Perioperative Simulation-based Medical Education in China: A Nationwide Cross- sectional Survey

Perioperative Simulation-based Medical Education in China: A Nationwide Cross- sectional Survey | 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 Perioperative Simulation-based Medical Education in China: A Nationwide Cross- sectional Survey Yuanyuan Yao, Min Rui, Xiangyong Zhou, Zixin Han, Ge Luo, Yi Liu, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6948208/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Dec, 2025 Read the published version in BMC Medical Education → Version 1 posted 12 You are reading this latest preprint version Abstract Background: Simulation-based medical education (SBME) has rapidly emerged as a new trend in perioperative medical education in China. However, our understanding of its role and impact on medical education remains unclear. This study surveyed medical educators to assess SBME from the perspectives of administrators, instructors, and learners, identifying both its advantages and shortcomings. Methods: A cross-sectional online survey was conducted in 2024, involving administrators, instructors, and learners from medical education institutes across China. The survey included a structured questionnaire focused on perioperative SBME with information regarding participant characteristics, their attitudes, and perceived teaching obstacles. Descriptive statistics were used to summarize the current status of perioperative SBME, and logistic regression analysis helped identify factors potentially affecting learners' satisfaction with the program. Results: A total of 1411 survey respondents, including 274 administrative staff, 285 course instructors, 681 learners, and 250 others, participated in our study. Among administrators, 81.8% believed that SBME was crucial for perioperative medical training, emphasizing its role in enhancing trainees’ clinical skills and decision-making abilities. Key challenges identified by administrators and instructors included insufficient training space, simulation models, and faculty. Administrators advocated for increased investment in simulation resources (88.7%) and faculty development (84.3%). Instructors stressed the importance of enhanced faculty training (92.6%), implementing standardized training protocols (69.1%), and increasing the proportion of simulation-based teaching (68.1%). Learners recommended optimizing teaching schedules (65.9%) and improving simulation methods (64.2%). Notably, SBME implementation varied across different regions in China, especially in tertiary hospitals, where medical institutes in Southern and Eastern China run more SBME programs. Conclusions: SBME development has progressed in China, but faces imbalances across different regions and institutions. Furthermore, the availability of qualified instructors, equipment, and financial investment still need to be addressed. This study provides a foundation for the continued advancement of SBME. Simulation medical education survey cross-sectional descriptive analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Simulation-based medical education (SBME) is a teaching method that can replace or even surpass real-world learning experiences in fully interactive environments 1, 2 . SBME originated in the 18 th and 19 th centuries, particularly in France and other European countries, where it was initially applied in fields such as anesthesiology and obstetrics 3, 4 . In the latter half of the 20th century, the development of various simulators, including for cardiopulmonary resuscitation, endotracheal intubation, and human body models simulating cardiac diseases further revolutionized medical education. In the rapidly evolving field of healthcare, it is crucial to ensure the highest standards of patient safety and care quality. Medical simulation has become an essential tool for educating and training healthcare professionals, offering a safe, controlled environment for practicing complex procedures and refining decision-making skills. Unlike traditional learning methods, which often focus on theoretical knowledge or observation, medical simulation provides hands-on experience, allowing learners to develop their abilities without risking patient safety 5 It is also cost-efficient and more feasible for certain education principles 6 . Beyond skill acquisition, medical simulation promotes teamwork, enhances communication, and prepares clinicians for real-world challenges, although its final effectiveness compared to conventional training remains debatable. As the complexity of medical interventions continues to increase, so does the necessity for simulation-based training to produce competent, confident, and capable healthcare providers. China, a large developing country, has also adopted this training methodology. However, to our knowledge, its applications are mainly associated with nursing, as highlighted in a recent study 7 . Perioperative medicine, a discipline spanning the entire perioperative period, encompasses various emergent situations. It is a primary application area where SBME is especially relevant and is the focus of this study 8 . Currently, there is a lack of comprehensive research on the application of perioperative SBME in China. We anticipate that key challenges commonly cited in medical education globally, such as financial support, resource management, and professional development, which are frequently mentioned in other countries, might be significant factors affecting the promotion of SBME in China 9 . Therefore, we designed an online questionnaire focused on perioperative SBME, collecting feedback from administrative staff, course instructors, and health learners. We conducted a large-scale cross-sectional study to comprehensively understand the current status of perioperative SBME implementation in China. We aimed to examine the advantages and shortcomings of SBME from various perspectives, identify areas for improvement and challenges, and provide recommendations for future advancements in this field. Methods Study design This nationwide cross-sectional survey was conducted in collaboration with the Anesthesia Residency Training Quality Control Center of Zhejiang Province and the Clinical Skills Center at the Second Affiliated Hospital, Zhejiang University School of Medicine. Invitations to participate in the survey were distributed via the New Youth Anesthesia Forum (www.xqnmz.com). The objective of this study is to provide a comprehensive overview of the current state of perioperative SBME implementation in China. Participants A total of 1411 perioperative healthcare professionals, including administrative staffers, course instructors, and health learners completed the questionnaire. With participants' consent, all collected data were anonymized. Ethical approval This study was approved by the Ethics Review Committee of the Second Affiliated Hospital, Zhejiang University School of Medicine (August 26, 2024, 20241027), and adhered to the Checklist for Reporting of Survey Studies (CROSS) guidelines 10 . This study was conducted in accordance with the Helsinki Declaration. All participants were fully informed about the content of this study and voluntarily provided their consent. Measures The questionnaire consisted of 52 items divided into two sections. The first section obtained informed consent from survey participants. Items 2 to 10 presented the general characteristics of the study subjects, including sex, city of residence, educational background, employment category, subject category, professional title, years of experience, hospital level, and role in the perioperative simulation program. The second section categorized the population into four groups: instructors, learners, administrators, and others. The level of participation in simulation teaching was assessed across these four categories. A Likert scale was used to measure learners' satisfaction with simulation teaching (1 = very dissatisfied; 2 = dissatisfied; 3 = neutral; 4 = satisfied; 5 = very satisfied). It took approximately 5 minutes to complete the electronic questionnaire. Validity test of the questionnaire Six experts in simulation teaching were invited to assess the consistency of each questionnaire item with the original content. Content validity analysis was conducted using SPSSAU 11 . All items, except for item 19, which had an Item-Content Validity Index (I-CVI) of 0.833 and a corrected Content Validity Index (adjusted Kappa, K*) of 0.816, all other items had a score of 1, indicating perfect agreement. The overall Scale-Level Content Validity Index (S-CVI/UA) was 0.981, and the average Scale-Level Content Validity Index (S-CVI/Ave) was 0.997, indicating strong content validity. Data collection Administrators were defined as administrative staff overseeing simulation programs in hospitals or colleges or directors of simulation centers. Instructors referred to teachers engaged in simulation teaching at various training institutions, while learners included health students or clinical practitioners participating in simulation training 12 . “Others” included clinicians and teaching physicians not directly involved in simulation teaching. The online questionnaire, designed using the Questionnaire Star platform, was primarily disseminated through the New Youth Anesthesia Forum (http://www.xqnmz.com) and WeChat (Tencent Holdings Limited, Shenzhen, China), and the audience was encouraged to complete the survey. Respondents could complete the questionnaire using either a computer or a mobile device, while allowing each IP address to be submitted only once. The survey was conducted from April 2024 to June 2024. Data Analysis Statistical analyses and graphical representations were performed using R software (version 4.4.0). The Shapiro-Wilk test assessed the normality of data distribution. Normally distributed data were expressed as mean ± standard deviation, while non-normally distributed data were represented as median (quartile) values. The relationship between various variables and outcomes was explored using the rms package. A p-value less than 0.05 was considered statistically significant. Results Participant characteristics The questionnaire covered 30 provincial-level administrative regions in China (Figure 1a). Figure 1b illustrates the distribution of responses received from each province, highlighting this survey as the most extensive and well-participated investigation of perioperative simulation teaching in China to date. General information on participants is presented in Table 1. The participants include 274 administrators, 285 instructors, 681 learners, and 250 individuals in other roles. The survey was primarily focused on operative personnel, with a focus on anesthesiology and surgery. Because of the inability to accurately determine the total number of individuals receiving a link to the questionnaire, it was not feasible to calculate the response rate. Table1. Demographic characteristics of participants Factor Administrator (n=274) Instructor (n=285) Learner (n=681) Sex, n (%) Male 160 (58.4) 148 (51.9) 307 (45.1) Female 114 (41.6) 137 (48.1) 374 (54.9) Educational background, n (%) Associate's degree 5 (1.8) 3 (1.1) 18 (2.6) Bachelor's degree 146 (53.3) 103 (36.1) 499 (73.3) Master's degree 105 (38.3) 141 (49.5) 149 (21.9) Doctor's degree 18 (6.6) 38 (13.3) 15 (2.2) Employment category, n (%) Doctor 224 (81.8) 267 (93.7) 587 (86.2) Nurse 16 (5.8) 10 (3.5) 90 (13.2) Manager 34 (12.4) 8 (2.8) 4 (0.6) Subject category, n (%) Anesthesiology 245 (89.4) 253 (88.8) 602 (88.4) Surgery and other subjects 29 (10.6) 32 (11.2) 79 (11.6) Professional title, n (%) Resident 12 (4.4) 8 (2.8) 293 (43.0) Attending 262 (95.6) 277 (97.2) 388 (57.0) Working years, median (IQR), years 17 (12, 25) 15 (10, 20) 8 (3, 13) Hospital level, n (%) Tertiary hospital (teaching hospital) 175 (63.9) 236 (82.8) 405 (59.5) Tertiary hospital (non-teaching hospital) 34 (12.4) 27 (9.5) 42 (6.2) Others 65 (23.7) 22 (7.7) 234 (34.3) Administrator Attitudes and Purposes The administrators primarily comprised physicians (81.8%), nursing staff (5.8%), and dedicated management personnel (12.4%), with 63.9% affiliated with tertiary teaching hospitals. In terms of educational and professional backgrounds, most administrative staff held a bachelor's degree (53.3%) or a master’s degree (38.3%), with a median work experience of 17 years. A total of 81.8% of administrators believed that SBME was essential for perioperative medical education and should be integrated into routine clinical teaching practices. Administrators indicated that the primary motivations for promoting simulation teaching included addressing the needs of clinical education (92.7%), providing clinical feedback (51.1%), aligning with mainstream educational trends (47.1%), and conducting scientific research (20.8%). Administrators believed that the primary significance of implementing SBME lies in enhancing learners' clinical skills, clinical decision-making abilities, teamwork, communication, and motivation to learn, as well as promoting patient safety during the perioperative period. Additionally, administrators expressed a desire to improve learners' competencies in humanistic care (66.1%) and enhance leadership skills (53.3%). Perioperative SBME implementation The median start time for implementing simulation teaching across sites was 2021. Figure 2a illustrates the number of sites initiating simulation training by year, revealing a rapid increase in recent years, especially after the COVID-19 pandemic. Tertiary teaching hospitals have more simulation sites than non-tertiary teaching hospitals. Figure 2b indicates that only 19.7% of sites currently have more than 10 teaching staff, while 68.3% of sites have less than 7 teaching staff (of which 4-6 staff account for 33.6% and ≤3 staff account for 34.7%). Among sites with more than 3 teaching staff, tertiary teaching hospitals outnumber other hospitals. However, in sites with 3 or fewer teaching staff, tertiary teaching hospitals and other non-tertiary hospitals are not much difference (17.9% and 16.8% respectively). SBME implementation is yet to be standardized, with 24.5% of administrators reporting uncertainty about the frequency of simulation training at their sites, and 17.2% of administrators indicating that simulation training occurs only 1-2 times per year. Table 2 outlines the current state of perioperative SBME implementation from both learner and instructor perspectives. Instructors identified the primary objective of simulation training as enhancing clinical skills (92.3%), clinical thinking (87.4%), crisis management (77.9%), teamwork (71.9%), doctor-patient communication (61.8%), and leadership (38.2%). However, learners placed less emphasis on improving doctor-patient communication (46.8%) and leadership skills (33.0%). While instructors frequently used high-fidelity simulators for teaching (40.7%), learners reported more frequent use of simple simulators (42.3%). Both groups indicated that simulation training commonly occurred in simulation operating rooms (41.7% vs. 39.3%), with typical session durations of 0.5 to 1 hour (51.1% vs. 47.4%), and class sizes ranging from 5 to 8 participants (48.8% vs. 54.4%). Most instructors conducted simulation training at predetermined frequencies (with an uncertainty rate of 16.5%). In contrast, learners reported that their participation in simulation training was often occasional or uncertain (37.3%). Table2. The objectives and implementation of SBME reported by learners and instructors Topic Learners (n= 681) Instructors (n=285) Learning/Teaching objective, n (%) Clinical skills 577 (84.7) 263 (92.3) Clinical thinking 598 (87.8) 249 (87.4) Crisis management 496 (72.8) 222 (77.9) Patient-doctor communication 319 (46.8) 176 (61.8) Teamwork 474 (69.6) 205 (71.9) Leadership 225 (33.0) 109 (38.2) Type of simulator, n (%) Standardized patients 184 (27.0) 75 (26.3) Simple simulator 288 (42.3) 94 (33.0) High fidelity mannequin 209 (30.7) 116 (40.7) Workplace, n (%) Simulated operating room 284 (41.7) 112 (39.3) Simulated ward 39 (5.7) 21 (7.4) Simulated resuscitation room 40 (5.9) 15 (5.3) Operating room 139 (20.4) 38 (13.3) Ward 20 (2.9) 6 (2.1) Resuscitation room 14 (2.1) 9 (3.2) Classroom 145 (21.3) 84 (29.5) Frequency, n (%) At least 2 times per month 90 (13.2) 70 (24.6) 1 time per month 114 (16.7) 76 (26.7) 1 time every 2~3 months 90 (13.2) 44 (15.4) 1~2 times per year 133 (19.5) 48 (16.8) Occasionally, uncertain 254 (37.3) 47 (16.5) Teaching duration, n (%) ≤ 0.5 hours 88 (12.9) 16 (5.6) 0.5 ~ 1 hour 348 (51.1) 135 (47.4) 1 ~ 2 hours 201 (29.5) 110 (38.6) > 2 hours 44 (6.5) 24 (8.4) Number of learners, n (%) 15 114 (16.7) 28 (9.8) Factors influencing learners' satisfaction with perioperative SBME Learners rated their satisfaction with perioperative simulation training at each site on a Likert scale, with scores ranging from 1 to 5 points. Satisfaction levels were categorized as unsatisfactory (1-3 points) or satisfactory (4-5 points). Variables such as the educational background, employment category, subject area, professional title, years of experience, hospital level, workplace, type of simulator used, training frequency, duration, and number of learners, were analyzed (as shown in Figure 3) to identify factors influencing learners' satisfaction with simulation training at each site. Single-factor logistic regression analysis revealed that, in general, physicians (compared to nurses and managers [OR: 2.46 (1.42-4.55)]), anesthesiologists (compared to surgeons [OR: 2.32 (1.29-4.50)]), attending physicians (compared to residents [OR: 1.98 (1.40-2.80)]), and learners with over 8 years of work experience (compared to those with less than 8 years [OR: 1.92 (1.37-2.68)]) were more likely to express dissatisfaction with simulation training. With regard to course settings, learners in non-tertiary hospitals [OR: 2.94 (2.10-4.14)], those trained in real environments or classrooms [OR: 1.80 (1.21-2.69), OR: 2.60 (1.72-3.93)], those using simple simulators for simulation training [OR: 3.63 (2.38-5.64)], and those participating in infrequent or irregular simulation training sessions [OR: 2.19 (1.39-3.52), OR: 3.25 (2.10-5.13)], or those for whom simulation training lasted less than 1 hour [OR: 2.09 (1.45-3.04)] were more likely to report learner dissatisfaction. Additionally, class sizes with more than 8 learners [OR: 1.54 (1.09-2.17)] were associated with higher dissatisfaction levels. Obstacles and suggestions for improvement in perioperative SBME The primary obstacles encountered by managers and instructors in perioperative simulation training are presented in Figure 4a. For administrators, the top challenges included shortages of space and simulators, as well as faculty. Instructors similarly identified faculty shortages as well as space and simulator constraints as the main hurdles. Suggestions for improving these deficiencies in perioperative SBME are presented in Figure 4b. Administrators emphasized the need for increased investment in teaching resources (88.7%) and faculty development (84.3%). Instructors also highlighted the need to intensify instructor training efforts (92.6%), establish standardized processes (69.1%), and increase simulation training durations (68.1%). Learners recommended optimizing simulation training time planning (65.9%) and improving simulation training methods (64.2%). Discussion Simulation training has become an increasingly popular teaching method in medical education, particularly for enhancing medical safety 13 . The development of perioperative SBME in China has progressed over a decade. To assess its current status and identify limiting factors, we conducted an online survey. Our findings revealed that SBME is applied across various provinces in China, though there are disparities in its regional distribution, implementation extent, and scale. For example, regions such as Zhejiang, Jiangsu, Shandong, and other regions in Eastern China adopted SBME before 2015, with relatively higher participant rates in the survey. Simulation centers with more than 7 faculty members are predominantly located in Eastern and Southern China. However, only 19.7% of centers have a faculty size exceeding 10, while 68.3% of centers have a faculty size of less than 6. Yao S et al. analyzed the countries of publication for SBME-related articles from 2011 to 2021, revealing a predominance of contributions from developed nations, with no representation from Asian countries. This indicates a significant regional imbalance in the global landscape of SBME 14 . In recent years, many developing countries, including China, have made varying degrees of progress in SBME. However, due to funding constraints, the application of standardized patients, part-task trainers, and basic simulators has been more common in simulation education. Riaz et al. suggested that organizations in resource-limited environments should initiate simulation training with standardized patients and part-task simulators, progressing to more advanced high-fidelity simulation centers as funding becomes available 15 . This approach provides practical guidance for regions in developing countries that have either not implemented SBME yet or are in the early stages of its development, particularly in settings with limited financial resources. Furthermore, research by Yao et al. underscores the necessity of establishing closer research collaborations among institutions to further the advancement of SBME 14 . In high-income countries such as Australia, the United Kingdom, and the United States, SBME is employed to prepare medical students to become safe and effective primary care physicians upon graduation, with comprehensive requirements, such as the ability to make clinical decisions, manage emergencies, deliver difficult news, and perform practical procedures 16 . Our survey results show that in China, participants place the highest value on clinical skills and decision-making abilities. In contrast, a study focused on low- and middle-income countries (LMICs) found that both instructors and learners prioritize knowledge and skill enhancement, which might be due to relatively lower levels of medical safety assurance and limited investment in SBME resources in these regions. Thus, the improvement of knowledge and skills can significantly enhance medical safety 9, 17, 18 . Furthermore, over 60% of perioperative SBME administrators and instructors in our survey highlighted the importance of non-technical skills, such as crisis management, teamwork, and doctor-patient communication for learners. This indicates that the educational approaches of SBME practitioners in China are in alignment with international standards 19 Our findings are in alignment with those of previous studies, indicating that the majority of learners perceive