Title

Exploring the Experiences and Challenges of Nurses Regarding Neonatal Resuscitation

Practices in a Tertiary Care Hospital: A Descriptive Exploratory Study

Submitted by

IFTAKHAR AHMED

Enrolment#: 2-1/2023/010

Program

MSN (Master of Science in Nursing)

Supervisor

Shahzad Bashir

Co-Supervisor

Raja Khatri

Date of Submission (April 24, 2025)

INTRODUCTION

Neonatal resuscitation is an integral aspect of newborn care, especially in the initial few

minutes following birth when prompt action dictates survival and future well-being.

Worldwide, nearly 2.6 million newborns die each year, and 99% of these deaths happen in

low- and middle-income nations (Biya et al., 2024; Goldenberg et al., 2019). Preterm birth,

infections, and birth asphyxia—of which respiratory distress is still the most preventable—

account for the top causes of neonatal death (Van Heerden et al., 2021). Neonatal

resuscitation, which includes procedures like airway clearance, stimulation, and assisted

ventilation, is essential to avert asphyxia-related deaths and respiratory failure (Soni &

Nagalli, 2025).

Though its significance cannot be underestimated, discrepancies continue to exist between

industrialized and poor countries. Industrialized countries like Sweden, Japan, and Finland

have reduced neonatal mortality to less than one per 1,000 live births due to sophisticated

neonatal care and highly trained staff (Okui, 2023; Sartorius et al., 2024). Conversely, nations

like Pakistan still experience shocking rates at 46 deaths per 1,000 live births, which relate to

issues like poor healthcare infrastructure, shortages of training, and limited resources (Bano

et al., 2024; Moro, 2018).

Nurses are key in neonatal resuscitation since they are the first to respond in delivery and

neonatal intensive care units (Owusu et al., 2024). Nonetheless, they encounter several

challenges such as knowledge deficits, limited experience, poor equipment, and emotional

distress, all of which can impede successful resuscitation (Sawyer et al., 2019; Wyckoff et al.,

2021). Additionally, the absence of institutional support, continuing professional education,

and interprofessional collaboration makes it difficult for nurses to provide high-quality

neonatal care (Niles et al., 2017).

It is important to understand the nurses' experiences and challenges during neonatal

resuscitation to enhance clinical outcomes and support fulfillment of the Sustainable

Development Goal of decreasing neonatal mortality to 12 per 1,000 live births by 2030

(World Health Organization [WHO], 2016a). Thus, this review has the intention to review

current literature on nurses' experiences, barriers, and coping styles regarding neonatal

resuscitation practices, and how to identify nursing capacity strengthening strategies and

neonatal survival improvement in low-resource settings.

Method and Material

A systematic and extensive literature review was performed to search for

scientific articles. Detailed data were retrieved from Google Scholar, CINAHL, PubMed, and

Science Direct by searching these Key terms: “Neonatal Resuscitation” OR “Practices” OR

“Methods" OR “Intervention” OR “Procedure” AND “Experience” AND “Barriers” to

identify relevant research articles. A total of thirty-four articles out of 1,647 were selected

based on their relevance to the topic and the quality of the research. Boolean operators (OR,

AND) were used in the search strategy. Moreover, filters of 2019 to 2025, English language,

full text, and free academic journals were applied to get more accurate data. Experiences,

Barriers, Challenges, Caregivers, Nurses, Knowledge, Newborn, Neonate, Neonatal

Resuscitation and Practice, and Intervention were used as keywords.

 PRISMA Flow Diagram

IDENTIFICATION
Science Direct = 80, PubMed = 280,
Cochrane Library= 10 (CINAHL) = 20
Total = 1647
Identification from added searches Google Scholar= 1257

ANALYSIS

Filters applied for Full-text articles, Last 5 years, English Language,

Related Keywords, Nurses experiences, and challenges

ELIGIBILITY Articles removed =1489

Articles after filtration
including adult, involves non
of duplicates = 158
healthcare providers.

Articles remained after

reading the abstract and
titles = 26 Articles removed = 132

Total articles removed = 1621

INCLUSION The number of articles

were finally reviewed.
Science Direct = 6,
PubMed = 3 CINAHL
Plus with full text =3
Google scholar= 14
TOTAL ARTICLE=26
Literature Review on Experiences and Challenges of Nurses Regarding Neonatal

Resuscitation Practices.

