Content area
Aim
To investigate the impact of ongoing workshop training of the "Helping Babies Breathe" program on the durability of midwives' knowledge and skills.
BackgroundImplementing the Helping Babies Breathe (HBB) program is crucial as a simple protocol for neonatal resuscitation in low-resource healthcare settings to decrease the rate of asphyxia and perinatal mortality by the initial healthcare providers. In addition to training in this program, it is also essential to guarantee the retention of the acquired knowledge and skills.
DesignA quasi-experimental clinical trial study with a single-group, pre-test-and-post-test design.
MethodsThis study was conducted throughout the year 2022, with a sample size of 61 midwives selected through a census sampling from those working in the delivery and operating rooms of X Hospital in x City. The midwives participated in 3-hour workshops. This study was performed in two stages: intervention and follow-up. The evaluation Instruments included the HBB educational package, which consisted of a questionnaire and 3 Objective Structured Clinical Exams. During the intervention phase, the HBB program training was conducted through a series of workshops held at four different time points over a span of six months. In the follow-up stage, the learners were not provided with any further training. The evaluation was done immediately after the initial training workshop of the HBB program, at the end of the final workshop in the sixth month and at the end of the follow-up period.
ResultsThe mean knowledge score of the baseline, at six months and at twelve months after the initial workshop were documented as (17 SD1.2), (17.79 SD 0.4) and (17.73 SD 0.5), respectively. There was a statistically significant difference in the mean knowledge scores between the baseline and the six and twelve months (P<0.05), but no statistically significant difference was observed between six and twelve months (P>0.05).
The mean skill scores showed a significant improvement and were maintained after six months compared with the initial assessment (P<0.05); however, there was a significant decrease in skill score twelve months later, in comparison to both the initial assessment and the first six months (P<0.05).
ConclusionsHealthcare workers can maintain their knowledge and skills by participating in ongoing training workshops. However, without continuous training, their skills may diminish. Therefore, it is essential to implement training programs that emphasize regular practice and repetition to ensure knowledge and skills retention.
Registration numberThe present research was a part of the research work with the ethics ID IR.IRSHUMS.REC.1400.019.
The World Health Organization's report indicates that 2.4 million infants passed away within the initial 28 days of life in 2020 (World Health Organization, 2022). One of the most challenging perinatal problems is the risk of neonatal asphyxia during birth, leading to sepsis and prematurity as the third leading cause of infant mortality (Lemma et al., 2022). Approximately 10 % of newborns need minimal assistance to initiate breathing, while about 1 % necessitate significant resuscitation efforts to sustain life; hence, healthcare professionals are tasked with mitigating the potentially severe consequences of asphyxia through timely and proficient resuscitation. The initial sixty seconds following birth are commonly referred to as the 'Golden Minute' and plays a vital role in initiating resuscitation of the neonate (Park et al., 2019; Kamath-Rayne et al., 2018; Mimoso, 2024).
According to surveys, approximately 30 % of newborn resuscitation procedures are either omitted or executed incorrectly. Research studies highlight the significance of resuscitation team training in enhancing the overall quality of this process. Both non-resuscitation and improper resuscitation contribute to an elevated risk of asphyxia, cerebral palsy and organ disorders in neonates, all leading to prolonged hospital stays in the neonatal intensive care unit, complications during hospitalization and increased mortality rates (Carbine et al., 2000; Wang et al., 2022; Heydarzadeh et al., 2020; Gillam-Krakauer and Gowen Jr, 2024).
Neonatal resuscitation presents a challenge due to the complexity of related techniques, making it difficult to learn and implement. To address this barrier, the American Academy of Pediatrics has introduced a simpler approach to neonatal resuscitation known as "Helping Babies Breathe" (HBB) (Singhal et al., 2020). This approach relies on the 'Golden Minute' which is vital for initiating breathing and providing ventilation using an Ambu bag. It is imperative to have at least one proficient individual in resuscitation present during each birth.
Resuscitation training must be firmly based on information, practical skills and the right attitude. Additionally, it should incorporate suitable teaching methods and educational equipment such as manikins and moulage. The scarcity of educational resources in the realm of resuscitation poses a challenge for healthcare professionals, whose abilities can be enhanced through ongoing and suitable training throughout their careers (Kamath-Rayne et al., 2018; Hosseini et al., 2023; Tabangin et al., 2018).
