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

Martono Tri Utomo; Mahendra Tri Arif Sampurna; Rufina Adelia Widyatama; Visuddho Visuddho; Ivan Angelo Albright; Risa Etika; Dina Angelika; Kartika Darma Handayani; Abyan Irzaldy

doi:10.12688/f1000research.109110.2

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Research Article

Revised

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

[version 2; peer review: 2 approved]

Martono Tri Utomo¹, Mahendra Tri Arif Sampurna ^1,2, Rufina Adelia Widyatama³, [...] Visuddho Visuddho³, Ivan Angelo Albright³, Risa Etika¹, Dina Angelika¹, Kartika Darma Handayani¹, Abyan Irzaldy⁴

Martono Tri Utomo¹, Mahendra Tri Arif Sampurna ^1,2, [...] Rufina Adelia Widyatama³, Visuddho Visuddho³, Ivan Angelo Albright³, Risa Etika¹, Dina Angelika¹, Kartika Darma Handayani¹, Abyan Irzaldy⁴

PUBLISHED 22 May 2023

Author details Author details

¹ Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, East Java, 60132, Indonesia
² Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Airlangga Teaching Hospital, Surabaya, East Java, 60115, Indonesia
³ Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, 60132, Indonesia
⁴ Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, South Holland, Postbus 2040, 3000 CA, Indonesia

Martono Tri Utomo
Roles: Conceptualization, Formal Analysis, Methodology, Project Administration, Resources, Validation, Writing – Original Draft Preparation

Mahendra Tri Arif Sampurna
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Methodology, Resources, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Rufina Adelia Widyatama
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Visualization, Writing – Original Draft Preparation

Visuddho Visuddho
Roles: Formal Analysis, Investigation, Writing – Original Draft Preparation

Ivan Angelo Albright
Roles: Data Curation, Formal Analysis, Investigation

Risa Etika
Roles: Conceptualization, Methodology, Supervision

Dina Angelika
Roles: Supervision, Validation

Kartika Darma Handayani
Roles: Supervision, Validation

Abyan Irzaldy
Roles: Validation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

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.

Keywords

Healthcare Personnel, Hospital, Neonate, Readiness, Resuscitation

Corresponding author: Mahendra Tri Arif Sampurna

Competing interests: No competing interests were disclosed.

Grant information: This work was supported by the Directorate of Research, Technology, and Community Service and the Directorate General of Higher Education, Research, and Technology; Ministry of Education, Culture, Research, and Technology of Indonesia via SIMLITABMAS (Sistem Informasi Manajemen Penelitian dan Pengabdian Kepada Masyarakat) program.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2023 Utomo MT et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Utomo MT, Sampurna MTA, Widyatama RA et al. Neonatal resuscitation: A cross-sectional study measuring the readiness of healthcare personnel [version 2; peer review: 2 approved]. F1000Research 2023, 11:520 (https://doi.org/10.12688/f1000research.109110.2) First published: 13 May 2022, 11:520 (https://doi.org/10.12688/f1000research.109110.1) Latest published: 22 May 2023, 11:520 (https://doi.org/10.12688/f1000research.109110.2)

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.

See the authors' detailed response to the review by Elisabeth M W Kooi
See the authors' detailed response to the review by Yellanthoor Ramesh Bhat

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^–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.

Methods

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.

Definitions

Type A–D hospitals are defined by the Regulation of the Minister of Health of the Republic of Indonesia No. 340/MENKES/PER/III/2010.²¹ The hospital type is classified based on the medical service facilities and their capabilities. For the type A hospitals there must be at least 4 Basic Specialists, 5 Medical Support Specialists, 12 Other Specialists and 13 Sub-specialist Services. Type B hospitals must have at least four Basic Specialists, four Medical Support Specialists, eight Other Specialists, and two Sub-specialist Services. Type C hospitals must have at least 4 Basic Specialists and 4 Medical Support Specialist Services. Finally, type D hospitals must have at least 2 Basic Specialist Medical Services.

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).

Results

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.

Table 1. Characteristics and demographics of participants.

Characteristics		Knowledge measured		Resuscitation experience
Characteristics		N	%	N	%
Types of Hospital	A	79	64.2	34	48.6
	B	12	12.0	15	21.4
	C	20	16.3	14	20.0
	D	12	9.8	7	10.0
Sex	Male	11	8.9	10	14.3
Sex	Female	112	91.1	60	85.7
Age	<30	69	56.1	27	38.6
	30-40	42	34.1	34	48.6
	40-50	10	8.1	8	11.4
	>50	2	1.6	1	1.4
Education	Associate Degree	67	54.5	26	37.1
	Bachelor Degree	54	43.9	42	60.0
	Master Degree	1	0.8	2	2.9
	Doctoral Degree	1	0.8	0	0.0
Type of Profession	Resident	27	22	23	32.9
	Midwife	46	37.4	6	8.6
	Nurse	41	33.3	32	45.7
	General Practitioners	9	7.3	9	12.9
Work Experience (Years)	<1	54	43.9	13	18.6
	1-5	26	21.1	24	34.3
	5-10	17	13.8	15	21.4
	10-15	11	8.9	7	10.0
	15-20	6	4.9	4	5.7
	>20	9	7.3	7	10.0
Employment Status	Permanent worker	33	26.8	28	40
	Contract worker	64	52.0	16	22.9
	Students	26	21.1	26	37.1
Unit Level	Level 1	64	52.0	24	34.29
	Level 2	4	3.25	5	7.14
	Level 3	55	44.72	41	58.57

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.

