Effect of Simulation-Based Training on Paramedics’ Competence in Transcutaneous Pacemaker Application: An Experimental Study

Effect of Simulation-Based Training on Paramedics’ Competence in Transcutaneous Pacemaker Application: An Experimental 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 Effect of Simulation-Based Training on Paramedics’ Competence in Transcutaneous Pacemaker Application: An Experimental Study Prof. Dr. Gülseren Keskin, DAMLA AKAR This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8652991/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose This experimental study aimed to evaluate a structured training program on paramedics' competence in transcutaneous pacemaker (TCP) application and to explore how paramedics’ self-efficacy and perceived stress affect TCP application. Methods The study involved 60 paramedics, members of TAPDER, who graduated in 2021–2022 and had basic ECG training. Initially, paramedics received TCP training, and their knowledge was tested before and after. Then, Self-Efficacy Scale (SES) and Perceived Stress Level Scale (PSL) were administered. Results Pre-training, the experimental group correctly answered 32.2% of knowledge questions. There was no significant difference in self-efficacy between groups (p > 0.05), with both showing high SES scores (experimental: 62.13, control: 63.73). The experimental group exhibited higher perceived stress levels. Post-training, according to the TCP competency guide, 72.56% of the experimental group mastered the skill compared to 39.08% in the control group. The control group had a higher proportion needing improvement (39.64%). Conclusion Participants demonstrated above-average self-efficacy but experienced elevated stress levels, reflecting the high-pressure nature of cardiovascular emergencies. Transcutaneous pacing (TCP) skills significantly improved following simulation-based training, which not only enhances skill retention but also reduces the time required to perform this critical intervention. For prehospital emergency professionals responsible for maintaining cardiac stability, prioritizing simulation-based training is essential to ensure rapid, accurate application of TCP, ultimately improving patient outcomes in life-threatening bradycardic events. Paramedic Pacemaker transcutaneous pacemaker pre-hospital ambulance INTRODUCTION Transcutaneous pacing (TCP) is a non-invasive procedure that utilizes defibrillator pads to regulate myocardial depolarization and improve hemodynamic stability in patients with bradycardia or selected tachyarrhythmias unresponsive to medication [ 1 ]. It serves as a temporary therapeutic measure or a bridge until more definitive interventions, such as transvenous pacing or permanent pacemaker insertion, can be performed [ 2 ]. Clinically, TCP is an effective treatment option for patients with hemodynamically compromised bradycardia resistant to atropine [ 3 , 4 ]. With an aging population and increasing life expectancy, the incidence of cardiovascular diseases continues to rise in developed nations, leading to greater demand for their timely and effective management. Cardiovascular diseases are expected to remain the leading cause of death globally for the foreseeable future [ 5 ]. According to 2022 data from the Turkish Statistical Institute (TUIK), ischemic heart disease accounted for 42.3% of all deaths in Turkey [ 6 ], highlighting a significant public health burden. As a result, there is an urgent need to improve diagnostic and therapeutic services for patients with bradyarrhythmias, particularly those requiring pacemaker support. Bradycardia is frequently encountered in emergency care settings, with presentations ranging from asymptomatic findings to life-threatening complete heart blocks. Accurate assessment of signs and symptoms is crucial [ 3 ]. One study reported that 20% of patients presenting with bradycardia to the emergency department required immediate temporary pacing, and 50% eventually underwent permanent pacemaker implantation [ 7 ]. TCP offers a simple, safe, and effective method for temporary ventricular stimulation that is rapid, accessible, and often well tolerated even by conscious patients. Effective implementation of TCP depends on the provider’s technical proficiency, including familiarity with indications, device operation, electrogram interpretation, and appropriate pad placement [ 8 ]. Pacemaker implantation is a skill-intensive procedure that requires hands-on, demonstrative learning. In this context, training programs that enhance clinical awareness, decision-making, and procedural competence are vital to improving healthcare providers’ readiness and performance [ 9 ]. Simulation-based training (SBT), which immerses learners in realistic clinical scenarios, has proven highly effective in enhancing these competencies while also improving stress management and patient safety outcomes [ 9 , 10 ]. While transvenous pacing (TVP) remains the gold standard for managing unstable bradycardia in hospital settings, transcutaneous pacing (TCP) is often the first—and sometimes the only—viable intervention in prehospital environments [ 11 ]. However, a review of the literature reveals a notable scarcity of studies examining TCP skills among emergency medical service providers. This indicates a significant gap in both training and clinical preparedness. Although TCP is a rare procedure in the prehospital context, it is critical, and a lack of knowledge and practical experience may pose serious risks to patient safety. Given the aging population and the increasing incidence of cardiac arrhythmias, proficiency in prehospital pacing is becoming increasingly essential. The role of emergency medical teams in cardiovascular emergency care is expanding, and their competence in early detection and management of cardiac rhythm disturbances directly affects patient outcomes. While TCP is a technically demanding and complex intervention, structured simulation-based training (SSBT) offers an effective method for rapid and lasting acquisition of these skills. Realistic practice in simulation environments enhances both technical competence and decision-making capacity under stress for emergency care providers. To improve the quality of prehospital cardiovascular care and ensure effective intervention in critical situations, it is necessary to integrate both theoretical and practical training on TCP application into the education programs of emergency medical personnel. This study aims to assess participants’ competence in TCP application following an SSBT program, as well as evaluate their self-perceived efficacy and stress levels post-training. The findings are expected to inform the development of educational strategies and curriculum enhancements that promote patient safety and preparedness in prehospital cardiovascular care. METHODS Research Type, Population, and Sample A mixed-method approach, incorporating both qualitative and quantitative methods, was used in this study. Data were collected between June and September 2022. The research population consisted of 60 paramedics aged 18–25, members of the Turkish Paramedic and Emergency Technicians Association (TAPDER), who had recently graduated and received training in EKG evaluation. Paramedics were randomized using a sealed opaque envelope technique, resulting in 30 participants in the experimental group and 30 in the control group. The sample size was calculated with a 95% confidence interval, 80% power, and a 0.05 alpha level, and it was accepted that this sample well-represented the population [ 12 ]. Before the simulated TCP training, each participant in both the experimental and control groups completed a questionnaire on demographic information and previous clinical and simulation experiences, and both before and after the training, they filled out TCP Knowledge