Article Text

Original research
Use of digital technologies for staff education and training programmes on newborn resuscitation and complication management: a scoping review
  1. Sayaka Horiuchi1,2,
  2. Tasmyn Soller1,
  3. Chloe Bykersma3,
  4. Shan Huang1,
  5. Rachel Smith1,
  6. Joshua P Vogel1
  1. 1 Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
  2. 2 Department of Epidemiology and Environmental Medicine, University of Yamanashi Graduate School of Medicine, Chuo, Yamanashi, Japan
  3. 3 Royal Children’s Hospital, Melbourne, Victoria, Australia
  1. Correspondence to Dr Sayaka Horiuchi; sayakahoriuchi{at}gmail.com

Abstract

Background Poor-quality care is linked to higher rates of neonatal mortality in low-income and middle-income countries (LMICs). Limited educational and upskilling opportunities for healthcare professionals, particularly those who work in remote areas, are key barriers to providing quality neonatal care. Novel digital technologies, including mobile applications and virtual reality, can help bridge this gap. This scoping review aims to identify, analyse and compare available digital technologies for staff education and training to improve newborn care.

Methods We conducted a structured search of seven databases (MEDLINE (Ovid), EMBASE (Ovid), EMCARE (Ovid), Global Health (CABI), CINAHL (EBSCO), Global Index Medicus (WHO) and Cochrane Central Register of Controlled Trials on 1 June 2023. Eligible studies were those that aimed to improve healthcare providers’ competency in newborn resuscitation and management of sepsis or respiratory distress during the early postnatal period. Studies published in English from 1 January 2000 onwards were included. Data were extracted using a predefined data extraction format.

Results The review identified 93 eligible studies, of which 35 were conducted in LMICs. E-learning platforms and mobile applications were common technologies used in LMICs for neonatal resuscitation training. Digital technologies were generally well accepted by trainees. Few studies reported on the long-term effects of these tools on healthcare providers’ education or on neonatal health outcomes. Limited studies reported on costs and other necessary resources to maintain the educational intervention.

Conclusions Lower-cost digital methods such as mobile applications, simulation games and/or mobile mentoring that engage healthcare providers in continuous skills practice are feasible methods for improving neonatal resuscitation skills in LMICs. To further consider the use of these digital technologies in resource-limited settings, assessments of the resources to sustain the intervention and the effectiveness of the digital technologies on long-term health provider performance and neonatal health outcomes are required.

  • Neonatology
  • Resuscitation
  • Technology
  • Health services research

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Novel digital technologies can help provide continual education for healthcare providers, especially for those working in remote areas in low-income and middle-income countries (LMICs).

WHAT THIS STUDY ADDS

  • e-Learning platforms or mobile applications were common technologies used for neonatal resuscitation training in LMICs, while high-fidelity mannequins are a more common technology used in high-income countries.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • This study suggests that the use of lower-cost digital technologies—such as mobile applications, simulation games and/or mobile mentoring—are feasible educational methods that could improve neonatal resuscitation skills in LMICs.

  • These digital technologies require further assessment, particularly on what resources are needed to sustain them, and their effectiveness on long-term performance of health providers, and on neonatal health outcomes.

Introduction

An estimated 2.3 million newborn deaths occurred worldwide in 2021,1 mainly due to preterm birth complications and intrapartum-related events.2 These deaths could have been averted by providing high-quality maternal and newborn care.3 Despite repeated calls for scaling up high-quality care, evidence suggests in low-income and middle-income countries (LMICs), less than half of the recommended maternal and newborn preventative and/or curative clinical actions are routinely provided.3

In order to ensure that high-quality newborn care is universally available, healthcare providers need access to initial and continued education and training opportunities. Available evidence has linked limited training opportunities for maternal and newborn health professionals to poor quality intrapartum and postnatal care.4 Limited access to in-service training is a particular issue for providers in rural or remote areas, which can also serve to worsen health inequities.5 Analysis of health facility data from five African countries suggests that the quality of maternity healthcare services is often lowest in primary healthcare facilities with low numbers of births.6 Similarly, provider newborn resuscitation skills and the ability to manage newborn complications may degrade more quickly in facilities where there are fewer births, and thus fewer opportunities to practice these skills.