Importance of Neonatal Resuscitation and Nurses' Role

Neonatal resuscitation plays a pivotal role in minimizing neonatal morbidity and

mortality, especially for infants who do not breathe on their own at birth. Indeed, about 10%

of neonates need to be resuscitated, and some receive advanced treatment such as positive-

pressure ventilation (AHA, 2015; Thakre, 2021). Further, effective and timely resuscitation

provides sufficient oxygenation and circulation, avoiding long-term neurological

complications (McCarthy et al., 2021). With this, as first responders in delivery rooms and

NICUs, nurses have a significant role in triggering resuscitation and following implemented

protocols, directly influencing neonatal outcomes (Soraisham & Srivastava, 2022; Kromah,

2023). Additionally, continuous training through initiatives like NRP and HBB are necessary

to sustain nurses' proficiency and readiness (Singhal et al., 2012; AAP, 2020). Thus, ongoing

education and organizational support are essential to upgrading the competency of nurses and

neonatal resuscitation procedures (Karlsson et al., 2023; Owusu et al., 2024).2.3 Neonatal

Resuscitation Guidelines, Training, and Protocols

International and national neonatal resuscitation guidelines, e.g., by the Neonatal

Resuscitation Program (NRP), World Health Organization (WHO), and American Academy

of Pediatrics (AAP), normalize resuscitation practice (Berglund et al., 2020). These

guidelines provide necessary steps, e.g., maintaining warmth, clearing airways, and

stimulating breathing. If these are not effective, positive pressure ventilation or chest

compressions are administered depending on the infant's heart rate and status. Nonetheless,

inconsistencies in persistent implementation are hindered by barriers. Hence, ongoing

competency-based training and education are essential for nurses' sustained capability.

Though uniform methods could exist, heterogeneities in neonatal resuscitation practices may
influence outcomes in neonates (Alves et al., 2024). Furthermore, training based on

simulation enhances skill, decision-making, and ease with neonatal care (Bekele et al., 2021).

Nurses’ Experiences and Emotional Challenges in Neonatal Resuscitation

The emotional and psychological reaction of nurses to neonatal resuscitation is complex and

strong. Purposive sampling was used to recruit sixteen nurses in a qualitative Swedish study

of 2023 and examined their attitudes and practices during neonatal resuscitation. Results

revealed that successful resuscitation had the nurses feel happy, proud, and professionally

satisfied, whereas unsuccessful resuscitation resulted in emotional exhaustion, sadness, and

anxiety (Karlsson et al., 2023). In the same vein, a qualitative phenomenological study in

Norway from August 2018 to January 2019 explored experiences of midwives during

neonatal resuscitation. Clinically experienced midwives with high anxiety, enhanced sense of

responsibility, and exposure to their feelings—especially during the Golden Minute—were

identified. Participants indicated that following resuscitation they required emotional support

and cited barriers of insufficient knowledge, skills, and experience (Ljungblad et al., 2020).

Similarly, nurses highlighted psychological support and vindication following resuscitation

incidents, given the emotional price of such experience. By doing so, organizational support

structures—i.e., formal debriefing, support groups with peers, and access to mental health

care—are invaluable in fostering resilience and emotional integrity. In Japan, by qualitative

research, it was explored the living experience among NICU nurses who encountered

ethically problematic resuscitation experiences. The research established that moral distress

was triggered by organizational restrictions, unresolved emotional occurrences, and

occupational regret. Failure to treat it with effective intervention will result in psychological

trauma and low self-esteem. Therefore, the development of moral resilience and
psychological safety was advocated to facilitate ethical decision-making in clinical practice

(Sakai et al., 2024). In addition, qualitative content analysis performed in Nepal in 2017

investigated nurses' attitudes toward team working during neonatal resuscitation. It revealed

that inefficient team working correlated with ill-defined guidelines, poor mutual

accountability, and poor leadership. The authors therefore concluded that well-

defined protocols, communication, and facilitative management

were essential to improve collaborative performance and neonatal outcome in low-resource

maternity facilities (Wrammert et al., 2017). Besides, an Indian qualitative

study examined traditional neonatal resuscitation practice within the Porja hilly tribe of

Andhra Pradesh. The research found that cultural beliefs had a strong impact on home-

based practices of resuscitation, some of which—like thumbs being pressed or

shouting very loudly—were symbolic in nature but not scientifically accurate. The

authors suggested sustaining positive traditional practices while avoiding dangerous ones

to enhance neonatal care in resource-poor environments (Samakya, Pati, & Acharya, 2022).