Questions, the TCP Competence Guide, the Self-Efficacy Scale, and the Perceived Stress Level Scale. Individual training on TCP was then provided. During training, participants were asked to explicitly state their actions during an actual patient encounter (e.g., talking to the patient and waiting for a response, examining the patient appropriately). Participants were then invited to the simulation room to start the scenario. The qualitative part of the study consisted of three sections, and the paramedics in the experimental group used the assigned device throughout the study. The first section included a 2-hour presentation and video demonstration of the TCP technique, with the content taught by an experienced instructor based on the assigned group. The next step of SBST involved comprehensive hands-on training on a model. In the second section, paramedics' TCP knowledge levels (pre- and post-training) were assessed through a written exam. In the third section, each paramedic performed at least one TCP application with the assigned device, with their TCP application times recorded. They were allowed to work until the scenario was completed or a maximum of 10 minutes. TCP application steps were categorized into three sections. Those who fully verbalized and accurately performed the task step were classified as 'mastered,' those who accurately verbalized the step but required instructor assistance during the application were classified as 'sufficient,' and those who could not verbalize or perform the step were classified as 'needs improvement.' Research inclusion criteria were (1) having taken a basic EKG course, (2) no physical disability preventing skill application, and (3) willingness to participate in the research. Data Collection Tools and Process TCP Knowledge Questions : Developed by researchers based on the literature [ 13 , 14 , 15 ], this tool includes 15 questions that assess paramedics' knowledge regarding the indications for TCP, the steps of the procedure, its complications, and contraindications. TCP Competence Guide : This guide was created by researchers based on the Ministry of Health Emergency Automation System quality documents titled "TCP Application Skills Learning Guide for Conscious Patients" [ 15 ] and "Transcutaneous Pacing Skills Checklist" [ 16 ]. It includes 13 items evaluated as 'Needs Improvement,' 'Sufficient,' or 'Mastered.' Self-Efficacy Scale (SES) : The scale was developed by Sherer et al. to determine individuals' self-efficacy [ 17 ]. The Turkish validity and reliability study of this 17-item, five-point Likert scale was conducted by Yıldırım and İlhan. The total scale score ranges from 17 to 85, with higher scores indicating higher self-efficacy. The Cronbach's alpha of the scale was found to be 0.80 [ 18 ]. Perceived Stress Level Scale (PSLS) : Developed by Cohen, Kamarck, and Mermelstein, this 14-item scale measures the extent to which individuals perceive certain situations in their lives as stressful [ 19 ]. The Turkish adaptation of the scale was performed by Baltaş et al. Total scores indicate stress levels, with 11–26 indicating low stress, 27–41 indicating moderate stress, and 42–56 indicating high stress [ 20 ]. The Cronbach's alpha of the scale varied between .84 and .85 in different groups. Data Analysis and Statistical Analysis Data analysis was conducted using SPSS 22.0. Descriptive statistics (number, percentage, mean, standard deviation, minimum, maximum, and median) were provided. The normality assumption was checked using the Shapiro-Wilk test, and homogeneity of variance was checked using the Levene test [ 21 ]. Continuous variables were presented as mean ± standard deviation for normally distributed data and median (minimum – maximum) for non-normally distributed data. Comparisons of independent pairs of groups were made using the Mann-Whitney U test, as the normality assumption was not met. Chi-square (χ²) analysis was applied by creating cross tables for the analysis of categorical data. The reliability of the scales was assessed using Cronbach's alpha coefficient. A power analysis was conducted at the end of the study. Ethical Considerations The study was conducted in accordance with the principles of the Helsinki Declaration. Prior to the study, approval was obtained from the Ege University Medical Research Ethics Committee (Decision No: E.752305, dated June 28, 2022) and the TAPDER Board of Directors (Document No: 2022/33, dated June 6, 2021). Participants were clearly informed that participation was based on confidentiality and voluntariness. Comprehensive information was provided to all participants before data collection, their consent was obtained, and they were informed that they could withdraw from the study at any stage if they wished. RESULTS Socio-demographic findings Demographic data of the participants are presented in Table 1. Comparison of the Scores of the Experimental and Control Groups on General Knowledge Checklist, SES, PSLS, and TCP Competence Scales The mean scores of the participants on the scales are shown in Table 2. Knowledge checklist and TCP competence scores, as well as PSLS scores, differed between the experimental and control groups, with the experimental group's post-training knowledge scores, TCP competence scores, and PSLS scores all increasing (z: 1357 ± 131, p 0.05; z: 353 ± 335, p 0.05). The experimental group’s pre-training TCP knowledge and competence levels were highly insufficient, but post-training scores significantly increased, indicating a high level of proficiency; PSLS levels increased in the control group but both groups showed moderate anxiety levels. SES scores were above average in both groups, indicating good perceived self-efficacy (Table 2). The experimental group’s TCP competence and knowledge scores showed no statistically significant difference based on gender, age group, education level, or economic status (p > 0.05). Evaluation of Answers to TCP Knowledge Questions Post-SBST Comparing the experimental group's responses to the TCP Knowledge Questions before and after SBST, the correct response rate to the question regarding 'Paramedics’ TCP application authorizations' increased from 87% to 100%, and the correct response rate to the question about 'types of TCP' increased from 33% to 80% (p < 0.001) (Table 3). Statistically significant differences were found between the experimental and control groups in knowledge levels regarding defibrillator mode (p < 0.001), body regions where defibrillator pads are placed (p < 0.007), setting energy levels (mA) in TCP application (p < 0.002), steps to be taken after setting speed and energy levels in TCP application (p < 0.003), indications for TCP application (p < 0.001), and possible complications and interventions after TCP application (p < 0.001) (Table 3). Evaluation of Answers to TCP Competence Questions Post-SBST Post-SBST, the experimental group took an average of 33 ± 2 minutes to apply the transcutaneous pacemaker on the simulator model, whereas the control group hesitated and could not complete the TCP application. The experimental group showed a pre-training success rate of 32.20% in knowledge questions, which increased to 90.46% post-training, with 72.56% mastering TCP application, 26.41% achieving sufficient competence, and 1.02% needing improvement. The TCP competence levels of the experimental group were statistically significantly higher than those of the control group (p < 0.05) (Table 4). DISCUSSION This study demonstrates that simulation-based structured training (SBST) can significantly enhance paramedics’ competence in transcutaneous pacing (TCP), a critical but infrequently performed emergency intervention. The observed improvement—from 32.20% to 90.46% correct responses in knowledge assessments—reflects not only cognitive gains but also suggests improved procedural