Impact of Advanced Simulated Case Scenarios on Medical Students' Perception of Non-Technical Skills: A Cross-Sectional Study

Impact of Advanced Simulated Case Scenarios on Medical Students' Perception of Non-Technical Skills: A Cross-Sectional Study | 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 Impact of Advanced Simulated Case Scenarios on Medical Students' Perception of Non-Technical Skills: A Cross-Sectional Study Momna Basher, Sami Mohamed, Amina Begum, Youness Zidoun, Ali El Houni This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6022596/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Simulation-based medical education (SBME) has emerged as an innovative approach to enhancing both technical and non-technical skills (NTS) in medical education. NTS, encompassing communication, teamwork, and decision-making, are essential for patient safety and clinical outcomes. Perception of NTS development through simulated case scenarios, particularly in undergraduate medical education, is constantly being examined. Objectives: This study aimed to assess the impact of advanced simulation-based case scenarios on final-year medical students’ perceptions of NTS, including communication, teamwork, and decision-making, and their role in improving patient care. Methods: A cross-sectional observational study was conducted at Dubai Medical University, involving 60 final-year female medical students. Participants engaged in five simulated case scenario sessions during their clinical rotation. Data was collected via a 5-point ordinal Likert scale structured questionnaire with parts adopted from the validated Observational Skill-based Clinical Assessment tool for Resuscitation (OSCAR), assessing perceptions of NTS and their influence on patient safety. Descriptive statistics and Spearman’s correlation were used for analysis utilizing the SPSS v29 software. Results: Out of the total 60 included participants, most reported high levels of agreement on the importance of NTS, with mean scores ranging from 4.47 to 4.58 across constructs. Communication demonstrated the strongest correlation with perceived impact on patient safety (rho = 0.774, p < 0.001), followed by teamwork (rho = 0.760, p < 0.001) and decision-making (rho = 0.671, p < 0.001). Feedback sessions and structured debriefings based on the Pendleton model enhanced participants’ understanding and application of NTS. Conclusion: Advanced simulated case scenarios incorporating structured briefing and debriefing positively influence NTS perception among medical students, in addition to their implications on patient safety and clinical outcomes. Future research should explore the integration of advanced technologies, such as virtual reality and artificial intelligence (AI). Longitudinal studies should evaluate real-world application of NTS in clinical settings as a result. Figures Figure 1 Figure 2 1. Introduction Health professions education is undergoing rapid transformation, with increasing emphasis on active, learner-centered strategies to address the growing complexity of clinical practice and patient safety requirements [ 1 ]. In line with evolving international frameworks for medical education, such as the Canadian Medical Education Directions for Specialists (CanMEDS) adopted by the Royal College of Physicians and Surgeons of Canada [ 2,3 ] and the Global Minimum Essential Requirements in Medical Education (GMER) [ 4 ], the United Arab Emirates’ (UAE) Ministry of Higher Education and Scientific Research (MOHESR) has developed and recently released the Emirates Competency Framework for Medical Education (EniratesMEDS), which highlights the importance of patient care provision and health advocacy, effective communication and collaboration, innovation and leadership as key parts of their thematic roles [ 5 ]. These competencies are adopted as means to enhance both technical and non-technical skills, and can potentially be reinforced through simulation based medical education (SBME) to replicate clinical environments, thereby further advancing immersive learning and reflective practice [ 6–8 ]. 1.1. Significance of Simulation-Based Medical Education SBME leverages diverse modalities, ranging from simple simulated environments to advanced simulations, in additions to technologies utilizing high-fidelity mannequins, virtual reality and AI, ultimately creating a safe learning spaces in which students can practice and refine essential clinical skills, both technical and non-technical, that align with a patient-centered care approach [ 9–11 ]. Moreover, integration of hands-on experience with timely feedback and structured debriefing can help in bridging the gap between theoretical knowledge and clinical application [ 12 ]. Studies have demonstrated that, in addition to improving knowledge retention, this approach can enhance learners’ confidence and reduce anxiety when transitioning to clinical settings [ 13 ]. Furthermore, a recent study found that resuscitation simulation significantly improved medical students’ diagnostic, therapeutic as well as team-related competencies following targeted sessions [ 14,15 ]. This aligns with a broader consensus asserting SBME as an educational strategy that is able to facilitate complex skill development across multiple domains [ 6 ]. Furthermore, SBME enables iterative, deliberate practice without jeopardizing patient safety, an aspect that is especially relevant in complex scenarios such as emergency medicine, trauma care, and obstetrics [ 16 ]. Additionally, simulation-based assessments are gradually being adopted to evaluate both technical competencies and broader professional capabilities in undergraduate and postgraduate medical education [ 17 ]. While SBME’s positive influence on knowledge, performance, and immediate skill acquisition is well documented [ 18,19 ], prior research also emphasizes the need for continuous follow-up to assess longer-term skill retention and real-world transferability [ 20 ]. However, evidence suggests that SBME has capacity to improve a range of learning outcomes extending to the understanding and implementation of non-technical skills, therefore underscoring its vital place medical education [ 21,22 ]. 1.2. Case-Based Scenarios Case-based learning is an effective educational strategy, promoting active problem-solving, critical thinking, and integrative reasoning. Within SBME, case-based scenarios replicate clinical realities by introducing clinical vignettes that require learners to synthesize knowledge, interpret findings and employ complex decision-making in real time [ 23 ]. These scenarios can range from emergency-based patient encounters to chronic disease management and follow up. By simulating relevant case material, students can practice clinical reasoning and refine their patient management strategies while enhancing their understanding the significance of teamwork, decision making and effective communication in an environment that mimics the cognitive demands of hospital based patient care [ 13,24 ]. Integrating simulation into case-based scenario teaching helps students maintain a high level of engagement while enhancing both immediate knowledge gains and the application of this knowledge in subsequent clinical tasks [ 25–27 ]. Moreover, advance technologies such as video-based, augmented reality and virtual reality integrated case scenarios have recently shown to help learners to visualize complex procedures and receive real-time feedback [ 7,8 ]. Simultaneously, interactive debriefings encourage reflective practice, reinforcing the importance of teamwork, communication, and leadership [ 12,15 ]. Case-based SBME is, therefore, a specialized educational strategy that contribute to NTS growth by helping medical students internalize sound application of their knowledge, skills and attitude through a holistic approach that didactics lack [ 28,29 ]. 1.3. Non-Technical Skills and Their Significance in Patient Care Non-technical skills (NTS) encompass a range of cognitive, social, and personal resource management competencies, such as communication, leadership, teamwork, and decision-making [ 26,30,31 ]. These skills have been increasingly recognized as pivotal in preventing medical errors, which often arise from breakdowns in teamwork or communication rather than a lack of technical proficiency. Thus making its training and development an essential part of patient safety and high-quality care [ 11,32 ]. Recent findings suggest that SBME is particularly well-suited for enhancing NTS in medical students [ 16,24,33 ]. Simulation creates realistic team-based scenarios, such as emergency patients’ encounters, where students coordinate tasks, allocate roles, and practice situational awareness in a safe setting [ 34 ]. It has been demonstrated that learners exposed to targeted NTS training show improvements in communication, leadership, and decision making skills, which in turn correlates with better clinical outcomes and greater efficiency in patient management [ 33 ]. Moreover, debriefing sessions that focus specifically on behavioral markers of NTS can produce measurable gains in performance, thus bridging a critical gap in conventional curricula that traditionally scoped through procedural and technical competencies [ 35 ]. This has led to the development of standardized frameworks and guidelines for simulation-based education in healthcare, such as the Healthcare Simulation Standards of Best Practice [ 36–38 ]. Despite the growing consensus on the benefits of SBME for both technical and non-technical skills development, examining how simulated case scenarios enhance medical students’ perceptions of their communication, decision-making, and teamwork competencies is still undergoing refinement [ 6,7,19,21,27,29 ]. Additionally, while immediate learning gains are evident, the impact of simulated case scenarios on medical students’ comprehension of NTS in enhancing patient care offers a foundational opportunity for early development before clinical practice. [ 19,34,39 ]. This study, therefore, intends to examine the impact of simulation-based case scenarios on medical students’ perceptions of different aspects of non-technical skills, including communication proficiency, decision-making, and teamwork, while exploring how students view the role of NTS in enhancing patient care. This integrated approach through dimensions of case scenarios, advanced simulation modalities, structured debriefing and NTS, offers a comprehensive perspective to this educational strategy. 2. Methods 2.1. Study Design This was a cross-sectional observational university-based study conducted at Dubai Medical University (DMU), Department of Clinical Sciences in Dubai, United Arab Emirates. The study population included final year medical students at the end of their clinical rotation years. Official enrollment in the final year and completion of clinical rotation, where simulation based education sessions took place, in addition to active participation in all simulation based case scenario sessions was set as inclusion criteria. Those who did not fully participate in all simulated case scenarios, or did not consent to participate, were excluded. DMU is open for both national and diverse international students and is exclusive for female students. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines were followed during preparation of the study. 