ORIGINAL

Niger J Paed 2015; 42 (2):88 –92

Oloyede IP

Udo PA

Nyong EE

Effectiveness of didactic training on

the cognitive knowledge of health

professionals on neonatal

resuscitation in southern Nigeria

DOI:http://dx.doi.org/10.4314/njp.v42i2.3

Accepted: 19th November 2014

Abstract Background: Nigeria

has a high neonatal mortality rate.

Most of these deaths can be pre-

vented by providing adequate

training for health providers with

available and functional basic

resuscitation equipments. Our aim

was to assess the effect of training

on the cognitive knowledge of

health practitioners on neonatal

resuscitation.

Method: We conducted neonatal

resuscitation trainings for selected

health professionals from all the

senatorial districts of Akwa Ibom

State, based on the Neonatal

Resuscitation programme (NRP)

of the American Academy of Pae-

diatrics (AAP). The facilitators

were trained and certified in the

NRP train-the trainers program of

the AAP conducted by the Paedi-

atric Association of Nigeria

Sixty five (35.9%) were doctors,

while 116 (64.9%) were nurses.

Physicians had similar pre- test but

significantly higher post- test

scores compared to the nurses:

46.35±15.34 vs 43.70± 14.51;

p=0.34 and 76.14±13.02vs

66.29±15.7; p=0.04 respectively.

All the health professionals

showed significantly higher post-

test scores compared to the pre-test

scores; p=0.001 respectively.

There was also a negative relation-

ship between the number of prac-

tice years and the pre-training

scores for the physicians and

nurses; spearman rho= -0.18;

p=0.45 and -0.43;p=0.003 respec-

tively.

Conclusion: Neonatal resuscitation

training leads to an improvement

in the cognitive knowledge of

health practitioners. All health

practitioners should be trained

irrespective of number of practice

years. Further studies are required

to assess its long term impact on

neonatal mortality.

(

Oloyede IP

Udo PA, Nyong EE

)

Department of Paediatrics

University of Uyo Teaching Hospital,

Uyo Akwa Ibom State, Nigeria.

Email: isooloyede@yahoo.com

(

PAN). Pre -and post-test were

organized during the training and

the test scores analyzed to assess

any improvement in the knowl-

edge of the health professionals

on neonatal resuscitation.

Results: One hundred and eighty-

one health professionals were

trained over a two year period.

Keywords: Neonatal Resuscita-

tion Training, knowledge, health

Introduction

resuscitation should be prioritized as advanced resuscita-

tion is infrequently required and may have limited addi-

tional mortality impact in low resource setting .

6

,7

Nigeria has a high neonatal mortality rate of 39 per 1000

live births with the highest percentage(32%) dying

within the first 24 hours of birth . Many of these deaths

occur due to prematurity and low birth weight, infec-

tions and birth asphyxia around the time of delivery.

The need for neonatal resuscitation is most urgent in low

1

Structured resuscitation programmes in the form of for-

mal resuscitation courses are used worldwide to attempt

to optimise standards of clinical practice in resuscitation

management, minimise error and decrease patient mor-

8

-resource settings, where access to intra-partum obstetric

bidity and mortality . These trainings usually differ in

care is poor and the incidence, mortality, and burden of

their content and target audience but are similar in the

delivery of lectures, use of simulation and assessments .

2

,3,4

8

long term impairment from birth asphyxia is highest

.

Basic neonatal resuscitation, including bag-and-mask

ventilation, is sufficient for most babies who would be

saved by resuscitation in low-resource settings .