the course to be beneficial, and their experience, when combined with timely and effective feedback, can yield positive learning outcomes 20 . Furthermore, for simulation instructors, SBME not only enhances their clinical teaching abilities but also improves their own clinical practice and interdisciplinary crisis management skills and treatment capabilities during the implementation of simulation training. This suggests that SBME implementation could enhance the professional skills of both learners and instructors, ultimately enhancing patient safety. We acknowledge the barriers and deficiencies in SBME reported by administrators and instructors, primarily related to faculty development, simulation resources, and financial support. Previous studies in Southeast Asia and other LMICs have also reported similar findings 21 . Additionally, these findings are in alignment with our analysis of factors influencing learner satisfaction. Through our analysis of factors influencing learner satisfaction with SBME, we found that learners from the anesthesiology department, physicians, attending physicians, and those with over eight years of work experience were more likely to express dissatisfaction. We attribute this to their higher expectations for simulation training, which might not be currently aligned with the existing faculty expertise, simulation training course arrangements, and management. Our survey results indicate that primary teaching scenarios currently include cardiac arrest, anaphylactic shock, and difficult airways, all of which are common high-risk emergency events in the perioperative period and are particularly relevant for novice learners. In SBME, selecting and designing teaching scenarios to match the varying needs of learners is crucial. This places a significant demand on SBME instructors, as they need to accurately understand their learners’ educational requirements and design simulation courses that address these needs effectively 22 . Our analysis of factors influencing learner satisfaction with SBME reveals that learners are more likely to be dissatisfied when the hospital is not a tertiary teaching hospital, the environment is not realistic, simple simulators are used, the frequency of sessions is less than once a month or remains uncertain, and when the class size exceeds eight participants. These factors may be attributable to the difficulty in obtaining teaching resources in non-tertiary teaching hospitals, less developed concepts of SBME, which may lead to insufficient investment in simulation facilities and settings, and less standardized simulation training management, all of which can negatively affect teaching effectiveness. Thus, to improve learner satisfaction with SBME, we recommend focusing on improving SBME management in the aforementioned areas. In our survey, 274 questionnaires were collected from administrators, and data revealed that most SBME administrators were clinical physicians with extensive work experience, higher educational degrees, and advanced professional titles. Administrators with clinical backgrounds are more likely to expect that SBME can effectively enhance learners' crisis management abilities and improve patient outcomes. This background seems to foster confidence, which in turn results in the steady promotion of SBME development when encountering difficulties. Thus, having physicians with clinical backgrounds as managers is practical and is likely to contribute to the positive development of SBME. Currently, we affirm the effectiveness of SBME for students; however, the most objective evidence should be derived from clinical sources 20, 23, 24 . Nayahangan et al. interviewed 13 managers across different levels, emphasizing the crucial role of evidence in enhancing patient safety to promote SBME implementation. Currently, research on SBME primarily emphasizes subjective perceptions, with limited studies assessing learner performance in simulated scenarios as measurable outcomes. Furthermore, even fewer studies specifically focus on clinical outcomes as a primary target for observation 6 . There is a need for more high-quality research in the future to provide compelling evidence of the impact of perioperative SBME on clinical outcomes. This online survey study was conducted via the New Youth Anesthesia Forum (www.xqnmz.com), to leverage its broad reach to gather reliable data. Participation was not mandatory; therefore, individuals interested in the content of this study were more likely to respond, potentially introducing some bias. In addition, while designing the questionnaire, the questionnaire focused only on the most important issues, omitting more in-depth questions that warrant further investigation in subsequent studies. In conclusion, despite these limitations, this nationwide cross-sectional study helps us comprehensively understand the current state of perioperative SBME development in China. This provides a basis for subsequent policy-making, thereby offering China’s valuable experience at the global level. Conclusion Our findings indicate that after over a decade of development, perioperative SBME has made notable progress in China. However, its development remains uneven across regions and institutions. Key challenges hindering its advancement include the unavailability of qualified instructors, equipment, and financial investment. This study provides a basis for interventions that maximize the advantages of SBME in perioperative training. Abbreviations SBME: Simulation-based medical education CROSS: the Checklist for Reporting Of Survey Studies I-CVI: Item-Content Validity Index LMICs: Low- and middle-income countries Declarations Ethical approval This study was approved by the Ethics Review Committee of the Second Affiliated Hospital, Zhejiang University School of Medicine with approval number (August 26, 2024, 20241027), and adhered to the Checklist for Reporting of Survey Studies (CROSS) guidelines. This study was conducted in accordance with the Helsinki Declaration. All participants were fully informed about the content of this study and voluntarily provided their consent. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding/Support This study was supported by the National Clinical Key Specialty Construction Project of China 2021(2021-LCZDZK-01) and Teaching Reform Research Incubation Project of the Second Affiliated Hospital, Zhejiang University School of Medicine (20240415). Author contributions YY: Project administration; questionnaire design; review and editing. MR: Questionnaire investigation and design; methodology; writing original draft. XZ: Questionnaire design, distribution and collection. ZH: Questionnaire investigation and design; data curation; formal analysis. GL, YL, JT, JG, BT: Questionnaire design. BZ: Review and editing. MY, YW: Project administration; supervision. All authors read and approved the final manuscript. Acknowledgments The authors would like to thank the participants in this study. We are also grateful to Yandong Jiang, PhD for his assistance in making this manuscript better. References Issenberg SB, McGaghie WC, Hart IR, Mayer, JW, Felner, JM, Petrusa, ER, et al. Simulation Technology for Health Care Professional Skills Training and Assessment [J]. Jama, 1999, 282(9): 861-866. DOI: https://doi.org/10.1001/jama.282.9.861 Kaur H, Kaur S, Singh A, Grover, U, Maheshwari, C, Chawla, SS. Simulation-based training in central venous catheterization for first-year postgraduate students: A prospective study [J]. Current Medicine Research and Practice, 2023, 13(5): 217-221. Buck GH. Development of simulators in medical education [J]. Gesnerus, 1991, 48(1): 7-28. Owen H, Pelosi MA. A historical examination of the Budin-Pinard phantom: what can contemporary obstetrics education learn from simulators of the past? [J]. Acad Med, 2013, 88(5): 652-656. DOI: 10.1097/ACM.0b013e31828b0464 Gaba DM. The future vision of simulation in health care [J]. Qual Saf Health Care, 2004, 13(Suppl 1): i2-10. DOI:10.1136/qshc.2004.009878 McGaghie WC, Issenberg SB, Barsuk JH, Wayne, DB. A critical review of simulation-based mastery learning with translational outcomes [J]. Med Educ, 2014, 48(4): 375-385. DOI:10.1111/medu.12391 Sanli J, Ye P, Yanglu L. An investigation of knowledge, attitude and practice on simulation teaching among nursing teachers from colleges and universities of China [J]. Chinese Journal of Nursing, 2021, 56(3): 415-420. Vetter TR. Managing a perioperative medicine program [J]. Best Pract Res Clin Anaesthesiol, 2022, 36(2): 283-298. DOI:10.1016/j.bpa.2022.04.008 Puri L, Das J, Pai M, Agrawal, P, Fitzgerald, JE, Kelley, et al. Enhancing quality of medical care in low income and middle income countries through simulation-based initiatives: Recommendations of the Simnovate Global Health Domain Group [J]. BMJ Simul Technol En, 2017, 3: S15-S22. DOI:10.1136/bmjstel-2016-000180 Sharma A, Minh Duc NT, Luu Lam Thang T, Nam, NH, Ng, SJ, Abbas, KS, et al. A consensus-based checklist for reporting of survey studies (CROSS) [J]. J Gen Intern Med, 2021, 36(10): 3179-3187. DOI:10.1007/s11606-021-06737-1 Terwee CB, Prinsen CA, Chiarotto A, Westerman, MJ, Patrick, DL, Alonso, J, et al. COSMIN methodology for evaluating the content validity of patient-reported outcome measures: a Delphi study [J]. Qual Life Res, 2018, 27: 1159-1170. DOI:10.1007/s11136-018-1829-0 Boonmak P, Suraseranivongse S, Pattaravit N, Boonmak, S, Jirativanont, T, Lertbunnaphong, T, et al. Simulation-based medical education in Thailand: a cross-sectional online national survey [J]. BMC Med Educ, 2022, 22(1): 298. DOI:10.1186/s12909-022-03369-9 Cook D A, Hatala R, Brydges R, Zendejas, B, Szostek, JH, Wang, AT, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis [J]. Jama, 2011, 306(9): 978-988. DOI:10.1001/jama.2011.1234 Yao S, Tang Y, Yi C, Xiao, Y, et al. Research Hotspots and Trend Exploration on the Clinical Translational Outcome of Simulation-Based Medical Education: A 10-Year Scientific Bibliometric Analysis From 2011 to 2021 [J]. Front Med-Lausanne, 2022, 8: 801277. DOI: https://doi.org/10.3389/fmed.2022.801277 Riaz S. How Simulation-Based Medical Education Can Be Started In Low Resource Settings [J]. J Ayub Med Coll Abbottabad, 2019, 31(4): 636-637. Rogers G D, McConnell H W, de Rooy N J, Ellem, F, Lombard, M. A randomised controlled trial of extended immersion in multi-method continuing simulation to prepare senior medical students for practice as junior doctors [J]. BMC Med Educ, 2014, 14: 1-10. DOI:10.1186/1472-6920-14-90 Bhangu A, Fitzgerald JEF, Ademuyiwa AO, Recinos G, Khatri C, Glasbey JC, et al. Mortality of emergency abdominal surgery in high-, middle- and low-income countries [J]. Br J Surg, 2016, 103(8): 971-988. DOI:10.1002/bjs.10151 Sylvia S, Shi Y, Xue H, Tian, X, Wang, H, Liu, Q, et al. Survey using incognito standardized patients shows poor quality care in China's rural clinics [J]. Health Policy Plan, 2015, 30(3): 322-333. DOI:10.1093/heapol/czu014 Boonmak P, Suraseranivongse S, Pattaravit N, Boonmak, S, Jirativanont, T, Lertbunnaphong, T, et al. Simulation-based medical education in Thailand: a cross-sectional online national survey [J]. BMC Med Educ, 2022, 22(1): 298. DOI:10.1186/s12909-022-03369-9 Barry Issenberg S, McGaghie WC, Petrusa ER, Lee Gordon, D, Scalese, RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review [J]. Med Teach, 2005, 27(1): 10-28. DOI:10.1080/01421590500046924 Amin Z, Hoon