Knowledge questionnaire

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.

Table 2. Answers to knowledge questionnaire.

The question number 2,3,4,5,6,10,15,19,21,22,24,25 were “reverse” questions which must be answered by false to get correct. ET: Endotracheal; HR: Heart Rate; PPV: Positive Pressure Ventilation.

No.	Questions	Answers
No.	Questions	Correct N (%)	Incorrect N (%)
1	The size of the ET Tube that is suitable for babies weighing 2,800 grams is 2.5 mm	90 (73.2)	33 (26.8)
2	During chest compressions, the sternum should be pushed in 1.2 to 1.9 cm	72 (58.5)	51 (41.5)
3	Epinephrine administration should be started immediately if HR <60 or 0, with or without previous PPV	30 (24.4)	93 (75.6)
4	Chest compressions and ventilation are performed at least 60 seconds before the second HR evaluation is performed	96 (78.1)	27 (21.2)
5	An ET tube or a 6-F or 8-F suction catheter can be used to suck meconium from the trachea	87 (70.7)	36 (29.3)
6	Delayed drying of a respiratory depressed infant can be used to initiate resuscitation efforts.	98 (79.7)	25 (20.3)
7	PPV in neonates is carried out at a rate of 30-40 times per minute	60 (48.8)	63 (51.2)
8	An orogastric catheter should be inserted if the infant requires balloon and mask ventilation for more than a few minutes.	71 (58.8)	52 (42.3)
9	Chest compressions should be initiated only if the HR is below 60 beats per minute and positive pressure ventilation has been performed for 15-30 seconds	16 (13)	108 (87)
10	In infants showing respiratory effort, the heart rate should be at least 100 beats per minute	11 (9)	112 (91)
11	Poor response to resuscitation is a sign of hypovolemia in neonates	92 (74.8)	31 (25.2)
12	When oxygenating neonates with a mask or oxygen tube, the flowmeter should be set at a dose of 5 lpm	54 (43.9)	69 (56.1)
13	The volume of the mask balloon for neonates should not exceed 750ml	111 (90.2)	12 (9.8)
14	When sucking secretions during intubation, the suction pressure should not exceed -100mmHg	116 (94.3)	7 (5.7)
15	The neonate's nose should be suctioned before the mouth	58 (47.2)	65 (52.8)
16	Each attempt at intubation should be limited to no more than 30 seconds to minimize hypoxia	115 (93.5)	8 (6.5)
17	In neonates, respiratory depression due to narcotics is mostly caused by giving narcotics to the baby's mother within 4 hours before delivery	109 (88.6)	14 (11.4)
18	Expansion of the chest and the presence of breath sounds in both lung fields can be used as indicators of adequate ventilation	120 (97.6)	3 (2.4)
19	When a baby is not breathing at birth, it is very easy to determine whether the baby is primary or secondary apnea	40 (32.5)	83 (67.5)
20	Chest compressions are always accompanied by coordinated positive-pressure ventilation	34 (27.6)	89 (72.4)
21	When secondary apnea occurs, oxygen and stimulation will usually trigger breathing	28 (22.8)	95 (77.2)
22	If the baby's heart rate is >100 and the chest expands, but the baby still shows symptoms of central cyanosis, the most appropriate course of action is to initiate positive pressure ventilation with a mask or an ET tube.	82 (66.7)	41 (33.3)
23	Placement of the ET tube can be confirmed by listening for breath sounds in both lung fields.	120 (97.6)	3 (2.4)
24	The APGAR score is used to determine when to start resuscitation and the goals of resuscitation	35 (28.5)	88 (71.5)
25	Complete resuscitation equipment should be available in the delivery room only when there is an indication of the need for resuscitation	114 (92.7)	9 (7.3)

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) (median 17.00; IQR 15.00–18.00) had higher knowledge than the permanent (median 15.00; IQR 13.00–16.50) and contract (median 15.00; IQR 15.00–15.00) workers (p = 0.001). The post-hoc analysis showed a significant difference (p = 0.013) of knowledge between the type A (median 15.00; IQR 15.00–16.00) and the type C hospitals (median 14.50; IQR 12.25–15.75).

Table 3. Comparison between participant characteristics and knowledge score.