Studies have shown that both knowledge and skills are

significantly improved after structured resuscitation

training compared with pre-training levels . Didactic

5

8,9

training using the Neonatal resuscitation Program (NRP)

of the American Association of Paediatrics (AAP) has

Therefore achieving high coverage with basic neonatal

8

9

been recognised as an avenue for the acquisition of re-

suscitation knowledge and skills by health workers who

attend mothers and babies at delivery . Various studies

depth hands on training in basic knowledge and skills

including initial resuscitation steps, bag and mask venti-

lation, chest compression, endotrachael intubation,

medications, ethics and end of life care. Mannequins

were used for the hands on demonstrations and each

participant was encouraged to practice the skills taught

and observed. The training lasted for two days. The neo-

natal resuscitation knowledge of participants was as-

sessed by a pre- and post-test organized before and after

the training and the test scores analyzed to see if there

was any improvement in the knowledge of the health

professionals on neonatal resuscitation. The questions

for the test tools were derived from the Neonatal resusci-

9

have shown that neonatal resuscitation training can be

followed immediately b₉_,y₁₀_,₁s₁i_,₁g₂nificant improvement in

health workers practices

. However little attention

has been paid to furnishing health workers with these

skills inspite of the widespread inappropriate, ineffective

13,14

forms of practice

.

In Akwa Ibom state it has been observed that the knowl-

edge on neonatal resuscitation was acquired during the

undergraduate or postgraduate training of most health-

care professionals as there is no periodic resuscitation

training currently available in the state.

5

tation textbook of the AAP .

Based on this observation, this study was therefore, con-

ducted to determine the effect of training on the knowl-

edge of health professionals in Akwa Ibom state, after a

training workshop using the AAP neonatal resuscitation

program. It is hoped that the outcome of this study will

further reinforce the necessity of periodic training in

neonatal resuscitation for all health workers involved in

attending to mothers and their babies at delivery.

Data analysis

The statistical package STATA 10, (StataCorp,Tx,

USA) was used to analyze the data. The chi-square test

and student t-test were applied in testing the differences

in the pre and post-test scores and also the differences in

scores between the nurses and doctors. The spearman

rho test was used to check for associations between the

test scores and years of practice.Results were summa-

rized as means and standard deviations and presented in

tables or as graphs. A p-value of <0.05 was taken as

statistically significant.

Materials and methods

This was a cross sectional descriptive study of all health

workers who attended a two day neonatal resuscitation

training (NRT) using the NRP of the AAP conducted in

Akwa Ibom State. The inclusion criteria for the study

were no previous attendance in a similar training within

the last two years and completion of both pre-test and

post-test. The participants were drawn from the three

senatorial districts of the state. The sampling method

was a simple randomised sampling. Twenty participants

per senatorial district were drawn per training session

with a total of four trainings. The participants were doc-

tors and nurses from the primary through the tertiary

health care facilities. The trainings took place between

June 2010 and November 2012.

Results

A total of 236 health professionals were trained, 76

(

32.2%) were doctors, while 160 (67.8%) were nurses.

Fifty five participants were excluded; because they did

not complete the pre- and post-test [50(90.9%)] or they

had been previously trained in the last two years [5

(

9.1%)]. Therefore a total of 181 health professionals

were involved in the study. Sixty five (35.9%) were doc-

tors, while 116 (64.9%) were nurses. Table 1 shows that

3

1 (49%) of the doctors trained were medical officers

working in the secondary and primary health facilities,

while 70 (60%) of the nurses trained were in the senior

cadre (Rank of Assistant Chief Nursing Officer and

above). The median year of practice for doctors was four

years, with a range of two months to 27 years (inter-

quartile range of two to eight years), while that of the

nurses was 20 years with a range of six months to 34

years (inter-quartile range of eight to 27 years). Twenty

two (12.15%) health professionals out of which six were

doctors and 16 were nurses had previously attended any

neonatal resuscitation training. Of the total number of

health workers trained 138 (51 doctors and 87 nurses)

had a complete pre- and post- test scores. The mean pre-

test score for all the health professionals was

The facilitators (three doctors and two nurses) had been

trained and certified in the Neonatal Resuscitation Pro-

gramme (NRP) train-the trainers program of the AAP

conducted by the Paediatric Association of Nigeria

(

PAN) in collaboration with the Latter Day Saints Chari-

ties (LDSC) based in the United States of America

USA). The studies were approved by the ethical

(

committee of the University of Uyo Teaching Hospital.