Lastly, a descriptive cross-sectional study in Lahore, Pakistan, explored the clinical practice

of 153 nurses to manage birth asphyxia. The research revealed that nurses with more than ten

years of experience had greater adherence to guidelines, while nurses with fewer than five

years of experience had worse practice (Noor et al., 2020).

Barriers to Effective Neonatal Resuscitation practices

In spite of the acknowledged need for neonatal resuscitation, a number of barriers are

still impeding its effectiveness. Institutional barriers in the form of poor staffing, lack of

sufficient equipment, and poor infrastructure dramatically undermine the quality of neonatal

resuscitation practice (Trevisanuto et al., 2022). A 57% response rate electronic cross-
sectional survey in 730 neonatal hospitals across Europe in 2018 revealed substantial

inconsistencies in the application of neonatal resuscitation policies, which reflected variations

in standardization and resource allocation (Trevisanuto et al., 2022). Similarly, the Union of

European Neonatal and Perinatal Societies (UENPS) conducted a cross-sectional survey via

the internet to assess knowledge, attitudes, and barriers to using the laryngeal mask airway

(LMA) in neonatal resuscitation. Of 858 respondents from 42 countries, 26.1% indicated that

LMAs were not available in delivery rooms, and only 6% had specifically been trained with

LMAs, indicating substantial concerns regarding available equipment and training of

providers (Trevisanuto et al., 2024).

In addition, systemic issues such as high workloads and corridor communication issues

contributed to inconsistencies in resuscitation practice. In Portugal, the authors of a cross-

sectional study noted that team briefings, thermal care completeness, and having equipment

were absent and collectively inhibited effective protocol performance (Alves et al., 2024). In

South Africa, a focused qualitative exploratory study of 12 purposively selected nurses

indicated barriers such as shortages in staff, poor neonatal intensive care unit (NICU) (for

example, no beds) infrastructure, overwork, and poor availability of necessary supply

(Mathebula et al., 2024). In Ghana, the authors of a qualitative descriptive study reporting on

12 purposively recruited nurses revealed that, while midwives demonstrated high compassion

and commitment in neonatal resuscitation efforts, important delays occurred as they were

variably prepared, warranting improved training and resources (Agbenohevi et al., 2024).

In terms of knowledge gaps, a cross-sectional study of 360 randomly recruited nurses in

Northwest Ethiopia found that only 45.6% of them had adequate knowledge neonatal

resuscitation. The writers emphasized the role of simulation training in enhancing healthcare

workers’ knowledge and preparedness (Bekelee et al., 2021). A descriptive quantitative study
at Zagazig University in Egypt indicated that 31% of the nurses had poor or fair practice and

only 22% had good practice in neonatal resuscitation (Mohamed Ali et al., 2023).

Providing neonatal care is further complicated by structural, logistical, and cultural barriers.

A qualitative study in India named some specific barriers including inadequate management

of facilities, supply and human resources, and a lack of referral systems. They also reported

that there are socio-cultural factors (e.g., a preference for male infants, clinical hierarchy) and

poverty, which were the major supra-structural barriers (Vail et al., 2018). In Kenya, there

was a qualitative study of the disinfection of neonatal resuscitators that shows that physical,

social and logistical factors inhibit the successful reprocessing of equipment. The researchers

suggested low-cost supply chains, transparency in protocols, and continuous education of

staff to support infection control and neonatal outcomes (Parsons et al., 2021).

Lastly, a quantitative study in Lahore, Pakistan, in 2021 assessed 200 nurses' knowledge,

attitude, and practice in neonatal resuscitation. The outcome indicated that participants

possessed fair knowledge, yet 53% were not performing well in immediate newborn care

practices, emphasizing the pressing need for focused training and institutional reforms

(Begum et al., 2021).

Strategies to Improve Nurses' Competence and Adherence to Neonatal Resuscitation

Practices

With regard to these endemic problems, several strategies have been advocated for to

improve nurses' competency and compliance with neonatal resuscitation practice guidelines.