Characteristics		Total knowledge score		p-value
Characteristics		Median	IQR	p-value
Type of Hospital	A	15.00	15.00-16.00	0.119
	B	15.00	13.00-17.00
	C	14.50	12.25-15.75
	D	15.00	13.25-16.75
Sex	Male	17.00	15.00-18.00	0.007*
Sex	Female	15.00	14.00-16.00	0.007*
Age (Year)	<30	15.00	15.00-15.00	0.169
	30-40	15.00	13.75-17.00
	40-50	16.00	14.75-17.25
	>50	13.00	12.00-14.00
Education	Associate Degree	15.00	14.00-15.00	0.009*
	Bachelor Degree	16.00	14.00-18.00
	Master Degree	15.00	15.00-15.00
	Doctoral Degree	18.00	18.00-18.00
Type of Profession	Resident	17.00	15.00-18.00	0.000*
	Midwife	15.00	15.00-15.00
	Nurse	14.00	12.50-16.00
	General Practitioners	15.00	14.50-17.00
Work Experience (Year)	<1	15.00	15.00-15.00	0.481
	1-5	16.00	13.75-18.00
	5-10	15.00	13.00-16.50
	10-15	14.00	13.00-18.00
	15-20	14.50	12.75-16.00
	>20	15.00	14.00-17.50
Employment Status	Permanent worker	15.00	13.00-16.50	0.001*
	Contract worker	15.00	15.00-15.00
	Students	17.00	15.00-18.00
Unit Level	Level 1	15.00	15.00-15.00	0.410
	Level 2	13.50	10.50-16.50
	Level 3	15.00	13.00-18.00
Post Hoc Analysis
Type of Hospital	A vs B		0.757
	A vs C		0.013*
	A vs D		0.463
	B vs C		0.261
	B vs D		0.799
	C vs D		0.376

* p-value < 0.05.

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 4. Answers to experience questionnaire.

The Experience Questionnaire using a Likert scale from one to five indicate ‘very rare’ to ‘very often’. PPV: Positive Pressure Ventilation.

No	Questions	Answers N (%)
No	Questions	1	2	3	4	5
1.	Provide care to neonates after delivery	11 (15.7)	6 (8.6)	9 (12.9)	9 (12.9)	35 (50)
2.	Drying, positioning, and suctioning the neonate	9 (12.9)	5 (7.1)	8 (11.4)	15 (21.4)	33 (47.1)
3.	Performing suction on the neonate with a suction catheter	9 (12.9)	6 (8.6)	9 (12.9)	16 (22.9)	30 (42.9)
4.	Listening to the newborn's heart rate with a stethoscope	5 (7.1)	6 (8.6)	8 (11.4)	22 (31.4)	29 (41.4)
5.	Feel the pulse through the umbilical cord	28 (40)	11 (15.7)	19 (27.1)	8 (11.4)	4 (5.7)
6.	Turn on the infant warmer before labor begins	7 (10)	3 (4.3)	4 (5.7)	8 (11.4)	48 (68.6)
7.	Assessing the APGAR Score in fit newborns	4 (5.7)	4 (5.7)	9 (12.9)	11 (15.7)	42 (60)
8.	Assessing the APGAR Score in sick newborns	9 (12.9)	6 (8.6)	10 (14.3)	15 (21.4)	30 (42.9)
9.	Inserting an orogastric tube in the neonate	14 (20)	3 (4.3)	10 (14.3)	9 (12.9)	34 (48.6)
10.	Performing airway suctioning in neonates with a suction machine	10 (14.3)	3 (4.3)	6 (8.6)	18 (25.7)	33 (47.1)
11.	Performing endotracheal suctioning in infants with meconium membranes	25 (35.7)	8 (11.4)	13 (18.6)	12 (17.1)	12 (17.1)
12.	Performing PPV with balloons and masks	10 (14.3)	2 (2.9)	16 (22.9)	21 (30)	21 (30)
13.	Perform or assist endotracheal intubation	19 (27.1)	14 (20)	12 (17.1)	9 (12.9)	16 (22.9)
14.	Performing chest compression on the neonate	12 (17.1)	6 (8.6)	19 (27.1)	15 (21.4)	18 (25.7)
15.	Perform/assist umbilical catheter installation	24 (34.3)	9 (12.9)	17 (24.3)	7 (10)	13 (18.6)
16.	Taking blood through an umbilical vein catheter	33 (47.1)	4 (5.7)	16 (22.9)	6 (8.6)	11 (15.7)
17.	Administer medications/fluids through an umbilical catheter	25 (35.7)	9 (12.9)	9 (12.9)	9 (12.9)	18 (25.7)
18.	Interpreting the neonate's blood sugar level	9 (12.9)	7 (10)	11 (15.7)	16 (22.9)	27 (38.6)
19.	Interpreting neonatal blood gas results	27 (38.6)	9 (12.9)	12 (17.1)	10 (14.3)	12 (17.1)
20.	Communicating with family during resuscitation	11 (15.7)	6 (8.6)	15 (21.4)	13 (18.6)	25 (35.7)
21.	Communicating with family after resuscitation	6 (8.6)	8 (11.4)	8 (11.4)	13 (18.6)	35 (50)
22.	Provide emotional support to family during resuscitation	9 (12.9)	5 (7.1)	12 (17.1)	18 (25.7)	26 (37.1)
23.	Provide emotional support to family during resuscitation	7 (10)	3 (4.3)	9 (12.9)	21 (30)	30 (42.9)

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).

Table 5. Comparison between participant characteristics and experience score.

