{"paper_id":"0e034a6c-a2ad-4212-b607-c047397fe76d","body_text":"Bridging Emergency Care Training Gaps Through In-Situ Interdisciplinary Simulation: A Pilot Study from a Tertiary Hospital in Rwanda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bridging Emergency Care Training Gaps Through In-Situ Interdisciplinary Simulation: A Pilot Study from a Tertiary Hospital in Rwanda Hubert Uwisanze, Mallika Manyapu, Vanessa Nadine Ineza, Mukarugwiza Florence Masters, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6856106/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: Emergency medicine is a rapidly developing specialty in Rwanda, with King Faisal Hospital, Rwanda (KFHR) playing a pivotal role as one of the teaching hospitals in the country. While simulation-based training is globally recognized for its effectiveness, its implementation at KFHR has been limited, especially in in-situ and interdisciplinary formats. This study aimed to evaluate the effectiveness of the first interdisciplinary in-situ simulation training at KFHR by assessing participants’ understanding of essential team dynamics concepts, including closed-loop communication, knowledge sharing, role clarity, and recognition of limitations. Additionally, it examined the training's impact on participant satisfaction and perceived usefulness for clinical practice. Methods: A quasi-experimental study was conducted over three months, involving 37 emergency department clinicians (73% nurses, 22% physicians, and 5% other faculty, including healthcare assistants and medical students). Participants completed a bilingual (English and Kinyarwanda) post-intervention survey. The survey included multiple-choice questions assessing comprehension of team dynamics concepts and Likert-scale items evaluating satisfaction and perceived applicability. Descriptive statistics were used for analysis. Results: Post-training, 86.5% of participants correctly answered the question assessing closed-loop communication, 40.5% correctly answered the question on knowledge sharing, and 92% correctly responded to the question on awareness of personal limitations during resuscitations. The average satisfaction score was 4.5 out of 5, and 89% reported they were likely or very likely to apply the skills in practice. Over 90% found the simulation cases relevant to real clinical scenarios. Feedback highlighted opportunities to improve communication consistency and team coordination. Discussion: These findings suggest that interdisciplinary in-situ simulation training can strengthen team dynamics, improve provider confidence, and enhance preparedness for emergency care delivery. The high satisfaction scores and evidence of learning support simulation as a valuable educational tool in resource-limited settings. As emergency medicine expands across Africa, this model offers a replicable framework to improve training and clinical outcomes. BACKGROUND Emergency medicine is a growing specialty in Africa, including Rwanda, where the establishment of the first emergency medicine residency program has marked a significant milestone ( 1 ). King Faisal Hospital, Rwanda, one of the four big national referral hospitals, is well-positioned to become a pioneer in the management of emergency patient care, like myocardial infarction, as it is the only one with a cardiac catheterization laboratory. A critical component of strengthening emergency medicine in Rwanda is the development of simulation-based training programs ( 1 , 2 , 3 ). The need for such training is underscored by the high burden of trauma, with approximately 50% of cases managed by the national emergency medical services attributed to physical trauma ( 4 ). Other prevalent emergencies - such as sepsis, respiratory distress, myocardial infarction, and stroke - also demand a coordinated, team-based approach involving physicians, nurses, and allied health professionals to ensure timely and effective care ( 1 , 4 ). Emergency medicine in low and middle-income countries like Rwanda faces unique challenges in addressing these needs, including limited resources, understaffing, and underdeveloped formal training programs. These gaps often result in inconsistent care delivery and communication breakdowns in high-pressure scenarios. In situ simulation, on-site training that mimics actual clinical emergencies, provides an effective, context-sensitive solution to these challenges. It allows healthcare teams to practice technical and non-technical skills in their actual working environment, bridging the gap between theory and real-world practice. In particular, interdisciplinary simulations foster team-based competencies, enhance role clarity, and improve patient outcomes by promoting seamless collaboration across professional boundaries ( 5 , 6 ). Simulation training offers a safe and controlled environment for teams to practice both technical and non-technical skills, including communication and collaboration ( 3 ). Studies conducted in Rwanda have shown that simulation-based training improves both knowledge and confidence among healthcare providers ( 2 , 4 ). As of today, no interdisciplinary in-situ simulation studies have previously been published in Rwanda. OBJECTIVES This study aimed to evaluate the effectiveness of interdisciplinary in-situ simulation training by assessing participants’ understanding of concepts of key team dynamics. Specifically, it examined their ability to correctly answer questions related to closed-loop communication, knowledge sharing, task allocation and role clarity, and recognition of constraints. The study also evaluated participants’ satisfaction with the training and its perceived relevance to their clinical practice, as measured through post-training surveys. METHODS Study Design and Setting: A quasi-experimental study was conducted