A Blended-Learning Two-Day Trauma Course Compared with the Traditional Three-Day Trauma Course: A Retrospective Non-Inferiority Study

A Blended-Learning Two-Day Trauma Course Compared with the Traditional Three-Day Trauma Course: A Retrospective Non-Inferiority Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Blended-Learning Two-Day Trauma Course Compared with the Traditional Three-Day Trauma Course: A Retrospective Non-Inferiority Study Marly Iskander, Frederike J. C. Haverkamp, Leo M. G. Geeraedts, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9214728/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background During the multidisciplinary Definitive Surgical and Anaesthetic Trauma Care (DSATC) course, trauma specialists are trained to apply damage control principles to polytrauma patients. The course transitioned in 2020 from a three-day, traditional format to a two-day format that combines online and traditional learning methods to enhance course quality and learning outcomes. Considering that learning opportunities on the work floor are scarce, continuous course evaluation is crucial to ensure benefits for medical professionals and their patients. Methods This retrospective non-inferiority study compared self-assessed confidence in technical and non-technical skills between a cohort in the traditional DSATC course and a cohort in the blended-learning DSATC course. Self-assessed confidence ratings were collected through quantitative pre-course and post-course questionnaires. Mean changes in confidence ratings were calculated and compared using independent samples t-tests with a non-inferiority margin of -0.5. Sub-analyses investigated differences between participants of the same profession, between physicians with different levels of experience, and investigated the influence of individual preparation on self-assessed confidence in skills before on-site training. Results A total of 180 (21%) participants completed the pre-course and one-day post-course questionnaires completely. Both cohorts showed increased self-assessed confidence in skills following course completion, with the blended-learning DSATC cohort demonstrating non-inferior improvements compared with the traditional cohort in general technical skills (mean difference (MD) 0.07, 97.5%-confidence interval (CI) lower confidence bound − 0.14, p < 0.001) and in general non-technical skills (MD 0.09, 97.5%-CI lower confidence bound − 0.09, p < 0.001). Self-assessed confidence in non-technical skills declined in the blended-learning cohort following individual preparation (MD -0.21, p = 0.042). Conclusions The blended-learning format of the DSATC course is at least as effective as the traditional model in improving self-assessed confidence in technical and non-technical skills. Individual pre-course preparation by participants may increase awareness of learning needs, fostering self-directed learning. The findings underscore the need to move beyond a traditional, one-size-fits-all approach to training and toward competency-based, individualized learning pathways, supported by blended-learning methods. Further research into the effectiveness of such pathways in multidisciplinary trauma education and patient outcomes is needed. Multidisciplinary trauma course self-efficacy blended learning traditional learning technical skills non-technical skills Figures Figure 1 Figure 2 Introduction The effective treatment of critically injured patients requires an integrated set of technical and non-technical skills, such as acute surgical skills, communication, and teamwork [ 1 – 3 ]. Educational opportunities aimed at the treatment of polytrauma patients are crucial to improve the readiness and competence of medical professionals in trauma care, since this influences the quality of care provided to patients [ 4 – 6 ]. However, learning opportunities in the clinical work environment are often limited by factors such as increased nonoperative management and the unpredictable and time-sensitive nature of trauma cases, which complicate the planning and delivery of educational initiatives, resulting in a lack of on-the-job learning opportunities [ 6 – 8 ]. In recognition of the need for trauma care education, various courses have been developed. Examples include Advanced Trauma Life Support (ATLS), Advanced Surgical Skills for Exposure in Trauma (ASSET), Definitive Surgical Trauma Care (DSTC) and Definitive Anaesthetic Trauma Care (DATC) courses [ 9 – 12 ]. Participation in such courses can enhance self-assessed competence, clinical performance, knowledge, and the efficiency of team-based patient care [ 1 , 12 – 14 ]. The Dutch DSTC and DATC courses were the first to be combined into one multidisciplinary course: the Definitive Surgical and Anaesthetic Trauma Care (DSATC) course [ 15 ]. The Dutch DSATC course has been in place since 2009 and provides learning opportunities to national and international participants involved in trauma care, such as intensivists, scrub nurses, anesthesia nurses, surgeons and anesthesiologists. The intention is to equip participants with knowledge and skills regarding the application of damage control principles to polytrauma patients through interactive workshops, group discussions, and lectures [ 15 – 16 ]. Hands-on experience with trauma cases is offered through simulation in a regulated environment, enabling skill development while eliminating risks for individual patients [ 10 , 17 – 18 ]. The unique multidisciplinary approach, which distinguishes the DSATC course, improves teamwork and team-based care for severely injured patients [ 1 , 10 , 14 , 19 ]. In 2020, the traditional three-day on-site DSATC course was redesigned into a blended-learning format that combines online modules with two days of in-person training, while maintaining the amount of hands-on experience. This shift, prompted by the COVID-19 pandemic and guided by previous faculty and participant feedback, can enhance