2.2. Simulated case scenarios methodology and educational strategies During their clinical rotation years, final year medical students participate in weekly medical simulation sessions within the division of internal medicine, this includes core clinical skills such as history taking and clinical examination, in addition to skills teaching of interpretation and simulated case scenarios as part of the curriculum. Simulated case scenarios span a total of five sessions, out of 18 total sessions delivered by the faculty for each subgroup of students in an equipped advance simulation unit. Session contents are based on approved learning objectives mapped with program learning outcomes that align with the UAE’s Competency Framework set by the Commission for Academic Accreditation (CAA) of the Ministry of Higher Education and Scientific Research (MOHESR) [ 5 ]. Scenarios include cases based on Cardiovascular (Chest pain), Respiratory (Shortness of Breath), Neurology (Stroke) and Endocrinology (Diabetic Ketoacidosis, Hypoglycemia) encounters in urgent patient care setting. However, scenarios involve deteriorating patients and do not include managing patients with cardiac arrest. Construction of the simulation session was based on competency framework, evidence-based simulation in health care standard in addition to recently studied educational strategies [ 15,36–38,40 ]. The simulation session flow chart and structure are outlined in (Figure 1) and (Figure 2) respectively. Students are provided with pre-learning materials for study prior to the session. At the start of the session, students are briefed by the faculty and instructors about learning objectives and scenario content, then they approach the simulation room in groups of 4-5, either alone or with a simulation technologist, to engage with the simulated scenario for 15 minutes, under remote supervision of the instructor, after which they return to a plenary room where they are debriefed by the faculty and instructors. Equipment used included an advanced simulation, mid to high fidelity, mannequin, which responds with automated eye movement and illicit perceivable physical findings. However, the instructor simulates the patients’ voice via microphone while observing from a different room through a televised audiovisual monitor (Figure 2). Additionally, the simulated scenario is programmed through software linked to the mannequin and monitoring equipment to control scenario outcome, perceivable findings and vital signs. Other standard equipment available during the scenario including hospital bed, intravenous line access, venous sampling, intravenous fluids, emergency drugs cart, lab results charts, oxygen supply and masks, bedside examination instruments and a defibrillator. The group approaches the scenario as a team without intervention from faculty and instructors to assess the patient, manage and monitor the progress mimicking a real life encounter at hospitals’ urgent care. During debriefing, following a standard learning conversation approach, each student is allowed to express and describe their experience and difficulties faced. Feedback is provided by faculty and instructors to the group following the Pendleton Method [ 41 ]. By employing learners’ self-assessment, The Pendleton model offers a structured way to start a feedback conversation by asking the learner to first identify what went well, followed by the instructor acknowledging then adding specifics. then, both address areas for improvement ultimately ensuring both positives and negatives are covered in a natural dialogue. It creates a safe environment by covering positive before those that should be improved, from the perspective of both the learner and instructor [ 42 ]. At the end of the session, students are then given the opportunity for reflection. Additionally, written student feedback about different aspects of their learning experience is collected anonymously from all students. Faculty and instructors review and deconstruct the information, develop an action plan and implement changes adopting students’ feedback and needs. Thus, ensuring progression through an experiential learning cycle as described by Kolb’s theory [ 43 ]. 2.3. Sampling Participants were selected from the official DMU listing for final year medical students attending College of Medicine who completed their clinical rotation, including all Medical Simulation sessions, using total coverage of all students who were enrolled in the batch during the period from January 2024 to April 2024. The total population size target was 60 comprising final year Medical Students in line with the inclusion criteria. The sample size was 60, which included all students and there were no non-responders. An informed written consent, which was approved by the institutional review board (IRB) and the College of Medicine’s Research Ethics Committee was obtained from each participant through electronic form prior to participation. Ethical approval was sought and granted by DMU’s IRB and the College of Medicine’s Research Ethics Committee. 2.4. Data acquisition Through an electronic based form using Google Forms. A structured face validated questionnaire was sent directly to all medical students to minimize unidentified responses. Through data collectors where part of the university staff, all medical students in the study population have already completed their clinical rotation final year including their end of term exams. This ensured elimination of bias resulting from forced or potential coerced participation in the study. The questionnaire was structured by the authors based on background knowledge with parts adopted with modification from the validated Observational Skill-based Clinical Assessment tool for Resuscitation (OSCAR) and was utilized after simple face validation. The chosen domains were limited to decision making, communication and teamwork tailoring information gathering to the context of the cases encountered and aligning with the study objectives. No further testing nor institutional validation was sought thereafter. Responses were measured using 5-point Likert scale, including the ordinal variables 1:Strongly Disagree, 2:Disagree, 3:Neutral, 4:Agree, 5:Strongly Agree, across all questions. 2.5. The Observational Skill-based Clinical Assessment tool for Resuscitation (OSCAR) The Observational Skill-based Clinical Assessment tool for Resuscitation (OSCAR) was developed to assess non-technical skills, specifically focusing on communication, decision-making, teamwork, and leadership within resuscitation teams, addressing a critical gap in existing assessment tools [ 44 ]. OSCAR underwent a comprehensive three-phase development process, which included a literature review, expert content validation, and thorough reliability assessments, ensuring its clinical relevance. It measures behavioral domains including communication, cooperation, coordination, monitoring, situation awareness, and decision-making, providing detailed feedback on individual team members' performance. Adaptation of the OSCAR for various clinical scenarios allows broader application and further refinement enhance medical education and improve patient safety in medical situations [ 45 ]. 2.6. Data analysis Statistical analysis was done using the SPSS version 29.0 software. Descriptive data analysis was presented as categorical variables, including perception of effective communication, teamwork and decision making skills variables, and demonstrated as frequencies, percentages, and standard deviation (SD). Questions 1 and 2 assess perception to decision making skills, Questions 3 to 8 for communication skills, Questions 9 to 17 for teamwork and Questions 18 to 20 for perception of NTS influence on patient safety and care. Descriptive statistics were used to summarize the data, frequencies and percentages. Further bivariate correlation analysis was employed to determine the level of perception of different non-technical skills and its relation to the perception of its significance in patient care enhancement. Spearman correlation test was utilized, accounting for ordinal variables of 5-points Likert scale used irrespective of distribution normality, with 95% confidence level, and a ‘two tail’ P-value less than 0.05 to be considered as significant. 2.7. Ethical consideration Ethical clearance was obtained from Dubai Medical University’s Institutional Review Board and College of Medicine’s Research Ethics Committee (Code: REC/AY2023/). The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. An informed electronic written consent including consent for publication was obtained from each participant before data collection while ensuring clear confidentiality and anonymity during data collection. 3. Results 3.1. Participant Characteristics and Data Collection Sixty final-year medical students who completed structured simulation-based case scenarios were involved, which comprises total coverage of the entire batch with no missing data and no nonresponses. All participants were females, as the college is exclusive for female students. Data were collected using a 20-Quesntions questionnaire, with responses rated on an ordinal 5-point Likert scale (from 1 = ‘Strongly Disagree’ to 5 = ‘Strongly Agree’). All responses were included in the analysis. Descriptive statistics were used to summarize the data, frequencies provided insights into response distributions (Table 1). Following computed analysis, these variables were further grouped into four constructs representing decision-making (Questions 1-2), communication (Questions 3-8), and teamwork (Questions 9-17). The composite was informed by emphasizing the interplay of these domains in patient care and was statistically validated with a Cronbach’s alpha > 0.8 (Table 2). 3.2. Descriptive Statistics and Frequencies The distribution of responses across individual questions, summarized in (Table 1), revealed high levels of agreement with positive perceptions of NTS and their role in patient safety. Mean scores across all constructs ranged from 4.4685 (teamwork) to 4.5778 (patient safety and care), reflecting consistently strong perceptions of these domains. Standard deviations across constructs were low, ranging from SD (0.71691 to SD 0.75631), indicating limited variability in participant responses. 3.3. Decision-making skills perception: Simulated case scenarios were perceived as beneficial for decision-making (Question 1). When assessing the impact on decision-making skills, a mean score of 4.48 (SD 0.811), with 58.3% of participants strongly agreeing, was recorded (Table 1). Similarly, evaluating the role of deliberate practice, however, revealed a mean score of 4.54 (SD 0.770), with 63.3% strongly agreeing (Question 2). The responses showed a narrow clustering around the mean, reinforcing the effectiveness of structured simulations in enhancing decision-making confidence and competence. 3.4. Communication skills perception: Communication was widely recognized as essential for clinical practice. The strongest agreement was on the importance of communication in clinical reasoning, with 83.3% of participants strongly agreeing, a mean score of 4.54 (SD 0.766) (Question 7) (Table 1). Similarly, the belief that communication is as important as technical skills received 81.7% strong agreement (Question 4). The role of action verbalization in patient care improvement demonstrated 68.3% strongly agreeing (Question 5). This suggests that participants recognize communication as a key factor in understanding clinical problems and enhancing team coordination. 3.5. Teamwork perception: Seeking assistance when needed was an agreed-upon teamwork principle, with 78.3% of participants strongly agreeing and a mean score of 4.47 (SD 0.799) (Question 14) (Table 1). In contrast, the idea that all concerns should be raised regardless of the potential impact received the lowest agreement, with only 38.3% strongly agreeing (Question 16). These findings indicate variability in participants’ confidence in open communication within a team setting. 