at King Faisal Hospital’s Emergency Department (ED) in Kigali, Rwanda, over three months. The study participants included a mix of emergency physicians, nurses, healthcare assistants, and occasionally medical students. A total of 37 emergency room staff participated in one or more simulation sessions. Inclusion criteria required participation in at least one team low-fidelity simulation, led by faculty members. The training included watching an 8-minute American Heart Association (AHA) video on team dynamics, followed by two case-based simulations where participants applied the concepts learned. The low fidelity simulation incorporated basic mannikins, stretchers, and supplies used in the emergency room. Facilitators conducted a pre-briefing to set the stage for discussion and a debriefing session to reinforce key takeaways and lessons learned. Simulation Design – Scenario Development: The in situ simulation program was developed with a focus on clinical relevance, interdisciplinary engagement, and contextual realism. Scenarios were co-designed by emergency physicians, nurses, and medical educators to reflect common and high-risk emergencies encountered in the ED, such as polytrauma, management of unconscious patients, and cardiac arrest. Each scenario was scripted to include key decision points, communication challenges, and dynamic patient deterioration to prompt critical thinking and teamwork. The simulations were briefed and debriefed using a structured framework that emphasized reflection, feedback, and systems thinking using the PEARLS framework ( 7 ). Simulation Design – Implementation and Team Roles: Simulations were conducted within the actual Emergency Department during non-peak hours (Mornings from 7:00 to 9:00 AM) to preserve clinical flow while maximizing realism. Roles were assigned to reflect real-life duties, and observers were tasked with noting communication patterns and team dynamics. Debriefing sessions were held immediately after each simulation and were led by trained facilitators who guided discussions on clinical performance, decision-making, communication, and areas for improvement. This approach ensured a safe, supportive environment where staff could learn from both successes and mistakes without fear of blame ( 8 , 9 ). Data Collection and Analysis: Data were collected using structured online surveys, which gathered information on participants' roles within the ED. The surveys included multiple-choice questions designed to assess understanding of key team dynamics concepts, such as closed-loop communication, knowledge sharing, and recognition of personal limitations during resuscitations. The survey was developed specifically for this study and is available as a supplementary file. The survey was provided in both English and in the local language, Kinyarwandan. Additionally, Likert-scale questions were used to evaluate participants' satisfaction with the training and its perceived relevance to clinical practice. Descriptive statistics were applied to analyze the results. RESULTS A total of 37 participants completed the training and assessments: 8 physicians (22%), 2 healthcare assistants (5%), and 25 nurses (73%). Six participants had no prior experience with simulation-based training. Understanding of team dynamics concepts: 86.5% of participants correctly answered the question on closed-loop communication. 40.5% correctly answered the question on knowledge sharing. 92% demonstrated awareness of their personal limitations during resuscitations. Satisfaction and clinical relevance: The average satisfaction score was 4.5 out of 5. 89% of participants reported they were likely or very likely to apply the skills learned in clinical practice. 71% of participants found the cases “very helpful” in reflecting real clinical scenarios and 29% of participants found the simulation cases “helpful”. General feedback: General commentary and feedback from participants was positive. Some of the comments are listed below: “The training was relevant and well conducted, participation was 100%, which is unusual.” \"We gained from the simulation session how to improve team dynamics to improve resuscitation outcomes.\" “That is crucial, very important training that is needed for everyone on the team.” System-level findings: In-situ simulation highlighted operational gaps, including inconsistent communication practices, variable clinical knowledge among team members, and limited availability of essential equipment. DISCUSSION Participants in the simulation-based interdisciplinary team training demonstrated substantial gains in understanding core principles such as closed-loop communication and recognition of personal limitations - skills essential to safe and efficient emergency care delivery. They reported higher satisfaction with the training's quality and relevance to clinical practice. Moreover, in-situ simulation identified key gaps in emergency care capacity, such as deficiencies in equipment, clinical knowledge, and communication among personnel, as well as identifying potential patient safety concerns ( 10 ). Contextually relevant interdisciplinary simulation-based learning improves team dynamics and should be integrated into all emergency medicine continuing education. This study on in-situ simulation-based interdisciplinary team training at King Faisal Hospital in Rwanda illustrates the need for innovative and frequent training to improve role clarity, communication, and team performance during emergency resuscitation, particularly in low-resource and high-volume environments. Performing it in-situ allowed trainees to feel a sense of realism that case-based discussion might not capture alone. High satisfaction scores among participants highlight the training's relevance and potential for broader adoption across