learning by offering greater flexibility for individual learners’ needs, reinforcing theoretical knowledge, and improving preparation for practical training [ 20 – 21 ]. The preparation for the previous course consisted mainly of theoretical preparation through course manuals, whereas the current format provides preparatory material through the renewed DSATC manual [ 22 ] and an online learning environment, comprising pre-recorded lectures, e-learnings and virtual simulation (Appendix A). Online learning complements traditional methods but cannot replace hands-on learning [ 20 – 21 , 23 ]. Given the significance of educational quality for participant development and, consequently, its potential implications for patient outcomes, it is essential to evaluate how differences in course design influence educational quality and learners’ self-efficacy [ 14 , 24 – 25 ]. Therefore, the objective of this study is to compare self-assessed confidence in skills between participants who attended a previous traditional DSATC course and those who completed the new blended-learning DSATC course. With this approach, the study aims to generate actionable learning points applicable to the DSATC and similar courses. To our knowledge, few studies have examined both technical and non-technical skills within such multidisciplinary settings. Previous studies also highlighted the need for research on the multidisciplinary aspects of trauma care courses. These points have been identified as gaps in research [ 1 , 19 , 26 – 27 ], which this study seeks to address. Methods Study design and setting This retrospective non-inferiority cohort study included two cohorts of attendees from the DSATC course at the Radboud University Medical Centre (Radboudumc) in Nijmegen, the Netherlands. Cohort 1 consisted of participants from traditional DSATC courses between 2016 and 2019. Cohort 2 consisted of participants who took part in the new blended-learning DSATC course between 2021 and 2024. Participants The study population comprised all participants ( n = 843) in the DSATC course at Radboudumc between 2016 and 2024. The participants included were mainly attending and resident surgeons and anesthesiologists, scrub nurses and anesthesia nurses from various countries. Course participants were informed about the conduction of research throughout the DSATC courses and were requested to complete the corresponding questionnaires. Subsequently, consent to participate in this study was implied by the voluntary completion of the questionnaires. This study was determined to be exempt from the Dutch Medical Research Involving Human Subjects Act (WMO) by a Medical Ethics Committee. Data collection All course participants received an invitational email to anonymously fill out quantitative digital questionnaires at five instances: one day before the course, and one day, three months, one year, and two years after the course. Reminders were sent four weeks later. The participants from the 2024 blended-learning DSATC course group received an additional questionnaire before receiving access to the individual preparatory materials. Answers were automatically collected and organized yearly into secure data files on Radboudumc servers by the Department of Surgery. Participants who wished not to participate could opt to be unsubscribed to future invitations and withdraw at any time. The questionnaires were identical at each timepoint (Appendix B) and data from the questionnaires were analyzed to reveal actionable learning points for the DSATC and similar multidisciplinary courses. The questions encompassed participant characteristics, including sex, age, and profession, as well as technical skills (e.g. trauma laparotomy, treating head trauma) and non-technical skills (communication, teamwork, leadership). Participants assessed their confidence in each skill using a five-point Likert scale (1 not confident – 5 very confident). Skills questions concerned general skills that applied to all participants, as well as specific skills for each of the main professions, namely surgeons (including orthopedic surgeons), anesthesiologists and anesthesia/scrub nurses. The questionnaires were based on previous resources consisting of course objectives and content, expert opinions, and a similar questionnaire utilized in a study by Gaarder et al. in 2005 [ 9 ]. Previous studies have utilized and published on the questionnaire [ 9 – 10 , 17 ]. Minor differences existed between the traditional and blended-learning course questionnaires, mainly regarding the newly developed individual preparations. The previous questionnaire was published in the 2020 study by Tan et al. [ 10 ]. Data analysis Participant characteristics and mean evaluation grades, collected from annual digital course evaluations, were analyzed descriptively. These are presented as the mean ± standard deviation (SD) or as numbers with percentages. Participant characteristics were analyzed comparatively between the traditional and blended-learning cohorts via a chi square test for categorical data and an independent samples t-test or one-sample t-test for numerical data. Prominent participant feedback from the evaluations and overall self-assessed skills progression observed throughout the surveys were also reported descriptively. The primary outcome measures were the mean changes in self-assessed confidence in general technical and non-technical skills, compared between the cohorts. For the comparative analysis, self-assessed confidence ratings of general skills questions were combined to compute the primary outcome variables: confidence in general technical and non-technical skills. Mean confidence ratings were calculated from the pre-course and one-day post-course questionnaires for each cohort. The data had been previously collected. Additional sub-analyses were conducted. One sub-analysis compared the mean change in self-assessed confidence in skills between the cohorts for each of the