Characteristics		Total experience score		p-value
Characteristics		Median	IQR	p-value
Types of Hospital	A	85.00	70.00-101.00	0.026*
	B	92.00	81.00-98.00
	C	81.00	68.25-87.00
	D	42.00	29.00-75.00
Sex	Male	74.00	53.25-80.75	0.051
Sex	Female	85.00	70.75-96.75	0.051
Age (Year)	<30	75.00	42.00-86.00	0.022*
	30-40	85.00	72.25-101.00
	40-50	91.00	81.50-94.50
	>50	96.00	96.00-96.00
Education	Associate Degree	85.00	73.75-93.00	0.453
	Bachelor Degree	83.00	55.75-100.75
	Master Degree	65.00	60.00-70.00
Type of Profession	Resident	83.00	70.00-111.00	0.002*
	Midwife	83.00	54.75-87.00
	Nurse	89.50	78.75-96.00
	General Practitioners	42.00	30.00-66.00
Work Experience (Year)	<1	52.00	33.50-74.50	0.006*
	1-5	81.00	62.50-105.00
	5-10	89.00	81.00-104.00
	10-15	85.00	81.00-98.00
	15-20	94.00	45.75-101.00
	>20	90.00	81.00-95.00
Employment Status	Permanent worker	87.50	78.75-95.75	0.230
	Contract worker	78.00	45.75-88.75
	Students	77.50	52.00-105.75
Unit Level	Level 1	74.00	42.00-84.50	0.002*
	Level 2	78.00	64.50-101.50
	Level 3	92.00	76.00-99.00
Post Hoc Analysis
Type of Hospital	A vs B		0.618
	A vs C		0.291
	A vs D		0.014*
	B vs C		0.073
	B vs D		0.007*
	C vs D		0.061

* p-value < 0.05.

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^–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.

Ethical considerations

This study was approved by the Ethics Committee of RSUD Dr. Soetomo Surabaya (Letter of Exemption 0335/LOE/301.4.2/II/2021).

Data availability

Underlying data

Figshare: Neonatal Resuscitation: Measuring The Readiness of Healthcare Personnel, https://doi.org//10.6084/m9.figshare.18865418.⁴⁷

The project contains the following underlying data:

• Experience.sav and
• Knowledge.sav.

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgements

We acknowledged the contribution of Peni Indriani and Paniani as the head of the Neonatal Intensive Care Unit (NICU) in Dr. Soetomo General Hospital.

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Version 2

VERSION 2 PUBLISHED 13 May 2022

Author details Author details

Martono Tri Utomo
Roles: Conceptualization, Formal Analysis, Methodology, Project Administration, Resources, Validation, Writing – Original Draft Preparation

Mahendra Tri Arif Sampurna
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Methodology, Resources, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Rufina Adelia Widyatama
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Visualization, Writing – Original Draft Preparation

Visuddho Visuddho
Roles: Formal Analysis, Investigation, Writing – Original Draft Preparation

Ivan Angelo Albright
Roles: Data Curation, Formal Analysis, Investigation

Risa Etika
Roles: Conceptualization, Methodology, Supervision

Dina Angelika
Roles: Supervision, Validation

Kartika Darma Handayani
Roles: Supervision, Validation

Abyan Irzaldy
Roles: Validation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

This work was supported by the Directorate of Research, Technology, and Community Service and the Directorate General of Higher Education, Research, and Technology; Ministry of Education, Culture, Research, and Technology of Indonesia via SIMLITABMAS (Sistem Informasi Manajemen Penelitian dan Pengabdian Kepada Masyarakat) program.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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https://doi.org/10.12688/f1000research.109110.2

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© 2023 Utomo MT et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Utomo MT, Sampurna MTA, Widyatama RA et al. Neonatal resuscitation: A cross-sectional study measuring the readiness of healthcare personnel [version 2; peer review: 2 approved]. F1000Research 2023, 11:520 (https://doi.org/10.12688/f1000research.109110.2)

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Reviewer Report 18 Jul 2023

Yellanthoor Ramesh Bhat, Department of Paediatrics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India

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https://doi.org/10.5256/f1000research.147939.r174525

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Reviewer Report 05 Jun 2023

Elisabeth M W Kooi, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, University of Groningen, Groningen, The Netherlands

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https://doi.org/10.5256/f1000research.147939.r174526

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Reviewer Report 13 Jul 2022

Yellanthoor Ramesh Bhat, Department of Paediatrics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India

Approved with Reservations

https://doi.org/10.5256/f1000research.120572.r140368

The article ‘Neonatal resuscitation: A cross-sectional study measuring the readiness of healthcare personnel” addresses the readiness of healthcare personnel with regard to the much needed topic on neonatal resuscitation. This study used questionnaire in 4 different types of hospitals. They found significantly higher experience scores among the healthcare personnel of type A and type B hospitals than the type D hospital. This need will help the local area to plan further training of personnel in type D hospital.