understanding. In high-stakes environments such as emergency care, where rapid decision-making and technical proficiency are essential, such educational approaches are increasingly recognized as effective tools for bridging gaps in clinical experience. Although TCP is often underutilized in some prehospital settings due to limited training and unfamiliarity, it remains a vital option in the management of hemodynamically unstable bradycardia. Guidelines from leading international bodies recommend that pacing procedures, even temporary ones, be performed by trained professionals following supervised practice and standardized protocols [ 8 ]. Yet, many emergency systems around the world lack formal structures to ensure such training at the paramedic level. Given the lack of strong evidence supporting TCP use in bradyasystolic cardiac arrest [ 22 ], its selective application in appropriate cases—such as unstable bradycardia—requires skilled judgment. This highlights the importance of integrating SBST into emergency medical education globally, not only to improve cardiovascular care outcomes but also to ensure procedural safety, consistency, and the highest standards of cardiac management across diverse prehospital and emergency care systems. Transcutaneous pacing (TCP) is generally utilized as a temporary life-saving intervention until transvenous pacing can be initiated or the underlying etiology of bradycardia is resolved. The clinical presentation of bradycardia is highly variable, ranging from asymptomatic incidental findings to severe, life-threatening heart block. In such time-sensitive emergencies, external pacing offers a critical bridge to stabilize the patient before definitive therapy can be administered. Particularly in prehospital settings—where access to advanced cardiac interventions is limited—TCP may represent the only viable means of maintaining adequate cardiac output and ensuring perfusion to vital organs [ 23 ]. Inadequate perfusion during transport has been shown to significantly increase the risk of adverse outcomes, including irreversible organ damage and mortality [ 24 , 25 ]. The American Heart Association (AHA) recommends prompt initiation of TCP in patients with symptomatic bradycardia when atropine fails to resolve the rhythm disturbance [ 26 ]. These guidelines underscore the critical importance of prehospital providers having the clinical expertise and technical proficiency to perform TCP promptly and effectively, ensuring optimal cardiovascular support and maintaining tissue perfusion during critical periods when advanced hospital-based interventions are not immediately accessible. Our findings underscore the urgency of this need. Following participation in a simulation-based structured training (SBST) program, paramedics in the experimental group demonstrated substantial improvements in both theoretical knowledge and applied skills. Correct responses on knowledge-based assessments rose from 32.20% to 90.46% post-training. Furthermore, 72.56% of participants achieved "mastery" in TCP competency, 26.41% were rated "competent," and only 1.02% required further training. Notably, the experimental group outperformed the control group in three simulation-based critical tasks reflecting real-world prehospital challenges. These outcomes affirm the value of realistic, high-fidelity simulations in preparing providers for low-frequency but high-stakes procedures such as TCP [ 27 ]. Simulation assessments not only capture psychomotor skills but also test cognitive reasoning and emotional resilience, making them more predictive of actual field performance than traditional written exams [ 28 ]. In the context of prehospital emergency care—where rapid intervention can mean the difference between life and death—equipping paramedics with structured, scenario-based TCP training is not only beneficial but essential. Incorporating SBST into emergency medical training programs worldwide would standardize cardiovascular emergency care and ensure that prehospital providers are equipped to deliver timely, precise interventions that optimize cardiac function and improve patient survival during critical cardiac events. In this study, paramedics in the experimental group successfully completed the TCP procedure in an average time of 3.30 ± 2 minutes, demonstrating notable efficiency following simulation-based training. This is clinically significant, as bradyasystolic rhythms account for approximately 16% to 27% of prehospital cardiac arrests [ 29 , 30 ]. Rapid recognition of this life-threatening rhythm and the prompt initiation of TCP as the first-line treatment are critical for survival [ 23 , 31 ]. Even minimal delays or technical errors during pacing can lead to irreversible outcomes—including persistent dysrhythmias, prolonged hypoxia, neurological injury, or death [ 32 , 33 , 35 ]. The gravity of such complications is reflected in estimates from the U.S. Institute of Medicine, which reported that medical errors or delayed interventions in cardiac emergencies result in 44,000 to 98,000 deaths annually in U.S. hospitals alone [ 34 ]. Our findings highlight that structured simulation training significantly enhances paramedics’ competence in key TCP tasks—such as defibrillator mode selection, correct pad placement, setting appropriate pacing rate and output current (mA), verifying mechanical capture through pulse palpation, and managing indications and complications. For example, 90% of participants correctly adjusted the pacing rate (60–90 bpm), and 66.7% accurately identified and applied the appropriate energy threshold to ensure electrical capture, with a further 60% successfully fine-tuning current amplitude following capture. These skills are vital, as TCP involves transmitting high-energy impulses through the chest wall, often causing painful skeletal muscle contractions and carrying risks such as skin burns if not properly executed [ 35 ]. Therefore, in prehospital environments—where time is limited and decisions are made under pressure—clinical mastery of TCP is not merely desirable but essential. Equipping emergency medical providers with the knowledge and hands-on proficiency to carry out this life-saving intervention can substantially improve cardiovascular stabilization and outcomes, reinforcing the critical role of structured training in enhancing the quality and safety of prehospital cardiac care. Literature indicates that determining the precise conditions under which simulation training enhances clinical performance remains a complex challenge, as performance outcomes are influenced by a range of psychological and situational variables [ 36 ]. In this study, we specifically examined the roles of perceived self-efficacy and stress—two critical factors in high-pressure, time-sensitive clinical environments such as prehospital emergency care. Our findings showed that both the experimental and control groups experienced moderate stress levels; however, the experimental group reported a higher average perceived stress score (34.13 vs. 29.67). This elevation may reflect increased situational awareness following simulation training, where participants more deeply internalized the high stakes of transcutaneous pacing (TCP) and its role as a life-saving intervention. The heightened stress may, in this context, reflect a realistic understanding of clinical urgency rather than a negative response. Importantly, previous research supports the idea that moderate stress, when managed effectively, can actually enhance performance in emergency settings. For instance, one study reported that nearly half of emergency assistants experienced moderate to high stress and demonstrated significant performance improvement when they could regulate that stress [ 37 ]. Similarly, LeBlanc et al. (2008) emphasized that moderate or low stress enhances clinical task