main professions: surgeons (including orthopedic surgeons), anesthesiologists and anesthesia/scrub nurses. The outcome variables were computed from specific skills questions from the pre-course and one-day post-course questionnaires. Surgeons’ non-technical skills covered leadership and teamwork, while nurses’ and anesthesiologists’ non-technical skills exclusively covered teamwork. A second sub-analysis compared the mean change in self-assessed confidence from pre-course to one-day post-course between attending and resident physicians within each cohort. A final sub-analysis was conducted using data from the 2024 DSATC course group ( n = 49), to assess how individual preparations might have influenced self-assessed confidence in general technical and non-technical skills before the on-site training. Participants who completed both the pre-course and one-day post-course questionnaires were included in the statistical analysis. Those who did not complete both or only completed them partly were excluded (Fig. 1). The questionnaires beginning three-months post-course were not analyzed statistically because of low response rates. Furthermore, participants of whom it was unclear which questionnaire they intended to complete were excluded, and missing answers were excluded per analysis. An independent samples t-test was deemed the appropriate statistical method for all analyses except the final sub-analysis, for which a paired samples t-test was used. All inferential statistics were conducted using IBM SPSS Statistics (version 29). For the primary analysis, a one-sided 97.5%-confidence interval (CI) was used to test the hypothesis that the results after the blended-learning course are not inferior to those of the traditional course, with a non-inferiority margin of -0.5 based on previous findings [ 10 , 17 ]. For the sub-analyses and analysis of participant characteristics, a two-sided α ≤ 0.05 was used. Results Participation and response rates An overview of the study population before and after the application of the inclusion criteria is depicted in Fig. 1. Participants of whom it was unclear which questionnaire they intended to complete were labeled non-respondents in the figure ( n = 4). Among the 843 DSATC course participants between 2016 and 2024, 180 (21%) participants completed both the pre-course and one-day post-course questionnaires. The number of participants who completed each subsequent questionnaire declined, with 85 (10%) responses up to three-months post-course, 31 (4%) responses up to one-year post-course, and 9 (1%) responses up to two-years post-course. In total, 667 (79%) individuals completed at least one questionnaire. A comprehensive respondent distribution can be consulted in Appendix C. Descriptive analysis Table 1 presents the background characteristics of the respondents who completed both the pre-course and one-day post-course surveys. Compared with the traditional course cohort, the blended-learning course cohort included a greater number of male participants ( p = 0.021) and had a different distribution of professional roles: the blended-learning course cohort had a lower proportion of nurses ( n = 15% vs. n = 27%) and a greater number of orthopedic surgeons ( n = 31 vs. n = 8) ( p = 0.048). The blended-learning course cohort also included more resident physicians ( n = 35, 31%) than did the traditional course cohort ( n = 9, 18%) ( p = 0.025). Characteristic Traditional DSATC course Blended-learning DSATC course Total n = 67 n = 113 n = 180 Sex (n, %) * Male 36 (46%) 80 (71%) 116 (64%) Female 31 (54%) 33 (29%) 64 (36%) Age in years (mean, SD) 40.3 (9.1) 40.3 (7.9) 40.3 (8.3) Profession (n, %) * Surgeon 23 (34%) 34 (30%) 57 (32%) Nurse 18 (27%) 17 (15%) 35 (19%) Anesthesiologist 18 (27%) 31 (27%) 49 (27%) Orthopedic surgeon 8 (12%) 31 (27%) 39 (22%) Current clinical work position a (n, %) * Attending physician 40 (82%) 61 (54%) 101 (56%) Resident physician 9 (18%) 35 (31%) 44 (24%) Years of work experience b (mean, SD) 15.2 (8.3) 16.1 (7.1) 15.8 (7.5) Hospital of employment (n, %) Academic or military 28 (42%) 44 (39%) 72 (40%) Peripheral or teaching 33 (49%) 67 (59%) 100 (56%) Other 3 (5%) 0 (0%) 3 (2%) Missing 3 (5%) 2 (2%) 5 (3%) Employed at a level 1 trauma center ( n, % ) Yes 29 (43%) 63 (56%) 92 (51%) No 5 (8%) 49 (43%) 54 (30%) Missing 33 (49%) 1 (1%) 34 (19%) Table 1 Background characteristics of respondents SD standard deviation, N.A. not applicable, n number of respondents Percentages are rounded a Only applicable to surgeons, orthopedic surgeons and anesthesiologists b Only applicable to anesthesia nurses and scrub nurses * Statistical analysis on the variable demonstrated significant differences between the cohorts Figure 2 depicts the longitudinal effect of both course formats on participants’ self-assessed confidence in skills. Compared with the blended-learning DSATC cohort, the traditional DSATC cohort consistently demonstrated higher confidence levels, but the mean self-assessed confidence levels remained higher than the pre-course confidence levels throughout the follow-up period in both cohorts. However, this was not analyzed statistically. Additionally, participants in the blended-learning course cohort were asked to rate their level of agreement with the statement ‘individual preparation is not necessary prior to the course’ on a five-point Likert scale (1 completely disagree – 5 completely agree). The respondents demonstrated a mean change in agreement of -0.04 (SD 1.1) toward greater disagreement with the statement after completing the course than before the course ( p = 0.002). The mean preparation time in this cohort was 14.2 hours (SD 7.9) for the online preparation modules and 18.3 hours (SD 11.8) in total, including course manuals and additional preparation. Primary analysis For the primary analysis, the mean changes in self-assessed confidence in general technical and non-technical skills were compared between the