We found no difference in the effect of high- versus low-fidelity mannequins on the acquisition and retention of technical skills necessary to intubate a neonate by junior pediatric residents from the two academic centers. However, we concluded that training junior pediatric residents using either simulator mannequins resulted in improved intubation skills both immediately and 6–9 months after training.

Experiential learning methods, as the case in simulation-based training, were shown to result in deeper learning and better retention [13, 14]. Experiential learning theory proposes that knowledge is generated through the transformation of experience [20]. In his work on experiential learning, Kolbe described how the learner moves through four stages of adaptive learning modes: more concrete experience, reflective observation, abstract conceptualization, and active experimentation. Dewey was the first to introduce the concept of experience plus reflection equals learning that was considered to be the foundation of simulation-based learning [15]. The quality and amount of active experimentation is judged by the degree to which it reproduces reality. Experiential learning helps individuals understand their strengths and weaknesses; gives the opportunity to apply skills for assessment, examination and evaluation and encourages critical thinking and the development of proficiency in an environment where errors do not have dire consequences. In theory, through experiential learning, trainees retain not only knowledge but also its practical application and how to use it when needed. As a result, novice trainees will move towards becoming experts.

Evidence supporting the use of HFS in neonatal resuscitation and the associated acquisition of technical skills does not agree with the evidence from other medical fields. Similar to our results, Campbell et al. reported that although pediatric residents randomly assigned to the HFS gave better satisfaction scores than those assigned to the LFS, they did not have improved written scores or intubation times [13]. In a small randomized controlled trial of ten second- and third-year pediatric residents, HFS training did not result in a better intubation technique or actual procedural success [20]. More recently, Finan et al. compared the effects of HFS versus LFS in a randomized trial of sixteen neonatal fellows and found no difference in stress measures between the two modalities [21]. Regarding the retention of the learned skills in simulation-based training, studies have shown degradation of the technical skills acquired in certification courses by health professionals over time, which can have significant effects on patient outcomes [19, 22,23,24,25].

We would like to acknowledge some of the limitations of this study. The small sample size limits the significance and generalizability of our study as it was a convenience sample of all junior pediatric residents from the two centers which agreed to participate. The high-fidelity mannequin was used both to train and to assess; therefore, additional training exposure might have introduced additional benefits, but that was not statistically evident. Moreover, the residents were allowed to practice 2–3 times on the simulator which might not be enough for robust skill acquisition. We did not record the number of practice repetitions residents did before their evaluation session which may have impacted the results of this study. Furthermore, residents’ experience during the lag time between the training course and assessment of the retention of learned intubation skills might differ as they do not all rotate through the NICU at a fixed time, which might expose some of them to more intubation trials than others. We recorded the intubation trials before the training course but not before the assessment of the retention of skills. We minimized the bias by structuring the training course in a way that only the type of mannequin was the changing variable and blinded the assessors to the intervention applied to strengthen the internal validity of the study. Additionally, the effect on improving noncognitive skills such as attentiveness, perseverance, and teamwork was not part of the current study. Although simulation teaching has been demonstrated to lead to improved educational outcomes, transfer of these skills from simulation to the real clinical world, and to the benefits of clinical patient outcomes will need to be studied.

In conclusion, simulation-based training resulted in improving pediatric residents’ intubation skills regardless of the level of fidelity. The benefit of training on a high-fidelity mannequin will need to be further assessed in real-life intubations to determine its effect on the management and clinical outcome of neonatal intubation.

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