Eng K, Gwee M, Dow Rhoon, K, Chay Hoon, T. Medical education in Southeast Asia: emerging issues, challenges and opportunities [J]. Med Educ, 2005, 39(8): 829-832. DOI:10.1111/j.1365-2929.2005.02229.x Hallmark B, Brown M, Peterson DT, Fey, M, Decker, S, Wells-Beede, E, et al. Healthcare Simulation Standards of Best PracticeTM Professional Development [J]. Clinical Simulation in Nursing, 2021, 58: 5-8. McGaghie WC, Issenberg SB, Cohen ER, Barsuk, JH, Wayne, DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence [J]. Acad Med, 2011, 86(6): 706-711. DOI: 10.1097/ACM.0b013e318217e119 Griswold-Theodorson S, Ponnuru S, Dong C, Szyld, D, Reed, T, McGaghie, WC. Beyond the simulation laboratory: a realist synthesis review of clinical outcomes of simulation-based mastery learning [J]. Acad Med, 2015, 90(11): 1553-1560. DOI: 10.1097/ACM.0000000000000938 Additional Declarations No competing interests reported. Supplementary Files SBMEQuestionnaire.docx Cite Share Download PDF Status: Published Journal Publication published 18 Dec, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 12 Sep, 2025 Reviews received at journal 06 Sep, 2025 Reviewers agreed at journal 25 Aug, 2025 Reviews received at journal 22 Aug, 2025 Reviews received at journal 19 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers agreed at journal 01 Aug, 2025 Reviewers invited by journal 30 Jul, 2025 Editor invited by journal 10 Jul, 2025 Editor assigned by journal 08 Jul, 2025 Submission checks completed at journal 08 Jul, 2025 First submitted to journal 22 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-6948208","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":494542222,"identity":"862fc921-1b62-4496-94d9-e0fd7df2661d","order_by":0,"name":"Yuanyuan Yao","email":"","orcid":"","institution":"Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yuanyuan","middleName":"","lastName":"Yao","suffix":""},{"id":494542223,"identity":"b1866df3-3fe7-4005-9283-6a2f0627f479","order_by":1,"name":"Min Rui","email":"","orcid":"","institution":"Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"Rui","suffix":""},{"id":494542224,"identity":"e4f8cbda-6367-40e1-b63d-71be9a0bb44e","order_by":2,"name":"Xiangyong Zhou","email":"","orcid":"","institution":"Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Xiangyong","middleName":"","lastName":"Zhou","suffix":""},{"id":494542225,"identity":"9c93a31d-4368-4af9-a4b2-d1cc85051d61","order_by":3,"name":"Zixin Han","email":"","orcid":"","institution":"Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Zixin","middleName":"","lastName":"Han","suffix":""},{"id":494542226,"identity":"1c93710f-feb2-4148-bdb1-d0f02dfb0130","order_by":4,"name":"Ge Luo","email":"","orcid":"","institution":"Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ge","middleName":"","lastName":"Luo","suffix":""},{"id":494542227,"identity":"c75b5e29-89c7-4558-b7eb-d8c3cd4b25f1","order_by":5,"name":"Yi Liu","email":"","orcid":"","institution":"Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Liu","suffix":""},{"id":494542228,"identity":"04fc249e-5ea9-46a1-9d7a-b6545f6110b7","order_by":6,"name":"Jiachun Tao","email":"","orcid":"","institution":"Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jiachun","middleName":"","lastName":"Tao","suffix":""},{"id":494542230,"identity":"d94e05b2-b7fa-4dbf-8857-358d7f932159","order_by":7,"name":"Jin Guo","email":"","orcid":"","institution":"Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Guo","suffix":""},{"id":494542233,"identity":"d6813e99-969a-49d0-9239-bc38d3b163c1","order_by":8,"name":"Biyun Tang","email":"","orcid":"","institution":"Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Biyun","middleName":"","lastName":"Tang","suffix":""},{"id":494542235,"identity":"84ce7654-941b-4613-b8ba-798f9fdc3fad","order_by":9,"name":"Bin Zheng","email":"","orcid":"","institution":"Surgical Simulation Research Laboratory, University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Zheng","suffix":""},{"id":494542236,"identity":"f5307b6d-3019-4c4b-be46-d2020c6b80ca","order_by":10,"name":"Yi Wang","email":"","orcid":"","institution":"Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Wang","suffix":""},{"id":494542238,"identity":"70aeedd4-85e3-4b4e-bf3d-2db52fb91eb3","order_by":11,"name":"Min Yan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYPACCQZ+BoYEIIOZBC2SDSRqYWAwOACmiNAiP/uM4efCHIs84/MHnkkwVFgnNrCfPYBXC2NfjrH0zG0SxWYHDqRJMJxJT2zgyUvAq4WZh8dAmnebROK2gw1pEoxthxMbJHgM8Gph4+Ex/g3SsrmZAajlHxFaeHh4zMC2bGADaWkgQosED1uZNUjLjDMMyRYJx9KN23hy8GuR72HefJt3W11if/+ZxBsfaqxl+9nP4NfCwMABU8CTAI5MNgLqgYD9AYxxgLDiUTAKRsEoGJEAABrvPCb2BycuAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Min","middleName":"","lastName":"Yan","suffix":""}],"badges":[],"createdAt":"2025-06-22 07:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6948208/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6948208/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-08445-4","type":"published","date":"2025-12-18T15:57:56+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88348366,"identity":"b2993d70-da71-4c1c-897c-ebdfed98efc9","added_by":"auto","created_at":"2025-08-05 13:59:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":315523,"visible":true,"origin":"","legend":"\u003cp\u003eParticipants distribution map and pie charts of provincial distributions\u003c/p\u003e\n\u003cp\u003eFigure 1a. The distribution density of participants across the country；Figure 1b. Ranking of participant proportions by province.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6948208/v1/5b0b1f02725d3c70e68ce428.png"},{"id":88348390,"identity":"03038afa-aff5-4bf7-93df-3f18a6289b4c","added_by":"auto","created_at":"2025-08-05 13:59:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":417577,"visible":true,"origin":"","legend":"\u003cp\u003eThe start time for implementing SBME at different level of hospital and the faculty composition.\u003c/p\u003e\n\u003cp\u003eFigure 2a. The x-axis represents the year when SBME started, the y-axis represents the number of institutions conducting SBME. Figure 2b. Pie chart of the composition of hospital faculty.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6948208/v1/1502769accf8f86f960bcb84.png"},{"id":88348370,"identity":"a2177be6-2998-4b3e-b33b-3c93223f5dcc","added_by":"auto","created_at":"2025-08-05 13:59:48","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":148340,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of learners' satisfaction\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6948208/v1/e1f4d5b4ec887338d87cd5ff.png"},{"id":88348388,"identity":"e91ba6e3-ce77-40f4-995d-3b1f875b1205","added_by":"auto","created_at":"2025-08-05 13:59:49","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":158687,"visible":true,"origin":"","legend":"\u003cp\u003eObstacles and suggestions faced by participants with different perspectives for improvement in perioperative SBME\u003c/p\u003e\n\u003cp\u003eFigure 4a. Obstacles faced by administrators; Figure 4b. Obstacles faced by instructors; Figure 4c. Suggestions from instructors, learners and administrators for improving SBME.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6948208/v1/4331b1550cfd8bd9b74b0f9a.png"},{"id":98813938,"identity":"b15aa29d-5184-4837-8e5f-d3b35356570d","added_by":"auto","created_at":"2025-12-22 16:08:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1528341,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6948208/v1/e0ef3c9c-f6ab-4bdc-90ef-59c1a515dbe4.pdf"},{"id":88348367,"identity":"1af6331b-550f-4327-8de5-c661e101d54c","added_by":"auto","created_at":"2025-08-05 13:59:48","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24676,"visible":true,"origin":"","legend":"","description":"","filename":"SBMEQuestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-6948208/v1/bb5490b75890762a28ff8669.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePerioperative Simulation-based Medical Education in China: A Nationwide Cross- sectional Survey\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSimulation-based medical education (SBME) is a teaching method that can replace or even surpass real-world learning experiences in fully interactive environments\u003csup\u003e1, 2\u003c/sup\u003e. SBME originated in the 18\u003csup\u003eth\u003c/sup\u003e and 19\u003csup\u003eth\u003c/sup\u003e centuries, particularly in France and other European countries, where it was initially applied in fields such as anesthesiology and obstetrics\u003csup\u003e3, 4\u003c/sup\u003e. In the latter half of the 20th century, the development of various simulators, including for cardiopulmonary resuscitation, endotracheal intubation, and human body models simulating cardiac diseases further revolutionized medical education.\u003c/p\u003e\n\u003cp\u003eIn the rapidly evolving field of healthcare, it is crucial to ensure the highest standards of patient safety and care quality. Medical simulation has become an essential tool for educating and training healthcare professionals, offering a safe, controlled environment for practicing complex procedures and refining decision-making skills. Unlike traditional learning methods, which often focus on theoretical knowledge or observation, medical simulation provides hands-on experience, allowing learners to develop their abilities without risking patient safety \u003csup\u003e5\u003c/sup\u003e It is also cost-efficient and more feasible for certain education principles\u003csup\u003e6\u003c/sup\u003e. Beyond skill acquisition, medical simulation promotes teamwork, enhances communication, and prepares clinicians for real-world challenges, although its final effectiveness compared to conventional training remains debatable. As the complexity of medical interventions continues to increase, so does the necessity for simulation-based training to produce competent, confident, and capable healthcare providers. China, a large developing country, has also adopted this training methodology. However, to our knowledge, its applications are mainly associated with nursing, as highlighted in a recent study\u003csup\u003e7\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003ePerioperative medicine, a discipline spanning the entire perioperative period, encompasses various emergent situations. It is a primary application area where SBME is especially relevant and is the focus of this study\u003csup\u003e8\u003c/sup\u003e. Currently, there is a lack of comprehensive research on the application of perioperative SBME in China. We anticipate that key challenges commonly cited in medical education globally, such as financial support, resource management, and professional development, which are frequently mentioned in other countries, might be significant factors affecting the promotion of SBME in China\u003csup\u003e9\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTherefore, we designed an online questionnaire focused on perioperative SBME, collecting feedback from administrative staff, course instructors, and health learners. We conducted a large-scale cross-sectional study to comprehensively understand the current status of perioperative SBME implementation in China. We aimed to examine the advantages and shortcomings of SBME from various perspectives, identify areas for improvement and challenges, and provide recommendations for future advancements in this field.