The efficacy of resuscitation training relies on a strong basis of knowledge, hands-on skills, a proper mindset and the implementation of suitable instructional techniques and educational resources such as manikins and moulages. The apparent deficiencies in conventional educational methods underscore the necessity for innovative approaches that incorporate new means of disseminating information. These approaches encompass the application of the internet in medical education, as well as the integration of computers, smartphones, modeling and simulation and instructional aids (Hosseini et al., 2023; Umoren et al., 2021a).
Researchers argue that every type of education leads to acquiring knowledge; nevertheless, the extent and longevity of that knowledge differ depending on the educational methods employed. In recent years, a substantial portion of research has focused on assessing the effectiveness of various educational initiatives in this area (Heydarzadeh et al., 2020; Wrammert et al., 2017).
Numerous studies have been conducted to find more effective training methods in neonatal resuscitation. These studies highlight the importance of improving the skills and proficiency of healthcare personnel through workshop training that includes simulation using moulage, along with the use of station tests (Tabangin et al., 2018; Wrammert et al., 2017). The results of a randomized controlled trial conducted in Nigeria and Kenya, focusing on practicing and evaluating neonatal resuscitation through virtual reality and videos among healthcare workers, revealed that the skills in neonatal resuscitation using virtual reality remained more sustainable over specified periods (1 month, 3 months and 6 months) in contrast to the video training and control groups. Moreover, healthcare workers showed a higher inclination towards using virtual reality for acquiring and retaining skills related to the neonatal resuscitation program, as opposed to alternative digital techniques (Umoren et al., 2021a).
The research conducted in Iran revealed that the quality of short-term resuscitation outcomes improved after implementing Question and Answer (Q&A) sessions after viewing real-life resuscitation videos, compared with conventional resuscitation workshops that used manikins.
This improvement was observed in various aspects including the duration of resuscitation, Apgar score, pulse recovery and skin color during resuscitation. Nevertheless, there was no significantly difference in the performance of resuscitation between these two training approaches (Heydarzadeh et al., 2020). Another study carried out in Iran demonstrated that using social networks for ongoing neonatal resuscitation training following workshops was effective in preserving the knowledge and skills of midwives. The intervention group displayed higher mean scores in terms of knowledge and skill when compared with the control group, even three months post-workshop training (Hosseini et al., 2023). Midwives have a vital role as the initial caregivers for newborns requiring resuscitation, making their training of utmost significance. It is imperative to enhance the longevity of this training and we aim to assess the retention of midwives' knowledge and skills in neonatal resuscitation through ongoing training in the HBB method.
Therefore, the aim of this quasi-experimental study is to evaluate the influence of ongoing workshop sessions on the retention of knowledge and skills pertaining to helping babies breathing among midwives at Iran Hospital in Iranshahr, Iran. The study focused on the following main question and hypotheses: Is it possible to maintain knowledge and skills through ongoing training? and ongoing helping babies breathing training program can improve the retention of the knowledge and skills.
2 Methods2.1 Design, samples and research setting
From January 2022 to January 2023, a quasi-experimental clinical trial was carried out with a pre-test-and-post-test design. Quasi-experimental studies are used when it is not possible to conduct a randomized design. The Pre-Post design, a form of quasi-experimental design, involves gathering data both before and after implementing an intervention, followed by a comparison of the results. To enhance the study, a control group may be included in a Pre-Post Design with a non-equivalent control group (Handley et al., 2018). A total of 61 participants were selected using a census sampling method from midwives employed in the Delivery Department and Operating Room of X Hospital, X University of Medical Sciences, X. Census refers to the procedure of gathering information from each individual within a population (Martínez-Mesa et al., 2016). The present study was extracted from a study entitled “Effect of workshop-based training of HBB program on newborn asphyxia among midwives working in X Hospital”. The training course lasted for a year and was implemented in two phases: intervention and follow-up. The ethics committee of X University of Medical Sciences approved this study with code IR.IRSHUMS. REC.1400.019. Obtaining informed consent from the participants and assuring them of their anonymity and confidentiality of data was another ethical consideration. Furthermore, permissions were acquired from both the university and hospital to access a list of employed midwives at the specified center (Further information is provided in Fig. 1).