Africa, potentially increasing inclusiveness and sustainability of simulation-based education across various low-resource contexts ( 15 ). By addressing identified gaps in emergency care, such as equipment deficiencies and communication challenges, the study provides a foundation for targeted interventions to enhance overall emergency care capacity. While simulation-based education has increased in prevalence across low- and middle-income countries, further research and standardized application are still lacking ( 11 ). This in situ simulation approach could serve as a model for other hospitals in Africa, promoting the scaling and replication of simulation-based training programs in high-constraint environments. The study also emphasizes the importance of integrating such training into continuing education for emergency department staff, which could influence healthcare policies and lead to sustained improvements in emergency care across the continent. As emergency medicine continues to grow as a specialty in Africa, this research advances the field by demonstrating the effectiveness of innovative training methods. Ultimately, the study could lead to better patient outcomes and more robust healthcare systems across Africa by improving resuscitation coordination and patient outcomes. More so, in-situ simulation can enhance staff confidence in managing emergency resuscitations. While high-income countries have long integrated simulation-based training into medical education, its adoption in Africa has been more recent and primarily concentrated in areas like obstetric care and relatively wealthier nations such as South Africa ( 12 , 13 ). Simulation-based training is usually considered cost-prohibitive due to high startup and operational expenses, an especially significant barrier in many African contexts. However, in-situ simulation offers an inexpensive and innovative solution, delivering high-impact, hands-on learning experiences within the actual clinical environment without the necessity of high-fidelity simulation equipment. CONCLUSIONS Interdisciplinary, in-situ simulation training at KFHR enhanced comprehension of essential team dynamics, provider satisfaction, and a sense of preparedness for emergency care. The approach also helped uncover system-level barriers to care delivery. This training is not just beneficial, it’s also essential in the ED to equip teams with the communication, coordination, and crisis-management skills necessary to deliver safe, effective, and efficient emergency care. Moreover, it plays a critical role in identifying and addressing system-level vulnerabilities before they impact real patients. Given these outcomes, we recommend integrating simulation-based team training into routine emergency department education in Rwanda and other African settings. Further studies in this loop may look at the cost-effective part of it and scalable strategies to improve emergency care delivery in resource-constrained hospitals. STUDY LIMITATIONS This was a single-site study without a control group, limiting generalizability and causal inference. Additionally, data were based on self-report, which may be subject to response bias. Abbreviations KFHR: King Faisal Hospital Rwanda AHA: American Health Association PEARLS: Pre-briefing, Engage, Analyze, Reflect, Learn, and Summarize Declarations Author Declarations: None Financial Support: None Conflicts of Interest: All authors report no conflict of interest. Acknowledgements: This project would not be possible without the support of King Faisal Hospital Rwanda and Ministry of Health of Rwanda. Clinical trial number: not applicable Ethical Considerations This study was conducted in accordance with the Declaration of Helsinki and received ethical approval from the King Faisal Hospital Rwanda Institutional Review Board. Informed consent was obtained from all participants, and measures were implemented to ensure the confidentiality and privacy of their data. Surveys were anonymous, and data were securely stored. Consent for publication Not applicable Availability of data and materials All data generated or analysed during this study are included in this published article and its supplementary information files. Competing Interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contributions HU directed the research activity. MM wrote the original draft. VI, MKN, AM, GN, AND TF reviewed and edited the final manuscript. References Mbanjumucyo, G., DeVos, E., Pulfrey, S., & Epino, H. (2015). State of emergency medicine in Rwanda 2015: an innovative trainee and trainer model. BMC Emergency Medicine, 8(1). https://doi.org/10.1186/s12245-015-0067-2 Janeway, H., et al. (2015). Training the trainers in emergency medicine: an advanced trauma training course in Rwanda’s medical simulation center. Pan African Medical Journal, 20. https://doi.org/10.11604/pamj.2015.20.242.6358 Livingston, P., et al. (2014). Development of a simulation and skills centre in East Africa: a Rwandan-Canadian partnership. Pan African Medical Journal, 17. https://doi.org/10.11604/pamj.2014.17.315.4211 Rosenberg, A., et al. (2020). Developing sustainable prehospital trauma education in Rwanda. African Journal of Emergency Medicine, 10(4), 234-238. https://doi.org/10.1016/j.afjem.2020.07.015 Fransen, A. F., De Boer, K. A., Kienhorst, D., Van Dongen, L., & Biert, J. (2022). In situ simulation improves self-efficacy and safety attitudes in trauma teams. Advances in Simulation, 7(1), 1–10. https://doi.org/10.1186/s41077-021-00154-4 Wehbi, N. K., Yamada, N. K., Baird, J. M., & Leung, D. T. (2021). Simulation in low- and middle-income countries: Barriers and strategies for success. Advances in Simulation, 6(1), 1–7. https://doi.org/10.1186/s41077-021-00145-5 Eppich, W., & Cheng, A. (2015). Promoting excellence and reflective