This randomized controlled simulation study was conducted from February 2021 to November 2021 at the University Hospital of Reims, France. The study was approved by the CERAR (Ethics Committee for Research in Anesthesia Resuscitation; approval number: 00010254-2021-048). All students provided written informed consent (Multimedia Appendix 1). All data were anonymized using research numbers. No compensation was provided to the residents who volunteered to participate in the study. Consent was provided for the video recording and analysis of primary and secondary outcomes. The CONSORT-eHealth checklist is provided (Checklist 1) [14].

Volunteer participants were recruited from third-, fourth-, and fifth-year anesthesiology and intensive care residency classes in Reims. None had previous courses or training in neonatal resuscitation. They were informed about the study via email from the teaching supervisor (DM). To confirm their participation, they had to ensure that they could be present at all times during the study (ie, 3 and 6 months).

The experimental design is summarized in Figure 1.

The initial training was conducted by a pediatric intensivist and an anesthetist. It consisted of a 45-minute course on the basics and essential knowledge required for neonatal resuscitation based on the International Liaison Committee on Resuscitation (ILCOR) 2020 recommendations [15]. Subsequently, the interns practiced ventilation using a low-fidelity mannequin using the Neopuff (Fisher & Paykel Healthcare), intubation, and cardiac massage. Subsequently, they individually participated in an HF simulation that included a presentation of the material, briefing, scenario execution, and debriefing (see scenario details in Multimedia Appendix 2). The simulation was conducted in a real-life delivery room setting at Reims University Hospital using the SimNewBorn mannequin (Laerdal Medical). The simulation sessions were recorded for later analysis.

Residents were randomized into three parallel groups (randomization.com) in a 1:1:1 ratio. The control group did not receive a recall session at 3 months. The two intervention groups received a recall session at 3 months after the initial session using either serious game (SG) screen-based simulation or HF simulation.

Data were collected directly on paper for the knowledge and self-confidence questionnaires, as well as for clinical and demographic information. The primary outcome measures were assessed via expert evaluation of the video recordings a posteriori.

Based on a previous study, a baseline ANTS score of approximately 12/20 was expected [21], with a target improvement to 16/20 through recall interventions. With an alpha risk of 5% and 80% power, the number of participants required per group was 9.

The statistical hypothesis tested whether SG and HF simulation were equivalent in reactivating skills and knowledge, with both differing from the control group. Data are presented as median (Q1-Q3) for continuous data, given the small sample size. Interrater reliability calculations were performed for both evaluations, showing good agreement between the two raters (kw>0.66; P=.01) [22]. The statistical analyses were conducted using the Friedman test and Wilcoxon test for paired samples, and the Kruskal-Wallis test for intergroup comparisons. All tests were two-tailed, with statistical significance considered at P<.05. Statistical analyses were performed using SPSS software (version 25.0; IBM Corp).

Twenty-eight participants were included in the study; 10 were randomly assigned to the control group, 9 to the HF simulation 6-month recall group (HF), and 9 to the screen-based simulation 6-month recall group (SG). All were anesthesiology and intensive care residents in their third, fourth, or fifth year of a 5-year training program in France. Seventeen participants (60%) were men, with a median age of 28 years (IQR 27-31). Baseline demographic and clinical characteristics are presented in Table 1. All participants completed the study (CONSORT [Consolidated Standards of Reporting Trials] flow diagram is provided) (Figure 3).

Seventy-five percent (21/28) of the participants had previously participated in training involving simulation. Twenty-one participants were familiar with HF simulation, and 15 had prior experience with a SG, though none had training in neonatal resuscitation. No participants had encountered or participated in a real neonatal resuscitation during the 6-month study period or benefited from other training. The findings are presented in Table 2.

This study highlights the benefits of a recall session 3 months after an initial neonatal resuscitation training for novice anesthesia and intensive care residents. Regardless of the recall technique—whether an SG or HF simulation—learning retention improved at 6 months.

