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Hybrid Educational Simulation Training for Parental Presence During Critical Situations in the Nicu: An Observational Study

This observational study demonstrates that a hybrid simulation training program, combining educational videos, role-playing with actors, and multidisciplinary debriefing, significantly reduced healthcare professionals' anxiety levels regarding parental presence during critical NICU events, though the findings are limited by the lack of a control group.

Original authors: Cristina Felice Civitillo, Francisca Barcos Munoz, Tiphaine Corbisier, Francesca Cipolat, Angelo Polito, Alice Bordessoule

Published 2026-07-12

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CC BY 4.0

Original authors: Cristina Felice Civitillo, Francisca Barcos Munoz, Tiphaine Corbisier, Francesca Cipolat, Angelo Polito, Alice Bordessoule

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Imagine the Neonatal Intensive Care Unit (NICU) as a high-stakes cockpit. Usually, the pilots (doctors and nurses) are trained to fly the plane while keeping the passengers (the parents) safely in the waiting lounge. But sometimes, the plane hits severe turbulence—like a baby having a seizure or stopping breathing—and the parents want to be right there in the cockpit to see what's happening.

While having parents watch can actually help them feel less scared later on, the pilots often feel their hands shaking. They worry, "If Mom or Dad is watching, will I mess up? Will they get angry if I have to do something scary?" This fear is like a heavy backpack of anxiety that makes it harder to fly the plane.

To help the pilots get comfortable with this new rule, researchers at the University Hospital of Geneva built a special "flight simulator" for the NICU. But this wasn't just a computer game. They created a hybrid training program that mixed three things:

A 45-minute video lesson on how to talk to worried parents (coached by a psychologist and a doctor).
Live-action role-play where real actors played the parents, complete with pre-written scripts to act out guilt, anger, or panic.
A "debriefing" session where a psychologist helped the team unpack what happened, letting the actors say, "Hey, when you looked at me like that, I felt ignored."

The Big Test
The researchers invited 76 healthcare workers (mostly nurses and doctors) to try this training. Before they stepped into the simulation, they filled out a survey to measure their anxiety on a scale of 1 to 20.

Before the training: The average anxiety score was 7.89.
After the training: The average anxiety score dropped to 6.44.

That's a significant drop! The study found that after going through this video-and-actor simulation, the medical team felt about 20% less anxious about having parents watch during a crisis.

What the Data Says (and Doesn't Say)
Here is the tricky part: The paper is careful to say this result is based only on simulations. It's like testing a new car on a closed track; we know it handles the turns well, but we haven't seen it drive in a real rainstorm yet.

The "Control" Problem: The study didn't have a second group of people who didn't do the training to compare against. Because of this, the authors suggest we shouldn't call this a "solved problem." The drop in anxiety might be because the training worked, or it might just be because the participants felt relieved after finishing the exercise, or because they were just happy to be part of a study (the "Hawthorne effect").
The "Who" Factor: The study checked if nurses who were specifically assigned to talk to parents felt different than the nurses saving the baby. The numbers showed no difference between the two groups (scores of 6.18 vs 6.20). However, the nurses saving the baby told the researchers they felt relieved knowing someone else was handling the parents.
The "Experience" Factor: Interestingly, the people who started with the highest anxiety (scores of 10 or higher) saw the biggest drop in fear. This suggests the training might be a super-helpful tool for newer staff members who haven't faced these scary moments as often.

The Bottom Line
This study suggests that mixing video lessons, acting, and psychological support can help NICU staff feel less jittery when parents are watching during critical moments. It's a promising step toward making the "cockpit" a place where families can stand alongside the pilots. But because this was a simulation without a control group, the authors warn that we need more real-world studies to prove this works in the messy, unpredictable reality of a hospital. For now, it's a very strong hint that training works, but not a final proof.

Technical Summary: Hybrid Educational Simulation Training for Parental Presence in the NICU

Problem Statement
Family-centred care in the Neonatal Intensive Care Unit (NICU) increasingly encourages parental presence during critical events, such as resuscitation and invasive procedures. While evidence suggests this practice improves psychological outcomes for families and does not negatively impact patient care, many healthcare professionals (HCPs) remain reluctant to implement it. This hesitation is primarily attributed to insufficient training in communication strategies and heightened anxiety regarding managing family members during high-stress clinical scenarios. Existing literature indicates that while family presence is beneficial in adult and paediatric settings, its specific application during NICU critical events remains underexplored and often lacks structured institutional support.