3.6. Perception of NTS influence on patient safety and care construct: The belief that teamwork enhances patient safety received strong agreement, with 73.3% of participants selecting ‘strongly agree’ (Question 20) (Table 1). Similarly, the perception that effective communication directly contributes to patient safety received 73.3% strong agreement (Question 19). Decision-making skills were also recognized as a crucial factor in patient safety, with 66.7% strongly agreeing and a mean score of 4.58 (SD 0.813) (Question 18). These results highlight participants’ recognition of non-technical skills as direct influencers of patient safety. 3.7. Construct-Level Correlation Analysis Spearman correlation analysis was performed to evaluate the relationships between the three NTS constructs in addition to the perception of their role in patient safety and care construct. This method was chosen due to its suitability for ordinal data and its ability to identify monotonic relationships. Positive correlations were observed across all constructs (Table 3), confirming their influence on patient safety perceptions. Perception of decision-making was moderately correlated with NTS role in patient safety and care perception (Spearman rho = 0.671, p < 0.001). Perception of communication skills had the strongest correlation with NTS role in patient safety and care perception (rho = 0.774, p < 0.001). Moreover, perception of teamwork also demonstrated a strong positive correlation with perception of NTS influence on patient safety and care (rho = 0.760, p < 0.001). 3.8. Response-Level Correlation Analysis To further understand the relationships between perception of specific behaviors related to NTS and their influence on patient safety perception, individual questions were correlated with those pertaining to patient safety and care (Questions 18 to 20). Most were positively and significantly correlated (Table 3). The perception that deliberate practice in simulated teams enhances decision-making showed the strongest correlation with participants' views on its impact on patient safety (ρ = 0.700, p < 0.001) (Question 2) (Table 3). Similarly, the belief that simulated case scenarios improve understanding of decision-making skills demonstrated a moderate correlation (ρ = 0.603, p < 0.001) (Question 1). These findings reinforce the importance of structured practice in developing decision-making competence and its perceived influence on patient safety. Furthermore, the perception that communication enhances role clarity showed a strong correlation with its perceived impact on patient safety and care (ρ = 0.734, p < 0.001) (Question 8) (Table 3). This was followed by the belief that communication is essential for clinical reasoning (ρ = 0.708, p < 0.001), and the significance of paraphrasing instructions (ρ = 0.640, p < 0.001) (Question 6). Similarly, the perception of teamwork’s role in improving flexibility during emergencies exhibited the strongest correlation with its influence on patient care and safety (ρ = 0.851, p < 0.001) (Question 15) (Table 3). Additionally, frequent summarization of patient findings was also fairly correlated with maintaining situational awareness (ρ = 0.655, p < 0.001) (Question 17). These findings underscore the significance of structured communication and teamwork in patient safety improvement. 4. Discussion This study provided insights into the role of simulation-based case scenarios in enhancing non-technical skills (NTS) perception and understating among final-year medical students. The high levels of agreement among participants across all constructs—decision-making, communication, and teamwork—underscore the perceived value of simulation-based medical education (SBME) in fostering these competencies. These findings align with prior research emphasizing the critical importance of NTS for improving patient safety and clinical outcomes [ 35 ]. 4.1. Simulated case scenarios and Non-Technical Skills The study demonstrated that students perceive simulation practice to significantly enhance their communication, decision-making, and teamwork abilities, as reflected in the mean scores across these domains. These findings are consistent with those of a recent qualitative study involving virtual reality (VR) technology in case-based simulation were learners’ confidence and mindfulness in clinical practice was observed in addition to NTS perception [ 46 ]. Though VR is an advanced technology in simulation, its effective yield in that alignment, that has extend to interprofessional training and potential integration into medical curricula, further strengthen the significance of case scenario simulation through advanced mid-high fidelity mannequin, as seen in this study [ 8,47 ]. Moreover, the significant correlation between NTS constructs and their perceived impact on patient safety reinforces the critical role of these skills in clinical care. A recent mixed methods study highlighted a similar correlation through a blended approach of SBME demonstrating an achievable implementation of a non-technical skills with limited simulation resources in association with observable improvements in clinical performance [ 48 ]. Furthermore, the results showed that communication had the strongest correlation with perceptions of NTS’ influence on patient safety (Spearman rho = 0.774, p < 0.001). Though variation in responses were narrow across the constructs, this finding is in agreement with a previous study that emphasized the centrality of communication in ensuring effective teamwork and situational awareness [ 31 ]. Similarly, it was highlighted that participants perceived communication as a core component of NTS that significantly contributes to safe and effective task performance [ 46 ]. In the present study, specific elements of communication, such as verbalization of activities and paraphrasing instructions, were strongly associated with better patient care outcomes. These results underscore the importance of targeted communication training within simulation settings. 4.2. Teamwork and Patient Safety Teamwork emerged as another critical domain with strong correlations to patient safety perceptions (rho = 0.760, p < 0.001). Within this construct, questions addressing role flexibility during emergencies and frequent patient updates by team leaders demonstrated the highest correlations. This aligns with previous findings [ 49 ], who noted that intense simulation programs significantly improve teamwork skills, particularly in areas like situational awareness and task management. Moreover, the effectiveness of team-based simulation training in crisis scenarios, such as airway emergencies, requires high levels of collaboration and coordination [ 35 ]. The structured debriefing sessions in the present study, which followed the Pendleton Model, likely contributed to the development of teamwork skills by fostering reflective practice. This approach is similar to a previous study that demonstrated the role of debriefing in reinforcing behavioral markers of NTS, such as mutual support and shared situational awareness [ 50 ]. These sessions provided participants with actionable feedback on their teamwork performance, which is crucial for translating simulation-based learning into clinical practice. 4.3. Decision-Making and Deliberate Practice The perception of decision-making skills, while showing a moderate correlation with patient safety perceptions (rho = 0.671, p < 0.001), remains a pivotal aspect of NTS development. The findings revealed that deliberate practice in simulated team settings (Question 2) had the strongest correlation with patient safety perceptions within this construct (rho = 0.700, p < 0.001). This supports previous findings that demonstrated the translation of NTS acquired during simulation training into clinical practice, particularly in decision-making and situational awareness [ 51 ]. However, the weak correlation between intrinsic motivation and NTS performance noted in prior research suggesting that instructional design and structured practice play more critical roles in enhancing decision-making skills [ 52 ]. The deliberate practice model employed in the current study, where students participated in multiple scenarios with pre-session briefings and post-session debriefings, appears to have been effective in bridging this gap. Such an approach aligns with other studies that reported that flipped learning methodologies in simulation settings enhance NTS performance by encouraging active engagement and iterative learning [ 33 ]. 4.4. Implications for Curriculum Development The findings of this study highlight the importance of integrating structured simulation-based case scenarios into medical curricula with a scope through NTS enhancement. It was previously established in a multinational randomized controlled trial that case scenario teaching is far more effective that didactics [ 29 ]. Further adaptation into simulation-based medical education has ensured fostering of psychomotor and affective domains, in addition to the cognitive domain, across multiple learning taxonomy dimensions [ 53 ]. This opens the door for NTS teaching through integration to solidify the learning experience in a holistic approach that can positively influence their performance [ 22 ], as similar findings were found in another randomized controlled trial [ 32 ]. Furthermore, the adoption of the Pendleton model for feedback during debriefing in this study, which fosters medical students’ ability for self-assessment, may have played a key role in their level of perception. A recent qualitative evaluation of medical students ‘perception of simulation based assessment found that it enhanced their self-confidence during clinical placements while underscoring the foundational competencies essential for success in their future professional practice [ 17 ]. This underscores the significance of its embedded role within the feedback model adopted. 4.5. Limitations The exclusive focus on female students from a single batch within one institution limited holistic representation of this study findings. Though DMU exclusively accepts female medical students’ enrollment as mentioned previously, the lack of demographic analysis based on ethnicity and background of participants limits the generalizability of results and outcomes encountered. Additionally, the responses showed limited variability, as reflected in the narrow standard deviations across constructs, which indicated homogeneity in participants' perceptions. The reliance on non-normally distributed data, on the other hand, necessitated the use of Spearman’s correlation rather than Pearson’s, which could affect the generalization of results. Furthermore, accounting for variations in intrinsic motivation among participants may have provided a more comprehensive understanding of the impact of simulated case scenarios on NTS development. 5. Conclusion Simulated case scenario sessions positively influence medical students’ understanding and perception of non-technical skills across communication, teamwork, and decision-making. This intern enhances their attention towards the critical role of these skills in improving patient safety and clinical outcomes. Further evaluation of NTS competency among medical students, incorporating emerging technologies such as virtual reality and AI, is warranted. Additionally, longitudinal studies should assess the integration and application of these skills in clinical practice, particularly when they are newly entering hospital settings. Abbreviations SBME : Simulation-based medical education, NTS: Non-technical skills, DMU : Dubai Medical University, SPSS : Statistical Package for the Social Sciences, OSCAR : Observational Skill-based Clinical Assessment tool for Resuscitation, CanMEDS : Canadian Medical Education Directions for Specialists, GMER : Global Minimum Essential Requirements in Medical Education, UAE : United Arab Emirates, MOHESR : Ministry of Higher Education and Scientific Research, CAA : Commission for Academic Accreditation, SD : standard deviation, VR : Virtual Reality. AI: Artificial Intelligence. Declarations Ethical Approval: Ethical clearance was obtained from relevant authorities, namely Dubai Medical University’s Institutional Review Board and College of Medicine’s Research Ethics Committee. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Consent to participate: An informed electronic written consent was obtained from each participant before data collection while ensuring clear confidentiality and anonymity during data collection, as approved by Dubai Medical University’s Institutional Review Board and College of Medicine’s Research Ethics Committee. Consent for publication: An informed electronic written consent including consent for publication was obtained from each participant before data collection while ensuring clear confidentiality and anonymity during data collection, as approved by Dubai Medical University’s Institutional Review Board and College of Medicine’s Research Ethics Committee. Data availability statement: Data sets generated during and/or analyzed during the study are available from the corresponding author on reasonable request. 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. Authors' contributions: M.B.: Conceptualization, methodology, literature review, investigation, data collection, manuscript preparation, manuscript review, editing and approval. S.M: Conceptualization, methodology, literature review, data analysis, table writing, visualization, manuscript preparation, manuscript writing, editing, validation, review and approval. A.B.: Methodology, literature review, investigation, data collection, figure drawing, visualization, manuscript review and approval. Y.Z.: Literature review, investigation, data analysis, visualization, manuscript preparation, editing, review and approval. A.E: Conceptualization, methodology, project administration, supervision, methodology, literature review, investigation, manuscript preparation, review, editing and approval. Acknowledgments: Appreciation towards Dubai Medical University for encouraging research and publication, and to all medical students who participated in this study. Appreciations and thanks to Dr. Fouzia Shersad for her support during the project. References Spencer JA, Jordan RK. Learner centred approaches in medical education. BMJ . 1999;318(7193):1280-1283. doi:10.1136/bmj.318.7193.1280 Royal College of Physicians and Surgeons of Canada. The CanMEDS Framework (2015). https://www.royalcollege.ca/en/standards-and-accreditation/canmeds.html Frank JR, Danoff D. The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. Medical Teacher . 2007;29(7):642-647. doi:10.1080/01421590701746983 Core Committee, Institute for International Medical Education. Global minimum essential requirements in medical education. 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The effectiveness of improving healthcare teams’ human factor skills using simulation-based training: a systematic review. Advances in simulation (London, England) . 2022;7(1):12-12. doi:10.1186/s41077-022-00207-2 McInerney N, Nally D, Khan MF, Heneghan H, Cahill RA. Performance effects of simulation training for medical students - a systematic review. GMS journal for medical education . 2022;39(5):Doc51-Doc51. doi:10.3205/zma001572 Cen XY, Hua Y, Niu S, Yu T. Application of case-based learning in medical student education: a meta-analysis. Eur Rev Med Pharmacol Sci . 2021;25(8):3173-3181. doi:10.26355/eurrev_202104_25726 Martinho B, Ferreira L, Koch MJ, et al. Observational Study About the Impact of Simulation Training of Non-Technical Skills on Teamwork: Towards a Paradigm Shift in Undergraduate Medical Training. Acta medica portuguesa . 2024;37(2):83-89. doi:10.20344/amp.19021 Alluri RK, Tsing P, Lee E, Napolitano J. A randomized controlled trial of high-fidelity simulation versus lecture-based education in preclinical medical students. Medical teacher . 2016;38(4):404-409. doi:10.3109/0142159X.2015.1031734 Glavin RJ. Skills, training, and education. Simulation in healthcare : journal of the Society for Simulation in Healthcare . 2011;6(1):4-7. doi:10.1097/SIH.0b013e31820aa1ee Kerr B, Hawkins TLA, Herman R, et al. Feasibility of scenario-based simulation training versus traditional workshops in continuing medical education: a randomized controlled trial. Medical education online . 2013;18:21312-21312. doi:10.3402/meo.v18i0.21312 Ladkany D, Pastorino A. Curriculum Development in Medical Simulation. In: StatPearls . StatPearls Publishing; 2025. Accessed January 30, 2025. http://www.ncbi.nlm.nih.gov/books/NBK554491/ Li CH, Kuan WS, Mahadevan M, et al. A multinational randomised study comparing didactic lectures with case scenario in a severe sepsis medical simulation course. Emerg Med J . 2012;29(7):559-564. doi:10.1136/emermed-2011-200068 Gaba DM. Training and nontechnical skills: the politics of terminology. Simulation in healthcare : journal of the Society for Simulation in Healthcare . 2011;6(1):8-10. doi:10.1097/SIH.0b013e31820f9a55 O’Connor P, O’Dea A. When I say … non‐technical skills. Medical Education . 2024;58(12):1439-1441. doi:10.1111/medu.15451 Hagemann V, Herbstreit F, Kehren C, et al. Does teaching non-technical skills to medical students improve those skills and simulated patient outcome? International journal of medical education . 2017;8:101-113. doi:10.5116/ijme.58c1.9f0d Moll-Khosrawi P, Zöllner C, Cencin N, Schulte-Uentrop L. Flipped learning enhances non-technical skill performance in simulation-based education: a randomised controlled trial. BMC medical education . 2021;21(1):353-353. doi:10.1186/s12909-021-02766-w Yule S, Parker SH, Wilkinson J, et al. Coaching Non-technical Skills Improves Surgical Residents’ Performance in a Simulated Operating Room. Journal of surgical education . 2015;72(6):1124-1130. doi:10.1016/j.jsurg.2015.06.012 Magill JC, Tolley N. Non-technical Skills Simulation Training. Curr Otorhinolaryngol Rep . 2020;8(1):106-110. doi:10.1007/s40136-020-00269-8 NHS HEalth Education England. Simulation-Based Education in Healthcare: Standards Framework and Guidance (2017) . ASPiH (Association for Simulated Practice in Healthcare) https://aspih.org.uk/wp-content/uploads/2017/07/standards-framework.pdf Oliver N, Edgar S, Mellanby E, May A. The Scottish Simulation ‘KSDP’ Design Framework: a sense-making and ordered approach for building aligned simulation programmes. Adv Simul . 2024;9(1):52. doi:10.1186/s41077-024-00321-3 INACSL Standards Committee. Healthcare Simulation Standards of Best PracticeTM. Clinical Simulation in Nursing . 2021;58:66. doi:10.1016/j.ecns.2021.08.018 Joseph N, Nelliyanil M, Jindal S, et al. Perception of Simulation-based Learning among Medical Students in South India. Annals of medical and health sciences research . 2015;5(4):247-252. doi:10.4103/2141-9248.160186 Varas J, Belmar F, Fuentes J, et al. Improving Medical Student Performance With Unsupervised Simulation and Remote Asynchronous Feedback. Journal of Surgical Education . 2024;81(12):103302. doi:10.1016/j.jsurg.2024.103302 Jug R, Jiang X “Sara”, Bean SM. Giving and Receiving Effective Feedback: A Review Article and How-To Guide. Archives of Pathology & Laboratory Medicine . 2019;143(2):244-250. doi:10.5858/arpa.2018-0058-RA Orsini C, Rodrigues V, Tricio J, Rosel M. Common models and approaches for the clinical educator to plan effective feedback encounters. J Educ Eval Health Prof . 2022;19:35. doi:10.3352/jeehp.2022.19.35 Kolb DA. Experiential Learning: Experience as the Source of Learning and Development . Prentice-Hall; 1984. Higham H, Greig P, Crabtree N, Hadjipavlou G, Young D, Vincent C. A study of validity and usability evidence for non-technical skills assessment tools in simulated adult resuscitation scenarios. BMC medical education . 2023;23(1):153-153. doi:10.1186/s12909-023-04108-4 Walker S, Brett S, McKay A, Lambden S, Vincent C, Sevdalis N. Observational Skill-based Clinical Assessment tool for Resuscitation (OSCAR): development and validation. Resuscitation . 2011;82(7):835-844. doi:10.1016/j.resuscitation.2011.03.009 Peddle M. Participant perceptions of virtual simulation to develop non-technical skills in health professionals. Journal of Research in Nursing . 2019;24(3-4):167-180. doi:10.1177/1744987119835873 Hamer JD, Nayyar R, Yarlaggadda S, et al. Interprofessional quality improvement simulation: A virtual simulation activity for geographically distributed learners. Journal of Interprofessional Education & Practice . 2025;38:100737. doi:10.1016/j.xjep.2024.100737 Coggins A, Desai M, Nguyen K, Moore N. Early acquisition of non-technical skills using a blended approach to simulation-based medical education. Advances in simulation (London, England) . 2017;2:12-12. doi:10.1186/s41077-017-0045-2 Martinou E, Chindambaran R, Krishnasamy G, et al. Simulation in undergraduate medical education: Designing a programme to improve medical students’ non-technical skills. International Journal of Surgery . 2015;23:S102. doi:10.1016/j.ijsu.2015.07.477 Prydz K, Dieckmann P, Fagertun H, Musson D, Wisborg T. Non-technical skills of Norwegian medical students at different training sites: a comparative, observational cohort study. BMC medical education . 2024;24(1):616-616. doi:10.1186/s12909-024-05597-7 Upadya P. Board 436 - Research Abstract Evaluation of Non-Technical Skills in Residency Candidates by Medical Students Versus Professional Facilitators (Submission #1284). Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare . 2013;8(6):601. doi:10.1097/01.SIH.0000441688.95804.62 Schulte-Uentrop L, Cronje JS, Zöllner C, Kubitz JC, Sehner S, Moll-Khosrawi P. Correlation of medical students’ situational motivation and performance of non-technical skills during simulation-based emergency training. BMC Med Educ . 2020;20(1):351. doi:10.1186/s12909-020-02247-6 Chiniara G, Cole G, Brisbin K, et al. Simulation in healthcare: A taxonomy and a conceptual framework for instructional design and media selection. Medical Teacher . 2013;35(8):e1380-e1395. doi:10.3109/0142159X.2012.733451 Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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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-6022596","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":415799667,"identity":"9493b456-25bd-451c-a148-b1346b693c56","order_by":0,"name":"Momna Basher","email":"","orcid":"","institution":"Dubai Medical University","correspondingAuthor":false,"prefix":"","firstName":"Momna","middleName":"","lastName":"Basher","suffix":""},{"id":415799670,"identity":"48b26f2c-8658-4bc0-b965-19e9c2ff3f51","order_by":1,"name":"Sami Mohamed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArklEQVRIiWNgGAWjYJCCAwwMNgwMEiRqSSNRCxAcJkGLfPvpxAM/c84n9s9uPviAocYmmqAWgzO5Gw72brudOOPOsWQDhmNpuQ0EtTDkbjjMCNTScCPHTIKx4TBhLfL9b0FaziXOJ1oLww2wLQcSNxCtxeDGW5Bfko033khLNkggxi/y/bmbP/zcZic770bywQcfamyIcBgUOIJVJhCrHATsSVE8CkbBKBgFIwwAABT3SAXI6gi1AAAAAElFTkSuQmCC","orcid":"","institution":"Dubai Medical University","correspondingAuthor":true,"prefix":"","firstName":"Sami","middleName":"","lastName":"Mohamed","suffix":""},{"id":415799672,"identity":"87b222e5-2295-45e2-be7c-f630843f6e6f","order_by":2,"name":"Amina Begum","email":"","orcid":"","institution":"Dubai Medical University","correspondingAuthor":false,"prefix":"","firstName":"Amina","middleName":"","lastName":"Begum","suffix":""},{"id":415799675,"identity":"129ea9c4-a7c1-4ac7-a27f-1c9084409526","order_by":3,"name":"Youness Zidoun","email":"","orcid":"","institution":"Dubai Medical University","correspondingAuthor":false,"prefix":"","firstName":"Youness","middleName":"","lastName":"Zidoun","suffix":""},{"id":415799677,"identity":"f3feeac6-a9eb-4d0b-ae76-6aa8d4e5943b","order_by":4,"name":"Ali El Houni","email":"","orcid":"","institution":"Dubai Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"El","lastName":"Houni","suffix":""}],"badges":[],"createdAt":"2025-02-13 11:23:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6022596/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6022596/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":76576461,"identity":"25d513dd-ab27-45c6-b470-503635a04ef1","added_by":"auto","created_at":"2025-02-18 14:17:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":96382,"visible":true,"origin":"","legend":"\u003cp\u003eThe Simulation Session Flow Chart showing Sequential cyclical Steps from Pre-Learning to feedback review and implementation\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6022596/v1/f8147014d8edaec53fc46c61.png"},{"id":76576459,"identity":"f56782b9-f107-457c-9e7f-b3e684a92337","added_by":"auto","created_at":"2025-02-18 14:17:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":120279,"visible":true,"origin":"","legend":"\u003cp\u003eThe simulation session structure layout showing spatial organization of key training areas\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6022596/v1/e13f46390fff2dd8d92f8c91.png"},{"id":76577707,"identity":"577a1c73-45e9-40a6-862f-c2ab5dd09f01","added_by":"auto","created_at":"2025-02-18 14:25:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":731772,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6022596/v1/ae6f569a-e201-43a9-b09c-55eddf832557.