learning in simulation (PEARLS): development and rationale for a blended approach to healthcare simulation debriefing. Simulation in Healthcare, 10(2), 106–115. https://doi.org/10.1097/SIH.0000000000000072 Patterson, M. D., Geis, G. L., Falcone, R. A., LeMaster, T., & Wears, R. L. (2016). In situ simulation: Detection of safety threats and teamwork training in a high-risk emergency department. BMJ Quality & Safety, 22(6), 468–477. https://doi.org/10.1136/bmjqs-2012-000942 Sorensen, J. L., Van der Vleuten, C., Lindschou, J., Gluud, C., & Østergaard, D. (2017). Design of simulation-based medical education and advantages and disadvantages of in situ simulation versus off-site simulation. BMC Medical Education, 17, 20. https://doi.org/10.1186/s12909-016-0830-3 Grace, Margaret A. Mb, Bch, BAO; O'Malley, Roisin PhD. Using In Situ Simulation to Identify Latent Safety Threats in Emergency Medicine: A Systematic Review. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare 19(4):p 243-253, August 2024. | DOI: 10.1097/SIH.0000000000000748 Robinson SJA, Ritchie AMA, Pacilli M, Nestel D, McLeod E, Nataraja RM. Simulation-based education of health workers in low- and middle-income countries: a systematic review. Glob Health Sci Pract. 2024;12(6):e2400187. https://doi.org/10.9745/GHSP-D-24-00187 Burch, Vanessa. (2014). Does simulation-based training have a future in Africa?. African Journal of Health Professions Education. 6. 117. 10.7196/ajhpe.534. Elendu, Chukwuka BSc, MDa,*; Amaechi, Dependable C. MBBSb; Okatta, Alexander U. MBBSc; Amaechi, Emmanuel C. MBBSd; Elendu, Tochi C. BNSc, RN, RM, RPHNc; Ezeh, Chiamaka P. MBBSe; Elendu, Ijeoma D. BNSc, RN, RM, RPHNc. The impact of simulation-based training in medical education: A review. Medicine 103(27):p e38813, July 05, 2024. | DOI: 10.1097/MD.0000000000038813 Mbanjumucyo, G., et al. (2018). Major incident simulation in Rwanda: a report of two exercises. African Journal of Emergency Medicine, 8(2), 75-78. Somerville, S., Howden, S., Ker, J., & Schofield, S. ( 2024). Exploring accessible, inclusive and sustainable simulation-based education in remote and rural communities: a realist review. International Journal of Healthcare Simulation. from 10.54531/porh1951. Additional Declarations No competing interests reported. Supplementary Files insitusupplementary.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 03 Sep, 2025 Reviews received at journal 08 Aug, 2025 Reviewers agreed at journal 05 Aug, 2025 Reviews received at journal 05 Aug, 2025 Reviewers agreed at journal 23 Jul, 2025 Reviewers agreed at journal 22 Jul, 2025 Reviewers invited by journal 21 Jul, 2025 Editor assigned by journal 16 Jul, 2025 Editor invited by journal 26 Jun, 2025 Submission checks completed at journal 25 Jun, 2025 First submitted to journal 25 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-6856106\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":489076964,\"identity\":\"9fa9a42c-95d8-4042-8fe4-d02715f81bb3\",\"order_by\":0,\"name\":\"Hubert Uwisanze\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"King Faisal Hospital Rwanda\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Hubert\",\"middleName\":\"\",\"lastName\":\"Uwisanze\",\"suffix\":\"\"},{\"id\":489076965,\"identity\":\"4d87b5b5-94de-442e-bb3c-ee5990386ee1\",\"order_by\":1,\"name\":\"Mallika 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Pilot Study from a Tertiary Hospital in Rwanda\",\"fulltext\":[{\"header\":\"BACKGROUND\",\"content\":\"\\u003cp\\u003eEmergency medicine is a growing specialty in Africa, including Rwanda, where the establishment of the first emergency medicine residency program has marked a significant milestone (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e). King Faisal Hospital, Rwanda, one of the four big national referral hospitals, is well-positioned to become a pioneer in the management of emergency patient care, like myocardial infarction, as it is the only one with a cardiac catheterization laboratory.\\u003c/p\\u003e\\u003cp\\u003eA critical component of strengthening emergency medicine in Rwanda is the development of simulation-based training programs (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). The need for such training is underscored by the high burden of trauma, with approximately 50% of cases managed by the national emergency medical services attributed to physical trauma (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). Other prevalent emergencies - such as sepsis, respiratory distress, myocardial infarction, and stroke - also demand a coordinated, team-based approach involving physicians, nurses, and allied health professionals to ensure timely and effective care (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eEmergency medicine in low and middle-income countries like Rwanda faces unique challenges in addressing these needs, including limited resources, understaffing, and underdeveloped formal training programs. These gaps often result in inconsistent care delivery and communication breakdowns in high-pressure scenarios. In situ simulation, on-site training that mimics actual clinical emergencies, provides an effective, context-sensitive solution to these challenges. It allows healthcare teams to practice technical and non-technical skills in their actual working environment, bridging the gap between theory and real-world practice. In particular, interdisciplinary simulations foster team-based competencies, enhance role clarity, and improve patient outcomes by promoting seamless collaboration across professional boundaries (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eSimulation training offers a safe and controlled environment for teams to practice both technical and non-technical skills, including communication and collaboration (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). Studies conducted in Rwanda have shown that simulation-based training improves both knowledge and confidence among healthcare providers (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). As of today, no interdisciplinary in-situ simulation studies have previously been published in Rwanda.