execution, particularly in dynamic and unpredictable care environments [ 38 ]. In our study, paramedics’ self-efficacy scores were uniformly high across both groups, which may be attributable to their recent graduation, up-to-date academic training, and recent clinical exposure through internships. High self-efficacy is associated with better team collaboration, which is crucial in emergency care, where coordinated action and rapid decision-making directly impact patient outcomes [ 39 ]. The simulation scenarios used in this study not only fostered technical skills but also replicated the time pressure and emotional intensity of real-life emergencies. As such, they may have played a key role in developing the emotional resilience and team communication essential for delivering rapid, coordinated cardiovascular interventions like TCP, ultimately improving hemodynamic stabilization and patient survival in critical cardiac emergencies. These findings suggest that integrating simulation-based training into emergency medical curricula does more than improve procedural knowledge—it equips healthcare providers with the skills to perform under pressure, manage stress, and collaborate effectively as a team. These competencies are crucial for the timely and precise delivery of cardiovascular life-saving interventions like TCP in prehospital settings, directly impacting patient hemodynamic stability and survival outcomes when seconds are critical. Limitations This study has some limitations. Data were collected from paramedics who had recently graduated, received training in EKG evaluation, and were members of the TAPDER association. Therefore, the results cannot be generalized to all healthcare personnel. Further studies from various levels and regions are needed. CONCLUSION Our study demonstrated that simulation-based training significantly enhanced the competence and success of emergency medical providers in performing transcutaneous pacing (TCP), a critical and time-sensitive intervention in cardiovascular emergency care. Given that TCP can be a life-saving procedure in prehospital settings—where rapid stabilization is essential to prevent irreversible organ damage or mortality—ensuring that emergency responders are highly skilled and confident in its application is vital. Both the experimental and control groups exhibited high self-efficacy and moderate anxiety levels, with a slight increase in anxiety following training, likely reflecting an increased awareness of the urgent and high-stakes nature of TCP in acute cardiac emergencies. These findings underscore the importance of integrating structured TCP simulation training into emergency medical education programs to strengthen prehospital cardiovascular care capabilities. Future research should investigate long-term skill retention, strategies for managing stress in high-pressure situations, and the effectiveness of team-based training models to further improve the quality of emergency cardiovascular interventions. Enhancing the preparedness of emergency medical personnel through targeted education ultimately contributes to improved patient outcomes during critical cardiac events where every second is crucial. Declarations Ethical approval The study has been carried out considering the principles of Helsinki Declaration. Ethical approval has been taken from the University's Non-Interventional Research Ethics Committee with the decision number ETHICS APPROVAL NO: E.75230 on the date of 28.06.2022. Permissions have been taken for the scales which have been conducted in the study. All participants were clearly informed that participation was based on the principles of confidentiality and volunteerism. Informed consent Individual consents were obtained from all individual participants included in the study. Acknowledgment The authors thank all individuals who participated in the research. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. Author Contribution GK: Study conception and design, data collection, data analysis and interpretation, drafting of the article, critical revision of the article. DA: Study conception and design, data analysis and interpretation, drafting of the article, critical revision of the article. GK: Study conception and design, drafting of the article, critical revision of the article. References TPA, Transcutaneous Pacemaker Application https:// ; 2019 (date of access :02.02.2021). Adams A, Adams C. Transcutaneous Pacing: An Emergency Nurse's Guide. J Emerg Nurs. 2021;47(2):326–30. 10.1016/j.jen.2020.11.003 . Bektas F, Soyuncu S. The efficacy of transcutaneous cardiac pacing in ED. 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Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files TABLEnew.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 15 Mar, 2026 Editor invited by journal 27 Feb, 2026 Editor assigned by journal 04 Feb, 2026 Submission checks completed at journal 04 Feb, 2026 First submitted to journal 20 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-8652991","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":606913026,"identity":"2ac99272-60b7-4ccb-84ff-6ac139e15bcd","order_by":0,"name":"Prof. Dr. Gülseren Keskin","email":"data:image/png;base64,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","orcid":"","institution":"Ege University","correspondingAuthor":true,"prefix":"","firstName":"Prof.","middleName":"Dr. Gülseren","lastName":"Keskin","suffix":""},{"id":606913028,"identity":"ce0a2213-b5f3-4492-a418-e8009ecea2a4","order_by":1,"name":"DAMLA AKAR","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"DAMLA","middleName":"","lastName":"AKAR","suffix":""}],"badges":[],"createdAt":"2026-01-20 21:09:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8652991/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8652991/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104842047,"identity":"58562f0a-b4b4-4b59-a98a-09779fffff3e","added_by":"auto","created_at":"2026-03-17 20:04:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":636946,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8652991/v1/8c9eaa36-3fa4-4fed-a306-3aaa6baaf3f7.pdf"},{"id":104842046,"identity":"83f23ca8-62ab-4a62-901c-91d147769af8","added_by":"auto","created_at":"2026-03-17 20:03:56","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":42377,"visible":true,"origin":"","legend":"","description":"","filename":"TABLEnew.docx","url":"https://assets-eu.researchsquare.com/files/rs-8652991/v1/252e2fed419192f3f7bf4d82.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of Simulation-Based Training on Paramedics’ Competence in Transcutaneous Pacemaker Application: An Experimental Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eTranscutaneous pacing (TCP) is a non-invasive procedure that utilizes defibrillator pads to regulate myocardial depolarization and improve hemodynamic stability in patients with bradycardia or selected tachyarrhythmias unresponsive to medication [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It serves as a temporary therapeutic measure or a bridge until more definitive interventions, such as transvenous pacing or permanent pacemaker insertion, can be performed [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Clinically, TCP is an effective treatment option for patients with hemodynamically compromised bradycardia resistant to atropine [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. With an aging population and increasing life expectancy, the incidence of cardiovascular diseases continues to rise in developed nations, leading to greater demand for their timely and effective management. Cardiovascular diseases are expected to remain the leading cause of death globally for the foreseeable future [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. According to 2022 data from the Turkish Statistical Institute (TUIK), ischemic heart disease accounted for 42.3% of all deaths in Turkey [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], highlighting a significant public health burden. As a result, there is an urgent need to improve diagnostic and therapeutic services for patients with bradyarrhythmias, particularly those requiring pacemaker support.