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e\n\u003cp\u003eThis nationwide cross-sectional survey was conducted in collaboration with the Anesthesia Residency Training Quality Control Center of Zhejiang Province and the Clinical Skills Center at the Second Affiliated Hospital, Zhejiang University School of Medicine. Invitations to participate in the survey were distributed via the New Youth Anesthesia Forum (www.xqnmz.com). The objective of this study is to provide a comprehensive overview of the current state of perioperative SBME implementation in China.\u003c/p\u003e\n\u003cp\u003eParticipants\u003c/p\u003e\n\u003cp\u003eA total of 1411 perioperative healthcare professionals, including administrative staffers, course instructors, and health learners completed the questionnaire. With participants\u0026apos; consent, all collected data were anonymized.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval\u003c/p\u003e\n\u003cp\u003eThis study was approved by\u0026nbsp;the Ethics Review Committee of the Second Affiliated Hospital, Zhejiang University School of Medicine (August 26, 2024, 20241027), and adhered to the Checklist for Reporting of Survey Studies (CROSS) guidelines\u003csup\u003e10\u003c/sup\u003e. This study was conducted in accordance with the Helsinki Declaration.\u0026nbsp;All participants were fully informed about the content of this study\u0026nbsp;and voluntarily provided their consent.\u003c/p\u003e\n\u003cp\u003eMeasures\u003c/p\u003e\n\u003cp\u003eThe questionnaire consisted of 52 items divided into two sections. The first section obtained informed consent from survey participants. Items 2 to 10 presented the general characteristics of the study subjects, including sex, city of residence,\u0026nbsp;educational background,\u0026nbsp;employment category,\u0026nbsp;subject\u0026nbsp;category, professional title, years of experience, hospital level, and role in the perioperative simulation program. The second section categorized the population into four groups: instructors, learners, administrators, and others. The level of participation in simulation teaching was assessed across these four categories. A Likert scale was used to measure learners\u0026apos; satisfaction with simulation teaching (1 = very dissatisfied; 2 = dissatisfied; 3 = neutral; 4 = satisfied; 5 = very satisfied). It took approximately 5 minutes to complete the electronic questionnaire.\u003c/p\u003e\n\u003cp\u003eValidity test of the questionnaire\u003c/p\u003e\n\u003cp\u003eSix experts in simulation teaching were invited to assess the consistency of each questionnaire item with the original content. Content validity analysis was conducted using SPSSAU\u003csup\u003e11\u003c/sup\u003e. All items, except for item 19, which had an Item-Content Validity Index (I-CVI) of 0.833 and a corrected Content Validity Index (adjusted Kappa, K*) of 0.816, all other items had a score of 1, indicating perfect agreement. The overall Scale-Level Content Validity Index (S-CVI/UA) was 0.981, and the average Scale-Level Content Validity Index (S-CVI/Ave) was 0.997, indicating strong content validity.\u003c/p\u003e\n\u003cp\u003eData collection\u003c/p\u003e\n\u003cp\u003eAdministrators were defined as administrative staff overseeing simulation programs in hospitals or colleges or directors of simulation centers. Instructors referred to teachers engaged in simulation teaching at various training institutions, while learners included health students or clinical practitioners participating in simulation training\u003csup\u003e12\u003c/sup\u003e. \u0026ldquo;Others\u0026rdquo; included clinicians and teaching physicians not directly involved in simulation teaching.\u0026nbsp;The online questionnaire, designed using the Questionnaire Star platform, was primarily disseminated through the New Youth Anesthesia Forum (http://www.xqnmz.com) and WeChat (Tencent Holdings Limited, Shenzhen, China), and the audience was encouraged to complete the survey.\u0026nbsp;Respondents could complete the questionnaire using either a computer or a mobile device, while allowing each IP address to be submitted only once. The survey was conducted from April 2024 to June 2024.\u003c/p\u003e\n\u003cp\u003eData Analysis\u003c/p\u003e\n\u003cp\u003eStatistical analyses and graphical representations were performed using R software (version 4.4.0). The Shapiro-Wilk test assessed the normality of data distribution. Normally distributed data were expressed as mean \u0026plusmn; standard deviation, while non-normally distributed data were represented as median (quartile) values. The relationship between various variables and outcomes was explored using the rms package. A p-value less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipant characteristics\u003c/p\u003e\n\u003cp\u003eThe questionnaire covered 30 provincial-level administrative regions in China (Figure 1a). Figure 1b illustrates the distribution of responses received from each province, highlighting this survey as the most extensive and well-participated investigation of perioperative simulation teaching in China to date. General information on participants is presented in Table 1. The participants include 274 administrators, 285 instructors, 681 learners, and 250 individuals in other roles. The survey was primarily focused on operative personnel, with a focus on anesthesiology and surgery.\u0026nbsp;Because of the inability to accurately determine the total number of individuals receiving a link to the questionnaire, it was not feasible to calculate the response rate.\u003c/p\u003e\n\u003cp\u003eTable1. Demographic characteristics of participants\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eAdministrator\u003c/p\u003e\n \u003cp\u003e(n=274)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eInstructor\u003c/p\u003e\n \u003cp\u003e(n=285)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eLearner\u003c/p\u003e\n \u003cp\u003e(n=681)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e160 (58.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e148 (51.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e307 (45.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e114 (41.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e137 (48.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e374 (54.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational background, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eAssociate\u0026apos;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e5 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e3 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e18 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eBachelor\u0026apos;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e146 (53.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e103 (36.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e499 (73.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eMaster\u0026apos;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e105 (38.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e141 (49.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e149 (21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eDoctor\u0026apos;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e18 (6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e38 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e15 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment category, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eDoctor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e224 (81.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e267 (93.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e587 (86.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e16 (5.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e10 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e90 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eManager\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e34 (12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e8 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e4 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubject category, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eAnesthesiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e245 (89.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e253 (88.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e602 (88.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eSurgery and other subjects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e29 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e32 (11.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e79 (11.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfessional title, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eResident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e12 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e8 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e293 (43.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eAttending\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e262 (95.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e277 (97.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e388 (57.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorking years, median (IQR), years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e17 (12, 25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e15 (10, 20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e8 (3, 13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital level, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eTertiary hospital (teaching hospital)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e175 (63.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e236 (82.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e405 (59.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eTertiary hospital (non-teaching hospital)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e34 (12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e27 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e42 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e65 (23.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e22 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e234 (34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAdministrator Attitudes and Purposes\u003c/p\u003e\n\u003cp\u003eThe administrators primarily comprised physicians (81.8%), nursing staff (5.8%), and dedicated management personnel (12.4%), with 63.9% affiliated with tertiary teaching hospitals. In terms of educational and professional backgrounds, most administrative staff held a bachelor\u0026apos;s degree (53.3%) or a master\u0026rsquo;s degree (38.3%), with a median work experience of 17 years.\u003c/p\u003e\n\u003cp\u003eA total of 81.8% of administrators believed that SBME was essential for perioperative medical education and should be integrated into routine clinical teaching practices. Administrators indicated that the primary motivations for promoting simulation teaching included addressing the needs of clinical education (92.7%), providing clinical feedback (51.1%), aligning with mainstream educational trends (47.1%), and conducting scientific research (20.8%). Administrators believed that the primary significance of implementing SBME lies in enhancing learners\u0026apos; clinical skills, clinical decision-making abilities, teamwork, communication, and motivation to learn, as well as promoting patient safety during the perioperative period. Additionally, administrators expressed a desire to improve learners\u0026apos; competencies in humanistic care (66.1%) and enhance leadership skills (53.3%).