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Advanced Simulated Case Scenarios on Medical Students' Perception of Non-Technical Skills: A Cross-Sectional Study","fulltext":[{"header":"1.\tIntroduction","content":"\u003cp\u003eHealth professions education is undergoing rapid transformation, with increasing emphasis on active, learner-centered strategies to address the growing complexity of clinical practice and patient safety requirements [\u003csup\u003e1\u003c/sup\u003e]. In line with evolving international frameworks for medical education, such as the Canadian Medical Education Directions for Specialists (CanMEDS) adopted by the Royal College of Physicians and Surgeons of Canada [\u003csup\u003e2,3\u003c/sup\u003e] and the Global Minimum Essential Requirements in Medical Education (GMER) [\u003csup\u003e4\u003c/sup\u003e], the United Arab Emirates\u0026rsquo; (UAE) Ministry of Higher Education and Scientific Research (MOHESR) has developed and recently released the Emirates Competency Framework for Medical Education (EniratesMEDS), which highlights the importance of patient care provision and health advocacy, effective communication and collaboration, innovation and leadership as key parts of their thematic roles [\u003csup\u003e5\u003c/sup\u003e]. These competencies are adopted as means to enhance both technical and non-technical skills, and can potentially be reinforced through simulation based medical education (SBME) to replicate clinical environments, thereby further advancing immersive learning and reflective practice [\u003csup\u003e6\u0026ndash;8\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.1. Significance of Simulation-Based Medical Education\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSBME leverages diverse modalities, ranging from simple simulated environments to advanced simulations, in additions to technologies utilizing high-fidelity mannequins, virtual reality and AI, ultimately creating a safe learning spaces in which students can practice and refine essential clinical skills, both technical and non-technical, that align with a patient-centered care approach [\u003csup\u003e9\u0026ndash;11\u003c/sup\u003e]. Moreover, integration of hands-on experience with timely feedback and structured debriefing can help in bridging the gap between theoretical knowledge and clinical application [\u003csup\u003e12\u003c/sup\u003e]. Studies have demonstrated that, in addition to improving knowledge retention, this approach can enhance learners\u0026rsquo; confidence and reduce anxiety when transitioning to clinical settings [\u003csup\u003e13\u003c/sup\u003e]. Furthermore, a recent study found that resuscitation simulation significantly improved medical students\u0026rsquo; diagnostic, therapeutic as well as team-related competencies following targeted sessions [\u003csup\u003e14,15\u003c/sup\u003e]. This aligns with a broader consensus asserting SBME as an educational strategy that is able to facilitate complex skill development across multiple domains [\u003csup\u003e6\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eFurthermore, SBME enables iterative, deliberate practice without jeopardizing patient safety, an aspect that is especially relevant in complex scenarios such as emergency medicine, trauma care, and obstetrics [\u003csup\u003e16\u003c/sup\u003e]. Additionally, simulation-based assessments are gradually being adopted to evaluate both technical competencies and broader professional capabilities in undergraduate and postgraduate medical education [\u003csup\u003e17\u003c/sup\u003e]. While SBME\u0026rsquo;s positive influence on knowledge, performance, and immediate skill acquisition is well documented [\u003csup\u003e18,19\u003c/sup\u003e], prior research also emphasizes the need for continuous follow-up to assess longer-term skill retention and real-world transferability [\u003csup\u003e20\u003c/sup\u003e]. However, evidence suggests that SBME has capacity to improve a range of learning outcomes extending to the understanding and implementation of non-technical skills, therefore underscoring its vital place medical education [\u003csup\u003e21,22\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.2. Case-Based Scenarios\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCase-based learning is an effective educational strategy, promoting active problem-solving, critical thinking, and integrative reasoning. Within SBME, case-based scenarios replicate clinical realities by introducing clinical vignettes that require learners to synthesize knowledge, interpret findings and employ complex decision-making in real time [\u003csup\u003e23\u003c/sup\u003e]. These scenarios can range from emergency-based patient encounters to chronic disease management and follow up. By simulating relevant case material, students can practice clinical reasoning and refine their patient management strategies while enhancing their understanding the significance of teamwork, decision making and effective communication in an environment that mimics the cognitive demands of hospital based patient care [\u003csup\u003e13,24\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eIntegrating simulation into case-based scenario teaching helps students maintain a high level of engagement while enhancing both immediate knowledge gains and the application of this knowledge in subsequent clinical tasks [\u003csup\u003e25\u0026ndash;27\u003c/sup\u003e]. Moreover, advance technologies such as video-based, augmented reality and virtual reality integrated case scenarios have recently shown to help learners to visualize complex procedures and receive real-time feedback [\u003csup\u003e7,8\u003c/sup\u003e]. Simultaneously, interactive debriefings encourage reflective practice, reinforcing the importance of teamwork, communication, and leadership [\u003csup\u003e12,15\u003c/sup\u003e]. Case-based SBME is, therefore, a specialized educational strategy that contribute to NTS growth by helping medical students internalize sound application of their knowledge, skills and attitude through a holistic approach that didactics lack [\u003csup\u003e28,29\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.3. Non-Technical Skills and Their Significance in Patient Care\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNon-technical skills (NTS) encompass a range of cognitive, social, and personal resource management competencies, such as communication, leadership, teamwork, and decision-making [\u003csup\u003e26,30,31\u003c/sup\u003e]. These skills have been increasingly recognized as pivotal in preventing medical errors, which often arise from breakdowns in teamwork or communication rather than a lack of technical proficiency. Thus making its training and development an essential part of patient safety and high-quality care [\u003csup\u003e11,32\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eRecent findings suggest that SBME is particularly well-suited for enhancing NTS in medical students [\u003csup\u003e16,24,33\u003c/sup\u003e]. Simulation creates realistic team-based scenarios, such as emergency patients\u0026rsquo; encounters, where students coordinate tasks, allocate roles, and practice situational awareness in a safe setting [\u003csup\u003e34\u003c/sup\u003e]. It has been demonstrated that learners exposed to targeted NTS training show improvements in communication, leadership, and decision making skills, which in turn correlates with better clinical outcomes and greater efficiency in patient management [\u003csup\u003e33\u003c/sup\u003e]. Moreover, debriefing sessions that focus specifically on behavioral markers of NTS can produce measurable gains in performance, thus bridging a critical gap in conventional curricula that traditionally scoped through procedural and technical competencies [\u003csup\u003e35\u003c/sup\u003e]. This has led to the development of standardized frameworks and guidelines for simulation-based education in healthcare, such as the Healthcare Simulation Standards of Best Practice [\u003csup\u003e36\u0026ndash;38\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eDespite the growing consensus on the benefits of SBME for both technical and non-technical skills development, examining how simulated case scenarios enhance medical students\u0026rsquo; perceptions of their communication, decision-making, and teamwork competencies is still undergoing refinement [\u003csup\u003e6,7,19,21,27,29\u003c/sup\u003e]. Additionally, while immediate learning gains are evident, the impact of simulated case scenarios on medical students\u0026rsquo; comprehension of NTS in enhancing patient care offers a foundational opportunity for early development before clinical practice. [\u003csup\u003e19,34,39\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eThis study, therefore, intends to examine the impact of simulation-based case scenarios on medical students\u0026rsquo; perceptions of different aspects of non-technical skills, including communication proficiency, decision-making, and teamwork, while exploring how students view the role of NTS in enhancing patient care. This integrated approach through dimensions of case scenarios, advanced simulation modalities, structured debriefing and NTS, offers a comprehensive perspective to this educational strategy.\u003c/p\u003e"},{"header":"2.\tMethods","content":"\u003cp\u003e\u003cem\u003e2.1. Study Design\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis was a cross-sectional observational university-based study conducted at Dubai Medical University (DMU), Department of Clinical Sciences in Dubai, United Arab Emirates. The study population included final year medical students at the end of their clinical rotation years. Official enrollment in the final year and completion of clinical rotation, where simulation based education sessions took place, in addition to active participation in all simulation based case scenario sessions was set as inclusion criteria. Those who did not fully participate in all simulated case scenarios, or did not consent to participate, were excluded. DMU is open for both national and diverse international students and is exclusive for female students. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines were followed during preparation of the study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.2. Simulated case scenarios methodology and educational strategies\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDuring their clinical rotation years, final year medical students participate in weekly medical simulation sessions within the division of internal medicine, this includes core clinical skills such as history taking and clinical examination, in addition to skills teaching of interpretation and simulated case scenarios as part of the curriculum. Simulated case scenarios span a total of five sessions, out of 18 total sessions delivered by the faculty for each subgroup of students in an equipped advance simulation unit. Session contents are based on approved learning objectives mapped with program learning outcomes that align with the UAE\u0026rsquo;s Competency Framework set by the Commission for Academic Accreditation (CAA) of the Ministry of Higher Education and Scientific Research (MOHESR) [\u003csup\u003e5\u003c/sup\u003e]. Scenarios include cases based on Cardiovascular (Chest pain), Respiratory (Shortness of Breath), Neurology (Stroke) and Endocrinology (Diabetic Ketoacidosis, Hypoglycemia) encounters in urgent patient care setting. However, scenarios involve deteriorating patients and do not include managing patients with cardiac arrest.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Construction of the simulation session was based on competency framework, evidence-based simulation in health care standard in addition to recently studied educational strategies [\u003csup\u003e15,36\u0026ndash;38,40\u003c/sup\u003e]. The simulation session flow chart and structure are outlined in (Figure 1) and (Figure 2) respectively.\u003c/p\u003e\n\u003cp\u003eStudents are provided with pre-learning materials for study prior to the session. At the start of the session, students are briefed by the faculty and instructors about learning objectives and scenario content, then they approach the simulation room in groups of 4-5, either alone or with a simulation technologist, to engage with the simulated scenario for 15 minutes, under remote supervision of the instructor, after which they return to a plenary room where they are debriefed by the faculty and instructors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEquipment used included an advanced simulation, mid to high fidelity, mannequin, which responds with automated eye movement and illicit perceivable physical findings. However, the instructor simulates the patients\u0026rsquo; voice via microphone while observing from a different room through a televised audiovisual monitor (Figure 2). Additionally, the simulated scenario is programmed through software linked to the mannequin and monitoring equipment to control scenario outcome, perceivable findings and vital signs. Other standard equipment available during the scenario including hospital bed, intravenous line access, venous sampling, intravenous fluids, emergency drugs cart, lab results charts, oxygen supply and masks, bedside examination instruments and a defibrillator.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe group approaches the scenario as a team without intervention from faculty and instructors to assess the patient, manage and monitor the progress mimicking a real life encounter at hospitals\u0026rsquo; urgent care. During debriefing, following a standard learning conversation approach, each student is allowed to express and describe their experience and difficulties faced. Feedback is provided by faculty and instructors to the group following the Pendleton Method [\u003csup\u003e41\u003c/sup\u003e]. By employing learners\u0026rsquo; self-assessment, The Pendleton model offers a structured way to start a feedback conversation by asking the learner to first identify what went well, followed by the instructor acknowledging then adding specifics. then, both address areas for improvement ultimately ensuring both positives and negatives are covered in a natural dialogue. It creates a safe environment by covering positive before those that should be improved, from the perspective of both the learner and instructor [\u003csup\u003e42\u003c/sup\u003e].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt the end of the session, students are then given the opportunity for reflection. Additionally, written student feedback about different aspects of their learning experience is collected anonymously from all students. Faculty and instructors review and deconstruct the information, develop an action plan and implement changes adopting students\u0026rsquo; feedback and needs. Thus, ensuring progression through an experiential learning cycle as described by Kolb\u0026rsquo;s theory [\u003csup\u003e43\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.3. Sampling\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were selected from the official DMU listing for final year medical students attending College of Medicine who completed their clinical rotation, including all Medical Simulation sessions, using total coverage of all students who were enrolled in the batch during the period from January 2024 to April 2024. The total population size target was 60 comprising final year Medical Students in line with the inclusion criteria. The sample size was 60, which included all students and there were no non-responders. An informed written consent, which was approved by the institutional review board (IRB) and the College of Medicine\u0026rsquo;s Research Ethics Committee was obtained from each participant through electronic form prior to participation. Ethical approval was sought and granted by DMU\u0026rsquo;s IRB and the College of Medicine\u0026rsquo;s Research Ethics Committee.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.4. Data acquisition\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThrough an electronic based form using Google Forms. A structured face validated questionnaire was sent directly to all medical students to minimize unidentified responses. Through data collectors where part of the university staff, all medical students in the study population have already completed their clinical rotation final year including their end of term exams. This ensured elimination of bias resulting from forced or potential coerced participation in the study. The questionnaire was structured by the authors based on background knowledge with parts adopted with modification from the validated Observational Skill-based Clinical Assessment tool for Resuscitation (OSCAR) and was utilized after simple face validation. The chosen domains were limited to decision making, communication and teamwork tailoring information gathering to the context of the cases encountered and aligning with the study objectives. No further testing nor institutional validation was sought thereafter. Responses were measured using 5-point Likert scale, including the ordinal variables 1:Strongly Disagree, 2:Disagree, 3:Neutral, 4:Agree, 5:Strongly Agree, across all questions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.5. The Observational Skill-based Clinical Assessment tool for Resuscitation (OSCAR)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Observational Skill-based Clinical Assessment tool for Resuscitation (OSCAR) was developed to assess non-technical skills, specifically focusing on communication, decision-making, teamwork, and leadership within resuscitation teams, addressing a critical gap in existing assessment tools [\u003csup\u003e44\u003c/sup\u003e]. OSCAR underwent a comprehensive three-phase development process, which included a literature review, expert content validation, and thorough reliability assessments, ensuring its clinical relevance. It measures behavioral domains including communication, cooperation, coordination, monitoring, situation awareness, and decision-making, providing detailed feedback on individual team members\u0026apos; performance. Adaptation of the OSCAR for various clinical scenarios allows broader application and further refinement enhance medical education and improve patient safety in medical situations [\u003csup\u003e45\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.6. Data analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Statistical analysis was done using the SPSS version 29.0 software. Descriptive data analysis was presented as categorical variables, including perception of effective communication, teamwork and decision making skills variables, and demonstrated as frequencies, percentages, and standard deviation (SD). Questions 1 and 2 assess perception to decision making skills, Questions 3 to 8 for communication skills, Questions 9 to 17 for teamwork and Questions 18 to 20 for perception of NTS influence on patient safety and care. Descriptive statistics were used to summarize the data, frequencies and percentages.\u003c/p\u003e\n\u003cp\u003eFurther bivariate correlation analysis was employed to determine the level of perception of different non-technical skills and its relation to the perception of its significance in patient care enhancement. Spearman correlation test was utilized, accounting for ordinal variables of 5-points Likert scale used irrespective of distribution normality, with 95% confidence level, and a \u0026lsquo;two tail\u0026rsquo; P-value less than 0.05 to be considered as significant.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.7. Ethical consideration\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from Dubai Medical University\u0026rsquo;s Institutional Review Board and College of Medicine\u0026rsquo;s Research Ethics Committee (Code: REC/AY2023/). The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. An informed electronic written consent including consent for publication was obtained from each participant before data collection while ensuring clear confidentiality and anonymity during data collection.\u003c/p\u003e"},{"header":"3.\tResults","content":"\u003cp\u003e\u003cem\u003e3.1. Participant Characteristics and Data Collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSixty final-year medical students who completed structured simulation-based case scenarios were involved, which comprises total coverage of the entire batch with no missing data and no nonresponses. All participants were females, as the college is exclusive for female students. Data were collected using a 20-Quesntions questionnaire, with responses rated on an ordinal 5-point Likert scale (from 1 = \u0026lsquo;Strongly Disagree\u0026rsquo; to 5 = \u0026lsquo;Strongly Agree\u0026rsquo;). All responses were included in the analysis. Descriptive statistics were used to summarize the data, frequencies provided insights into response distributions (Table 1). Following computed analysis, these variables were further grouped into four constructs representing decision-making (Questions 1-2), communication (Questions 3-8), and teamwork (Questions 9-17). The composite was informed by emphasizing the interplay of these domains in patient care and was statistically validated with a Cronbach\u0026rsquo;s alpha \u0026gt; 0.8 (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.2. Descriptive Statistics and Frequencies\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe distribution of responses across individual questions, summarized in (Table 1), revealed high levels of agreement with positive perceptions of NTS and their role in patient safety. Mean scores across all constructs ranged from 4.4685 (teamwork) to 4.5778 (patient safety and care), reflecting consistently strong perceptions of these domains. Standard deviations across constructs were low, ranging from SD (0.71691 to SD 0.75631), indicating limited variability in participant responses.