Overall the study appears reasonable. The information may help plan the policy regarding neonatal resuscitation and the target groups.
The first sentence, “Neonatal mortality is one of the standards of neonatal care”-this sentence should be modified as ‘To decrease the neonatal mortality in developing countries, there is an urgent need to improve the neonatal care”.
Copyediting will be required throughout the manuscript.
Minimize the repetitions especially in methods and discussion.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

References

1. Deorari AK, Paul VK, Singh M, Vidyasagar D, et al.: Impact of education and training on neonatal resuscitation practices in 14 teaching hospitals in India.Ann Trop Paediatr. 2001; 21 (1): 29-33 PubMed Abstract

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Pediatrics, Neonatology, Intensive care, Ventilation

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 26 May 2023

Mahendra Tri Arif Sampurna, Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, 60132, Indonesia

26 May 2023

Author Response

We are very thankful for your availability and willingness to help us to become our reviewer on our manuscript entitled "Neonatal Resuscitation: A cross-sectional study measuring the readiness of healthcare ... Continue reading We are very thankful for your availability and willingness to help us to become our reviewer on our manuscript entitled "Neonatal Resuscitation: A cross-sectional study measuring the readiness of healthcare personnel". We have revised our manuscript based point-on-point revision suggested.

1. "The first sentence, “Neonatal mortality is one of the standards of neonatal care”-this sentence should be modified as ‘To decrease the neonatal mortality in developing countries, there is an urgent need to improve the neonatal care”."

Response: Thank you for your valuable suggestion. We have revised the sentence to clear our research aim.

2. "Copyediting will be required throughout the manuscript."

Response: Thank you for your valuable suggestion. We have done copy editing using the help from professional English editing services.

3. "Minimize the repetitions especially in methods and discussion."

Response: Thank you for your valuable suggestion. We now have minimized the repetitions and keep the methods and discussion concisely.
We are very thankful for your availability and willingness to help us to become our reviewer on our manuscript entitled "Neonatal Resuscitation: A cross-sectional study measuring the readiness of healthcare personnel". We have revised our manuscript based point-on-point revision suggested.

1. "The first sentence, “Neonatal mortality is one of the standards of neonatal care”-this sentence should be modified as ‘To decrease the neonatal mortality in developing countries, there is an urgent need to improve the neonatal care”."

Response: Thank you for your valuable suggestion. We have revised the sentence to clear our research aim.

2. "Copyediting will be required throughout the manuscript."

Response: Thank you for your valuable suggestion. We have done copy editing using the help from professional English editing services.

3. "Minimize the repetitions especially in methods and discussion."

Response: Thank you for your valuable suggestion. We now have minimized the repetitions and keep the methods and discussion concisely.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 26 May 2023

Mahendra Tri Arif Sampurna, Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, 60132, Indonesia

26 May 2023

Author Response

We are very thankful for your availability and willingness to help us to become our reviewer on our manuscript entitled "Neonatal Resuscitation: A cross-sectional study measuring the readiness of healthcare ... Continue reading We are very thankful for your availability and willingness to help us to become our reviewer on our manuscript entitled "Neonatal Resuscitation: A cross-sectional study measuring the readiness of healthcare personnel". We have revised our manuscript based point-on-point revision suggested.

1. "The first sentence, “Neonatal mortality is one of the standards of neonatal care”-this sentence should be modified as ‘To decrease the neonatal mortality in developing countries, there is an urgent need to improve the neonatal care”."

Response: Thank you for your valuable suggestion. We have revised the sentence to clear our research aim.

2. "Copyediting will be required throughout the manuscript."

Response: Thank you for your valuable suggestion. We have done copy editing using the help from professional English editing services.

3. "Minimize the repetitions especially in methods and discussion."

Response: Thank you for your valuable suggestion. We now have minimized the repetitions and keep the methods and discussion concisely.
We are very thankful for your availability and willingness to help us to become our reviewer on our manuscript entitled "Neonatal Resuscitation: A cross-sectional study measuring the readiness of healthcare personnel". We have revised our manuscript based point-on-point revision suggested.

1. "The first sentence, “Neonatal mortality is one of the standards of neonatal care”-this sentence should be modified as ‘To decrease the neonatal mortality in developing countries, there is an urgent need to improve the neonatal care”."

Response: Thank you for your valuable suggestion. We have revised the sentence to clear our research aim.

2. "Copyediting will be required throughout the manuscript."

Response: Thank you for your valuable suggestion. We have done copy editing using the help from professional English editing services.

3. "Minimize the repetitions especially in methods and discussion."

Response: Thank you for your valuable suggestion. We now have minimized the repetitions and keep the methods and discussion concisely.
Competing Interests: No competing interests were disclosed. Close
Report a concern

Views

Reviewer Report 11 Jul 2022

Elisabeth M W Kooi, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, University of Groningen, Groningen, The Netherlands

Approved with Reservations

https://doi.org/10.5256/f1000research.120572.r137948

This study is an important attempt to receive more insight in resuscitation readiness of various levels of staff in Indonesian hospitals of several levels. A questionnaire was developed and tested in ten nurses and then send out to a large number of hospital workers in neonatal departments. The results show a better readiness and experience in higher level hospitals, and some differences between characteristics of the participants.