\u003c/p\u003e\n\u003cp\u003ePerioperative SBME implementation\u003c/p\u003e\n\u003cp\u003eThe median start time for implementing simulation teaching across sites was 2021. Figure 2a illustrates the number of sites initiating simulation training by year, revealing a rapid increase in recent years, especially after the COVID-19 pandemic. Tertiary teaching hospitals have more simulation sites than non-tertiary teaching hospitals. Figure 2b indicates that only 19.7% of sites currently have more than 10 teaching staff, while 68.3% of sites have less than 7 teaching staff (of which 4-6 staff account for 33.6% and \u0026le;3 staff account for 34.7%). Among sites with more than 3 teaching staff, tertiary teaching hospitals outnumber other hospitals. However, in sites with 3 or fewer teaching staff, tertiary teaching hospitals and other non-tertiary hospitals are not much difference (17.9% and 16.8% respectively). SBME implementation is yet to be standardized, with 24.5% of administrators reporting uncertainty about the frequency of simulation training at their sites, and 17.2% of administrators indicating that simulation training occurs only 1-2 times per year.\u003c/p\u003e\n\u003cp\u003eTable 2 outlines the current state of perioperative SBME implementation from both learner and instructor perspectives. Instructors identified the primary objective of simulation training as enhancing clinical skills (92.3%), clinical thinking (87.4%), crisis management (77.9%), teamwork (71.9%), doctor-patient communication (61.8%), and leadership (38.2%). However, learners placed less emphasis on improving doctor-patient communication (46.8%) and leadership skills (33.0%). While instructors frequently used high-fidelity simulators for teaching (40.7%), learners reported more frequent use of simple simulators (42.3%). Both groups indicated that simulation training commonly occurred in simulation operating rooms (41.7% vs. 39.3%), with typical session durations of 0.5 to 1 hour (51.1% vs. 47.4%), and class sizes ranging from 5 to 8 participants (48.8% vs. 54.4%). Most instructors conducted simulation training at predetermined frequencies (with an uncertainty rate of 16.5%). In contrast, learners reported that their participation in simulation training was often occasional or uncertain (37.3%).\u003c/p\u003e\n\u003cp\u003eTable2. The objectives and implementation of SBME reported by learners and instructors\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"662\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003eTopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eLearners\u003c/p\u003e\n \u003cp\u003e(n= 681)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eInstructors\u003c/p\u003e\n \u003cp\u003e(n=285)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003eLearning/Teaching objective, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eClinical skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e577 (84.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e263 (92.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eClinical thinking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e598 (87.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e249 (87.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eCrisis management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e496 (72.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e222 (77.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003ePatient-doctor communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e319 (46.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e176 (61.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eTeamwork\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e474 (69.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e205 (71.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eLeadership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e225 (33.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e109 (38.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003eType of simulator, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eStandardized patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e184 (27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e75 (26.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eSimple simulator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e288 (42.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e94 (33.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eHigh fidelity mannequin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e209 (30.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e116 (40.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003eWorkplace, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eSimulated operating room\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e284 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e112 (39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eSimulated ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e39 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e21 (7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eSimulated resuscitation room\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e40 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e15 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eOperating room\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e139 (20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e38 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eWard\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e20 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e6 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eResuscitation room\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e14 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e9 (3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eClassroom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e145 (21.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e84 (29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003eFrequency, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eAt least 2 times per month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e90 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e70 (24.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e1 time per month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e114 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e76 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e1 time every 2~3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e90 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e44 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e1~2 times per year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e133 (19.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e48 (16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003eOccasionally, uncertain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e254 (37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e47 (16.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003eTeaching duration, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026le;\u0026nbsp;0.5 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e88 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e16 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e0.5 ~ 1 hour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e348 (51.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e135 (47.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e1 ~ 2 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e201 (29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e110 (38.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026gt; 2 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e44 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e24 (8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003eNumber of learners, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026lt;\u0026nbsp;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e126 (18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e48 (16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e5 ~ 8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e332 (48.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e155 (54.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e9 ~ 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e109 (16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e54 (18.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026gt; 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e114 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e28 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFactors influencing learners\u0026apos; satisfaction with perioperative SBME\u003c/p\u003e\n\u003cp\u003eLearners rated their satisfaction with perioperative simulation training at each site on a Likert scale, with scores ranging from 1 to 5 points. Satisfaction levels were categorized as unsatisfactory (1-3 points) or satisfactory (4-5 points). Variables such as the educational background, employment category, subject area, professional title, years of experience, hospital level, workplace, type of simulator used, training frequency, duration, and number of learners, were analyzed (as shown in Figure 3) to identify factors influencing learners\u0026apos; satisfaction with simulation training at each site. Single-factor logistic regression analysis revealed that, in general, physicians (compared to nurses\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eand managers [OR: 2.46 (1.42-4.55)]), anesthesiologists (compared to surgeons [OR: 2.32 (1.29-4.50)]), attending physicians (compared to residents [OR: 1.98 (1.40-2.80)]), and learners with over 8 years of work experience (compared to those with less than 8 years [OR: 1.92 (1.37-2.68)]) were more likely to express dissatisfaction with simulation training. With regard to course settings, learners in non-tertiary hospitals [OR: 2.94 (2.10-4.14)], those trained in real environments or classrooms [OR: 1.80 (1.21-2.69), OR: 2.60 (1.72-3.93)], those using simple simulators for simulation training [OR: 3.63 (2.38-5.64)], and those participating in infrequent or irregular simulation training sessions [OR: 2.19 (1.39-3.52), OR: 3.25 (2.10-5.13)], or those for whom simulation training lasted less than 1 hour [OR: 2.09 (1.45-3.04)] were more likely to report learner dissatisfaction. Additionally, class sizes with more than 8 learners [OR: 1.54 (1.09-2.17)] were associated with higher dissatisfaction levels.\u003c/p\u003e\n\u003cp\u003eObstacles and suggestions for improvement in perioperative SBME\u003c/p\u003e\n\u003cp\u003eThe primary obstacles encountered by managers and instructors in perioperative simulation training are presented in Figure 4a. For administrators, the top challenges included shortages of space and simulators, as well as faculty. Instructors similarly identified faculty shortages as well as space and simulator constraints as the main hurdles.