traditional learning DSATC group ( n = 67) and the blended-learning DSATC group ( n = 113) (Table 2 ). For general technical skills, the mean difference (MD) between the groups was 0.07, with a greater increase in self-assessed confidence in the blended-learning DSATC group. The lower bound of the 97.5%-CI was − 0.14 ( p < 0.001). For general non-technical skills, the MD between the groups was 0.09, again with a greater increase in self-assessed confidence in the blended-learning DSATC group. The lower bound of the 97.5%-CI for this difference was − 0.09 ( p < 0.001). Neither of the lower limits of the 97.5%-CI exceeded the pre-specified non-inferiority margin of -0.5. Table 2 Self-assessed confidence in general skills compared between two DSATC course formats General skills c Traditional DSATC n = 67 Blended-learning DSATC n = 113 Mean difference (CI) e p value Mean rating (SD) d Mean rating (SD) d Pre-course One-day post-course Mean change (SE) Pre-course One-day post-course Mean change (SE) Non-technical Communication 3.9 (0.6) 4.1 (0.6) 0.25 (0.08) 3.8 (0.7) 4.1 (0.6) 0.36 (0.06) 0.11 (-0.08,0.30) < 0.001 Teamwork 3.6 (0.6) 4.1 (0.6) 0.51 (0.08) 3.5 (0.7) 4.0 (0.5) 0.52 (0.07) 0.01 (-0.20,0.22) < 0.001 Technical Trauma laparotomy 3.3 (1.2) 4.2 (0.9) 0.94 (0.13) 2.5 (1.3) 3.7 (1.2) 1.19 (0.11) 0.26 (-0.08,0.59) < 0.001 Damage control surgery 3.2 (1.2) 4.0 (0.9) 0.81 (0.12) 2.5 (1.2) 3.5 (1.2) 1.01 (0.10) 0.20 (-0.13,0.52) < 0.001 Head trauma 3.0 (1.0) 3.6 (1.0) 0.55 (0.11) 2.8 (1.2) 3.2 (1.1) 0.42 (0.10) − 0.13 (-0.43,0.18) 0.009 Neck trauma 2.9 (0.9) 3.6 (0.8) 0.73 (0.11) 2.7 (1.1) 3.4 (0.8) 0.70 (0.10) − 0.03 (-0.34,0.27) 0.001 Blast injury 2.5 (0.9) 3.4 (0.9) 0.97 (0.10) 2.2 (1.0) 3.2 (1.0) 0.96 (0.09) − 0.01 (-0.29,0.28) < 0.001 Ballistic/penetrating injury 2.7 (0.8) 3.5 (0.9) 0.79 (0.09) 2.4 (1.1) 3.5 (1.0) 1.07 (0.10) 0.28 (0.02,0.54) < 0.001 Burn injury 2.8 (0.8) 3.6 (0.8) 0.75 (0.09) 2.7 (1.0) 3.4 (1.0) 0.66 (0.08) − 0.09 (-0.33,0.16) < 0.001 Pooled non-technical 3.8 (0.5) 4.1 (0.6) 0.32 (0.07) 3.7 (0.6) 4.1 (0.5) 0.41 (0.05) 0.09 (-0.09,0.26) < 0.001 Pooled technical 2.9 (0.7) 3.7 (0.7) 0.80 (0.07) 2.5 (0.9) 3.4 (0.8) 0.86 (0.07) 0.07 (-0.14,0.27) < 0.001 Combined 3.4 (0.5) 3.9 (0.6) 0.56 (0.06) 3.1 (0.6) 3.8 (0.6) 0.64 (0.05) 0.08 (-0.07,0.23) < 0.001 SD standard deviation, SE standard error of the mean, n number of respondents Level of significance α ≤ 0.025 c Absence of questions about teamwork, trauma laparotomy, damage control surgery and burn injury in the traditional course of 2019 reduced the number of respondents to n = 64 for these general skills d Scale: 1 completely disagree – 5 completely agree e Mean difference between cohorts in the change in self-assessed confidence in skills from pre-course to one-day post-course, with negative values indicating a greater change in self-assessed confidence among traditional DSATC participants compared to blended-learning DSATC participants Sub-analysis The first sub-analysis revealed no significant differences between the cohorts in self-assessed confidence in either technical or non-technical skills for each of the main professional groups. The second sub-analysis examined differences in the mean change in self-assessed confidence between residents and attending physicians. In both cohorts, residents demonstrated a greater increase in self-assessed confidence in both technical and non-technical skills than did attending physicians, although the difference was not statistically significant. In the traditional DSATC group, the mean increase for residents exceeded that of attending physicians by 0.14 ( p = 0.498) for technical skills and 0.28 ( p = 0.175) for non-technical skills. In the blended-learning DSATC group, the differences were 0.20 ( p = 0.134) and 0.07 ( p = 0.518) for technical and non-technical skills, respectively. The final sub-analysis assessed the impact of completing the online individual preparations on participants’ self-assessed confidence prior to the on-site sessions of the 2024 blended-learning DSATC course. For both general technical and non-technical skills, self-assessed confidence declined after completing individual preparations. While the decline in confidence in technical skills was not significant (MD -0.06, p = 0.597), the decline in self-assessed confidence in non-technical skills was indeed significant (MD -0.21, p = 0.042). Course evaluations The evaluation scores for the DSATC courses are summarized in Table 3 . The 2017 traditional course received the lowest grade (mean 8.37 ± SD 1.46), whereas the 2024 blended-learning course received the highest (mean 8.67 ± SD 0.74). Generally, the blended-learning courses received higher grades than the traditional courses did. Table 3 Annual DSATC course evaluation grades with response rates Course year 2016 2017 2018 2019 2021 2022 2023 2024 Grade (mean, SD) f 8.50 (0.88) 8.37 (1.46) 8.49 (0.75) 8.41 (0.76) 8.56 (0.73) 8.63 (0.71) 8.50 (0.73) 8.67 (0.74) Response rate (%, n/total) 96% (53/55) 67% (41/61) 92% (82/89) 91% (79/87) 64% (90/140) 54% (73/134) 72% (101/141) 63% (85/136) SD standard deviation, (n/total) number of respondents/number of invitees Percentages are rounded f Scale: 1 very poor – 10 excellent Participants highlighted the importance of practical surgical skills and problem-solving across all evaluations. Despite this, participants from both course formats noted that the integration of crew resource management (CRM) principles into the individual preparation and on-site training remains underdeveloped. These principles cover non-technical skills such as problem-solving, leadership, situational awareness and decision-making [ 3 ]. While some found the anatomy and operative porcine laboratories morally challenging, they were considered indispensable by traditional course participants and very beneficial by blended-learning course participants. Practical workshops were consistently rated as the best feature, whereas the quantity