\u003c/p\u003e \u003cp\u003eBradycardia is frequently encountered in emergency care settings, with presentations ranging from asymptomatic findings to life-threatening complete heart blocks. Accurate assessment of signs and symptoms is crucial [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. One study reported that 20% of patients presenting with bradycardia to the emergency department required immediate temporary pacing, and 50% eventually underwent permanent pacemaker implantation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. TCP offers a simple, safe, and effective method for temporary ventricular stimulation that is rapid, accessible, and often well tolerated even by conscious patients. Effective implementation of TCP depends on the provider\u0026rsquo;s technical proficiency, including familiarity with indications, device operation, electrogram interpretation, and appropriate pad placement [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Pacemaker implantation is a skill-intensive procedure that requires hands-on, demonstrative learning. In this context, training programs that enhance clinical awareness, decision-making, and procedural competence are vital to improving healthcare providers\u0026rsquo; readiness and performance [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Simulation-based training (SBT), which immerses learners in realistic clinical scenarios, has proven highly effective in enhancing these competencies while also improving stress management and patient safety outcomes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile transvenous pacing (TVP) remains the gold standard for managing unstable bradycardia in hospital settings, transcutaneous pacing (TCP) is often the first\u0026mdash;and sometimes the only\u0026mdash;viable intervention in prehospital environments [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, a review of the literature reveals a notable scarcity of studies examining TCP skills among emergency medical service providers. This indicates a significant gap in both training and clinical preparedness. Although TCP is a rare procedure in the prehospital context, it is critical, and a lack of knowledge and practical experience may pose serious risks to patient safety. Given the aging population and the increasing incidence of cardiac arrhythmias, proficiency in prehospital pacing is becoming increasingly essential.\u003c/p\u003e \u003cp\u003eThe role of emergency medical teams in cardiovascular emergency care is expanding, and their competence in early detection and management of cardiac rhythm disturbances directly affects patient outcomes. While TCP is a technically demanding and complex intervention, structured simulation-based training (SSBT) offers an effective method for rapid and lasting acquisition of these skills. Realistic practice in simulation environments enhances both technical competence and decision-making capacity under stress for emergency care providers. To improve the quality of prehospital cardiovascular care and ensure effective intervention in critical situations, it is necessary to integrate both theoretical and practical training on TCP application into the education programs of emergency medical personnel. This study aims to assess participants\u0026rsquo; competence in TCP application following an SSBT program, as well as evaluate their self-perceived efficacy and stress levels post-training. The findings are expected to inform the development of educational strategies and curriculum enhancements that promote patient safety and preparedness in prehospital cardiovascular care.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch Type, Population, and Sample\u003c/h2\u003e \u003cp\u003eA mixed-method approach, incorporating both qualitative and quantitative methods, was used in this study. Data were collected between June and September 2022. The research population consisted of 60 paramedics aged 18\u0026ndash;25, members of the Turkish Paramedic and Emergency Technicians Association (TAPDER), who had recently graduated and received training in EKG evaluation. Paramedics were randomized using a sealed opaque envelope technique, resulting in 30 participants in the experimental group and 30 in the control group. The sample size was calculated with a 95% confidence interval, 80% power, and a 0.05 alpha level, and it was accepted that this sample well-represented the population [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Before the simulated TCP training, each participant in both the experimental and control groups completed a questionnaire on demographic information and previous clinical and simulation experiences, and both before and after the training, they filled out TCP Knowledge Questions, the TCP Competence Guide, the Self-Efficacy Scale, and the Perceived Stress Level Scale. Individual training on TCP was then provided. During training, participants were asked to explicitly state their actions during an actual patient encounter (e.g., talking to the patient and waiting for a response, examining the patient appropriately). Participants were then invited to the simulation room to start the scenario. The qualitative part of the study consisted of three sections, and the paramedics in the experimental group used the assigned device throughout the study. The first section included a 2-hour presentation and video demonstration of the TCP technique, with the content taught by an experienced instructor based on the assigned group. The next step of SBST involved comprehensive hands-on training on a model. In the second section, paramedics' TCP knowledge levels (pre- and post-training) were assessed through a written exam. In the third section, each paramedic performed at least one TCP application with the assigned device, with their TCP application times recorded. They were allowed to work until the scenario was completed or a maximum of 10 minutes. TCP application steps were categorized into three sections. Those who fully verbalized and accurately performed the task step were classified as 'mastered,' those who accurately verbalized the step but required instructor assistance during the application were classified as 'sufficient,' and those who could not verbalize or perform the step were classified as 'needs improvement.' Research inclusion criteria were (1) having taken a basic EKG course, (2) no physical disability preventing skill application, and (3) willingness to participate in the research.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection Tools and Process\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eTCP Knowledge Questions\u003c/b\u003e: Developed by researchers based on the literature [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], this tool includes 15 questions that assess paramedics' knowledge regarding the indications for TCP, the steps of the procedure, its complications, and contraindications.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTCP Competence Guide\u003c/b\u003e: This guide was created by researchers based on the Ministry of Health Emergency Automation System quality documents titled \"TCP Application Skills Learning Guide for Conscious Patients\" [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and \"Transcutaneous Pacing Skills Checklist\" [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. It includes 13 items evaluated as 'Needs Improvement,' 'Sufficient,' or 'Mastered.'