\u003c/p\u003e\n\u003cp\u003eSuggestions for improving these deficiencies in perioperative SBME are presented in Figure 4b. Administrators emphasized the need for increased investment in teaching resources (88.7%) and faculty development (84.3%). Instructors also highlighted the need to intensify instructor training efforts (92.6%), establish standardized processes (69.1%), and increase simulation training durations (68.1%). Learners recommended optimizing simulation training time planning (65.9%) and improving simulation training methods (64.2%).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSimulation training has become an increasingly popular teaching method in medical education, particularly for enhancing medical safety \u003csup\u003e13\u003c/sup\u003e. The development of perioperative SBME in China has progressed over a decade. To assess its current status and identify limiting factors, we conducted an online survey. Our findings revealed that SBME is applied across various provinces in China, though there are disparities in its regional distribution, implementation extent, and scale. For example, regions such as Zhejiang, Jiangsu, Shandong, and other regions in Eastern China adopted SBME before 2015, with relatively higher participant rates in the survey. Simulation centers with more than 7 faculty members are predominantly located in Eastern and Southern China. However, only 19.7% of centers have a faculty size exceeding 10, while 68.3% of centers have a faculty size of less than 6.\u003c/p\u003e\n\u003cp\u003eYao S\u0026nbsp;et al. analyzed the countries of publication for SBME-related articles from 2011 to 2021, revealing a predominance of contributions from developed nations, with no representation from Asian countries. This indicates a significant regional imbalance in the global landscape of SBME\u003csup\u003e14\u003c/sup\u003e.\u0026nbsp;In recent years, many developing countries, including China, have made varying degrees of progress in SBME. However, due to funding constraints, the application of standardized patients, part-task trainers, and basic simulators has been more common in simulation education. Riaz et al. suggested that organizations in resource-limited environments should initiate simulation training with standardized patients and part-task simulators, progressing to more advanced high-fidelity simulation centers as funding becomes available\u003csup\u003e15\u003c/sup\u003e.\u0026nbsp;This approach provides practical guidance for regions in developing countries that have either not implemented SBME yet or are in the early stages of its development, particularly in settings with limited financial resources. Furthermore, research by Yao et al. underscores the necessity of establishing closer research collaborations among institutions to further the advancement of SBME\u003csup\u003e14\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn high-income countries such as Australia, the United Kingdom, and the United States, SBME is employed to prepare medical students to become safe and effective primary care physicians upon graduation, with comprehensive requirements, such as the ability to make clinical decisions, manage emergencies, deliver difficult news, and perform practical procedures\u003csup\u003e16\u003c/sup\u003e. Our survey results show that in China, participants place the highest value on clinical skills and decision-making abilities. In contrast, a study focused on low- and middle-income countries (LMICs) found that both instructors and learners prioritize knowledge and skill enhancement, which might be due to relatively lower levels of medical safety assurance and limited investment in SBME resources in these regions. Thus, the improvement of knowledge and skills can significantly enhance medical safety\u003csup\u003e9, 17, 18\u003c/sup\u003e. Furthermore, over 60% of perioperative SBME administrators and instructors in our survey highlighted the importance of non-technical skills, such as crisis management, teamwork, and doctor-patient communication for learners. This indicates that the educational approaches of SBME practitioners in China are in alignment with international standards \u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOur findings are in alignment with those of previous studies, indicating that the majority of learners perceive the course to be beneficial, and their experience, when combined with timely and effective feedback, can yield positive learning outcomes\u003csup\u003e20\u003c/sup\u003e. Furthermore, for simulation instructors, SBME not only enhances their clinical teaching abilities but also improves their own clinical practice and interdisciplinary crisis management skills and treatment capabilities during the implementation of simulation training. This suggests that SBME implementation could enhance the professional skills of both learners and instructors, ultimately enhancing patient safety.\u003c/p\u003e\n\u003cp\u003eWe acknowledge the barriers and deficiencies in SBME reported by administrators and instructors, primarily related to faculty development, simulation resources, and financial support. Previous studies in Southeast Asia and other LMICs have also reported similar findings\u003csup\u003e21\u003c/sup\u003e.\u0026nbsp;Additionally, these findings are in alignment with our analysis of factors influencing learner satisfaction.\u003c/p\u003e\n\u003cp\u003eThrough our analysis of factors influencing learner satisfaction with SBME, we found that learners from the anesthesiology department, physicians, attending physicians, and those with over eight years of work experience were more likely to express dissatisfaction. We attribute this to their higher expectations for simulation training, which might not be currently aligned with the existing faculty expertise, simulation training course arrangements, and management. Our survey results indicate that primary teaching scenarios currently include cardiac arrest, anaphylactic shock, and difficult airways, all of which are common high-risk emergency events in the perioperative period and are particularly relevant for novice learners. In SBME, selecting and designing teaching scenarios to match the varying needs of learners is crucial. This places a significant demand on SBME instructors, as they need to accurately understand their learners\u0026rsquo; educational requirements and design simulation courses that address these needs effectively\u003csup\u003e22\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eOur analysis of factors influencing learner satisfaction with SBME reveals that learners are more likely to be dissatisfied when the hospital is not a tertiary teaching hospital, the environment is not realistic, simple simulators are used, the frequency of sessions is less than once a month or remains uncertain, and when the class size exceeds eight participants. These factors may be attributable to the difficulty in obtaining teaching resources in non-tertiary teaching hospitals, less developed concepts of SBME, which may lead to insufficient investment in simulation facilities and settings, and less standardized simulation training management, all of which can negatively affect teaching effectiveness. Thus, to improve learner satisfaction with SBME, we recommend focusing on improving SBME management in the aforementioned areas.\u003c/p\u003e\n\u003cp\u003eIn our survey, 274 questionnaires were collected from administrators, and data revealed that most SBME administrators were clinical physicians with extensive work experience, higher educational degrees, and advanced professional titles. Administrators with clinical backgrounds are more likely to expect that SBME can effectively enhance learners\u0026apos; crisis management abilities and improve patient outcomes. This background seems to foster confidence, which in turn results in the steady promotion of SBME development when encountering difficulties. Thus, having physicians with clinical backgrounds as managers is practical and is likely to contribute to the positive development of SBME.\u003c/p\u003e\n\u003cp\u003eCurrently, we affirm the effectiveness of SBME for students; however, the most objective evidence should be derived from clinical sources \u003csup\u003e20, 23, 24\u003c/sup\u003e. Nayahangan et al. interviewed 13 managers across different levels, emphasizing the crucial role of evidence in enhancing patient safety to promote SBME implementation. Currently, research on SBME primarily emphasizes subjective perceptions, with limited studies assessing learner performance in simulated scenarios as measurable outcomes. Furthermore, even fewer studies specifically focus on clinical outcomes as a primary target for observation\u003csup\u003e6\u003c/sup\u003e. There is a need for more high-quality research in the future to provide compelling evidence of the impact of perioperative SBME on clinical outcomes.\u003c/p\u003e\n\u003cp\u003eThis online survey study was conducted via the New Youth Anesthesia Forum (www.xqnmz.com), to leverage its broad reach to gather reliable data. Participation was not mandatory; therefore, individuals interested in the content of this study were more likely to respond, potentially introducing some bias. In addition, while designing the questionnaire, the questionnaire focused only on the most important issues, omitting more in-depth questions that warrant further investigation in subsequent studies. In conclusion, despite these limitations, this nationwide cross-sectional study helps us comprehensively understand the current state of perioperative SBME development in China. This provides a basis for subsequent policy-making, thereby offering China\u0026rsquo;s valuable experience at the global level.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur findings indicate that after over a decade of development, perioperative SBME has made notable progress in China. However, its development remains uneven across regions and institutions. Key challenges hindering its advancement include the unavailability of qualified instructors, equipment, and financial investment. This study provides a basis for interventions that maximize the advantages of SBME in perioperative training.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSBME: Simulation-based medical education\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCROSS: the Checklist for Reporting Of Survey Studies\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI-CVI: Item-Content Validity Index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLMICs: Low- and middle-income countries\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical approval\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Review Committee of the Second Affiliated Hospital, Zhejiang University School of Medicine with approval number (August 26, 2024, 20241027), and adhered to the Checklist for Reporting of Survey Studies (CROSS) guidelines. This study was conducted in accordance with the Helsinki Declaration. All participants were fully informed about the content of this study and voluntarily provided their consent.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding/Support \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was supported by\u0026nbsp;the National Clinical Key Specialty Construction Project of China 2021(2021-LCZDZK-01) and\u0026nbsp;\u003cem\u003eTeaching Reform Research Incubation Project of\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003ethe Second Affiliated Hospital, Zhejiang University School of Medicine (20240415).\u003c/p\u003e\n\u003cp\u003eAuthor contributions\u003c/p\u003e\n\u003cp\u003eYY: Project administration; questionnaire design; review and editing.