and quality of presentations were rated lower. Language barriers hindered the effective application of CRM principles. Participant feedback on the individual preparation of the blended-learning course revealed mixed views. While some found it useful and interactive, others, particularly nurses, indicated that it was too extensive, beyond their expertise and mostly aimed at surgeons. Non-technical skills preparation was seen as insufficient. Moreover, disparities in professional backgrounds affected perceptions of course relevance: nurses felt inadequately involved, anesthesiologists expressed a wish for more depth or cross-disciplinary insights, and orthopedic surgeons and lower-level trauma center participants reported feeling out of place. Despite this, practical workshops increased confidence in trauma management for some participants. Suggestions for course improvement differed by cohort, with traditional DSATC course participants favoring a reduction in on-site training by one day, whereas blended-learning DSATC course participants favored less individual preparation or an additional on-site training day. Discussion This study explored the impact of transitioning a multidisciplinary trauma care course from a three-day, traditional learning format to a two-day, blended-learning format on participants’ self-assessed confidence in their technical and non-technical skills. The findings indicate that the blended-learning format is at least as effective as the traditional format in enhancing Dutch DSATC course participants’ self-assessed confidence, with both cohorts reporting increased confidence following course completion. Notably, participants in the blended-learning cohort reported greater gains in non-technical skills and several technical skills. The effectiveness of blended learning in healthcare education has been well established, with its success often attributed to factors such as personalized learning, enhancement of knowledge, facilitation of skill acquisition, and the reinforced connection between theory and practice [ 20 – 21 , 28 ]. For example, a study by Bergmans et al. demonstrated the non-inferiority of a blended-learning approach in the context of technical skill acquisition and retention in the European Trauma Course (ETC) compared with traditional face-to-face teaching [ 29 ]. Even so, however, the effectiveness depends on course design, skill complexity and participant characteristics such as motivation, time management and digital experience [ 21 , 29 ]. The mixed perceptions expressed in the DSATC course participants’ feedback highlight how differences in the design, delivery and individual engagement with blended-learning programs can lead to varied educational outcomes. This underscores the idea that online education – despite its benefits – cannot fully replace all aspects of in-person curricula and that both should be customized with the individual learner in mind [ 20 – 21 , 23 , 27 ]. The individual preparations of the blended-learning DSATC course further illustrate both the potential and challenges of blended learning. The cohort that completed the newly developed individual preparatory material presented lower baseline confidence in non-technical skills (i.e., prior to the on-site training sessions). According to Kolb’s Learning Theory, the preparatory phase may have primarily engaged participants in reflective observation and abstract conceptualization, as they were exposed to theoretical material without the benefit of hands-on experience [ 30 ]. This could have increased the perceived complexity of the material or heightened participants’ awareness of their knowledge gaps, which, in turn, may have contributed to lower pre-course confidence ratings [ 31 ]. Nevertheless, this phase is a necessary and effective component of the learning process, as it encourages active and critical reflection on one’s understanding. This facilitates the recognition and formulation of learning needs and goals, laying the foundation for goal-directed actions [ 30 ]. Smyth et al. (2012) reported that postgraduate students in a blended-learning program described developing an increased sense of responsibility for their own learning [ 32 ]. In support of this, participants in the blended-learning DSATC cohort – despite the initial report of lower self-assessed confidence before the on-site training – showed greater gains in self-assessed confidence after the course. Following the on-site training, respondents from this cohort also deemed individual preparation to be more necessary than they had initially deemed it before the course. In contrast, the traditional preparatory course manual, which was also distributed prior to the pre-course questionnaire, was reported to be underutilized and likely had minimal impact on participants’ learning process and self-perceived readiness. Finally, some of the findings could be explained by differences between the cohorts. The blended-learning cohort included more resident physicians than attending physicians. Although not statistically significant, resident physicians had a greater increase in self-assessed confidence in both technical and non-technical skills. Experience may influence self-efficacy, as less experienced participants often exhibit lower pre-course self-efficacy but are just as likely to achieve competence as more experienced participants [ 33 ]. Another source of heterogeneity was sex: compared with the traditional learning cohort, the blended-learning cohort comprised significantly more male participants than female participants. Differences in sex have been shown to influence self-perception in clinical education, with some studies indicating that women may underestimate their competence despite their performance being equivalent or superior to the performance of male colleagues [ 34 – 35 ]. Strengths and limitations This study extends previous observations by investigating how course modifications affect