I have several concerns:

The results are based on the responses of a relatively small part of the invited population. This low response rate may have biased the results which should be assessed and discussed in more detail. i.e.: Were certain levels of staff overrepresented?
Also the validity of both questionnaires needs a critical reflection, including the assumed clinical relevant difference: even though there may be statistical significant differences, most of the time the difference between two groups is (only?) 1 or 2 points: is this relevant? The conclusion of the manuscript is fully based on this questionnaire that may need further validation including the assessment of a minimal clinical relevant difference.
Also, are the questions based on an implemented national guideline that all neonatal caretakers should be aware of? How sure are the authors about the supposed correct answers to the questions, as some are consensus based?

Other concerns include:

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.
Table 4 needs legends on what the various answers mean, apart from what is written in the main text.
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 response rate should be mentioned in abstract.
I recognize a few language issues, i.e. what does "divided the room into..." mean? I would suggest to have the text reviewed on its details.
In the conclusion the authors suggest to refer infants in need of resuscitation, I would rephrase into ‘risk at need for resuscitation’, otherwise referral will be too late. Also the authors conclude that more training is needed. Although this may very well be true, it is not what was investigated in this study, which is why I would weaken this statement.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

No
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Neonatology

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Report a concern

Author Response 26 May 2023

Mahendra Tri Arif Sampurna, Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, 60132, Indonesia

26 May 2023

Author Response

We are very thankful for your availability and willingness to help us to become our reviewer on our manuscript entitled "Neonatal Resuscitation: A cross-sectional study measuring the readiness of healthcare ... Continue reading We are very thankful for your availability and willingness to help us to become our reviewer on our manuscript entitled "Neonatal Resuscitation: A cross-sectional study measuring the readiness of healthcare personnel". We have revised our manuscript based point-on-point revision suggested.

1. "The results are based on the responses of a relatively small part of the invited population. This low response rate may have biased the results which should be assessed and discussed in more detail. i.e.: Were certain levels of staff overrepresented?"

Response: Thank you for your valuable comment. We notice that our small sample may introduce the bias to our study. However, in this study we are trying to get the sample during a specific period to make sure there is no time bias. We have added mentions about this issue on the strength and limitation subsection.

2. "The validity of both questionnaires needs a critical reflection, including the assumed clinical relevant difference: even though there may be statistical significant differences, most of the time the difference between two groups is (only?) 1 or 2 points: is this relevant? The conclusion of the manuscript is fully based on this questionnaire that may need further validation including the assessment of a minimal clinical relevant difference."

Response: Thank you for your valuable suggestions. We use the validated questionnaire from prior publication of Jukkala et al in 2007. 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.

3. "Are the questions based on an implemented national guideline that all neonatal caretakers should be aware of? How sure are the authors about the supposed correct answers to the questions, as some are consensus based?"

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.

4. "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.

5. "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."

Response: Thank you for your valuable suggestion, we now have added a brief explanation about the questionnaire and included effect sizes in the abstract.

7. "I recognize a few language issues, i.e. what does "divided the room into..." mean? I would suggest having the text reviewed on its details."

Response: Thank you for your valuable suggestion. We have done copy editing using the help from professional English editing services.

8. "In the conclusion the authors suggest referring to infants in need of resuscitation, I would rephrase into ‘risk at need for resuscitation’, otherwise referral will be too late. Also the authors conclude that more training is needed. Although this may very well be true, it is not what was investigated in this study, which is why I would weaken this statement."

Response: Thank you for your valuable comment. We agree and have revised our conclusion. Again, thank you for your help.
We are very thankful for your availability and willingness to help us to become our reviewer on our manuscript entitled "Neonatal Resuscitation: A cross-sectional study measuring the readiness of healthcare personnel". We have revised our manuscript based point-on-point revision suggested.

1. "The results are based on the responses of a relatively small part of the invited population. This low response rate may have biased the results which should be assessed and discussed in more detail. i.e.: Were certain levels of staff overrepresented?"

Response: Thank you for your valuable comment. We notice that our small sample may introduce the bias to our study. However, in this study we are trying to get the sample during a specific period to make sure there is no time bias. We have added mentions about this issue on the strength and limitation subsection.

2. "The validity of both questionnaires needs a critical reflection, including the assumed clinical relevant difference: even though there may be statistical significant differences, most of the time the difference between two groups is (only?) 1 or 2 points: is this relevant? The conclusion of the manuscript is fully based on this questionnaire that may need further validation including the assessment of a minimal clinical relevant difference."

Response: Thank you for your valuable suggestions. We use the validated questionnaire from prior publication of Jukkala et al in 2007. 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.

3. "Are the questions based on an implemented national guideline that all neonatal caretakers should be aware of? How sure are the authors about the supposed correct answers to the questions, as some are consensus based?"

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.

4. "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.

5. "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."

Response: Thank you for your valuable suggestion, we now have added a brief explanation about the questionnaire and included effect sizes in the abstract.

7. "I recognize a few language issues, i.e. what does "divided the room into..." mean? I would suggest having the text reviewed on its details."

Response: Thank you for your valuable suggestion. We have done copy editing using the help from professional English editing services.

8. "In the conclusion the authors suggest referring to infants in need of resuscitation, I would rephrase into ‘risk at need for resuscitation’, otherwise referral will be too late. Also the authors conclude that more training is needed. Although this may very well be true, it is not what was investigated in this study, which is why I would weaken this statement."