\\u003c/p\\u003e\\n\\u003ch3\\u003eOBJECTIVES\\u003c/h3\\u003e\\n\\u003cp\\u003eThis study aimed to evaluate the effectiveness of interdisciplinary in-situ simulation training by assessing participants’ understanding of concepts of key team dynamics. Specifically, it examined their ability to correctly answer questions related to closed-loop communication, knowledge sharing, task allocation and role clarity, and recognition of constraints. The study also evaluated participants’ satisfaction with the training and its perceived relevance to their clinical practice, as measured through post-training surveys.\\u003c/p\\u003e\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003cdiv id=\\\"Sec4\\\" class=\\\"Section3\\\"\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\n\\n\\n\\n\\n\\n\"},{\"header\":\"METHODS\",\"content\":\"\\u003ch2\\u003eStudy Design and Setting:\\u003c/h2\\u003e\\u003cp\\u003eA quasi-experimental study was conducted at King Faisal Hospital’s Emergency Department (ED) in Kigali, Rwanda, over three months. The study participants included a mix of emergency physicians, nurses, healthcare assistants, and occasionally medical students. A total of 37 emergency room staff participated in one or more simulation sessions. Inclusion criteria required participation in at least one team low-fidelity simulation, led by faculty members. The training included watching an 8-minute American Heart Association (AHA) video on team dynamics, followed by two case-based simulations where participants applied the concepts learned. The low fidelity simulation incorporated basic mannikins, stretchers, and supplies used in the emergency room. Facilitators conducted a pre-briefing to set the stage for discussion and a debriefing session to reinforce key takeaways and lessons learned.\\u003c/p\\u003e\\u003ch3\\u003eSimulation Design – Scenario Development:\\u003c/h3\\u003e\\u003cp\\u003eThe in situ simulation program was developed with a focus on clinical relevance, interdisciplinary engagement, and contextual realism. Scenarios were co-designed by emergency physicians, nurses, and medical educators to reflect common and high-risk emergencies encountered in the ED, such as polytrauma, management of unconscious patients, and cardiac arrest. Each scenario was scripted to include key decision points, communication challenges, and dynamic patient deterioration to prompt critical thinking and teamwork. The simulations were briefed and debriefed using a structured framework that emphasized reflection, feedback, and systems thinking using the PEARLS framework (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e).\\u003c/p\\u003e\\u003ch3\\u003eSimulation Design – Implementation and Team Roles:\\u003c/h3\\u003e\\u003cp\\u003eSimulations were conducted within the actual Emergency Department during non-peak hours (Mornings from 7:00 to 9:00 AM) to preserve clinical flow while maximizing realism. Roles were assigned to reflect real-life duties, and observers were tasked with noting communication patterns and team dynamics. Debriefing sessions were held immediately after each simulation and were led by trained facilitators who guided discussions on clinical performance, decision-making, communication, and areas for improvement. This approach ensured a safe, supportive environment where staff could learn from both successes and mistakes without fear of blame (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e).\\u003c/p\\u003e\\u003ch3\\u003eData Collection and Analysis:\\u003c/h3\\u003e\\u003cp\\u003eData were collected using structured online surveys, which gathered information on participants' roles within the ED. The surveys included multiple-choice questions designed to assess understanding of key team dynamics concepts, such as closed-loop communication, knowledge sharing, and recognition of personal limitations during resuscitations. The survey was developed specifically for this study and is available as a supplementary file. The survey was provided in both English and in the local language, Kinyarwandan. Additionally, Likert-scale questions were used to evaluate participants' satisfaction with the training and its perceived relevance to clinical practice. Descriptive statistics were applied to analyze the results.\\u003c/p\\u003e\"},{\"header\":\"RESULTS\",\"content\":\"\\u003cp\\u003eA total of 37 participants completed the training and assessments: 8 physicians (22%), 2 healthcare assistants (5%), and 25 nurses (73%). Six participants had no prior experience with simulation-based training.\\u003c/p\\u003e\\n\\u003ch3\\u003eUnderstanding of team dynamics concepts:\\u003c/h3\\u003e\\n\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003e 86.5% of participants correctly answered the question on closed-loop communication.\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e40.5% correctly answered the question on knowledge sharing.\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e92% demonstrated awareness of their personal limitations during resuscitations.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003eSatisfaction and clinical relevance:\\u003c/h3\\u003e\\n\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003eThe average satisfaction score was 4.5 out of 5.\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e89% of participants reported they were likely or very likely to apply the skills learned in clinical practice.