participants’ self-assessed confidence in skills in a multidisciplinary educational setting. As recommended by other studies, all trauma team members [ 1 , 19 ] and various technical and non-technical skills were included (Appendix B) [ 19 , 26 – 27 ]. Additionally, the inclusion of attending physicians is noteworthy since they can also benefit from such courses due to the scarcity of on-the-job learning opportunities, but there is a paucity of literature reporting on attending physicians as trainees [ 26 ]. The diversity of participants in terms of profession and professional experience enhances the potential generalizability of the findings to other multidisciplinary trauma training contexts, particularly those aiming to integrate blended learning. With 180 participants in the primary analysis, this study is among the larger evaluations of trauma professionals’ self-assessed confidence in skills following a multidisciplinary trauma course. Despite the group sizes, comparisons between the cohorts were sometimes challenging, resulting in missing answers (Table 2 ). This was mainly due to simplifications and alterations made to the questionnaires, although the overall intent remained the same. Heterogeneity between the cohorts also played a role. Finally, the results were based on self-assessments, which should be considered with some caution when interpreting them. Self-assessments are essential in adult educational processes to enhance learning but are subject to various factors that influence accuracy, such as work experience and self-perceived competence [ 34 – 36 ]. Objective assessments using procedure-specific checklists or global rating scales, or the use of video playback could be more reliable [ 37 – 38 ]. Moreover, the effectiveness of trauma care education on performance through, for example, increased confidence and teamwork has been observed [ 9 , 39 ], but it is unknown exactly to what extent and precisely how increased confidence translates to improved performance in daily practice and, most importantly, improved patient outcomes [ 13 , 39 – 41 ]. To our knowledge, few studies have proven the effectiveness of such training in reducing patient morbidity and mortality [ 5 ]. While improved patient outcomes are the main goal of trauma care courses, such as the DSATC course, they remain a challenging area to investigate because of the many environmental variables [ 5 , 42 ]. Conclusion This study highlights the potential advantages of a blended-learning model in multidisciplinary trauma education, as demonstrated by the Dutch DSATC course. Both the traditional and blended-learning cohorts showed increased confidence following the course, with the blended-learning format proving to be at least as effective as the traditional format. The quantitative data and participant feedback offer complementary insights into the educational effectiveness of this approach, emphasizing the role of individual learner backgrounds and preferences in cultivating self-efficacy in both technical and non-technical skills. Given the critical importance of a multidisciplinary approach in preparing trauma teams for the effective treatment of critically injured patients, current educational methods, particularly the individual preparation component, may need further alignment with the needs of individuals from diverse professional backgrounds. Future research should explore the influence of participant characteristics and incorporate long-term follow-up to evaluate the impact of blended learning on skill retention and patient outcomes in trauma care courses. Abbreviations ATLS Advanced Trauma Life Support ASSET Advanced Surgical Skills for Exposure in Trauma DSTC Definitive Surgical Trauma Care DATC Definitive Anaesthetic Trauma Care DSATC Definitive Surgical and Anaesthetic Trauma Care Radboudumc Radboud University Medical Center WMO Dutch Medical Research Involving Human Subjects Act SD standard deviation CI confidence interval MD mean difference CRM Crew Resource Management ETC European Trauma Course Declarations Ethics approval and consent to participate: This study was reviewed by METC Oost-Nederland (Medical Research Ethics Committee), which determined it does not fall under the Dutch Medical Research Involving Human Subjects Act (WMO) as participants are not subjected to WMO-relevant procedures or burdens. Consent for publication: Not applicable. Availability of data and materials: All data generated or analyzed during this study are included in the published article and its supplementary information files. The primary research data are not publicly available and are owned by the Department of Surgery of the Radboud University Medical Center (Radboudumc) in Nijmegen, the Netherlands. Competing interests: LMGG and SJAvB are currently the course directors of the Dutch DSATC course. ECTHT is vice chair of the DSATC course. Funding: No funding was utilized for this work. Authors’ contributions: MI: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Data curation, Writing – original draft, Writing – review & editing, Visualization, Project administration. FJCH: Conceptualization, Methodology, Validation, Resources, Data curation, Writing – original draft, Writing – review & editing, Visualization, Supervision. LMGG: Conceptualization, Investigation, Writing – review & editing, Supervision. SJAvB: Conceptualization, Investigation, Writing – review & editing, Supervision. ECTHT: Conceptualization, Methodology, Validation, Investigation, Resources, Data curation, Writing – original draft, Writing – review & editing, Visualization, Supervision. All authors read and approved the final manuscript. Acknowledgements: The authors thank Dr. Rogier Donders for his assistance with the methodology and statistical analysis and Charles Spronk and Bram Saleming for their assistance in data acquisition and curation. Authors’ information: MI, BSc, is currently completing her medical studies at Radboud