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.3. Decision-making skills perception:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSimulated case scenarios were perceived as beneficial for decision-making (Question 1). When assessing the impact on decision-making skills, a mean score of 4.48 (SD 0.811), with 58.3% of participants strongly agreeing, was recorded (Table 1). Similarly, evaluating the role of deliberate practice, however, revealed a mean score of 4.54 (SD 0.770), with 63.3% strongly agreeing (Question 2). The responses showed a narrow clustering around the mean, reinforcing the effectiveness of structured simulations in enhancing decision-making confidence and competence.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.4. Communication skills perception:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCommunication was widely recognized as essential for clinical practice. The strongest agreement was on the importance of communication in clinical reasoning, with 83.3% of participants strongly agreeing, a mean score of 4.54 (SD 0.766) (Question 7) (Table 1). Similarly, the belief that communication is as important as technical skills received 81.7% strong agreement (Question 4). The role of action verbalization in patient care improvement demonstrated 68.3% strongly agreeing (Question 5). This suggests that participants recognize communication as a key factor in understanding clinical problems and enhancing team coordination.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.5. Teamwork perception:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeeking assistance when needed was an agreed-upon teamwork principle, with 78.3% of participants strongly agreeing and a mean score of 4.47 (SD 0.799) (Question 14) (Table 1). In contrast, the idea that all concerns should be raised regardless of the potential impact received the lowest agreement, with only 38.3% strongly agreeing (Question 16). These findings indicate variability in participants\u0026rsquo; confidence in open communication within a team setting.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.6. Perception of NTS influence on patient safety and care construct:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe belief that teamwork enhances patient safety received strong agreement, with 73.3% of participants selecting \u0026lsquo;strongly agree\u0026rsquo; (Question 20) (Table 1). Similarly, the perception that effective communication directly contributes to patient safety received 73.3% strong agreement (Question 19). Decision-making skills were also recognized as a crucial factor in patient safety, with 66.7% strongly agreeing and a mean score of 4.58 (SD 0.813) (Question 18). These results highlight participants\u0026rsquo; recognition of non-technical skills as direct influencers of patient safety.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.7. Construct-Level Correlation Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSpearman correlation analysis was performed to evaluate the relationships between the three NTS constructs in addition to the perception of their role in patient safety and care construct. This method was chosen due to its suitability for ordinal data and its ability to identify monotonic relationships. Positive correlations were observed across all constructs (Table 3), confirming their influence on patient safety perceptions. Perception of decision-making was moderately correlated with NTS role in patient safety and care perception (Spearman rho = 0.671, p \u0026lt; 0.001). Perception of communication skills had the strongest correlation with NTS role in patient safety and care perception (rho = 0.774, p \u0026lt; 0.001). Moreover, perception of teamwork also demonstrated a strong positive correlation with perception of NTS influence on patient safety and care (rho = 0.760, p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.8. Response-Level Correlation Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo further understand the relationships between perception of specific behaviors related to NTS and their influence on patient safety perception, individual questions were correlated with those pertaining to patient safety and care (Questions 18 to 20). Most were positively and significantly correlated (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe perception that deliberate practice in simulated teams enhances decision-making showed the strongest correlation with participants\u0026apos; views on its impact on patient safety (\u0026rho; = 0.700, p \u0026lt; 0.001) (Question 2) (Table 3). Similarly, the belief that simulated case scenarios improve understanding of decision-making skills demonstrated a moderate correlation (\u0026rho; = 0.603, p \u0026lt; 0.001) (Question 1). These findings reinforce the importance of structured practice in developing decision-making competence and its perceived influence on patient safety.\u003c/p\u003e\n\u003cp\u003eFurthermore, the perception that communication enhances role clarity showed a strong correlation with its perceived impact on patient safety and care (\u0026rho; = 0.734, p \u0026lt; 0.001) (Question 8) (Table 3). This was followed by the belief that communication is essential for clinical reasoning (\u0026rho; = 0.708, p \u0026lt; 0.001), and the significance of paraphrasing instructions (\u0026rho; = 0.640, p \u0026lt; 0.001) (Question 6).\u003c/p\u003e\n\u003cp\u003eSimilarly, the perception of teamwork\u0026rsquo;s role in improving flexibility during emergencies exhibited the strongest correlation with its influence on patient care and safety (\u0026rho; = 0.851, p \u0026lt; 0.001) (Question 15) (Table 3). Additionally, frequent summarization of patient findings was also fairly correlated with maintaining situational awareness (\u0026rho; = 0.655, p \u0026lt; 0.001) (Question 17). These findings underscore the significance of structured communication and teamwork in patient safety improvement.\u0026nbsp;\u003c/p\u003e"},{"header":"4.\tDiscussion","content":"\u003cp\u003eThis study provided insights into the role of simulation-based case scenarios in enhancing non-technical skills (NTS) perception and understating among final-year medical students. The high levels of agreement among participants across all constructs\u0026mdash;decision-making, communication, and teamwork\u0026mdash;underscore the perceived value of simulation-based medical education (SBME) in fostering these competencies. These findings align with prior research emphasizing the critical importance of NTS for improving patient safety and clinical outcomes [\u003csup\u003e35\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.1.\u0026nbsp; Simulated case scenarios and Non-Technical Skills\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study demonstrated that students perceive simulation practice to significantly enhance their communication, decision-making, and teamwork abilities, as reflected in the mean scores across these domains. These findings are consistent with those of a recent qualitative study involving virtual reality (VR) technology in case-based simulation were learners\u0026rsquo; confidence and mindfulness in clinical practice was observed in addition to NTS perception [\u003csup\u003e46\u003c/sup\u003e]. Though VR is an advanced technology in simulation, its effective yield in that alignment, that has extend to interprofessional training and potential integration into medical curricula, further strengthen the significance of case scenario simulation through advanced mid-high fidelity mannequin, as seen in this study [\u003csup\u003e8,47\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Moreover, the significant correlation between NTS constructs and their perceived impact on patient safety reinforces the critical role of these skills in clinical care. A recent mixed methods study highlighted a similar correlation through a blended approach of SBME demonstrating an achievable implementation of a non-technical skills with limited simulation resources in association with observable improvements in clinical performance [\u003csup\u003e48\u003c/sup\u003e].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, the results showed that communication had the strongest correlation with perceptions of NTS\u0026rsquo; influence on patient safety (Spearman rho = 0.774, p \u0026lt; 0.001). Though variation in responses were narrow across the constructs, this finding is in agreement with a previous study that emphasized the centrality of communication in ensuring effective teamwork and situational awareness [\u003csup\u003e31\u003c/sup\u003e]. Similarly, it was highlighted that participants perceived communication as a core component of NTS that significantly contributes to safe and effective task performance [\u003csup\u003e46\u003c/sup\u003e]. In the present study, specific elements of communication, such as verbalization of activities and paraphrasing instructions, were strongly associated with better patient care outcomes. These results underscore the importance of targeted communication training within simulation settings.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.2. Teamwork and Patient Safety\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTeamwork emerged as another critical domain with strong correlations to patient safety perceptions (rho = 0.760, p \u0026lt; 0.001). Within this construct, questions addressing role flexibility during emergencies and frequent patient updates by team leaders demonstrated the highest correlations. This aligns with previous findings [\u003csup\u003e49\u003c/sup\u003e], who noted that intense simulation programs significantly improve teamwork skills, particularly in areas like situational awareness and task management. Moreover, the effectiveness of team-based simulation training in crisis scenarios, such as airway emergencies, requires high levels of collaboration and coordination [\u003csup\u003e35\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eThe structured debriefing sessions in the present study, which followed the Pendleton Model, likely contributed to the development of teamwork skills by fostering reflective practice. This approach is similar to a previous study that demonstrated the role of debriefing in reinforcing behavioral markers of NTS, such as mutual support and shared situational awareness [\u003csup\u003e50\u003c/sup\u003e]. These sessions provided participants with actionable feedback on their teamwork performance, which is crucial for translating simulation-based learning into clinical practice.