For instance, in a 2024 ethnographic study conducted in New South Wales, Australia, the

researchers utilized the snowball sampling technique in order to examine rural nurses'

experience of being pre- and post-resuscitation prepared. Findings confirmed that simulation
training and workshop hands-on sessions were highly ranked as being extremely effective in

developing resuscitation competence, decision-making, and self-perception of confidence

(Karlsson et al., 2023). Likewise, Olaniyi, Ncama, and Amod (2021) commenced a scoping

review protocol whose aim was to establish the impact of neonatal resuscitation training on

practice among unqualified birth attendants in low-income countries. The review was

intended to map existing evidence on the effect of the training on practice and self-efficacy

with the ultimate goal of a decrease in neonatal mortality caused by birth asphyxia. This

research highlights the requirement for suitable and well-structured training in the context of

resource-constrained settings for improved outcomes in care.

A qualitative Australian study also looked at the staff attitudes towards simulating neonatal

resuscitation training for student midwives. The research highlighted that simulation training

broadly increased student knowledge and understanding of resuscitation practices and

improved their self-confidence. The most common themes which emerged were confidence

development, knowing when help to seek, and curriculum changes to know the key themes

related to the learner need. Active learning was highlighted through developing their skills

and knowledge, or as the authors called it - replicating manual simulation and validating that

they were ready for neonatal emergency practice (Carolan et al., 2017).

In addition, another qualitative study conducted in Australia examined the experiences of

NICU clinicians undergoing the Neonatal Resuscitation Video Review (NRVR) program.

The study established that NRVR facilitated experiential learning, reflective practice, and

facilitated team discussion. Despite some psychological safety concerns were disclosed,

participants overwhelmingly supported the program because of its anticipated educational

benefit. The findings were supportive of NRVR's potential to enhance situational awareness,
interprofessional communication, and improve clinical performance in neonatal resuscitation

(Weimar et al., 2024).

There was one systematic review and meta-analysis conducted in Eastern Africa in an

attempt to assess the neonatal resuscitation competencies of the providers in the region.

Pooled estimates among 7038 providers were 48% (95% CI: 34–62), with the highest (57%)

and lowest (14%) results from Ethiopia and Somalia, respectively. Skill levels correlated

significantly with neonatal resuscitation training (OR = 1.87), resuscitation knowledge (OR =

2.08), and age (>35 years; OR = 0.16) and indicate that trained and knowledgeable workers

performed better than their untrained counterparts (Eyeberu et al., 2025).

Finally, institutional protocols and regular interventions continue to play a key role in

maintaining compliance with neonatal resuscitation guidelines. A cross-sectional Portuguese

survey of professionals estimated institutional compliance with neonatal resuscitation

guidelines. There were disparities in equipment availability, course instruction, and

application of protocols and hence uniform training and standardized application of policies

are advised (Alves et al., 2024). In addition to these structural enhancements, mentorship and

emotional support programs have also been documented as pathways to promote nurses' self-

efficacy and resilience while conducting neonatal resuscitation (Mathebula et al., 2024).

Additionally, resource accessibility optimization and system-level enhancements are

paramount in enabling improved neonatal resuscitation outcomes and minimizing care

disparities.

Literature Gap Analysis

This review of literature identifies several important gaps relating to the experience and

challenge that nurses face in neonatal resuscitation practices in tertiary hospitals in Pakistan.
One of the major limitations is the dominance of quantitative studies, with most current

studies focusing mostly on technical skills and not looking into the lived experiences,

emotional reactions, and clinical decision-making of nurses involved in neonatal

resuscitation. The lack of qualitative research in this area means that there is limited

understanding of the situational and psychosocial challenges encountered by nurses in these

high-stakes scenarios—making this an under-researched area. Furthermore, there is a critical

gap in both practice and knowledge, with numerous studies stating that nurses do not follow

neonatal resuscitation guidelines. This nonadherence is primarily attributed to a lack of

experience and formal training, limited simulation opportunities, and even less available

institutions. Literature notes systemic issues as barriers (e.g.. inadequate staffing, limited

resources, poor patient-nurse ratios) , but explains little about how these barriers may have

cascade effects resulting in clinical errors, delays in care, and preventable neonatal deaths.