University, Nijmegen, the Netherlands. Besides her research activities, she is involved in emergency medical education for bachelor students and contributes to the development of educational materials on diversity and culture for master students. Email address: [email protected] . FJCH, MD, PhD, is a surgery resident at Radboud University Medical Center (Radboudumc), in Nijmegen, the Netherlands. She completed her PhD in collaboration with the Dutch Ministry of Defense, focusing on global surgery in conflict settings and medical preparedness for humanitarian and military deployment. In addition to her clinical work, she remains active in research. Email address: [email protected] . LMGG MD, PhD, MSc, is a trauma surgeon and military surgeon at the Amsterdam University Medical Center (AmsterdamUMC), in Amsterdam, the Netherlands. In addition to his clinical work, he is an instructor for medical courses such as the ATLS and ASSET and currently serves as a course director of the Dutch DSATC course. He also initiated the ‘Stop the Bleed – Save a Life’ campaign in the Netherlands, aiming to teach bystanders to act as immediate responders in cases of life-threatening blood loss. Email address: [email protected] . SJAvB, MD, is an anesthesiologist at the Elisabeth-TweeSteden hospital (ETZ), in Tilburg, the Netherlands. He is an instructor for several courses, including the Dutch DSATC course, for which he currently serves as course director. Email address: [email protected] . ECTHT, MD, PhD, is a trauma surgeon, HEMS physician and associate professor at Radboud University Medical Center (Radboudumc, in Nijmegen, the Netherlands. He is involved in both prehospital and in-hospital acute care and previously served as a military trauma surgeon. In addition to his clinical work, he is actively involved in the education of medical students and medical professionals and frequently supervises several research projects and PhD candidates. He currently serves as vice chair of the Dutch DSATC educational committee. Email address: [email protected] . References Frengley RW, Weller JM, Torrie J, Dzendrowskyj P, Yee B, Paul AM, et al. The effect of a simulation-based training intervention on the performance of established critical care unit teams. Crit Care Med. 2011. 10.1097/CCM.0b013e3182282a98 . Marsden NJ, Tuma F. Polytraumatized Patient . [Updated 3 July 2023]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554426/ Accessed 13 February 2026. O’Dea A, O’Connor P, Keogh I. A meta-analysis of the effectiveness of crew resource management training in acute care domains. Postgrad Med J. 2014. 10.1136/postgradmedj-2014-132800 . Jun LV, Tan Y, Peng F, Wang B, Liu Q, Jiang Z. Knowledge, attitude, and practice toward hypothermia in severe trauma patients among healthcare professionals in emergency departments and trauma centers in Shanghai: a cross-sectional study. Front Med. 2026. 10.3389/fmed.2026.1629603 . Ali J, Adam R, Butler AK, Chang H, Howard M, Gonsalves D, et al. Trauma outcome improves following the advanced trauma life support program in a developing country. J Trauma. 1993. 10.1097/00005373-199306000-00022 . Tallón-Aguilar L, Durán-Muñoz-Cruzado VM, Martínez-Casas I, Aranda-Narváez JM, Pérez-Díaz MD, Montón-Condón S, et al. Are Spanish surgeons prepared to treat trauma patients? Multicentre descriptive observational study. Eur J Trauma Emerg Surg. 2022. 10.1007/s00068-020-01492-0 . Engels PT, Bradley NL, Ball CG. The current state of resident trauma training: are we losing a generation? Can J Surg. 2018. 10.1503/cjs.014417 . Kuhls DA, Risucci DA, Bowyer MW, Luchette FA. Advanced surgical skills for exposure in trauma: a new surgical skills cadaver course for surgery residents and fellows. J Trauma Acute Care Surg. 2013. 10.1097/TA.0b013e31827d5e20 . Gaarder C, Naess PA, Buanes T, Pillgram-Larsen J. Advanced surgical trauma care training with a live porcine model. Injury. 2005. 10.1016/j.injury.2004.12.024 . Tan ECTH, Rijnhout TWH, Rensink M, Alken APB, Bleeker CP, Bowyer MW. Self-assessment of skills by surgeons and anesthesiologists after a trauma surgery masterclass. World J Surg. 2020. 10.1007/s00268-019-05174-w . Bell RM, Krantz BE, Weigelt JA. ATLS: a foundation for trauma training. Ann Emerg Med. 1999. 10.1016/s0196-0644(99)70238-6 . Bowyer MW, Kuhls DA, Haskin D, Sallee RA, Henry SM, Garcia GD, et al. Advanced surgical skills for exposure in trauma (ASSET): the first 25 courses. J Surg Res. 2013. 10.1016/j.jss.2013.02.005 . Capella J, Smith S, Philp A, Putnam T, Gilbert C, Fry W, et al. Teamwork training improves the clinical care of trauma patients. J Surg Educ. 2010. 10.1016/j.jsurg.2010.06.006 . Long AM, Lefebvre CM, Masneri DA, Mowery NT, Chang MC, Johnson JE, et al. The golden opportunity: multidisciplinary simulation training improves trauma team efficiency. J Surg Educ. 2019. 10.1016/j.jsurg.2019.01.003 . Definitive Surgical and Anaesthetic Trauma Care Course. https://www.dstc-datc.nl/ . Accessed 12 February 2026. Champion HR, Fingerhut A, Leppäniemi A. International Association for Trauma Surgery and Intensive Care (IATSIC): a historical vignette. World J Surg. 2012. 10.1007/s00268-012-1765-z . Haverkamp FJC, Rahim I, Hoencamp R, Fluit CRMG, Van Laarhoven KJHM, Tan ECTH. Self-efficacy and application of skills in the workplace after multidisciplinary trauma masterclass participation: a mixed methods survey and interview study. Eur J Trauma Emerg Surg. 2023. 10.1007/s00068-022-02159-8 . Steadman RH, Coates WC, Huang YM, Matevosian R, Larmon BR, McCullough L, et al. Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills. Crit Care Med. 2006. 10.1097/01.ccm.0000190619.42013.94 . Alexandrino H, Baptista S, Vale L, Júnior JHZ, Espada PC, Junior DS, et al. Improving intraoperative communication in trauma: the educational effect of the joint DSTC™-DATC™ courses. World J Surg. 2020. 