\u003c/p\u003e \u003cp\u003e \u003cb\u003eSelf-Efficacy Scale\u003c/b\u003e \u003cb\u003e(SES)\u003c/b\u003e: The scale was developed by Sherer et al. to determine individuals' self-efficacy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The Turkish validity and reliability study of this 17-item, five-point Likert scale was conducted by Yıldırım and İlhan. The total scale score ranges from 17 to 85, with higher scores indicating higher self-efficacy. The Cronbach's alpha of the scale was found to be 0.80 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003ePerceived Stress Level Scale\u003c/b\u003e \u003cb\u003e(PSLS)\u003c/b\u003e: Developed by Cohen, Kamarck, and Mermelstein, this 14-item scale measures the extent to which individuals perceive certain situations in their lives as stressful [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The Turkish adaptation of the scale was performed by Baltaş et al. Total scores indicate stress levels, with 11\u0026ndash;26 indicating low stress, 27\u0026ndash;41 indicating moderate stress, and 42\u0026ndash;56 indicating high stress [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The Cronbach's alpha of the scale varied between .84 and .85 in different groups.\u003c/p\u003e\n\u003ch3\u003eData Analysis and Statistical Analysis\u003c/h3\u003e\n\u003cp\u003eData analysis was conducted using SPSS 22.0. Descriptive statistics (number, percentage, mean, standard deviation, minimum, maximum, and median) were provided. The normality assumption was checked using the Shapiro-Wilk test, and homogeneity of variance was checked using the Levene test [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Continuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for normally distributed data and median (minimum \u0026ndash; maximum) for non-normally distributed data. Comparisons of independent pairs of groups were made using the Mann-Whitney U test, as the normality assumption was not met. Chi-square (χ\u0026sup2;) analysis was applied by creating cross tables for the analysis of categorical data. The reliability of the scales was assessed using Cronbach's alpha coefficient. A power analysis was conducted at the end of the study.\u003c/p\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e The study was conducted in accordance with the principles of the Helsinki Declaration. Prior to the study, approval was obtained from the Ege University Medical Research Ethics Committee (Decision No: E.752305, dated June 28, 2022) and the TAPDER Board of Directors (Document No: 2022/33, dated June 6, 2021). Participants were clearly informed that participation was based on confidentiality and voluntariness. Comprehensive information was provided to all participants before data collection, their consent was obtained, and they were informed that they could withdraw from the study at any stage if they wished.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic findings\u003c/h2\u003e \u003cp\u003eDemographic data of the participants are presented in Table\u0026nbsp;1.\u003c/p\u003e \u003cp\u003e \u003cb\u003eComparison of the Scores of the Experimental and Control Groups on General Knowledge Checklist, SES, PSLS, and TCP Competence Scales\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe mean scores of the participants on the scales are shown in Table\u0026nbsp;2. Knowledge checklist and TCP competence scores, as well as PSLS scores, differed between the experimental and control groups, with the experimental group's post-training knowledge scores, TCP competence scores, and PSLS scores all increasing (z: 1357\u0026thinsp;\u0026plusmn;\u0026thinsp;131, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; z: 3413\u0026thinsp;\u0026plusmn;\u0026thinsp;467, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05; z: 353\u0026thinsp;\u0026plusmn;\u0026thinsp;335, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No difference was found in SES scores (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The experimental group\u0026rsquo;s pre-training TCP knowledge and competence levels were highly insufficient, but post-training scores significantly increased, indicating a high level of proficiency; PSLS levels increased in the control group but both groups showed moderate anxiety levels. SES scores were above average in both groups, indicating good perceived self-efficacy (Table\u0026nbsp;2). The experimental group\u0026rsquo;s TCP competence and knowledge scores showed no statistically significant difference based on gender, age group, education level, or economic status (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEvaluation of Answers to TCP Knowledge Questions Post-SBST\u003c/h3\u003e\n\u003cp\u003eComparing the experimental group's responses to the TCP Knowledge Questions before and after SBST, the correct response rate to the question regarding 'Paramedics\u0026rsquo; TCP application authorizations' increased from 87% to 100%, and the correct response rate to the question about 'types of TCP' increased from 33% to 80% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;3). Statistically significant differences were found between the experimental and control groups in knowledge levels regarding defibrillator mode (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), body regions where defibrillator pads are placed (p\u0026thinsp;\u0026lt;\u0026thinsp;0.007), setting energy levels (mA) in TCP application (p\u0026thinsp;\u0026lt;\u0026thinsp;0.002), steps to be taken after setting speed and energy levels in TCP application (p\u0026thinsp;\u0026lt;\u0026thinsp;0.003), indications for TCP application (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and possible complications and interventions after TCP application (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;3).\u003c/p\u003e\n\u003ch3\u003eEvaluation of Answers to TCP Competence Questions Post-SBST\u003c/h3\u003e\n\u003cp\u003ePost-SBST, the experimental group took an average of 33\u0026thinsp;\u0026plusmn;\u0026thinsp;2 minutes to apply the transcutaneous pacemaker on the simulator model, whereas the control group hesitated and could not complete the TCP application. The experimental group showed a pre-training success rate of 32.20% in knowledge questions, which increased to 90.46% post-training, with 72.56% mastering TCP application, 26.41% achieving sufficient competence, and 1.02% needing improvement. The TCP competence levels of the experimental group were statistically significantly higher than those of the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;4).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study demonstrates that simulation-based structured training (SBST) can significantly enhance paramedics\u0026rsquo; competence in transcutaneous pacing (TCP), a critical but infrequently performed emergency intervention. The observed improvement\u0026mdash;from 32.20% to 90.46% correct responses in knowledge assessments\u0026mdash;reflects not only cognitive gains but also suggests improved procedural understanding. In high-stakes environments such as emergency care, where rapid decision-making and technical proficiency are essential, such educational approaches are increasingly recognized as effective tools for bridging gaps in clinical experience. Although TCP is often underutilized in some prehospital settings due to limited training and unfamiliarity, it remains a vital option in the management of hemodynamically unstable bradycardia. Guidelines from leading international bodies recommend that pacing procedures, even temporary ones, be performed by trained professionals following supervised practice and standardized protocols [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Yet, many emergency systems around the world lack formal structures to ensure such training at the paramedic level. Given the lack of strong evidence supporting TCP use in bradyasystolic cardiac arrest [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], its selective application in appropriate cases\u0026mdash;such as unstable bradycardia\u0026mdash;requires skilled judgment. This highlights the importance of integrating SBST into emergency medical education globally, not only to improve cardiovascular care outcomes but also to ensure procedural safety, consistency, and the highest standards of cardiac management across diverse prehospital and emergency care systems.