14.1 NRP Key Behavioral Skills
Key Takeaways
- NRP lists ten Key Behavioral Skills that determine whether technical steps succeed under stress: environment knowledge, anticipation, leadership, communication, delegation, attention allocation, information use, resource use, early help, and professional behavior
- Technical mastery without behavioral skills fails in real resuscitations—most NRP simulation failures are teamwork failures, not device failures
- One clear leader directs priorities, assigns roles, and maintains a shared mental model while still inviting input from the team
- Call for help early when risk is high or the infant is not responding; waiting until the room is chaotic is an exam and clinical error
- Map each behavioral skill to a concrete delivery-room action so you can recognize correct and incorrect teamwork on NRP scenarios
Why Behavioral Skills Are on the NRP Exam
NRP is not only an airway and medication algorithm. The American Academy of Pediatrics and American Heart Association built Key Behavioral Skills into simulation and evaluation because most delivery-room failures are team failures: equipment not ready, no leader, vague orders, two people doing the same task while compressions lag, or silence when someone sees a wrong tube depth.
Technical skill answers “What is the next step?” Behavioral skill answers “How does a team execute that step without chaos?” Exam scenarios often embed both. You may know that heart rate below 60 after effective PPV means compressions—but the correct choice may be who calls it out, who starts compressions, and who reassesses—not a second lecture on anatomy.
This section teaches the classic ten NRP Key Behavioral Skills, each with a delivery-room example and an exam-style application.
The Ten Skills at a Glance
| # | Key Behavioral Skill | One-line meaning |
|---|---|---|
| 1 | Know your environment | Where is equipment, who is available, what works in this room |
| 2 | Anticipate and plan | Pre-birth briefing, risk-based staffing, what-if plans |
| 3 | Assume the leadership role | One clear leader directs priorities and synthesizes input |
| 4 | Communicate effectively | Clear, directed, closed-loop, shared mental model |
| 5 | Delegate workload optimally | Right task to right person; no duplication or gaps |
| 6 | Allocate attention wisely | Leader stays big-picture; avoid tunnel vision |
| 7 | Use all available information | Monitors, maternal history, appearance, team observations |
| 8 | Use all available resources | People, equipment, protocols, specialists, backup |
| 9 | Call for help early | Escalate before the crisis peaks |
| 10 | Maintain professional behavior | Calm, respectful, no blame during the event |
Memorize the list as a set. NRP questions rarely ask for the list by number, but they ask you to choose the behavior that matches the skill.
1. Know Your Environment
Meaning: Before birth (and continuously during resuscitation), know layout, equipment function, gas sources, warmer controls, code buttons, and who can respond.
Delivery-room example: The PPV provider discovers the T-piece is not connected to blended oxygen. Someone who already checked the warmer circuit and oxygen blender can fix it in seconds. Someone who never oriented to the room wastes the Golden Minute hunting cables.
Exam application: Correct answers emphasize equipment check and room familiarity before the infant arrives, not improvising after apnea is recognized. “I will dry and stimulate first; someone else can find the bag later” is wrong when preparation was possible.
2. Anticipate and Plan
Meaning: Use perinatal risk factors and the four pre-birth questions to decide who attends, what equipment is open, and what the first branch points will be (PPV likely? preterm? meconium? multiple gestation?).
Delivery-room example: For a 28-week twin delivery, the team opens plastic wrap, sets a lower starting oxygen concentration plan per protocol, assigns one provider per infant, and names who will intubate if needed.
Exam application: Choose proactive briefing and role assignment over “wait and see.” Anticipation is not over-reaction; it is NRP standard when risk is elevated.
3. Assume the Leadership Role
Meaning: One person leads. The leader states priorities, assigns or reassigns roles, tracks time and heart rate trends, and invites input without surrendering direction. Leadership can transfer deliberately (“You take lead—I’m intubating”), but the room must never have two competing directors or zero directors.
Delivery-room example: “I am leading. You do PPV. You place the pulse ox and ECG. Call out HR every 30 seconds. Tell me if the chest is not moving.”
Exam application: The best answer usually names a single leader and clear role map. Options where everyone “does what they think is best” or the most senior person stays silent while juniors flail are wrong.
Leadership is a function, not only a hierarchy. A competent nurse or RT can lead while a late-arriving physician takes a technical role—if the handoff of leadership is explicit.
4. Communicate Effectively
Meaning: Speak clearly, address people by name or role, use closed-loop communication (call-out → check-back → confirmation), and share what you see so the whole team shares one mental model.
Delivery-room example: “Heart rate is 50 on the monitor—start compressions now.” Compressions provider: “Starting compressions.” Leader: “Correct—continue 3:1.”
Exam application: Prefer specific, directed language over vague phrases like “give some epi” or “somebody start compressions.” Communication failures are the most frequent behavioral distractors on scenario items.
(Section 14.2 deepens closed-loop technique.)