2.2 Inclusion and exclusion criteria2.2.1 Inclusion criteria
To be eligible for inclusion in the study, participants had to meet several criteria. These criteria included being a midwife with experience in delivery and/ or operating room, displaying a willingness to take part in the study and achieving a minimum score on the Objective Structured Clinical Exams (OSCE’s). The OSCE’s consisted of three components: OSCE A, OSCE B and OSCE bag-mask ventilation (BMV; HBB manual; 2nd edition, 2018). To pass the OSCE’s, participants needed to score at least 9 out of 12 in OSCE A, 17 out of 23 in OSCE B and achieve a perfect score of 14 points in OSCE BMV.
2.2.2 Exclusion criteriaParticipants who did not take part in the workshop retraining sessions as part of the intervention, as well as those who were transferred to a different healthcare facility, were not considered eligible for the study.
2.3 Instrumentation2.3.1 Demographic information form
This form collects data regarding age, marital status, educational background, professional experience, employment status and department of work within the hospital.
2.3.2 Educational package of HBB to measure knowledge and skills2.3.2.1 Multiple choice questionnaire (MCQ)
including 18 four-choice questions about the importance of ventilation in the first minute of birth, preparation for birth, preparing the delivery room, how to keep the baby warm and clean, diagnosing a baby with normal conditions, the first steps of baby care, clamp time Umbilical cord, primary and secondary measures required for babies with abnormal conditions, babies needing suction, complications of unnecessary suction, proper ventilation of babies and required corrective measures, infection control of babies.
2.3.2.2 Three OSCEs: A, B and BMVOSCE BMV includes four items: initiating ventilation using a bag and mask, positioning the neonate's head and neck appropriately for ventilation, speed of ventilation and measures required to improve ventilation. On the other hand, OSCE A is composed of 12 questions divided into 4 sections focusing on the basic care of full-term newborns, such as birth preparedness, initial newborn care procedures, facilitating spontaneous breathing in the newborn and managing a newborn with spontaneous respiration. OSCE B includes 23 questions and 7 items focusing on the essential care of premature neonates. This includes preparation for birth, helping neonates with apnea to initiate spontaneous breathing, rapid and accurate ventilation of neonates with resistant apnea, duration of ventilation and assessment of neonatal breathing status, corrective measures for neonates requiring ventilation, appropriate ventilation criteria and management of preterm and low birth weight neonates with normal heart rate and breathing following ventilation (Further information is provided in Table 1)
The Neonatal Health Department of the Ministry of Health and Medical Education of Iran verified the reliability and validity of the educational package of HBB. This was confirmed through a study conducted by Hosseini et al (Hosseini et al., 2023).
2.4 Data gathering procedure2.4.1 Intervention
Following the establishment of the educational framework, a prominent instructor who had successfully finished the HBB training course efficiently grouped the midwives into sets of 8. To minimize any bias, everyone was given a specific code. The selection of group members was done through a random number table. The educational package from HBB was presented through workshops that lasted for 3 h. The workshops were conducted under standardized conditions for all participants, encompassing lectures, slide presentations, interactive Q&A sessions, group discussions and engaging hands-on exercises.
Immediately at the end of the first workshop, the participants promptly filled out the HBB knowledge questionnaire, which was a prerequisite for successfully passing the OSCEs of the HBB program. To proceed with the study, learners were required to achieve the minimum score specified in the assessment tools during the OSCE tests. In the OSCE's tests, learners must obtain the minimum score mentioned in the tools to enter the study. If the minimum score is not achieved, the HBB educational program will be repeated for the students concerned on the same day. Furthermore, at intervals of 3, 5 and 6 months following the first HBB program workshop, the workshop's educational material was reviewed and practiced in identical settings, with the same instructors, through slide presentations, group discussions and practical exercises. At the conclusion of the intervention (6 months after the initial workshop), all participants will undergo the knowledge assessment test and station tests of the HBB program once again.
2.4.2 Post intervention (follow-up)During the follow-up phase, which lasted six months after the final workshop of the HBB program, the participants were not provided with any further training. On the conclusion of this stage, evaluations were carried out to assess the knowledge, skills and performance of the participants through the HBB program's station tests.