In the last two decades, diverse digital technologies for healthcare settings have been developed, aimed at improving front-line clinical practice and healthcare professional education and training.7 More recently, service disruptions due to COVID-19 have accelerated the use of digital technologies in routine care provision in many countries, including LMICs.8

Digital technologies can support continuous professional education and training for providers, including those in limited-resource or remote contexts.9 Systematic reviews from diverse health topics have found that the use of various digital technologies for education and training—such as online/offline computers, mobile applications, simulation manikins and virtual reality technologies—can increase health providers’ knowledge.10–13 However, no previous review has explored the use of digital technologies for education and training in relation to newborn care. Therefore, the aim of this scoping review was to identify, analyse and compare digital technologies used for staff education and training on newborn care. We also evaluated the acceptability and required resources for digital technologies, and their potential application in the low-resource context.

Methods

This review was conducted per the Joanna Briggs Institute Methodology for Scoping Reviews and the Preferred Reporting Items for Systematic Reviews14 and Meta-Analyses extension for Scoping Reviews standards.15 The protocol for this scoping review was registered in the Open Science Framework.16 The WHO classification of digital health interventions focuses on the use of digital technologies for healthcare providers.7 17 As such, our review focused on the use of digital technologies for in-service training and did not include studies that focused on preservice training. Only studies where the main goal of the training programme was to improve healthcare providers clinical competence were included in the review.

Patient and public involvement

This scoping review did not involve direct patient or public involvement.

Selection criteria

Eligible studies were those that described the use of digital technologies for education and training programmes for health professionals providing newborn care. We included studies that focused on newborn resuscitation and complication management for neonatal sepsis and/or respiratory distress. We chose these three clinical practices as they are the major lethal conditions requiring treatment interventions in the early neonatal period, and healthcare providers in facilities with few births have fewer opportunities to practise, therefore, would benefit from regular training. Eligible studies involved use of a digital technology only, or a digital technology used in combination with other education and training activities. We excluded studies that related to interventions aimed only at undergraduate or postgraduate students (ie, preservice training), as our focus was to support in-service education and training. We included primary studies of any design (qualitative, quantitative or mixed methods) as well as study protocols and case reports. We did not include systematic, narrative or literature reviews. Studies from any country were eligible, provided they were published in English from 1 January 2000 onwards, as this was the period during which a rapid increase in the use of digital technologies for health was recognised.18

Search strategy and screening for eligibility

We consulted an information specialist and developed a search strategy based on the above criteria (online supplemental material 1). Seven databases were searched on 1 June 2023—MEDLINE (Ovid), EMBASE (Ovid), EMCARE (Ovid), Global Health (CABI), CINAHL (EBSCO), Global Index Medicus (WHO) and Cochrane Central Register of Controlled Trials (CENTRAL). All recovered citations were imported into systematic review software Covidence19 and duplicates removed. Abstract and full text screening were performed in duplicate on Covidence by four reviewers. Disagreements were resolved through discussion.

Supplemental material

Data extraction and synthesis

Data extraction was performed in duplicate using Covidence, according to a predefined data extraction form (online supplemental material 2). The form was pretested by extracting data from five studies and then revised and agreed on the reviewers. Extracted data were summarised descriptively and categorised according to types of digital technologies and how they were used (exclusive or blended), and the mode in which training was delivered (group, individual, mentoring or mixed). We categorised studies as ‘exclusive’ when they used a digital technology to deliver the entire training, and ‘blended’ when the digital technology was used in conjunction with other methods to deliver the training.