The importance of knowledge and skill maintenance has been demonstrated several times in medical education, although no ideal interval or optimal method has been defined. A significant loss of skills over time is observed in the absence of continuous training [23,24]. Short, systematic, and regularly repeated training sessions help to optimize the retention of skills, as the consolidation of learning is based on repetition [25,26]. Retention is a marker that is regularly used to assess the quality of learning. The literature demonstrates a significant variability in the duration of retention depending on the type of skills taught and the learner population. In an HF simulation study on the cricothyroidotomy technique involving already qualified anesthetists, retention lasted up to a year after training [27]. This may be attributed to the complexity of the taught task and the high expertise of the learners. However, for a group of novices training in new technical skills, retention can be significantly shorter [28]. Therefore, the teaching format, learners, and the type of skill taught all have an impact on the duration of retention.

Screen-based simulation serves as an alternative to HF simulation or an interesting addition to training programs, as it represents an innovative contribution in line with the expectations of newer generations. It offers flexibility in terms of usage and learning methods—whether individual or group-based, remote or in-person—while preserving a safe environment for immersive and realistic training that is conducive to making mistakes. Additionally, screen-based simulation is less expensive than HF simulation [29]. A recent study examined its implementation to facilitate the development of medical teaching programs using screen-based simulation [30].

Few studies have assessed retention of learning after screen-based simulation training in the medical field. In aviation, one study found better knowledge retention after immersive digital simulator training compared to conventional training tools after one week [31]. In a medical study, the contribution of screen-based simulation was evaluated in comparison to traditional teaching for head and neck physiology and anatomy for second-year medical students. Knowledge retention, assessed through a questionnaire at 6 months, was similar between groups; the traditional teaching group showed progression over time, whereas the screen-based simulation group did not [10]. Another study involving nursing students compared knowledge retention after a 45-minute course on managing respiratory distress, followed by either screen-based simulation or low-fidelity simulation. Screen-based simulation resulted in superior knowledge retention at two months [32]. Additionally, a recent study demonstrated the potential of an online SG as an effective learning tool for improving and retaining knowledge related to the diagnosis and treatment planning of oral lesions, with good knowledge retention observed at one week [33].

Our study is the first to analyze the impact of a 3-month recall session on the retention of learning at 6 months and to compare two recall techniques: screen-based simulation and HF simulation. It is important to emphasize that both recall groups benefitted from identical training durations at 3 months (45 min in total), allowing for a direct comparison of the training methods. Our findings confirm the benefits of a 3-month recall session, with improvement in learning in both recall groups, unlike the control group without recall, in which skills declined.

A 3-month recall appears to enable an improvement in knowledge, particularly in technical and nontechnical skills and participants’ self-confidence. The only element that progressed similarly in the control group was the knowledge questionnaire score, though this may be the least reliable criterion, as learners had the opportunity to review the ILCOR algorithm before participating in the 6-month session. Assessing skills is a more discriminating measure of learning retention.

The main limitation of our study is the sample size. The study involved voluntary third-, fourth-, and fifth-year anesthesia and intensive care residents, resulting in a limited number of eligible participants (28 out of 35), which corresponds to the sample size calculation but did not allow us to detect any differences between the groups. Notably, the baseline level of the ANTS score was higher than expected, particularly in the control group. However, our population was homogeneous, consisting of neonatal resuscitation novices, and we were able to follow them over the 6 months of the study.

Although this study is a good reflection of a typical educational program, our findings remain to be confirmed using larger cohorts. Additionally they should be validated using other pedagogical themes to refine the role of screen-based simulation in educational pathways and to assess the effect of different methods on the long-term retention of learning.

A 3-month recall after initial neonatal resuscitation training for novice residents results in improved learning retention at 6 months, regardless of the teaching technique used—numerical or HF simulation. While our findings should be confirmed by future studies with larger sample sizes, they support the value and feasibility of incorporating screen-based simulation into training programs.