\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e71% of participants found the cases \\u0026ldquo;very helpful\\u0026rdquo; in reflecting real clinical scenarios and 29% of participants found the simulation cases \\u0026ldquo;helpful\\u0026rdquo;.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eGeneral feedback:\\u003c/h2\\u003e\\u003cp\\u003e General commentary and feedback from participants was positive. Some of the comments are listed below:\\u003c/p\\u003e\\u003cp\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u0026ldquo;The training was relevant and well conducted, participation was 100%, which is unusual.\\u0026rdquo;\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e\\\"We gained from the simulation session how to improve team dynamics to improve resuscitation outcomes.\\\"\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u0026ldquo;That is crucial, very important training that is needed for everyone on the team.\\u0026rdquo;\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eSystem-level findings:\\u003c/h2\\u003e\\u003cp\\u003eIn-situ simulation highlighted operational gaps, including inconsistent communication practices, variable clinical knowledge among team members, and limited availability of essential equipment.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"DISCUSSION\",\"content\":\"\\u003cp\\u003eParticipants in the simulation-based interdisciplinary team training demonstrated substantial gains in understanding core principles such as closed-loop communication and recognition of personal limitations - skills essential to safe and efficient emergency care delivery. They reported higher satisfaction with the training's quality and relevance to clinical practice. Moreover, in-situ simulation identified key gaps in emergency care capacity, such as deficiencies in equipment, clinical knowledge, and communication among personnel, as well as identifying potential patient safety concerns (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). Contextually relevant interdisciplinary simulation-based learning improves team dynamics and should be integrated into all emergency medicine continuing education.\\u003c/p\\u003e\\u003cp\\u003eThis study on in-situ simulation-based interdisciplinary team training at King Faisal Hospital in Rwanda illustrates the need for innovative and frequent training to improve role clarity, communication, and team performance during emergency resuscitation, particularly in low-resource and high-volume environments. Performing it in-situ allowed trainees to feel a sense of realism that case-based discussion might not capture alone.\\u003c/p\\u003e\\u003cp\\u003eHigh satisfaction scores among participants highlight the training's relevance and potential for broader adoption across Africa, potentially increasing inclusiveness and sustainability of simulation-based education across various low-resource contexts (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e). By addressing identified gaps in emergency care, such as equipment deficiencies and communication challenges, the study provides a foundation for targeted interventions to enhance overall emergency care capacity. While simulation-based education has increased in prevalence across low- and middle-income countries, further research and standardized application are still lacking (\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e). This in situ simulation approach could serve as a model for other hospitals in Africa, promoting the scaling and replication of simulation-based training programs in high-constraint environments.\\u003c/p\\u003e\\u003cp\\u003eThe study also emphasizes the importance of integrating such training into continuing education for emergency department staff, which could influence healthcare policies and lead to sustained improvements in emergency care across the continent. As emergency medicine continues to grow as a specialty in Africa, this research advances the field by demonstrating the effectiveness of innovative training methods. Ultimately, the study could lead to better patient outcomes and more robust healthcare systems across Africa by improving resuscitation coordination and patient outcomes. More so, in-situ simulation can enhance staff confidence in managing emergency resuscitations.\\u003c/p\\u003e\\u003cp\\u003eWhile high-income countries have long integrated simulation-based training into medical education, its adoption in Africa has been more recent and primarily concentrated in areas like obstetric care and relatively wealthier nations such as South Africa (\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). Simulation-based training is usually considered cost-prohibitive due to high startup and operational expenses, an especially significant barrier in many African contexts. However, in-situ simulation offers an inexpensive and innovative solution, delivering high-impact, hands-on learning experiences within the actual clinical environment without the necessity of high-fidelity simulation equipment.\\u003c/p\\u003e\"},{\"header\":\"CONCLUSIONS\",\"content\":\"\\u003cp\\u003eInterdisciplinary, in-situ simulation training at KFHR enhanced comprehension of essential team dynamics, provider satisfaction, and a sense of preparedness for emergency care. The approach also helped uncover system-level barriers to care delivery. This training is not just beneficial, it’s also essential in the ED to equip teams with the communication, coordination, and crisis-management skills necessary to deliver safe, effective, and efficient emergency care. Moreover, it plays a critical role in identifying and addressing system-level vulnerabilities before they impact real patients.\\u003c/p\\u003e\\u003cp\\u003eGiven these outcomes, we recommend integrating simulation-based team training into routine emergency department education in Rwanda and other African settings. Further studies in this loop may look at the cost-effective part of it and scalable strategies to improve emergency care delivery in resource-constrained hospitals.