Supplemental material

Results

Characteristics of included studies

The database search yielded 3136 citations after removal of 2252 duplications (figure 1). After title and abstract screening, and full text review, a total of 93 articles were included (online supplemental table 1a,b). Of these, 35 were conducted in LMICs, of which 26 were in South Asian or sub-Saharan African countries (table 1). Neonatal resuscitation was included in 86 studies. There were two studies specific to sepsis20 21 and five to respiratory distress.22–26 Six studies described digital devices that were intended to be used for future staff training in newborn care but did not provide information on the design of educational interventions.27–32

Supplemental material

Supplemental material

Table 1

Characteristics of included studies (n=93)

What digital technologies were used in education and training, and how they were used

Across the included studies, the following digital technologies were identified: teleconference, eLearning platforms, mobile applications, social network services, high-fidelity mannequins, video laryngoscopy, computer-based simulated games, virtual reality, mobile phone and text messaging services, and motion camera to record skills performance. High-fidelity mannequins are life-like mannequins that can mimic human physiology.

Digital technologies were used exclusively in 42 studies (table 2). Remote education was provided via eLearning platforms (n=12),20 22 23 33–41 teleconference (n=9),42–50 mobile applications for self-directed learning (n=7),51–57 mobile-based simulated games (n=4),58–61 computer-based simulated games (n=8), of which 5 reported the same intervention,62–69 mobile virtual reality for simulation (n=1)70 or social network service (n=1).71 One computer-based simulated game was implemented onsite as it required a specific device for sensory interface.69

Table 2

Use of digital technology and modes of delivery of educational interventions (n=87)

Digital technology was blended with other non-digital training activities in the other 45 studies, including onsite simulation-based training for neonatal resuscitation (n=43); multifaceted educational materials on sepsis management (n=1)21; applied mobile application to support mentors providing tailored feedback on daily maternal and neonatal care (n=1).72 In 32 studies providing simulation-based training, high-fidelity mannequins were used to increase fidelity of clinical scenarios.24–26 73–101 The other 11 simulation-based studies used digital technologies to supplement on-site simulation-based training with digital learning materials,102–109 video laryngoscopy110 or provided mobile mentoring following on-site training activities.111 112

Digital technologies by income level

A total of 35 studies were conducted in LMICs, of which 22 used digital technology exclusively. The most common methods were eLearning platforms (n=10)22 33 35–38 40 41 109 and mobile applications (n=9). Mobile applications included the Safe Delivery App (SDA),51 53–57 Helping Babies Breathe Prompt58 and the Life-Saving Instruction for Emergencies applications.59 60 Blended use of digital technology was more common in high-income countries (HICs) (n=34), as was use of high-fidelity mannequins for simulation-based neonatal resuscitation training (n=27).

Educational outcomes of digital technology-based training

There were 29 studies that compared the educational outcomes between intervention and control groups. Of these, 10 studies reported statistically significant better educational outcomes in intervention groups while 1 reported better outcomes in a control group. There were three studies on the SDA, a mobile application providing point-of-care access to clinical protocols. One trial reported improved neonatal resuscitation knowledge at 3 months.51 Another trial reported improved neonatal resuscitation skills at 12 months, however, there was no significant reduction in perinatal mortality.53 The third SDA trial was an interventional study that reported significant improvement in knowledge and confidence scores in neonatal care.57

There were two trials of ‘mobile mentoring’ with frequent skill practice: one improved neonatal resuscitation knowledge and skill at 1 year and demonstrated a reduction in neonatal mortality (adjusted relative risk 0.30, 95% CI 0.21 to 0.43)111; another study improved skills scores at 1 year.112

Four studies evaluated simulation-based training. One study comparing with and without in situ high-fidelity simulation-based training reported greater improvement in scores of neonatal resuscitation skill and team performance at immediate postintervention.88 Another study compared on-site simulation training with a preceding online classroom and training without an online classroom and reported immediate improvements in knowledge and skills in the intervention group.105 The other two studies reported improvement in intubation performance during the training intervention.43 110