Response: Thank you for your valuable comment. We agree and have revised our conclusion. Again, thank you for your help.
Competing Interests: No competing interests were disclosed. Close
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Author Response 26 May 2023

Mahendra Tri Arif Sampurna, Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, 60132, Indonesia

26 May 2023

Author Response

We are very thankful for your availability and willingness to help us to become our reviewer on our manuscript entitled "Neonatal Resuscitation: A cross-sectional study measuring the readiness of healthcare ... Continue reading We are very thankful for your availability and willingness to help us to become our reviewer on our manuscript entitled "Neonatal Resuscitation: A cross-sectional study measuring the readiness of healthcare personnel". We have revised our manuscript based point-on-point revision suggested.

1. "The results are based on the responses of a relatively small part of the invited population. This low response rate may have biased the results which should be assessed and discussed in more detail. i.e.: Were certain levels of staff overrepresented?"

Response: Thank you for your valuable comment. We notice that our small sample may introduce the bias to our study. However, in this study we are trying to get the sample during a specific period to make sure there is no time bias. We have added mentions about this issue on the strength and limitation subsection.

2. "The validity of both questionnaires needs a critical reflection, including the assumed clinical relevant difference: even though there may be statistical significant differences, most of the time the difference between two groups is (only?) 1 or 2 points: is this relevant? The conclusion of the manuscript is fully based on this questionnaire that may need further validation including the assessment of a minimal clinical relevant difference."

Response: Thank you for your valuable suggestions. We use the validated questionnaire from prior publication of Jukkala et al in 2007. 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.

3. "Are the questions based on an implemented national guideline that all neonatal caretakers should be aware of? How sure are the authors about the supposed correct answers to the questions, as some are consensus based?"

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.

4. "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.

5. "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."

Response: Thank you for your valuable suggestion, we now have added a brief explanation about the questionnaire and included effect sizes in the abstract.

7. "I recognize a few language issues, i.e. what does "divided the room into..." mean? I would suggest having the text reviewed on its details."

Response: Thank you for your valuable suggestion. We have done copy editing using the help from professional English editing services.

8. "In the conclusion the authors suggest referring to infants in need of resuscitation, I would rephrase into ‘risk at need for resuscitation’, otherwise referral will be too late. Also the authors conclude that more training is needed. Although this may very well be true, it is not what was investigated in this study, which is why I would weaken this statement."

Response: Thank you for your valuable comment. We agree and have revised our conclusion. Again, thank you for your help.
We are very thankful for your availability and willingness to help us to become our reviewer on our manuscript entitled "Neonatal Resuscitation: A cross-sectional study measuring the readiness of healthcare personnel". We have revised our manuscript based point-on-point revision suggested.

1. "The results are based on the responses of a relatively small part of the invited population. This low response rate may have biased the results which should be assessed and discussed in more detail. i.e.: Were certain levels of staff overrepresented?"

Response: Thank you for your valuable comment. We notice that our small sample may introduce the bias to our study. However, in this study we are trying to get the sample during a specific period to make sure there is no time bias. We have added mentions about this issue on the strength and limitation subsection.

2. "The validity of both questionnaires needs a critical reflection, including the assumed clinical relevant difference: even though there may be statistical significant differences, most of the time the difference between two groups is (only?) 1 or 2 points: is this relevant? The conclusion of the manuscript is fully based on this questionnaire that may need further validation including the assessment of a minimal clinical relevant difference."

Response: Thank you for your valuable suggestions. We use the validated questionnaire from prior publication of Jukkala et al in 2007. 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.

3. "Are the questions based on an implemented national guideline that all neonatal caretakers should be aware of? How sure are the authors about the supposed correct answers to the questions, as some are consensus based?"

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.

4. "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.

5. "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."

Response: Thank you for your valuable suggestion, we now have added a brief explanation about the questionnaire and included effect sizes in the abstract.

7. "I recognize a few language issues, i.e. what does "divided the room into..." mean? I would suggest having the text reviewed on its details."

Response: Thank you for your valuable suggestion. We have done copy editing using the help from professional English editing services.

8. "In the conclusion the authors suggest referring to infants in need of resuscitation, I would rephrase into ‘risk at need for resuscitation’, otherwise referral will be too late. Also the authors conclude that more training is needed. Although this may very well be true, it is not what was investigated in this study, which is why I would weaken this statement."

Response: Thank you for your valuable comment. We agree and have revised our conclusion. Again, thank you for your help.
Competing Interests: No competing interests were disclosed. Close
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VERSION 2 PUBLISHED 13 May 2022

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Version 2 (revision) 22 May 23	read	read
Version 1 13 May 22	read	read

Elisabeth M W Kooi, University of Groningen, Groningen, The Netherlands
Yellanthoor Ramesh Bhat, Manipal Academy of Higher Education, Manipal, India

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5 Views

18 Jul 2023 | for Version 2

Yellanthoor Ramesh Bhat, Department of Paediatrics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India

5 Views Cite this report Responses(0)

Approved

Authors revised the article and the revised version is accepted

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Pediatrics, Neonatology, Intensive care, Ventilation

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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7 Views

05 Jun 2023 | for Version 2

Elisabeth M W Kooi, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, University of Groningen, Groningen, The Netherlands

7 Views Cite this report Responses(0)

Approved

I am satisfied with the responses by the authors and will endorse indexing of the paper.