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.3. Decision-Making and Deliberate Practice\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe perception of decision-making skills, while showing a moderate correlation with patient safety perceptions (rho = 0.671, p \u0026lt; 0.001), remains a pivotal aspect of NTS development. The findings revealed that deliberate practice in simulated team settings (Question 2) had the strongest correlation with patient safety perceptions within this construct (rho = 0.700, p \u0026lt; 0.001). This supports previous findings that demonstrated the translation of NTS acquired during simulation training into clinical practice, particularly in decision-making and situational awareness [\u003csup\u003e51\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eHowever, the weak correlation between intrinsic motivation and NTS performance noted in prior research suggesting that instructional design and structured practice play more critical roles in enhancing decision-making skills [\u003csup\u003e52\u003c/sup\u003e]. The deliberate practice model employed in the current study, where students participated in multiple scenarios with pre-session briefings and post-session debriefings, appears to have been effective in bridging this gap. Such an approach aligns with other studies that reported that flipped learning methodologies in simulation settings enhance NTS performance by encouraging active engagement and iterative learning [\u003csup\u003e33\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.4. Implications for Curriculum Development\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe findings of this study highlight the importance of integrating structured simulation-based case scenarios into medical curricula with a scope through NTS enhancement. It was previously established in a multinational randomized controlled trial that case scenario teaching is far more effective that didactics [\u003csup\u003e29\u003c/sup\u003e]. Further adaptation into simulation-based medical education has ensured fostering of psychomotor and affective domains, in addition to the cognitive domain, across multiple learning taxonomy dimensions [\u003csup\u003e53\u003c/sup\u003e]. This opens the door for NTS teaching through integration to solidify the learning experience in a holistic approach that can positively influence their performance [\u003csup\u003e22\u003c/sup\u003e], as similar findings were found in another randomized controlled trial [\u003csup\u003e32\u003c/sup\u003e]. Furthermore, the adoption of the Pendleton model for feedback during debriefing in this study, which fosters medical students\u0026rsquo; ability for self-assessment, may have played a key role in their level of perception. A recent qualitative evaluation of medical students \u0026lsquo;perception of simulation based assessment found that it enhanced their self-confidence during clinical placements while underscoring the foundational competencies essential for success in their future professional practice [\u003csup\u003e17\u003c/sup\u003e]. This underscores the significance of its embedded role within the feedback model adopted.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.5. Limitations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe exclusive focus on female students from a single batch within one institution limited holistic representation of this study findings. Though DMU exclusively accepts female medical students\u0026rsquo; enrollment as mentioned previously, \u0026nbsp;the lack of demographic analysis based on ethnicity and background of participants limits the generalizability of results and outcomes encountered. Additionally, the responses showed limited variability, as reflected in the narrow standard deviations across constructs, which indicated homogeneity in participants\u0026apos; perceptions. The reliance on non-normally distributed data, on the other hand, necessitated the use of Spearman\u0026rsquo;s correlation rather than Pearson\u0026rsquo;s, which could affect the generalization of results. Furthermore, accounting for variations in intrinsic motivation among participants may have provided a more comprehensive understanding of the impact of simulated case scenarios on NTS development.\u003c/p\u003e"},{"header":"5.\tConclusion","content":"\u003cp\u003eSimulated case scenario sessions positively influence medical students\u0026rsquo; understanding and perception of non-technical skills across communication, teamwork, and decision-making. This intern enhances their attention towards the critical role of these skills in improving patient safety and clinical outcomes. Further evaluation of NTS competency among medical students, incorporating emerging technologies such as virtual reality and AI, is warranted. Additionally, longitudinal studies should assess the integration and application of these skills in clinical practice, particularly when they are newly entering hospital settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eSBME\u003c/strong\u003e: Simulation-based medical education, \u003cstrong\u003eNTS:\u0026nbsp;\u003c/strong\u003eNon-technical skills, \u003cstrong\u003eDMU\u003c/strong\u003e: Dubai Medical University, \u003cstrong\u003eSPSS\u003c/strong\u003e: Statistical Package for the Social Sciences, \u003cstrong\u003eOSCAR\u003c/strong\u003e: Observational Skill-based Clinical Assessment tool for Resuscitation, \u003cstrong\u003eCanMEDS\u003c/strong\u003e: Canadian\u0026nbsp;Medical Education Directions for Specialists, \u003cstrong\u003eGMER\u003c/strong\u003e: Global Minimum Essential Requirements in Medical Education, \u003cstrong\u003eUAE\u003c/strong\u003e: United Arab Emirates, \u003cstrong\u003eMOHESR\u003c/strong\u003e: Ministry of Higher Education and Scientific Research, \u003cstrong\u003eCAA\u003c/strong\u003e: Commission for Academic Accreditation, \u003cstrong\u003eSD\u003c/strong\u003e: standard deviation, \u003cstrong\u003eVR\u003c/strong\u003e: Virtual Reality. AI: Artificial Intelligence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from relevant authorities, namely Dubai Medical University\u0026rsquo;s Institutional Review Board and College of Medicine\u0026rsquo;s Research Ethics Committee. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn informed electronic written consent was obtained from each participant before data collection while ensuring clear confidentiality and anonymity during data collection, as approved by Dubai Medical University\u0026rsquo;s Institutional Review Board and College of Medicine\u0026rsquo;s Research Ethics Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn informed electronic written consent including consent for publication was obtained from each participant before data collection while ensuring clear confidentiality and anonymity during data collection, as approved by Dubai Medical University\u0026rsquo;s Institutional Review Board and College of Medicine\u0026rsquo;s Research Ethics Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sets generated during and/or analyzed during the study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\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\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.B.: Conceptualization, methodology, literature review, investigation, data collection, manuscript preparation, manuscript review, editing and approval. S.M: Conceptualization, methodology, literature review, data analysis, table writing, visualization, manuscript preparation, manuscript writing, editing, validation, review and approval. A.B.: Methodology, literature review, investigation, data collection, figure drawing, visualization, manuscript review and approval. Y.Z.: Literature review, investigation, data analysis, visualization, manuscript preparation, editing, review and approval. A.E: Conceptualization, methodology, project administration, supervision, methodology, literature review, investigation, manuscript preparation, review, editing and approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAppreciation towards Dubai Medical University for encouraging research and publication, and to all medical students who participated in this study. Appreciations and thanks to Dr. Fouzia Shersad for her support during the project.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSpencer JA, Jordan RK. Learner centred approaches in medical education. \u003cem\u003eBMJ\u003c/em\u003e. 1999;318(7193):1280-1283. doi:10.1136/bmj.318.7193.1280\u003c/li\u003e\n\u003cli\u003eRoyal College of Physicians and Surgeons of Canada. The CanMEDS Framework (2015). https://www.royalcollege.ca/en/standards-and-accreditation/canmeds.html\u003c/li\u003e\n\u003cli\u003eFrank JR, Danoff D. The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. \u003cem\u003eMedical Teacher\u003c/em\u003e. 2007;29(7):642-647. doi:10.1080/01421590701746983\u003c/li\u003e\n\u003cli\u003eCore Committee, Institute for International Medical Education. 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Simulation in healthcare: A taxonomy and a conceptual framework for instructional design and media selection. \u003cem\u003eMedical Teacher\u003c/em\u003e. 2013;35(8):e1380-e1395. doi:10.3109/0142159X.2012.733451\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\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":"[email protected]","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-6022596/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6022596/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eSimulation-based medical education (SBME) has emerged as an innovative approach to enhancing both technical and non-technical skills (NTS) in medical education. NTS, encompassing communication, teamwork, and decision-making, are essential for patient safety and clinical outcomes. Perception of NTS development through simulated case scenarios, particularly in undergraduate medical education, is constantly being examined.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eThis study aimed to assess the impact of advanced simulation-based case scenarios on final-year medical students’ perceptions of NTS, including communication, teamwork, and decision-making, and their role in improving patient care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA cross-sectional observational study was conducted at Dubai Medical University, involving 60 final-year female medical students. Participants engaged in five simulated case scenario sessions during their clinical rotation. Data was collected via a 5-point ordinal Likert scale structured questionnaire with parts adopted from the validated Observational Skill-based Clinical Assessment tool for Resuscitation (OSCAR), assessing perceptions of NTS and their influence on patient safety. Descriptive statistics and Spearman’s correlation were used for analysis utilizing the SPSS v29 software.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOut of the total 60 included participants, most reported high levels of agreement on the importance of NTS, with mean scores ranging from 4.47 to 4.58 across constructs. Communication demonstrated the strongest correlation with perceived impact on patient safety (rho = 0.774, p \u0026lt; 0.001), followed by teamwork (rho = 0.760, p \u0026lt; 0.001) and decision-making (rho = 0.671, p \u0026lt; 0.001). Feedback sessions and structured debriefings based on the Pendleton model enhanced participants’ understanding and application of NTS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eAdvanced\u003cstrong\u003e \u003c/strong\u003esimulated case scenarios incorporating structured briefing and debriefing positively influence NTS perception among medical students, in addition to their implications on patient safety and clinical outcomes. Future research should explore the integration of advanced technologies, such as virtual reality and artificial intelligence (AI). Longitudinal studies should evaluate real-world application of NTS in clinical settings as a result.\u003c/p\u003e","manuscriptTitle":"Impact of Advanced Simulated Case Scenarios on Medical Students' Perception of Non-Technical Skills: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-18 14:16:56","doi":"10.21203/rs.3.rs-6022596/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-18T08:58:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-02-14T11:16:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-02-14T11:04:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-02-13T11:19:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","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":"c88b854b-3f88-4c7a-96b9-090356e75211","owner":[],"postedDate":"February 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-02-18T14:16:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-18 14:16:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6022596","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6022596","identity":"rs-6022596","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}