Two studies evaluated coaching via teleconferencing: one showed significant immediate improvements in ventilation performance in the intervention group50 while another study showed a significant reduction in neonatal resuscitation skill scores in the intervention group.49

In pre–post studies, 22 out of 24 studies that assessed trainees’ knowledge, skills, performance or confidence scores showed an improvement in the scores at postevaluation. The time points for scoring in the pre–post studies were immediately (n=20), at 1.5 months,61 at 2 and 5 months (n=2),65 67 and at 6 months (n=1)54 postintervention. When measured, there was no reported improvement in team performance.26 One study showed a reduction in neonatal deaths from 0.8% to 0.6% (as a percentage of all live births).74 Three studies did not show a significant improvement in neonatal deaths regardless of improvement in neonatal resuscitation performance among healthcare providers.93 98 109

Resource requirement for use of digital technologies

Only five studies reported on the cost of using digital technology for educational interventions. Of these, three reported on simulation-based training that involved high-fidelity mannequins. One reported that it cost US$290 000 to develop the simulation programme,84 another reported a total of US$2985 to run a training workshop,87 and the third reported that the simulation required an investment of US$3390 to achieve one clinical improvement during the actual clinical care subsequent to the simulation.94 While the actual cost or cost estimates were not reported in the other two studies, both reported that distance learning was more cost-effective than face-to-face training due to reduced travel expenses for trainers.42 45

Participants’ perception of digital technologies

32 studies reported participants’ perception of the use of digital technologies in training programmes. The digital technologies included high-fidelity mannequins (n=10),73 75 77 84 86 87 89 90 96 97 teleconferencing (n=6),42 44 45 47 49 103 e-Learning platforms (n=6),20 33 40 41 105 106 mobile applications (n=5),51 55 57 58 104 virtual reality platforms (n=2),28 108 computer-based gaming (n=1),62 a social network service (n=1)71 and a motion camera to record clinical practice (n=1).31 Trainees reported positive feelings or high satisfaction after using high-fidelity mannequins in all 10 studies. Of these, two studies comparing trainee preference between digital simulators and traditional training found that trainees preferred training with digital simulators.73 75 Three studies on teleconferencing for neonatal resuscitation training reported negative feedback from participants about logistical issues and the quality of facilitation.45 47 49 Furthermore, Jones-Bamman et al reported that half of the participants felt that simulation training would work better face-to-face than with teleconferencing.45 The other modalities were positively accepted by trainees with high satisfaction rates and no critical feedback was reported.

Discussion

This scoping review explored the landscape of digital technologies for educational interventions on neonatal resuscitation and management of respiratory distress and sepsis. A majority of the studies used digital technologies to teach neonatal resuscitation and included opportunity for learners to practise or interact. In LMICs, e-Learning platforms or mobile applications were common technologies used for neonatal resuscitation training. In HICs, simulation training that involved high-fidelity mannequins was a more common technology used. Given the use of high-fidelity mannequins is resource intense and requires significant investment in technologies and equipment,113 it is not surprising that these are more commonly available and applied in high-resource settings. A 2013 literature review reported that interactive strategies such as simulation-based training and hands-on practice would be more effective than passive transfer of information such as lectures and reading.114 However, the review concluded that both the setting for the training and the digital technologies used should be considered in relation to supporting educational technique and intended learning not merely availability.