\u003c/p\u003e \u003cp\u003eTranscutaneous pacing (TCP) is generally utilized as a temporary life-saving intervention until transvenous pacing can be initiated or the underlying etiology of bradycardia is resolved. The clinical presentation of bradycardia is highly variable, ranging from asymptomatic incidental findings to severe, life-threatening heart block. In such time-sensitive emergencies, external pacing offers a critical bridge to stabilize the patient before definitive therapy can be administered. Particularly in prehospital settings\u0026mdash;where access to advanced cardiac interventions is limited\u0026mdash;TCP may represent the only viable means of maintaining adequate cardiac output and ensuring perfusion to vital organs [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Inadequate perfusion during transport has been shown to significantly increase the risk of adverse outcomes, including irreversible organ damage and mortality [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The American Heart Association (AHA) recommends prompt initiation of TCP in patients with symptomatic bradycardia when atropine fails to resolve the rhythm disturbance [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. These guidelines underscore the critical importance of prehospital providers having the clinical expertise and technical proficiency to perform TCP promptly and effectively, ensuring optimal cardiovascular support and maintaining tissue perfusion during critical periods when advanced hospital-based interventions are not immediately accessible.\u003c/p\u003e \u003cp\u003eOur findings underscore the urgency of this need. Following participation in a simulation-based structured training (SBST) program, paramedics in the experimental group demonstrated substantial improvements in both theoretical knowledge and applied skills. Correct responses on knowledge-based assessments rose from 32.20% to 90.46% post-training. Furthermore, 72.56% of participants achieved \"mastery\" in TCP competency, 26.41% were rated \"competent,\" and only 1.02% required further training. Notably, the experimental group outperformed the control group in three simulation-based critical tasks reflecting real-world prehospital challenges. These outcomes affirm the value of realistic, high-fidelity simulations in preparing providers for low-frequency but high-stakes procedures such as TCP [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Simulation assessments not only capture psychomotor skills but also test cognitive reasoning and emotional resilience, making them more predictive of actual field performance than traditional written exams [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In the context of prehospital emergency care\u0026mdash;where rapid intervention can mean the difference between life and death\u0026mdash;equipping paramedics with structured, scenario-based TCP training is not only beneficial but essential. Incorporating SBST into emergency medical training programs worldwide would standardize cardiovascular emergency care and ensure that prehospital providers are equipped to deliver timely, precise interventions that optimize cardiac function and improve patient survival during critical cardiac events.\u003c/p\u003e \u003cp\u003eIn this study, paramedics in the experimental group successfully completed the TCP procedure in an average time of 3.30\u0026thinsp;\u0026plusmn;\u0026thinsp;2 minutes, demonstrating notable efficiency following simulation-based training. This is clinically significant, as bradyasystolic rhythms account for approximately 16% to 27% of prehospital cardiac arrests [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Rapid recognition of this life-threatening rhythm and the prompt initiation of TCP as the first-line treatment are critical for survival [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Even minimal delays or technical errors during pacing can lead to irreversible outcomes\u0026mdash;including persistent dysrhythmias, prolonged hypoxia, neurological injury, or death [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The gravity of such complications is reflected in estimates from the U.S. Institute of Medicine, which reported that medical errors or delayed interventions in cardiac emergencies result in 44,000 to 98,000 deaths annually in U.S. hospitals alone [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings highlight that structured simulation training significantly enhances paramedics\u0026rsquo; competence in key TCP tasks\u0026mdash;such as defibrillator mode selection, correct pad placement, setting appropriate pacing rate and output current (mA), verifying mechanical capture through pulse palpation, and managing indications and complications. For example, 90% of participants correctly adjusted the pacing rate (60\u0026ndash;90 bpm), and 66.7% accurately identified and applied the appropriate energy threshold to ensure electrical capture, with a further 60% successfully fine-tuning current amplitude following capture. These skills are vital, as TCP involves transmitting high-energy impulses through the chest wall, often causing painful skeletal muscle contractions and carrying risks such as skin burns if not properly executed [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Therefore, in prehospital environments\u0026mdash;where time is limited and decisions are made under pressure\u0026mdash;clinical mastery of TCP is not merely desirable but essential. Equipping emergency medical providers with the knowledge and hands-on proficiency to carry out this life-saving intervention can substantially improve cardiovascular stabilization and outcomes, reinforcing the critical role of structured training in enhancing the quality and safety of prehospital cardiac care.\u003c/p\u003e \u003cp\u003eLiterature indicates that determining the precise conditions under which simulation training enhances clinical performance remains a complex challenge, as performance outcomes are influenced by a range of psychological and situational variables [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In this study, we specifically examined the roles of perceived self-efficacy and stress\u0026mdash;two critical factors in high-pressure, time-sensitive clinical environments such as prehospital emergency care. Our findings showed that both the experimental and control groups experienced moderate stress levels; however, the experimental group reported a higher average perceived stress score (34.13 vs. 29.67). This elevation may reflect increased situational awareness following simulation training, where participants more deeply internalized the high stakes of transcutaneous pacing (TCP) and its role as a life-saving intervention. The heightened stress may, in this context, reflect a realistic understanding of clinical urgency rather than a negative response. Importantly, previous research supports the idea that moderate stress, when managed effectively, can actually enhance performance in emergency settings. For instance, one study reported that nearly half of emergency assistants experienced moderate to high stress and demonstrated significant performance improvement when they could regulate that stress [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Similarly, LeBlanc et al. (2008) emphasized that moderate or low stress enhances clinical task execution, particularly in dynamic and unpredictable care environments [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In our study, paramedics\u0026rsquo; self-efficacy scores were uniformly high across both groups, which may be attributable to their recent graduation, up-to-date academic training, and recent clinical exposure through internships. High self-efficacy is associated with better team collaboration, which is crucial in emergency care, where coordinated action and rapid decision-making directly impact patient outcomes [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The simulation scenarios used in this study not only fostered technical skills but also replicated the time pressure and emotional intensity of real-life emergencies. As such, they may have played a key role in developing the emotional resilience and team communication essential for delivering rapid, coordinated cardiovascular interventions like TCP, ultimately improving hemodynamic stabilization and patient survival in critical cardiac emergencies.