Methodology
This study employed a pre–post interventional design to evaluate a hybrid simulation-based educational program aimed at reducing HCP anxiety during parental presence in critical NICU situations. The program consisted of three integrated components:

Preparatory Education: Participants viewed a 45-minute educational video developed with a psychologist and an attending physician, focusing on communication strategies for managing distressed parents.
In Situ Hybrid Simulation: Simulations were conducted within the actual NICU environment using high-fidelity mannequins (Premature Anne and Newborn Anne). Two actors, portraying parents with predefined emotional responses (e.g., guilt, anger, agitation), were integrated into four specific critical scenarios: accidental extubation, severe apnoea during skin-to-skin contact, neonatal seizures, and severe necrotizing enterocolitis.
Multidisciplinary Debriefing: Following each simulation, a structured debriefing session was led by a psychologist and a NICU physician. This session included feedback from the actors regarding the support received and reflection on communication challenges.

The study population comprised 76 HCPs (physicians, nurses, and nursing assistants) from the University Hospital of Geneva. Anxiety levels were measured using the short version of the State–Trait Anxiety Inventory (STAI-5). "State anxiety" (situational) was measured both before and after the simulation, while "trait anxiety" (baseline disposition) was assessed only pre-simulation. Statistical analysis utilized the Mann–Whitney test to compare pre- and post-simulation scores and univariate logistic regression to explore associations between baseline trait anxiety and anxiety reduction.

Key Results

Anxiety Reduction: A statistically significant reduction in perceived state anxiety was observed following the intervention. The mean state anxiety score decreased from 7.89/20 (± 2.39 SD) pre-simulation to 6.44/20 (± 1.8 SD) post-simulation ( $p < 0.001$ ).
Role Differentiation: No significant difference was found in the magnitude of anxiety reduction between nurses responsible for patient care and those assigned to family support. However, qualitative feedback indicated that patient-care nurses felt relief knowing a dedicated team member was managing parental communication.
Baseline Anxiety Correlation: Participants with higher baseline trait anxiety scores (STAI $\ge$ 10, representing the 75th percentile) demonstrated a greater reduction in state anxiety levels compared to those with lower baseline scores, suggesting the training may be particularly beneficial for less experienced or more anxious staff.
Demographics: The cohort included 47.4% nurses, 38.2% physicians, and 14.5% nursing assistants. Most participants had over five years of NICU experience, and nearly half had no prior experience with simulations involving actors.

Significance and Claims
The authors claim this is the first study to evaluate a hybrid simulation program that specifically combines video-based communication preparation, actors portraying parents, and structured multidisciplinary debriefing to address HCP anxiety in the context of parental presence during NICU critical events.

The study concludes that such a program is associated with a measurable reduction in perceived anxiety among healthcare professionals, potentially aiding in the implementation of family presence protocols in real-world clinical settings. The authors emphasize that the inclusion of a dedicated "family facilitator" role and the psychological safety provided by the debriefing process are critical components of the intervention.

Limitations and Cautions
The paper maintains a modest tone regarding its conclusions, explicitly noting several limitations:

Absence of a Control Group: Without a control group, the observed anxiety reduction cannot be definitively attributed solely to the hybrid program; it may reflect non-specific effects such as familiarity with the scenario or the Hawthorne effect.
Data Linking Issues: Technical errors prevented the linking of individual pre- and post-simulation questionnaires, precluding paired statistical analyses and limiting the precision of within-person change estimates.
Generalizability: The authors state that further studies including control groups are warranted to evaluate the long-term impact on clinical practice and family/patient outcomes.

In summary, the paper posits that simulation-based training incorporating communication preparation and psychological support can help clinicians feel better prepared to manage family presence during high-stress neonatal situations, though the findings require validation through more rigorous study designs.

Technical Summary: Hybrid Educational Simulation Training for Parental Presence in the NICU

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