There is also very little discourse about how nurses are utilizing their theoretical knowledge

to practice within emergencies—resulting in a significant gap in knowledge about why

practitioners may diverge from protocols, and possibilities for improving adherence.

Another significant gap exists with regard to the absence of contextually appropriate training

programs, which cater to the particular challenges in healthcare provision in Pakistan. Current

studies only focus on uniform neonatal resuscitation guidelines without taking into

consideration the everyday practical barriers like response latency, skill decay, lack of

neonatal care equipment, and hierarchical factors influencing clinical judgments. These

unrepresentative factors greatly impede the application of best practices in actual clinical

environments.

To the researcher's best knowledge, no qualitative study in Pakistan exists that thoroughly

examines nurses' actual experiences and issues related to neonatal resuscitation. Moreover,
there is a lack of recent local studies that examine the widespread gap between theoretical

knowledge and clinical practice—a gap regarded as one of the key factors in poor neonatal

outcomes. The main objective of the current research is to achieve a better understanding of

these complex issues and the nature of support nurses need in order to enhance neonatal

survival rates. An identification of such gaps will help guide the implementation of evidence-

based targeted interventions, context-based training programs, and policy reforms aimed at

building capacity in neonatal resuscitation practices throughout Pakistan.

Conclusion.

Neonatal resuscitation is a life-saving intervention with important consequences for neonatal

survival and future health outcomes. As first-line providers, nurses play a key role in

facilitating effective resuscitation delivery. Yet, various factors impede best practice, such as

emotional distress, inadequate knowledge, and organizational barriers. Interventions like

simulation-based training, formal institutional support, and the use of standardized

resuscitation guidelines have been found to have potential in improving both neonatal

outcomes and nurses' confidence and clinical proficiency. As such, there is a strong need for

future studies to assess the effect of nurse-specific interventions on professional readiness and

neonatal survival rates, especially in resource-constrained environments.

Recommendations

From the findings obtained in the reviewed literature, various recommendations can be made

to improve neonatal resuscitation practice and remedy challenges encountered by nurses in

tertiary healthcare facilities.

1. Continuous Professional Development

Institutionalization of structured and regular training programs should be implemented to

ensure nurses' skill retention and proficiency in neonatal resuscitation. Simulation education,

refresher workshops, and certification like the Neonatal Resuscitation Program (NRP) and

Helping Babies Breathe (HBB) are established methods to enhance knowledge retention and

procedural adherence (Karlsson et al., 2023; Singhal et al., 2012). Incorporating these into the

policies of hospitals can provide for sustained professional growth and minimize skill erosion

over time.

2. Institutional and Administrative Support

Health facilities should guarantee regular availability of resuscitation devices, drugs, and

properly manned NICUs. Administrative measures like enforcing SOPs, regular clinical

audits, and ensuring accountability can improve adherence to evidence-based practice

(Trevisanuto et al., 2022; World Health Organization [WHO], 2016). Support from leaders

plays a crucial role in instilling a culture of safety, where there is prioritization of learning

and improvement as opposed to blame.

3. Psychological and Emotional Support

Nurses tend to feel emotional stress, moral distress, and burnout after and even before

neonatal resuscitation attempts. In order to avoid these, institutions must offer psychological

support facilities in the form of post-resuscitation debriefings, counseling, and peer-support

programs (Ljungblad et al., 2020; Sakai et al., 2024). Meeting mental health demands can

help nurses' well-being, enhance job satisfaction, and maintain professional motivation.
4. Strengthening Interprofessional Collaboration

Effective neonatal resuscitation demands effective teamwork and communication between

healthcare professionals. Interprofessional education and simulation team training has the

potential to increase collaboration among nurses, physicians, and midwives, hence enhancing

coordination and improved patient outcomes (Wrammert et al., 2017). Respect, shared

accountability, and distinct role delegation within teams create a more effective and

integrated resuscitation setting.

5. Policy Reforms and Research Initiatives

Policy-level strategies should prioritize workforce development, resource allocation, and

equitable access to training opportunities. National and institutional policies must ensure that

neonatal resuscitation programs are regularly updated to reflect international best practices

(Bano et al., 2024). Additionally, more qualitative and interventional research is needed in

Pakistan to explore nurses’ lived experiences, identify context-specific barriers, and design

culturally appropriate solutions aligned with the Sustainable Development Goals (WHO,

2020).

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