Simulation-based training has been proven to be effective to strengthen procedural skills for performing good quality of neonatal resuscitation, however, it has not been conclusively shown whether high fidelity would be more effective than low-fidelity in improving healthcare providers’ performance, consequently improving neonatal outcomes.115 Moreover, the present review found that high-fidelity mannequins were expensive and were mostly implemented in HICs. Simulation-based learning via mobile applications, games or virtual reality could be feasible alternatives to resource-intensive measures such as high-fidelity mannequins to improve neonatal resuscitation skills in LMICs. Low-dose high-frequency (LDHF) practice sessions combined with mobile mentoring were reported to be effective in improving provider performance and neonatal health outcomes in the resource-limited settings.111 However, LDHF with automated feedback did not reduce neonatal mortality.93 Application of digital technologies varied between studies, and supporting educational technology and intended learning were different, making it difficult to compare outcomes and conclude which digital technology is most promising. In addition, it was difficult to compare which digital technology was more cost-effective, as no studies reported economic costs of using digital technologies in relation to health outcomes in low-resource contexts.

Currently, translation and adaptation of digital training programmes are expensive and time-consuming. However, the rapid advancement of technologies, including artificial intelligence (AI) translation programmes, may in the future be another advantage of digital training programmes.116 Affordable and effective translation could support fast scale-up of effective training programmes. Further research is required to evaluate aspects of ease of expansion and impact on healthcare providers’ performance and neonatal health outcomes. The WHO guideline on digital interventions for health systems strengthening states that digital technologies for staff education should be considered as a complement to, but not a substitute for, in-service training.7 Online provision of information can help scale-up interventions, however, exclusive use of these technologies without a mechanism for interaction may have a limited impact on positive educational outcomes.114 .

This review identified a lack of research that evaluated long-term outcomes of trainee performance, and whether these digital technologies improve neonatal health outcomes. Additionally, few studies reported on resources required to implement, maintain or scale up digital technology-based training. Future studies should focus on whether a particular digital technology for educational intervention can improve long-term healthcare providers’ performance and neonatal health outcomes. Research also needs to examine whether the intervention is cost-effective compared with conventional educational approaches that do not use any digital technologies. Despite the current research gap, the recent increase in the availability of digital technologies has the potential to provide widespread opportunities for continuing education for healthcare providers and improve neonatal care. However, there are also concerns that digital technologies may increase inequalities by providing better access to those in urban areas and those with higher digital skills.116 Future implementation of digital-based training needs to be carefully designed to be accessible and acceptable to healthcare providers in remote areas and to be easily managed and sustained without intensive resources.

Strengths and limitations

The strength of this review is that it identified studies conducted in countries of all income levels to identify all available digital technologies for educational interventions. In addition, this review included any forms of digital technology to understand how digital technologies can enhance traditional educational interventions. A limitation is that we did not conduct quality appraisal of the included studies, as we included a wide range of evidence sources. However, we consider that the quality of the included studies was assured at a certain level as almost all studies were published in peer-reviewed journals. Another limitation was that we only included articles that were published in English. Therefore, some studies reporting on educational interventions using digital technologies were not included.

Conclusion

Digital technologies are increasingly used to provide training in neonatal resuscitation. Lower-cost methods such as mobile mentoring that engage healthcare providers in continuous skills practice are feasible methods to improve neonatal resuscitation skills in LMICs. To further consider the use of these digital technologies in resource-limited settings, an assessment of resources required to sustain the digital technologies is required. Evaluation of the effectiveness of the digital technologies on long-term health provider performance and neonatal health outcomes is also needed.

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.

Ethics statements

Patient consent for publication

References

Supplementary materials

Footnotes

  • Contributors SHoriuchi and JPV conceptualised this study. SHoriuchi drafted protocol with input from JPV and RS. SHoriuchi, SHuang, TS and CB performed literature screening and data extraction. JPV and RS provided critical input into advising on the scoping review. SHoriuchi prepared an original draft. All authors contributed to the interpretation and editing the paper. LR advised on the development of the search strategy. SHoriuchi is responsible for the overall content as guarantor.

  • Funding This work was supported by Grants-in-Aid for Scientific Research (KAKEN), grant number 19KK0333 and 19K19469. JPV is supported by NHMRC Investigator Grant (GNT1194248).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.