2.5 Data analysisGiven that the data did not follow a normal distribution, the Generalized Estimating Equation was used as an alternative to the repeated measures analysis of variance test. This approach accounted for the dependence of the data over time by incorporating time clusters in the analysis, thereby considering the similarity between the data (Chen and Xu, 2020)
3 ResultsThe average scores for the age and work experience of the midwives were calculated to be 31.5 (SD 4.29) and 7.6 (SD 3.29) years, respectively. It was discovered that half of the midwives had participated in a workshop on newborn resuscitation. Additional details can be found in Table 2.
The initial knowledge score at the baseline (right after the initial workshop), the knowledge score after six months of the first HBB workshop (the first 6 months) and the knowledge score after twelve months of the first workshop (the second 6 months) were recorded as (17 SD 1.2), (17.79 SD 0.4) and (17.73 SD 0.5), respectively. A significant difference was observed between the baseline knowledge score and the score after six months (P<0.05). However, there was no significant difference in the knowledge score between the initial and second six months. Shifting the reference points (comparison times), the evaluation of the knowledge scores for the first six months in contrast to the second six months revealed that the mean knowledge score for the latter period remained consistent with that of the former (P>0.05). Additionally, Table-3 illustrates that factors such as age, work experience, marital status, prior education and employment type did not exert a significant influence on the knowledge score (P>0.05). Further details can be found in Table 3.
The mean score of the BMV scale showed a decrease at both the six and twelve-month score, when compared with the baseline. Additionally, there was a significant decrease observed six months after the intervention (P˂0.05) (Table 4).
On the other hand, the mean scores of OSCE A and B exhibited improvement at the end of the six months but experienced a significant decrease at the end of the twelve months, in comparison to the baseline (P˂0.05) (Table 4).
The mean skill score showed a significant decrease at the twelve-month score compared with the six-month score in the OSCE BMV, A and B tests. Specifically, the decrease was statistically significant in the OSCE BMV test (P˂0.001). Further information is presented in Table 4.
Table 4 further illustrates that aside from the individual's prior training history, factors like age, years of work experience, marital status and employment type did not yield a significant impact on the skill score (P˃0.05).
4 DiscussionThis quasi-experimental research was conducted to assess the retention of knowledge and skills in neonatal resuscitation using the HBB method among midwives who underwent continuous training. The neonatal resuscitation program and HBB play a vital role in enhancing the competencies and understanding of healthcare providers, especially midwives (Briggs et al., 2021a). In the hospital where the present study was conducted, it was found that 24 % of the midwives lacked the essential skills to effectively performspecific procedures during newborn resuscitation. In a study conducted by Kembabazi's in Uganda, it was observed that most midwives possessed a satisfactory comprehension of neonate resuscitation techniques. Nevertheless, a significant 40 % of midwives were observed to neglect certain crucial steps during the resuscitation process (Kembabazi, 2016).
A study carried out by Sintayehu et al in Ethiopia found that around 11.2 % of nurses and midwives showed competence in neonatal resuscitation techniques (Sintayehu et al., 2020). Furthermore, healthcare professionals in East Africa were found to have inadequate knowledge and skills in newborn resuscitation (Mihretie et al., 2024). These findings underscore the significance of educating individuals on infant resuscitation and implementing strategies to sustain the acquired knowledge and skills.
According to the aim and main results of the present research, following the intervention (baseline) and throughout the six-month duration of the retraining HBB workshops, the midwives' knowledge of neonatal resuscitation showed enhancement and retention even at the end of the 12-month period post baseline workshops. Nevertheless, the skill scores remained consistent only in the OSCEs A and B at six months, but not after twelve months. A study carried out in Jordan on midwives demonstrated that implementing the HBB training program and conducting a re-evaluation after 8 months resulted in an improvement in both the skills (in OSCEs A and B) and knowledge of the midwives (Hatamleh et al., 2021). This study confirm the results of the present study and showed that education increases knowledge and skills, but it declines over time and requires continuous professional updating (Achaliwie et al., 2023). Continuing education leads to the attainment of knowledge and skills, ensuring the maintenance of proficient performance (Mlambo et al., 2021). Semakula et al. conducted a study in Uganda to investigate and contrast two educational approaches. The first approach involved regular public service announcements on health issues, which served as the control group. The second approach involved listening to podcasts on the desired content for a duration of 7–10 weeks, forming the intervention group. The study's findings revealed that although there was an initial retention of knowledge and skills immediately after the intervention, the level of learning, especially in terms of skills, declined after one year and was not maintained (Semakula et al., 2020). Research has shown that basic knowledge and skills often diminish between 1 and 6 months following training, potentially due to insufficient practice or motivation, as well as reinforcement (Cetinkaya et al., 2022). This decline has been observed to occur within a time frame of 3–12 months post-training, particularly in developed countries (Briggs et al., 2021a).