\u003c/p\u003e \u003cp\u003eThese findings suggest that integrating simulation-based training into emergency medical curricula does more than improve procedural knowledge\u0026mdash;it equips healthcare providers with the skills to perform under pressure, manage stress, and collaborate effectively as a team. These competencies are crucial for the timely and precise delivery of cardiovascular life-saving interventions like TCP in prehospital settings, directly impacting patient hemodynamic stability and survival outcomes when seconds are critical.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has some limitations. Data were collected from paramedics who had recently graduated, received training in EKG evaluation, and were members of the TAPDER association. Therefore, the results cannot be generalized to all healthcare personnel. Further studies from various levels and regions are needed.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eOur study demonstrated that simulation-based training significantly enhanced the competence and success of emergency medical providers in performing transcutaneous pacing (TCP), a critical and time-sensitive intervention in cardiovascular emergency care. Given that TCP can be a life-saving procedure in prehospital settings\u0026mdash;where rapid stabilization is essential to prevent irreversible organ damage or mortality\u0026mdash;ensuring that emergency responders are highly skilled and confident in its application is vital. Both the experimental and control groups exhibited high self-efficacy and moderate anxiety levels, with a slight increase in anxiety following training, likely reflecting an increased awareness of the urgent and high-stakes nature of TCP in acute cardiac emergencies. These findings underscore the importance of integrating structured TCP simulation training into emergency medical education programs to strengthen prehospital cardiovascular care capabilities. Future research should investigate long-term skill retention, strategies for managing stress in high-pressure situations, and the effectiveness of team-based training models to further improve the quality of emergency cardiovascular interventions. Enhancing the preparedness of emergency medical personnel through targeted education ultimately contributes to improved patient outcomes during critical cardiac events where every second is crucial.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study has been carried out considering the principles of Helsinki Declaration. Ethical approval has been taken from the University's Non-Interventional Research Ethics Committee with the decision number\u0026nbsp;ETHICS APPROVAL NO: E.75230 on\u0026nbsp;the date of 28.06.2022. Permissions have been taken for the scales which have been conducted in the study. All participants were clearly informed that participation was based on the principles of confidentiality and volunteerism.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIndividual consents were obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all individuals who participated in the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Conflicting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGK: Study conception and design, data collection, data analysis and interpretation, drafting of the article, critical revision of the article. 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Intensive Crit Care Nurs. 2022;69:103154. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.iccn.2021.103154\u003c/span\u003e\u003cspan address=\"10.1016/j.iccn.2021.103154\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 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":"Paramedic, Pacemaker, transcutaneous pacemaker, pre-hospital, ambulance","lastPublishedDoi":"10.21203/rs.3.rs-8652991/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8652991/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis experimental study aimed to evaluate a structured training program on paramedics' competence in transcutaneous pacemaker (TCP) application and to explore how paramedics\u0026rsquo; self-efficacy and perceived stress affect TCP application.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study involved 60 paramedics, members of TAPDER, who graduated in 2021\u0026ndash;2022 and had basic ECG training. Initially, paramedics received TCP training, and their knowledge was tested before and after. Then, Self-Efficacy Scale (SES) and Perceived Stress Level Scale (PSL) were administered.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePre-training, the experimental group correctly answered 32.2% of knowledge questions. There was no significant difference in self-efficacy between groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), with both showing high SES scores (experimental: 62.13, control: 63.73). The experimental group exhibited higher perceived stress levels. Post-training, according to the TCP competency guide, 72.56% of the experimental group mastered the skill compared to 39.08% in the control group. The control group had a higher proportion needing improvement (39.64%).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eParticipants demonstrated above-average self-efficacy but experienced elevated stress levels, reflecting the high-pressure nature of cardiovascular emergencies. Transcutaneous pacing (TCP) skills significantly improved following simulation-based training, which not only enhances skill retention but also reduces the time required to perform this critical intervention. For prehospital emergency professionals responsible for maintaining cardiac stability, prioritizing simulation-based training is essential to ensure rapid, accurate application of TCP, ultimately improving patient outcomes in life-threatening bradycardic events.\u003c/p\u003e","manuscriptTitle":"Effect of Simulation-Based Training on Paramedics’ Competence in Transcutaneous Pacemaker Application: An Experimental Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-17 20:03:38","doi":"10.21203/rs.3.rs-8652991/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-03-16T01:19:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-27T10:52:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-04T05:10:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-04T05:08:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-01-20T20:28:13+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":"431cc61c-4ec5-4600-89cd-b7d3bfe71a3a","owner":[],"postedDate":"March 17th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-17T20:03:39+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-17 20:03:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8652991","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8652991","identity":"rs-8652991","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}