Procedure

A train -the –trainer educational programme utilized

various teaching methods for participants learning in-

cluding clinical practice sessions and demonstrations to

train health professionals.

4

6

4.59±14.60%, while the mean post test score was

8.39± 15.73.

Table 2 shows that doctors had higher and statistically

significant (p=0.04) scores in the post test than the

nurses. Table 3 shows that the post-test scores were sig-

nificantly higher than the pre-test scores for all the

Health professionals included nurses and doctors drawn

from primary, secondary and tertiary health facilities.

The neonatal resuscitation course content included an in

9

0

health professionals; p=<0.0001for the doctors and

nurses respectively. Figure 1 and 2 shows the negative

association between the practice years with the pre-test

score for the doctors and nurses.

Discussion

Our study has shown that the post-test scores of health

professionals who participated in a two day NRT train-

ing using the NRP of the AAP were significantly higher

than their Pre-test scores. The higher post-test compared

to pre-test scores for all health practitioners confirms

that there was a significant improvement in the cognitive

knowledge of health practitioners after the course. This

Table 1: Specialty of Doctors and Rank of Nurses attending

the neonatal resuscitation training

Doctors

No (%)

Nurses

Specialty

Rank

No (%)

1

5,16

.

Anaesthesia

Medical officer

Obstetrician

Paediatrician

Total

6(8.80)

*Senior cadre

59 (51.0)

33 (27.5)

5 (21.5)

trend has also been observed in earlier studies

31(49.10)

14 (21.05)

65(100)

**Middle level cadre

#

Opiyo et al also observed an improvement in cognitive

knowledge and skills over a seven week period and a

reduction in harmful resuscitation practices between the

Junior Cadre

Total

116 (100)

1

0

trained and untrained health workers .

*

Senior Cadre: Assistant Director Nursing Services, Chief Nursing

Officer, Assistant Chief Nursing Officer

*Middle level Cadre: Principal Nursing Officer, Senior Nursing

Officer

Junior Cadre: Nursing Officer I, Nursing Officer II

The similar pre-test scores of doctors compared to

nurses in our study is in contrast to the study carried out

in Ghana and South Africa where nurses and midwives

dem₁₆o_,₁n₇strated the least cognitive knowledge before train-

ing . This may be explained by the general dearth of

knowledge on the current consensus on neonatal resusci-

tation prevalent in the area as these series of training

happen to be the first in the state. Even in developed

countries a study has shown that basic life support skills

of many health professionals who have previously re-

*

#

Table 2: Mean pre-test and post test scores for both doctors

and nurses

Doctors

Mean ±SD

Nurses

Mean± SD

(%)

p-value

Scores

95% CI

(%)

Pretest

Post test

46.35±15.34

76.14±13.02

41.68-51.05

71.28-81.00

43.70± 14.51

66.29±15.71

40.56-46.86 0.340

62.95-66.60 0.040

1

8

ceived resuscitation training is of poor quality . How-

ever the index study also showed that physicians had the

highest improvement in cognitive kn₆o_,₁w₇ ledge after the

Table 3: The difference between the mean pre- and post-test

scores for the doctors and the nurses.

1

training in contrast to earlier studies . This may not

Health professional Pretest

Post test

P value

be unrelated to the extensive information given in a rela-

tively short period of time. It is also possible that this

finding is a reflection of pre-existing knowledge as a

derivative of school curricula.