\\u003c/p\\u003e\"},{\"header\":\"STUDY LIMITATIONS\",\"content\":\"\\u003cp\\u003eThis was a single-site study without a control group, limiting generalizability and causal inference. Additionally, data were based on self-report, which may be subject to response bias.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eKFHR: King Faisal Hospital Rwanda\\u003c/p\\u003e\\n\\u003cp\\u003eAHA: American Health Association \\u003c/p\\u003e\\n\\u003cp\\u003ePEARLS: Pre-briefing, Engage, Analyze, Reflect, Learn, and Summarize\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAuthor Declarations:\\u0026nbsp;\\u003c/strong\\u003eNone\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFinancial Support:\\u0026nbsp;\\u003c/strong\\u003eNone\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConflicts of Interest:\\u0026nbsp;\\u003c/strong\\u003eAll authors report no conflict of interest.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements:\\u0026nbsp;\\u003c/strong\\u003eThis project would not be possible without the support of King Faisal Hospital Rwanda and Ministry of Health of Rwanda.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eClinical trial number:\\u003c/strong\\u003e not applicable\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthical Considerations\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was conducted in accordance with the Declaration of Helsinki and received ethical approval from the King Faisal Hospital Rwanda Institutional Review Board. Informed consent was obtained from all participants, and measures were implemented to ensure the confidentiality and privacy of their data. Surveys were anonymous, and data were securely stored.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll data generated or analysed during this study are included in this published article and its supplementary information files.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting Interests\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contributions\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eHU directed the research activity. MM wrote the original draft. VI, MKN, AM, GN, AND TF reviewed and edited the final manuscript.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eMbanjumucyo, G., DeVos, E., Pulfrey, S., \\u0026amp; Epino, H. (2015). State of emergency medicine in Rwanda 2015: an innovative trainee and trainer model. BMC Emergency Medicine, 8(1). https://doi.org/10.1186/s12245-015-0067-2 \\u003c/li\\u003e\\n\\u003cli\\u003eJaneway, H., et al. (2015). Training the trainers in emergency medicine: an advanced trauma training course in Rwanda\\u0026rsquo;s medical simulation center. Pan African Medical Journal, 20. https://doi.org/10.11604/pamj.2015.20.242.6358\\u003c/li\\u003e\\n\\u003cli\\u003eLivingston, P., et al. (2014). Development of a simulation and skills centre in East Africa: a Rwandan-Canadian partnership. Pan African Medical Journal, 17. https://doi.org/10.11604/pamj.2014.17.315.4211\\u003c/li\\u003e\\n\\u003cli\\u003eRosenberg, A., et al. (2020). Developing sustainable prehospital trauma education in Rwanda. African Journal of Emergency Medicine, 10(4), 234-238. https://doi.org/10.1016/j.afjem.2020.07.015\\u003c/li\\u003e\\n\\u003cli\\u003eFransen, A. F., De Boer, K. A., Kienhorst, D., Van Dongen, L., \\u0026amp; Biert, J. (2022). In situ simulation improves self-efficacy and safety attitudes in trauma teams. Advances in Simulation, 7(1), 1\\u0026ndash;10. https://doi.org/10.1186/s41077-021-00154-4\\u003c/li\\u003e\\n\\u003cli\\u003eWehbi, N. K., Yamada, N. K., Baird, J. M., \\u0026amp; Leung, D. T. (2021). Simulation in low- and middle-income countries: Barriers and strategies for success. Advances in Simulation, 6(1), 1\\u0026ndash;7. https://doi.org/10.1186/s41077-021-00145-5\\u003c/li\\u003e\\n\\u003cli\\u003eEppich, W., \\u0026amp; Cheng, A. (2015). Promoting excellence and reflective learning in simulation (PEARLS): development and rationale for a blended approach to healthcare simulation debriefing. Simulation in Healthcare, 10(2), 106\\u0026ndash;115. https://doi.org/10.1097/SIH.0000000000000072\\u003c/li\\u003e\\n\\u003cli\\u003ePatterson, M. D., Geis, G. L., Falcone, R. A., LeMaster, T., \\u0026amp; Wears, R. L. (2016). In situ simulation: Detection of safety threats and teamwork training in a high-risk emergency department. BMJ Quality \\u0026amp; Safety, 22(6), 468\\u0026ndash;477. https://doi.org/10.1136/bmjqs-2012-000942 \\u003c/li\\u003e\\n\\u003cli\\u003eSorensen, J. L., Van der Vleuten, C., Lindschou, J., Gluud, C., \\u0026amp; \\u0026Oslash;stergaard, D. (2017). Design of simulation-based medical education and advantages and disadvantages of in situ simulation versus off-site simulation. BMC Medical Education, 17, 20. https://doi.org/10.1186/s12909-016-0830-3 \\u003c/li\\u003e\\n\\u003cli\\u003eGrace, Margaret A. Mb, Bch, BAO; O\\u0026apos;Malley, Roisin PhD. Using In Situ Simulation to Identify Latent Safety Threats in Emergency Medicine: A Systematic Review. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare 19(4):p 243-253, August 2024. | DOI: 10.1097/SIH.0000000000000748\\u003c/li\\u003e\\n\\u003cli\\u003eRobinson SJA, Ritchie AMA, Pacilli M, Nestel D, McLeod E, Nataraja RM. Simulation-based education of health workers in low- and middle-income countries: a systematic review. Glob Health Sci Pract. 2024;12(6):e2400187. https://doi.org/10.9745/GHSP-D-24-00187\\u003c/li\\u003e\\n\\u003cli\\u003eBurch, Vanessa. (2014). Does simulation-based training have a future in Africa?. African Journal of Health Professions Education. 6. 117. 10.7196/ajhpe.534.