Briggs et al showed conflicting results compared with the present study. They carried out research in Nigeria involving healthcare professionals, who underwent a rigorous eight-hour training session in one day. Evaluations were done prior to the intervention, right after the training and at three- and six-months post-training. They concluded that the knowledge and skill score decreased in six months. The difference between Briggs et al.'s study and the present study can be attributed to differences in the study procedure. The training program in Briggs et al.'s research consisted of an 8-hour educational session in a single day, followed by two assessments at three and six months after the training course (Briggs et al., 2021a). Throughout the present study, a sequence of training workshops was carried out over a span of six months. The workshops included slide presentations, group discussions and hands-on exercises, along with practicing with a neonatal resuscitation mannequin. Neonatal resuscitation is a complex procedure that cannot be fully mastered in just one training session. Therefore, it is crucial to maintain learning and skills through regular training and continuous practice over an extended period (Briggs et al., 2021b).
The findings of the present study indicated that the scores for OSCEs A and B showed greater longevity compared with the BMV scores. The BMV scores demonstrated a decrease at both the six-month, but not significant and twelve-month scores following the initial HBB workshop in the OSCEs. Similar outcomes were observed in a study conducted in Jordan on Midwives (Hatamleh et al., 2021).
In contrast to the present study, the study conducted in Ghana revealed conflicting results regarding the retention of knowledge and OSCEs in BMV. Odongkara et al. demonstrated that the implementation of video-debriefing methods during standard HBB training led to enhanced and sustained skills and knowledge among the participants (Odongkara et al., 2020). The study conducted by Omron et al. in Nigeria and Kenya also presented contrasting findings when compared with the present study. In their research, nurses and midwives were randomly divided into two intervention groups: one group underwent mobile visual reality simulation, while the other group watched videos. The control group, on the other hand, received only routine training. The results indicated that the retention of BMV skills after a 6-month follow-up was higher in the visual reality simulation group compared with the video and control groups. The study demonstrated that BMV skills exhibited greater retention at the 6-month follow-up in the virtual reality simulation. Furthermore, OSCE B scores were found to be higher in the virtual reality simulation compared with the video and control groups. These results showed the retention of BMV after the follow-up period (Umoren et al., 2021b). The difference between the results of the two studies can be attributed to the type of training. There are various factors that could explain these differences. One potential explanation is that using traditional teaching methods to support HBB might lead to a decline in skill rather than knowledge as time goes on (Bang et al., 2016). Research indicates that most the information (80 %) disseminated through lectures and workshops tends to fade from memory over time (Button et al., 2014). In the absence of practical application, individuals are likely to gradually lose the skills they have acquired (Hosseini et al., 2023; Tabangin et al., 2018). The use of game simulation in neonatal resuscitation training results in enhanced knowledge, skills, self-assurance and contentment among the learners (Sarvan and Efe, 2022). Furthermore, the study carried out by Bang and et al. illustrated that a range of factors, including overwhelming workloads, understaffing, limited time for skill practice and lack of confidence in executing new skills, can have a substantial impact on skill retention (Hatamleh et al., 2021; Bang et al., 2016). The acquisition of cognitive, behavioural and technical skills is crucial for the successful resuscitation of neonates (Xu et al., 2023). Consequently, the lack of appropriate training, insufficient post-training reinforcement and the passage of time will result in a decline in the skills of newborn resuscitation techniques (Quadri et al., 2021).
The primary strength of the present study lies in its execution through a multi-phase and continuous training approach, which stands out as a key feature and strength of this study. On the other hand, the main limitations of this study was the usation of a newborn simulator, preventing the massaging of actual babies due to ethical concerns. Additional limitations encompass the restricted sample size, the study's single-center setting, the absence of a control group and the fact that it was a single-group study. Due to the exclusive presence of the women and children's hospital in this city, enforcing specific restrictions became unattainable. The restricted number of samples and the decrease in participants significantly affect the applicability of the findings to a broader population, underscoring the necessity for future studies to be carried out with a more extensive sample size and across multiple medical centers.