Doctor

Nurse

46.35±15.34 76.14±13.03 <0.0001

43.70±14.51 66.29± 15.71 <0.0001

Fig 1: Association of practice years and pre-test scores for

doctors

This study has shown that nurses are as expected more

numerous than physicians and as such proper neonatal

resuscitation training of nurses will optimize the impact

on maternal and newborn health in the facilities where

they work. Due to their sheer number they tend to be the

frontline health care practitioners in the absence of a

doctor. This has been demonstrated in a study which

showed that early newborn care training of midwives

decreased early neonatal mortality in the facilities and

the impact was larger in infants of mothers without sec-

1

5

ondary education . The index study also showed a

skewed pattern in terms of number during the training in

favour of nurses of senior cadre. The major flaw in this

is the issue of selection bias. This bias results from the

fact that the more senior nurses are the nurse administra-

tors and are most likely to select fellow colleagues and

or friends nurses for training experiences. It may also

result from the fact that heads of units were mostly

selected with the aim that they will step down the train-

ings to the more junior members of their unit. This how-

ever may raise a lot of questions on the cadre of health

professionals that should be trained with some quarters

advocating the training of junior nurses on neonatal re-

suscitation as they are believed to be involved in the

direct resuscitation while the senior nurses are more

involved with administration.

Fig 2 : Association of practice years and pre-test scores for

nurses

Our finding of a negative correlation between the

9

1

number of practice years and the pre-course cognitive

levels of physicians and nurses makes a case for the con-

tinuous and regular training of all health practitioners on

neonatal resuscitation irrespective of cadre and years of

practice. This finding may not be unrelated to revision in

the content of school curricula over time in line with

current best evidence and practice. Durojaiye et al also

observed that despite a high level of experience and pre-

vious paediatric training many candidates in their study

who were involved in a one day paediatric life support

course lacked the basic knowledge in the resuscitation of

seriously ill or injured children. Even after the course,

the median time for the retention of the knowledge

consider the cost and cost effectiveness of training in

order to optimise health policy decisions. The incorpora-

tion of neonatal resuscitation training into continuous

medical education programmes and professional medical

education is also highly recommended.

Conclusion

In conclusion our study has shown that neonatal resusci-

tation training leads to an improvement in the cognitive

knowledge of health professionals. Health professionals

especially the older ones may need more frequent

booster trainings to aid their resuscitation practices. To

ensure a high proportion of resuscitation episodes are

managed correctly, the Federal and State ministries of

health should be involved in the training of a large

proportion of health professionals.

1

9

gained was four months .

Our study has added to the body of evidence that neona-

tal resuscitation training has an important role in the

improvement of resuscitation knowledge in developing

countries. However, the effect of these training can only

be assessed if it is widespread and if there are available,

accessible and functioning equipment for basic resusci-

tation in the health facilities in resource poor settings.

Author’s contribution

Further studies are needed to evaluate the long term

effects of these trainings and assess the duration of re-

tention of knowledge of these trainings. This is of par-

ticular importance because some studies have shown

that deterioration in skills and to a lesser extent knowl-

edge is highly likely as early as_,₁t₈hree months following

We write to confirm that all authors have made substan-

tial contributions in the conception and design of the

study, acquisition of data, revision of article critically

for intellectual content and the final approval of the

version to be submitted.

The undersigned authors certify that the article is origi-

nal, is not under consideration by any other journal and

has not been previously published.

9

structured resuscitation training , hence there may be a

need for booster or refresher sessions to improve an in-

dividual’s ability to retain resuscitation skills after initial

training.

Conflicts of Interest: None

Funding: None

Our study had various limitations including our inability

to get all participants to take the pre-and post- test and

also our inability to do a follow-up assessment of the

impact of the training on the day to day practice of

neonatal resuscitation among participants.

Acknowledgement

We therefore recommend that for low resource settings

as ours, with a high neonatal mortality rate, the impact

of neonatal resuscitation training on the neonatal mortal-

ity and morbidity should be assessed by further studies.

These studies should assess the long term impact and

The authors wish to thank Akwa Ibom State Ministry of

Health for funding two of the training sessions and

Nestle Nutrition Institute Africa for funding one of the

training sessions. We also acknowledge the help of Dr

Udeme Ekrikpo in Data Analysis.

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