5. Delegate Workload Optimally
Meaning: Match tasks to skill and free capacity. Avoid two skilled people both trying to intubate while no one ventilates. Avoid leaving compressions to the least prepared person without coaching.
Delivery-room example: When compressions start, the leader assigns: airway provider ventilates via advanced airway; second provider compresses; third prepares epinephrine and UVC/IO access; recorder tracks times.
Exam application: Correct choices eliminate task collision and cover critical paths (ventilation never stops; someone owns meds; someone owns timing).
6. Allocate Attention Wisely
Meaning: The leader maintains situational awareness—time since birth, whether MR SOPA was completed, oxygen concentration, temperature—while task performers may focus narrowly. Anyone may call out a critical cue (“Still no chest rise!”).
Delivery-room example: The intubator is focused on the larynx. The leader watches SpO2 trend, HR, and the clock and stops a prolonged attempt if the infant is deteriorating.
Exam application: Wrong options show tunnel vision (endless intubation without ventilation) or leader doing every hands-on task so no one tracks the big picture.
7. Use All Available Information
Meaning: Integrate maternal history, prenatal ultrasound findings, appearance (tone, breathing, color), auscultation, pulse oximetry, ECG when indicated, CO2 detector after intubation, and team observations.
Delivery-room example: History of abruption plus pale, floppy infant with poor perfusion → prepare volume expander early, not only “more epi” after every cycle.
Exam application: Choose answers that connect information to the next action, not that ignore history or monitor data in favor of a fixed script.
8. Use All Available Resources
Meaning: Resources include people (second team, NICU, anesthesia, respiratory therapy), equipment (LMA, meconium aspirator if indicated for obstruction, UVC tray), and cognitive aids (algorithm card, dose chart).
Delivery-room example: Difficult airway → call anesthesia early and open LMA as a primary alternative pathway rather than only repeating failed face-mask attempts.
Exam application: “Use what you have and escalate” beats “keep trying alone with the same failing method.”
9. Call for Help Early
Meaning: Do not wait until the infant has received multiple rounds of epinephrine with a disorganized team. Call for additional skilled help when risk is high pre-birth or when the infant is not responding as expected.
Delivery-room example: Anticipated very preterm birth with thick meconium and maternal fever → extra skilled personnel at the bedside before delivery, not a frantic page at 90 seconds of life.
Exam application: Early help is almost always preferred over delayed help. Pride and “we can handle it” are traps.
10. Maintain Professional Behavior
Meaning: Stay calm, respectful, and focused. No yelling, blaming, or shaming mid-code. Professionalism protects psychological safety so someone can speak up about a wrong dose or esophageal tube.
Delivery-room example: After a misheard dose, the leader says “Stop—read back the epinephrine dose and route” without humiliation; the team corrects and continues.
Exam application: Correct options preserve respect and safety. Options that silence concern or mock a colleague are never right—even if the technical step is correct.
Integrating Skills During a Full Resuscitation
Picture a term infant after abruption: apneic, HR 40 after initial steps.
- Anticipate/plan & environment: Team already briefed; warmer, PPV device, advanced airway, UVC tray open.
- Leadership & delegation: Leader assigns PPV, monitors, access, meds.
- Communication: HR called out; closed-loop on “start PPV,” then “chest not moving—MR SOPA,” then “HR still 40 after effective PPV—compressions and 100% oxygen.”
- Attention & information: Leader tracks time, response to ventilation, and need for volume.
- Resources & help: Second team called early; blood available given blood-loss concern.
- Professionalism: Calm corrections; family update planned after stabilization.
Technical steps (PPV → airway → compressions → epi/volume) only work when these behaviors hold the team together.
Common Exam Traps
| Trap | Why it fails | Better behavior |
|---|---|---|
| No leader / competing leaders | Conflicting orders, missed steps | One explicit leader |
| Silent competent observer | Wasted skill, delayed escalation | Speak up; reassign roles |
| “Somebody…” orders | No ownership | Named person + check-back |
| Heroics without help | Delayed backup | Call early |
| Blame during code | Stops speaking up | Correct the action, not the person |
| Equipment unknown at birth | Golden Minute wasted | Know environment pre-birth |
Bottom Line for Section 14.1
NRP Key Behavioral Skills are testable, actionable habits, not soft fluff. On every scenario, ask: Is there a leader? Is the plan shared? Are roles clear? Is communication closed-loop? Is help coming early enough? Is the team professional enough that errors get voiced? If any answer is no, the behavioral fix is part of the correct clinical answer.
Which action best demonstrates the NRP Key Behavioral Skill “know your environment” before a high-risk delivery?
During a neonatal resuscitation, two providers simultaneously give conflicting instructions and no one is clearly leading. Which NRP behavioral response is most appropriate?
A preterm infant is not improving after prolonged face-mask PPV with poor chest rise. The team has not called additional help. Which skill is most clearly missing?