\\u003c/li\\u003e\\n\\u003cli\\u003eElendu, Chukwuka BSc, MDa,*; Amaechi, Dependable C. MBBSb; Okatta, Alexander U. MBBSc; Amaechi, Emmanuel C. MBBSd; Elendu, Tochi C. BNSc, RN, RM, RPHNc; Ezeh, Chiamaka P. MBBSe; Elendu, Ijeoma D. BNSc, RN, RM, RPHNc. The impact of simulation-based training in medical education: A review. Medicine 103(27):p e38813, July 05, 2024. | DOI: 10.1097/MD.0000000000038813\\u003c/li\\u003e\\n\\u003cli\\u003eMbanjumucyo, G., et al. (2018). Major incident simulation in Rwanda: a report of two exercises. African Journal of Emergency Medicine, 8(2), 75-78.\\u003c/li\\u003e\\n\\u003cli\\u003eSomerville, S., Howden, S., Ker, J., \\u0026amp;amp; Schofield, S. ( 2024). Exploring accessible, inclusive and sustainable simulation-based education in remote and rural communities: a realist review. International Journal of Healthcare Simulation. from 10.54531/porh1951. \\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-medical-education\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"meed\",\"sideBox\":\"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/meed/default.aspx\",\"title\":\"BMC Medical Education\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6856106/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6856106/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground:\\u003c/strong\\u003e Emergency medicine is a rapidly developing specialty in Rwanda, with King Faisal Hospital, Rwanda (KFHR) playing a pivotal role as one of the teaching hospitals in the country. While simulation-based training is globally recognized for its effectiveness, its implementation at KFHR has been limited, especially in in-situ and interdisciplinary formats. This study aimed to evaluate the effectiveness of the first interdisciplinary in-situ simulation training at KFHR by assessing participants’ understanding of essential team dynamics concepts, including closed-loop communication, knowledge sharing, role clarity, and recognition of limitations. Additionally, it examined the training's impact on participant satisfaction and perceived usefulness for clinical practice.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods:\\u003c/strong\\u003e A quasi-experimental study was conducted over three months, involving 37 emergency department clinicians (73% nurses, 22% physicians, and 5% other faculty, including healthcare assistants and medical students). Participants completed a bilingual (English and Kinyarwanda) post-intervention survey. The survey included multiple-choice questions assessing comprehension of team dynamics concepts and Likert-scale items evaluating satisfaction and perceived applicability. Descriptive statistics were used for analysis.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults:\\u003c/strong\\u003e Post-training, 86.5% of participants correctly answered the question assessing closed-loop communication, 40.5% correctly answered the question on knowledge sharing, and 92% correctly responded to the question on awareness of personal limitations during resuscitations. The average satisfaction score was 4.5 out of 5, and 89% reported they were likely or very likely to apply the skills in practice. Over 90% found the simulation cases relevant to real clinical scenarios. Feedback highlighted opportunities to improve communication consistency and team coordination.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eDiscussion:\\u003c/strong\\u003e These findings suggest that interdisciplinary in-situ simulation training can strengthen team dynamics, improve provider confidence, and enhance preparedness for emergency care delivery. The high satisfaction scores and evidence of learning support simulation as a valuable educational tool in resource-limited settings. As emergency medicine expands across Africa, this model offers a replicable framework to improve training and clinical outcomes.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Bridging Emergency Care Training Gaps Through In-Situ Interdisciplinary Simulation: A Pilot Study from a Tertiary Hospital in Rwanda\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-07-23 13:49:31\",\"doi\":\"10.21203/rs.3.rs-6856106/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-09-03T05:08:13+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-08-08T21:48:25+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"229289699718864895775173535469107922827\",\"date\":\"2025-08-05T22:02:53+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-08-05T18:18:07+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"292370833943370363002923207948076933848\",\"date\":\"2025-07-23T18:49:50+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"59389428354786258361596336232068183505\",\"date\":\"2025-07-22T06:15:40+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-07-21T18:31:11+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-07-16T14:46:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-06-26T05:25:11+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-06-26T00:01:43+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Medical Education\",\"date\":\"2025-06-25T23:59:02+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-medical-education\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"meed\",\"sideBox\":\"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/meed/default.aspx\",\"title\":\"BMC Medical Education\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"4134974b-a6fa-4af8-9953-d19f28528c33\",\"owner\":[],\"postedDate\":\"July 23rd, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-09-16T14:08:27+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-07-23 13:49:31\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6856106\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6856106\",\"identity\":\"rs-6856106\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}