5 ConclusionsThe findings of the present study suggest that the long-term effectiveness of education relies on the repetition of educational content. While workshop initiatives can enhance knowledge and skills, they do not ensure long-term sustainability. Therefore, to improve the quality of care and clinical outcomes, it is recommended that healthcare professionals employ both theoretical and practical approaches and make provisions for the repetition of courses. In this regard, highlighting the regular recurrence of training sessions in a workshop format for an extended period can be viewed as an effective approach, as it fosters active engagement from participants.
Funding sourcesThis study was not funded.
CRediT authorship contribution statementFerdows Bameri: Writing – original draft, Validation, Methodology, Investigation, Conceptualization. Rashideh Ghaderi: Validation, Investigation. Omid Aboubakri: Methodology, Formal analysis, Conceptualization. Nastaran Heydarikhayat: Writing – review & editing, Writing – original draft, Validation, Supervision, Methodology, Conceptualization.
Declaration of Competing InterestThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
AcknowledgementsThe authors sincerely appreciate and thank all the midwives of Iran Hospital, Iranshahr University of Medical Sciences, who contributed to the implementation and advancement of this research.
| Code | Initiates ventilation with a bag and mask | Code | |
| BMV 01 | Positions the baby in the specified ventilation area. | OS B 01 | Dries the baby thoroughly. |
| BMV 02 | Stands at the top of the newborn’s head. | OS B 02 | Sets aside the damp towel. |
| BMV 03 | Checks to ensure the mask size is appropriate. | Prompts: Shows that the baby is not crying. No secretions are visible in the baby's mouth and nose, and no sound of secretions is heard. | |
| 2. 2. Ventilates the baby using a bag and mask. | OS B 03 | Adjust the head positions and clears the airway. | |
| BMV 04 | Gently tilted the babies’ head back. | OS B 04 | Stimulates breathing by gently rubbing the back. |
| BMV 05 | Places the mask on the baby’s face. | Prompts: Indicates that the baby is not breathing. | |
| BMV 06 | Secures the mask in place on the face. | OS B 05 | Identifies that the baby is not breathing. |
| BMV 07 | Squeezes the bag so that the chest moves slowly. | OS B 06 | Detaches the umbilical cord and transports the baby to the ventilation area or places the baby on the mother's abdomen for ventilation. |
| 3. Continues ventilation for up to one minute. | OS B 07 | Utilizes a bag and a mask to provide ventilation within the golden minute (less than a minute). | |
| BMV 08 | The chest moves slowly by each ventilation | OS B 08 | Fixes a mask on the baby’s face so that the chest moves. |
| BMV 09 | Ventilates at a speed of 40 times per minute (30–50 times per minute is also acceptable( | OS B 09 | Effective ventilation time (beginning of gentle movement of the chest in seconds…) |
| QUICKLY: By moving the baby's chest ventilation, you can show me what it is doing to improve ventilation.4. Improves the process of ventilation. | OS B 10 | Ventilates at a speed of 40 times per minute (30–50 times per minute is also acceptable) | |
| BMV 10 | Moves the mask. | OS B 11 | Assesses breathing and chest movement. |
| BMV 11 | Gives to the head of the situation. | Prompts: Shows that the baby is not breathing. | |
| BMV 12 | Cleans the secretions of the mouth and nose | OS B 12 | Detects that the baby is not breathing. |
| BMV 13 | Opens the mouth. | OS B 13 | Requests help. |
| BMV 14 | Presses the bag with more forces. | OS B 14 | Continues to ventilate. |
| A Osce Steps | Prompts: Shows that the chest does not move.After performing one or two steps to improve ventilation, say the baby's chest is moving. | ||
