make sure of their competency in neonatal resuscitation. We confirm that questions which we obtained from Jukkala et al were suitable to assess the knowledge and skill of neonatal intensive care unit health providers.

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Have the authors assessed whether differences between subject characteristics were confounded by the other characteristics, i.e. were more men working in level A hospitals with more experience? This needs further analysis." Response: Thank you for your valuable suggestion. We now have analyzed that there are variables that confounded others. The Profession may be related with Education, Work Experience, Employee Status, and Care Level. Age was also related to work experience. However, because of this collinearity, we cannot perform the multivariate analysis to distinguish the effect of each variable. We are trying our best to explain this issue in the results.

"Table 4 needs legends on what the various answers mean, apart from what is written in the main text."
Response: Thank you for your valuable suggestion, we now have added the information on Table 4.

6.
"The abstract needs a brief explanation on the questionnaire (self-developed, ranges) in the methods section in order to be able to interpret the results section. Also, in my opinion it is not relevant to mention only p-values in the abstract results, but please include effect sizes and their uncertainties. Also the response rate should be mentioned in the abstract."