\u003c/p\u003e\n\u003cp\u003eMR: Questionnaire investigation and design; methodology; writing original draft.\u003c/p\u003e\n\u003cp\u003eXZ: Questionnaire design, distribution and collection.\u003c/p\u003e\n\u003cp\u003eZH: Questionnaire investigation and design; data curation; formal analysis.\u003c/p\u003e\n\u003cp\u003eGL, YL, JT, JG, BT: Questionnaire design.\u003c/p\u003e\n\u003cp\u003eBZ: Review and editing.\u003c/p\u003e\n\u003cp\u003eMY, YW: Project administration; supervision.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgments \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the participants in this study. We are also grateful to Yandong Jiang, PhD for his assistance in making this manuscript better.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eIssenberg SB, McGaghie WC, Hart IR, Mayer, JW, Felner, JM, Petrusa, ER, et al. Simulation Technology for Health Care Professional Skills Training and Assessment [J]. Jama, 1999, 282(9): 861-866. DOI: https://doi.org/10.1001/jama.282.9.861\u003c/li\u003e\n \u003cli\u003eKaur H, Kaur S, Singh A, Grover, U, Maheshwari, C, Chawla, SS. Simulation-based training in central venous catheterization for first-year postgraduate students: A prospective study [J]. Current Medicine Research and Practice, 2023, 13(5): 217-221.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBuck GH. Development of simulators in medical education [J]. Gesnerus, 1991, 48(1): 7-28.\u003c/li\u003e\n \u003cli\u003eOwen H, Pelosi MA. A historical examination of the Budin-Pinard phantom: what can contemporary obstetrics education learn from simulators of the past? [J]. Acad Med, 2013, 88(5): 652-656. DOI: 10.1097/ACM.0b013e31828b0464\u003c/li\u003e\n \u003cli\u003eGaba DM. The future vision of simulation in health care [J]. Qual Saf Health Care, 2004, 13(Suppl 1): i2-10. DOI:10.1136/qshc.2004.009878\u003c/li\u003e\n \u003cli\u003eMcGaghie WC, Issenberg SB, Barsuk JH, Wayne, DB. A critical review of simulation-based mastery learning with translational outcomes [J]. Med Educ, 2014, 48(4): 375-385. DOI:10.1111/medu.12391\u003c/li\u003e\n \u003cli\u003eSanli J, Ye P, Yanglu L. An investigation of knowledge, attitude and practice on simulation teaching among nursing teachers from colleges and universities of China [J]. Chinese Journal of Nursing, 2021, 56(3): 415-420.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eVetter TR. Managing a perioperative medicine program [J]. Best Pract Res Clin Anaesthesiol, 2022, 36(2): 283-298. DOI:10.1016/j.bpa.2022.04.008\u003c/li\u003e\n \u003cli\u003ePuri L, Das J, Pai M, Agrawal, P, Fitzgerald, JE, Kelley, et al. Enhancing quality of medical care in low income and middle income countries through simulation-based initiatives: Recommendations of the Simnovate Global Health Domain Group [J]. BMJ Simul Technol En, 2017, 3: S15-S22. DOI:10.1136/bmjstel-2016-000180\u003c/li\u003e\n \u003cli\u003eSharma A, Minh Duc NT, Luu Lam Thang T, Nam, NH, Ng, SJ, Abbas, KS, et al. A consensus-based checklist for reporting of survey studies (CROSS) [J]. J Gen Intern Med, 2021, 36(10): 3179-3187. DOI:10.1007/s11606-021-06737-1\u003c/li\u003e\n \u003cli\u003eTerwee CB, Prinsen CA, Chiarotto A, Westerman, MJ, Patrick, DL, Alonso, J, et al. COSMIN methodology for evaluating the content validity of patient-reported outcome measures: a Delphi study [J]. Qual Life Res, 2018, 27: 1159-1170. DOI:10.1007/s11136-018-1829-0\u003c/li\u003e\n \u003cli\u003eBoonmak P, Suraseranivongse S, Pattaravit N, Boonmak, S, Jirativanont, T, Lertbunnaphong, T, et al. Simulation-based medical education in Thailand: a cross-sectional online national survey [J]. BMC Med Educ, 2022, 22(1): 298. DOI:10.1186/s12909-022-03369-9\u003c/li\u003e\n \u003cli\u003eCook D A, Hatala R, Brydges R, Zendejas, B, Szostek, JH, Wang, AT, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis [J]. Jama, 2011, 306(9): 978-988. DOI:10.1001/jama.2011.1234\u003c/li\u003e\n \u003cli\u003eYao S, Tang Y, Yi C, Xiao, Y, et al. Research Hotspots and Trend Exploration on the Clinical Translational Outcome of Simulation-Based Medical Education: A 10-Year Scientific Bibliometric Analysis From 2011 to 2021 [J]. Front Med-Lausanne, 2022, 8: 801277. DOI: https://doi.org/10.3389/fmed.2022.801277\u003c/li\u003e\n \u003cli\u003eRiaz S. How Simulation-Based Medical Education Can Be Started In Low Resource Settings [J]. J Ayub Med Coll Abbottabad, 2019, 31(4): 636-637.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRogers G D, McConnell H W, de Rooy N J, Ellem, F, Lombard, M. A randomised controlled trial of extended immersion in multi-method continuing simulation to prepare senior medical students for practice as junior doctors [J]. BMC Med Educ, 2014, 14: 1-10. DOI:10.1186/1472-6920-14-90\u003c/li\u003e\n \u003cli\u003eBhangu A, Fitzgerald JEF, Ademuyiwa AO, Recinos G, Khatri C, Glasbey JC, et al. Mortality of emergency abdominal surgery in high-, middle- and low-income countries [J]. Br J Surg, 2016, 103(8): 971-988. DOI:10.1002/bjs.10151\u003c/li\u003e\n \u003cli\u003eSylvia S, Shi Y, Xue H, Tian, X, Wang, H, Liu, Q, et al. Survey using incognito standardized patients shows poor quality care in China\u0026apos;s rural clinics [J]. Health Policy Plan, 2015, 30(3): 322-333. DOI:10.1093/heapol/czu014\u003c/li\u003e\n \u003cli\u003eBoonmak P, Suraseranivongse S, Pattaravit N, Boonmak, S, Jirativanont, T, Lertbunnaphong, T, et al. Simulation-based medical education in Thailand: a cross-sectional online national survey [J]. BMC Med Educ, 2022, 22(1): 298. DOI:10.1186/s12909-022-03369-9\u003c/li\u003e\n \u003cli\u003eBarry Issenberg S, McGaghie WC, Petrusa ER, Lee Gordon, D, Scalese, RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review [J]. Med Teach, 2005, 27(1): 10-28. DOI:10.1080/01421590500046924\u003c/li\u003e\n \u003cli\u003eAmin Z, Hoon Eng K, Gwee M, Dow Rhoon, K, Chay Hoon, T. Medical education in Southeast Asia: emerging issues, challenges and opportunities [J]. Med Educ, 2005, 39(8): 829-832. DOI:10.1111/j.1365-2929.2005.02229.x\u003c/li\u003e\n \u003cli\u003eHallmark B, Brown M, Peterson DT, Fey, M, Decker, S, Wells-Beede, E, et al. Healthcare Simulation Standards of Best PracticeTM Professional Development [J]. Clinical Simulation in Nursing, 2021, 58: 5-8.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMcGaghie WC, Issenberg SB, Cohen ER, Barsuk, JH, Wayne, DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence [J]. Acad Med, 2011, 86(6): 706-711. DOI: 10.1097/ACM.0b013e318217e119\u003c/li\u003e\n \u003cli\u003eGriswold-Theodorson S, Ponnuru S, Dong C, Szyld, D, Reed, T, McGaghie, WC. Beyond the simulation laboratory: a realist synthesis review of clinical outcomes of simulation-based mastery learning [J]. Acad Med, 2015, 90(11): 1553-1560. DOI: 10.1097/ACM.0000000000000938\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"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":"Simulation, medical education, survey, cross-sectional, descriptive analysis","lastPublishedDoi":"10.21203/rs.3.rs-6948208/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6948208/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 rapidly emerged as a new trend in perioperative medical education in China. However, our understanding of its role and impact on medical education remains unclear. This study surveyed medical educators to assess SBME from the perspectives of administrators, instructors, and learners, identifying both its advantages and shortcomings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA cross-sectional online survey was conducted in 2024, involving administrators, instructors, and learners from medical education institutes across China. The survey included a structured questionnaire focused on perioperative SBME with information regarding participant characteristics, their attitudes, and perceived teaching obstacles. Descriptive statistics were used to summarize the current status of perioperative SBME, and logistic regression analysis helped identify factors potentially affecting learners' satisfaction with the program.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 1411 survey respondents, including 274 administrative staff, 285 course instructors, 681 learners, and 250 others, participated in our study. Among administrators, 81.8% believed that SBME was crucial for perioperative medical training, emphasizing its role in enhancing trainees’ clinical skills and decision-making abilities. Key challenges identified by administrators and instructors included insufficient training space, simulation models, and faculty. Administrators advocated for increased investment in simulation resources (88.7%) and faculty development (84.3%). Instructors stressed the importance of enhanced faculty training (92.6%), implementing standardized training protocols (69.1%), and increasing the proportion of simulation-based teaching (68.1%). Learners recommended optimizing teaching schedules (65.9%) and improving simulation methods (64.2%). Notably, SBME implementation varied across different regions in China, especially in tertiary hospitals, where medical institutes in Southern and Eastern China run more SBME programs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eSBME development has progressed in China, but faces imbalances across different regions and institutions. Furthermore, the availability of qualified instructors, equipment, and financial investment still need to be addressed. This study provides a foundation for the continued advancement of SBME.\u003c/p\u003e","manuscriptTitle":"Perioperative Simulation-based Medical Education in China: A Nationwide Cross- sectional Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-05 13:59:41","doi":"10.21203/rs.3.rs-6948208/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-12T04:35:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-06T19:16:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"269375632936733703580265781635493265094","date":"2025-08-25T23:12:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-23T01:07:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-19T11:20:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"170648180645717552369844268270753523107","date":"2025-08-19T11:00:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"253452438298333064095315037299111039978","date":"2025-08-02T03:07:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-30T18:41:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-10T10:37:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-08T13:05:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-08T13:02:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-06-22T07:26:04+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":"3cc40c30-bade-45a5-b38e-ce61131451cc","owner":[],"postedDate":"August 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T16:01:53+00:00","versionOfRecord":{"articleIdentity":"rs-6948208","link":"https://doi.org/10.1186/s12909-025-08445-4","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-12-18 15:57:56","publishedOnDateReadable":"December 18th, 2025"},"versionCreatedAt":"2025-08-05 13:59:41","video":"","vorDoi":"10.1186/s12909-025-08445-4","vorDoiUrl":"https://doi.org/10.1186/s12909-025-08445-4","workflowStages":[]},"version":"v1","identity":"rs-6948208","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6948208","identity":"rs-6948208","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}