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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14 Views

13 Jul 2022 | for Version 1

Yellanthoor Ramesh Bhat, Department of Paediatrics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India

14 Views Cite this report Responses(1)

Approved With Reservations

Overall the study appears reasonable. The information may help plan the policy regarding neonatal resuscitation and the target groups.
The first sentence, “Neonatal mortality is one of the standards of neonatal care”-this sentence should be modified as ‘To decrease the neonatal mortality in developing countries, there is an urgent need to improve the neonatal care”.
Copyediting will be required throughout the manuscript.
Minimize the repetitions especially in methods and discussion.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Pediatrics, Neonatology, Intensive care, Ventilation

Respond to this report

Responses (1)

Author Response

26 May 2023

Mahendra Tri Arif Sampurna, Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, 60132, Indonesia

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Competing Interests

No competing interests were disclosed.

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20 Views

11 Jul 2022 | for Version 1

Elisabeth M W Kooi, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, University of Groningen, Groningen, The Netherlands

20 Views Cite this report Responses(1)

Approved With Reservations

The results are based on the responses of a relatively small part of the invited population. This low response rate may have biased the results which should be assessed and discussed in more detail. i.e.: Were certain levels of staff overrepresented?
Also the validity of both questionnaires needs a critical reflection, including the assumed clinical relevant difference: even though there may be statistical significant differences, most of the time the difference between two groups is (only?) 1 or 2 points: is this relevant? The conclusion of the manuscript is fully based on this questionnaire that may need further validation including the assessment of a minimal clinical relevant difference.
Also, are the questions based on an implemented national guideline that all neonatal caretakers should be aware of? How sure are the authors about the supposed correct answers to the questions, as some are consensus based?

Other concerns include:

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.
Table 4 needs legends on what the various answers mean, apart from what is written in the main text.
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 response rate should be mentioned in abstract.
I recognize a few language issues, i.e. what does "divided the room into..." mean? I would suggest to have the text reviewed on its details.
In the conclusion the authors suggest to refer infants in need of resuscitation, I would rephrase into ‘risk at need for resuscitation’, otherwise referral will be too late. Also the authors conclude that more training is needed. Although this may very well be true, it is not what was investigated in this study, which is why I would weaken this statement.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

No
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Neonatology

Respond to this report

Responses (1)

Author Response

26 May 2023

Mahendra Tri Arif Sampurna, Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, 60132, Indonesia

We are very thankful for your availability and willingness to help us to become our reviewer on our manuscript entitled "Neonatal Resuscitation: A cross-sectional study measuring the readiness of healthcare personnel". We have revised our manuscript based point-on-point revision suggested.

1. "The results are based on the responses of a relatively small part of the invited population. This low response rate may have biased the results which should be assessed and discussed in more detail. i.e.: Were certain levels of staff overrepresented?"

Response: Thank you for your valuable comment. We notice that our small sample may introduce the bias to our study. However, in this study we are trying to get the sample during a specific period to make sure there is no time bias. We have added mentions about this issue on the strength and limitation subsection.

2. "The validity of both questionnaires needs a critical reflection, including the assumed clinical relevant difference: even though there may be statistical significant differences, most of the time the difference between two groups is (only?) 1 or 2 points: is this relevant? The conclusion of the manuscript is fully based on this questionnaire that may need further validation including the assessment of a minimal clinical relevant difference."

Response: Thank you for your valuable suggestions. We use the validated questionnaire from prior publication of Jukkala et al in 2007. 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.

3. "Are the questions based on an implemented national guideline that all neonatal caretakers should be aware of? How sure are the authors about the supposed correct answers to the questions, as some are consensus based?"

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.

4. "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.

5. "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."

Response: Thank you for your valuable suggestion, we now have added a brief explanation about the questionnaire and included effect sizes in the abstract.

7. "I recognize a few language issues, i.e. what does "divided the room into..." mean? I would suggest having the text reviewed on its details."

Response: Thank you for your valuable suggestion. We have done copy editing using the help from professional English editing services.

8. "In the conclusion the authors suggest referring to infants in need of resuscitation, I would rephrase into ‘risk at need for resuscitation’, otherwise referral will be too late. Also the authors conclude that more training is needed. Although this may very well be true, it is not what was investigated in this study, which is why I would weaken this statement."

Response: Thank you for your valuable comment. We agree and have revised our conclusion. Again, thank you for your help.

View more View less

Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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

Abstract

Keywords

Revised Amendments from Version 1

Background

Methods

Study design and participants

Data collection

Definitions

Statistical analysis

Results

Study participant characteristics

Table 1. Characteristics and demographics of participants.

Knowledge questionnaire

Table 2. Answers to knowledge questionnaire.

Table 3. Comparison between participant characteristics and knowledge score.

Experience questionnaire

Table 4. Answers to experience questionnaire.

Table 5. Comparison between participant characteristics and experience score.

Discussion

Research strengths and limitations

Conclusion

Ethical considerations

Data availability

Underlying data

Acknowledgements

References

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