| OS A 01 | Selects a helper and reviews the emergency plan. | OS B 15 | Repositions the mask. |
| OS A 02 | Prepares a place for delivery (warm, well-lit, clean) | OS B 16 | Gives the head a new position. |
| OS A 03 | washes her hands | OS B 17 | Clears secretions from the mouth and nose (as needed) |
| OS A 04 | Prepares a place for resuscitation and tests the functioning of the bag, mask and suction device. | OS B 18 | Opens the baby’s mouth s;ightely |
| Quickly:After a period of 5–7 min, transfer the baby to the learner and communicate the presence of meconium in the amniotic fluid. The baby will be positioned on the mother's abdomen, demonstrate your ability in caring for the newborn. | Prompts: Shows that the chest does not move; Heart rate is normal. | ||
| OS A 05 | Dries the baby thoroughly. | OS B 19 | Detects that the baby is not breathing, but the heart rate is normal. |
| OS A 06 | Sets aside the damp towel. | OS B 20 | Continues ventilation. |
| Quickly: Shows that the baby is not crying. Say: meconium has closed the baby's mouth. | Prompts: Show that the heart rate is 120 beats per minute and the baby is breathing (after 3 min). | ||
| OS A 07 | Detects that the baby is not breathing. | OS B 21 | Detects that the baby is breathing and the heart rate is normal. |
| OS A 08 | Positions the head and cleans the airway. | OS B 22 | Stops ventilation. |
| OS A 09 | Stimulates breathing by rubbing the back. | OS B 23 | Monitors the baby closely and communicates with the mother. |
| Quickly: Shows that the baby is breathing well (crying) | |||
| OS A 10 | Recognizes that the baby is crying and breathing well. | ||
| OS A 11 | Clamps or closes the umbilical cord and detaches it. | ||
| OS A 12 | Puts the baby in skin-to-skin contact with the mother's skin and puts a hat on the baby's head, communicates with the mother. | ||
| Demographic variables | ||||||||||
| time | Baseline (Reference) | |||
| 2 | 1.07 | 0.00 | (.66, 1.47) | |
| 3 | .90 | 0.00 | (.45, 1.35) | |
| Age | -.002 | 0.96 | (-.08,.085) | |
| Work experience total (year) | .05 | 0.35 | (-.06,.17) | |
| Marital status | Single(Reference) | |||
| Married | -.25 | 0.22 | (-.66,.15) | |
| History of resuscitation training | Yes(Reference) | |||
| No | .11 | 0.57 | (-.28,.52) | |
| Employment | Temporary-to-permanent(Reference) | |||
| Under-a-contract | .59 | 0.28 | (-.48, 1.67) | |
| Permanent | .58 | 0.30 | (-.52, 1.69) | |
| Short-term | -.16 | 0.77 | (-1.29,.97) |
| OSCE BMV | OSCE A | OSCE B | ||||||||
| subcategory | Coefficient | P>z | Coefficient. | P>z | Coefficient. | P>z | ||||
| time | Baseline(Reference) | |||||||||
| 2 | -.19 | 0.319 | (-.58,.18) | .56 | 0.01 | (.11, 1.00) | 1.11 | 0.01 | (.25, 1.98) | |
| 3 | -1.48 | 0.000 | (-1.88, −1.09) | -.81 | 0.00 | (-1.26, −.36) | -1.57 | 0.00 | (-2.44, −.70) | |
| Age (year) | .04 | 0.154 | (-.01,.11) | .08 | 0.06 | (-.00,.18) | .16 | 0.06 | (-.01,.34) | |
| Work experience total (year) | -.07 | 0.087 | (-.16,.011) | -.09 | 0.14 | (-.21,.031) | -.17 | 0.14 | (-.41,.06) | |
| Marital Status | Single(Reference) | |||||||||
| married | .27 | 0.091 | (-.04,.60) | .008 | 0.96 | (-.42,.43) | .04 | 0.91 | (-.78,.87) | |
| History Of Resuscitation Training | Yes(Reference) | |||||||||
| No | .51 | 0.001 | (.20,.82) | .64 | 0.00 | (.22, 1.06) | 1.26 | 0.00 | (.45, 2.07) | |
| Employment2 | Temporary-to-permanent(Reference) | |||||||||
| Under-a-contract | .45 | 0.296 | (-.39, 1.31) | .47 | 0.41 | (-.67, 1.63) | .93 | 0.41 | (-1.29, 3.17) | |
| Permanent | .34 | 0.433 | (-.52, 1.21) | .41 | 0.49 | (-.76, 1.58) | .82 | 0.47 | (-1.45, 3.09) | |
| Short-term | .30 | 0.525 | (-.62, 1.22) | .30 | 0.62 | (-.91, 1.53) | .56 | 0.63 | (-1.80, 2.94) | |
| _cons | 12.31 | 0.000 | (10.45, 14.16) | 8.53 | 0.00 | (5.95, 11.10) | 16.32 | 0.00 | (11.34, 21.30) | |
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