Approval from the Ethics Committee of Helsinki University Central Hospital was initially sought but the authors were informed that such approval was not actually required due to the observational nature of the study and lack of patient involvement. A signed consent was received from the participants to allow the use of the video-recordings from the simulation scenarios for research purposes.

The participants registered for a single 1-day simulation training session from eight possible days provided. Participants created the teams themselves and the groups were drawn by lots to an intervention or a control group. Sixty-two professionals formed the I-group with nine teams, and 37 constituted the C-group with six teams (Fig. 1). All the teams had five to seven members with a composition that was similar to those teams in real emergency cases. Each team had a pediatric or an anesthesia consultant or a pediatric registrar who acted as a team leader. The team members included an obstetrician, a paediatrician, an anesthesiologist, a specialised neonatal nurse and one to two midwives (Table 1). Neonatologists were not available for the simulation scenarios. Each team participated in two scenarios and also observed two scenarios on a screen and was then debriefed after each scenario in both the I- and C-groups (Fig. 1).

The I-group attended an hour interactive lecture of the CRM and ANTS measures prior to running the first scenario. The CRM and ANTS measures comprise four skill categories (task management, team working, situation awareness, and decision making), which are in turn divided into 15 elements [16]. Self- and peer-assessment forms were used for the I-group to enhance the participants’ reflection of their own performance. The participants in the I-group performed either self- or peer-assessment during and immediately after each scenario depending on whether they had acted or observed.

The facilitators of the simulation sessions were a neonatologist and simulation instructor (L.R.), a specialist in simulation pedagogics (M.S.), and a specialised simulation nurse-instructor (M.M.M). The scenarios were designed as standard simulations of newborn emergencies. The scenarios were validated in preliminary simulation sessions for registrars. A case history was provided prior to the scenario. The first optional scenario was a sick newborn with breathing difficulty secondary to a serious infection or a newborn with asphyxia after birth. The second optional scenario was a newborn with hypovolemic shock due to either placental abruption or a navel cord interruption. All participants were given a similar introduction to the simulation mannequin, emergency room, and all the necessary equipment. Each scenario lasted 15–20 min and was followed by a 40 min debriefing session. At the beginning of the debriefing, each participant in the scenario gave their impression of their own performance. Both technical and non-technical issues related to performance and teamwork were discussed during the debriefing. Potentially serious clinical errors were pointed out either by the team members or the facilitators.

The simulation scenarios were run in the emergency rooms of the delivery units of the Maternity Hospital and Jorvi Hospital with the existing equipment (in situ training). A high-fidelity newborn mannequin was used in the simulation scenarios (Newborn HAL^® S3010; Gaumard, Miami, FL, USA). A recording and debriefing system (PRO+; Gaumard) was used for recording of all the scenarios. The live video stream of each scenario were captured and transmitted to the next room for the observers.

The teamwork performance of each team was scored by three anesthesiologists who independently viewed all the video-recordings. The first 10 min of video recording from a team’s performance in each scenario was used for the scoring based on the validation of scenarios. The raters were blinded to which teams were assigned to the intervention and control treatments. Teamwork performances were rated using the TEAM instrument with 11 items each with a score between 1 and 4 points [13]. The first two items dealt with leadership, the next seven items with teamwork, and the last two items with task management. The maximum TEAM score was 44 points. Additionally, an overall team performance rating was given to each team. The members of the team were expected to follow the Finnish national neonatal resuscitation guidelines [22].

SPSS software, version 17.0 (SPSS, Chicago, IL, USA) was used for the statistical analyses. Normally distributed demographic data of the participants and teamwork scores of the intervention and control teams were analyzed using a paired t-test. Cronbach’s alpha was used to test the internal consistency of the items on the forms for teamwork scoring. p-values of less than 0.05 were considered to indicate statistically significant differences.

The inter-rater reliability for the degree of agreement among the scores of the three coders (experts) for teamwork performance was tested with kappa variants. A kappa value was computed for all coder pairs and then the arithmetic mean of these estimates was used to provide an overall index of agreement. Conventionally, a kappa of <0.2 is considered poor agreement, 0.21–0.4 fair, 0.41–0.6 moderate, 0.61–0.8 strong and more than 0.8 near complete agreement [23].

The linear mixed-effects model regression analysis for repeated measures was used to define the predictors of teamwork performance. R package, version 3.0.3 (nlme package) was used in the analysis and values are reported as the values of L-R-ratio (D value).

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