10.1007/s00268-020-05421-5 . Ehrlich H, McKenney M, Elkbuli A. We Asked the Experts: Virtual Learning in Surgical Education During the COVID-19 Pandemic-Shaping the Future of Surgical Education and Training. World J Surg. 2020. 10.1007/s00268-020-05574-3 . Vallée A, Blacher J, Cariou A, Sorbets E. Blended Learning Compared to Traditional Learning Education: Systematic Review and Meta-Analysis. J Med Internet Res. 2020. 10.2196/16504 . Boffard KD. Manual of Definitive Surgical Trauma Care: Incorporating Definitive Anaesthetic Trauma Care. 5th ed. [place unknown]: CRC; 2019. Mitchnik IY, Rivkind AI. Succeeding in continuing trauma education during a pandemic. World J Surg. 2022. 10.1007/s00268-022-06462-8 . Søreide E, Morrison L, Hillman K, Monsieurs K, Sunde K, Zideman D, et al. The formula for survival in resuscitation. Resuscitation. 2013. 10.1016/j.resuscitation.2013.07.020 . Sonesson L, Boffard K, Lundberg L, Rydmark M, Karlgren K. Decision-Making in Management of the Complex Trauma Patient: Changing the Mindset of the non-trauma Surgeon. World J Surg. 2018. 10.1007/s00268-018-4460-x . Mackenzie CF, Tisherman SA, Shackelford S, Sevdalis N, Elster E, Bowyer MW. Efficacy of trauma surgery technical skills training courses. J Surg Educ. 2019. 10.1016/j.jsurg.2018.10.004 . Lockey A, Bland A, Stephenson J, Bray J, Astin F. Blended learning in health care education: an overview and overarching meta-analysis of systematic reviews. J Contin Educ Health Prof. 2022. 10.1097/CEH.0000000000000455 . Elgohary M, Palazzo FS, Breckwoldt J, Cheng A, Pellegrino J, Schnaubelt S, et al. Blended learning for accredited life support courses – A systematic review. Resusc Plus. 2022. 10.1016/j.resplu.2022.100240 . Bergmans E, Billington A, Thies KC. From tradition to innovation: a comparison of the traditional 4-step approach versus a blended learning modification for technical skills teaching. Scand J Trauma Resusc Emerg Med. 2023. 10.1186/s13049-023-01127-4 . Kolb DA. Experiential learning: experience as the source of learning and development. New Jersey: Prentice Hall; 1984. Nacca N, Holliday J, Ko PY. Randomized trial of a novel ACLS teaching tool: does it improve student performance? West J Emerg Med. 2014. 10.5811/westjem.2014.9.20149 . Smyth S, Houghton C, Cooney A, Casey D. Students’ experiences of blended learning across a range of postgraduate programmes. Nurse Educ Today. 2012. 10.1016/j.nedt.2011.05.014 . Clanton J, Gardner A, Cheung M, Mellert L, Evancho-Chapman M, George RL. The relationship between confidence and competence in the development of surgical skills. J Surg Educ. 2013. 10.1016/j.jsurg.2013.08.009 . Blanch-Hartigan D. Medical students’ self-assessment of performance: results from three meta-analyses. Patient Educ Couns. 2011. 10.1016/j.pec.2010.06.037 . Minter RM, Gruppen LD, Napolitano KS, Gauger PG. Gender differences in the self-assessment of surgical residents. Am J Surg. 2005. 10.1016/j.amjsurg.2004.11.035 . Arora S, Miskovic D, Hull L, Moorthy K, Aggarwal R, Johannsson H, et al. Self vs expert assessment of technical and non-technical skills in high fidelity simulation. Am J Surg. 2011. 10.1016/j.amjsurg.2011.01.024 . Shackelford S, Garofalo E, Shalin V, Pugh K, Chen H, Pasley J, et al. Development and validation of trauma surgical skills metrics: preliminary assessment of performance after training. J Trauma Acute Care Surg. 2015. 10.1097/TA.0000000000000685 . Ward M, MacRae H, Schlachta C, Mamazza J, Poulin E, Reznick R, et al. Resident self-assessment of operative performance. Am J Surg. 2003. 10.1016/s0002-9610(03)00069-2 . Osebo CD, Munthali VJ, Rwanyuma LJ, Ndeserua RH, Ikoshi BM, Lemnge AF, et al. Building Resilience in Trauma Care at a Sub-Saharan African Tertiary Center: A Longitudinal Assessment of Multidisciplinary Trauma and Disaster Team Response Training Impact. Ann Surg Open. 2025. 10.1097/AS9.0000000000000633 . Petroze RT, Byiringiro JC, Ntakiyiruta G, Briggs SM, Deckelbaum DL, Razek T, et al. Can focused trauma education initiatives reduce mortality or improve resource utilization in a low-resource setting? World J Surg. 2015. 10.1007/s00268-014-2899-y . Neutel E, Kuhn S, Driscoll P, Gwinnutt C, Moreira Z, Veloso A, et al. Does participation in the European Trauma Course lead to new behaviours and organisational change? A Portuguese experience. BMC Med Educ. 2023. 10.1186/s12909-023-04322-0 . Haută A, Iacobescu RA, Corlade-Adrei M, Nedelea PL, Cimpoeșu CD. Translating training to medical practice in trauma care, a literature review. Eur J Trauma Emerg Surg. 2024. 10.1007/s00068-024-02548-1 . Additional Declarations Competing interest reported. LMGG and SJAvB are currently the course directors of the Dutch DSATC course. ECTHT is vice chair of the DSATC course. Supplementary Files AdditionalfileAppendixA.docx For appendix A: please see the additional Microsoft Word document (.docx) “Additional file Appendix A”. The title of the data in this file is: “Comparison of the traditional and blended-learning DSATC course formats”. The file contains two tables outlining the timeline of each course and the preparation material for each of the main professions in both course formats. AdditionalfileAppendixB.docx For appendix B: please see the additional Microsoft Word document (.docx) “Additional file Appendix B”. The title of the data in this file is: “Questionnaire of the blended-learning DSATC course”. The file contains all questions included in the questionnaires distributed to the blended-learning DSATC course participants. AdditionalfileAppendixC.docx For appendix C: please see the additional Microsoft Word document (.docx) “Additional file Appendix C”. The title of the data in this file is: “Respondent distribution”. The file contains two table depicting the response to each questionnaire separately and cumulatively for all of the course groups included in this study. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9214728","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":613571245,"identity":"e5d018c5-312b-4c7b-a6fc-d2e506f3d543","order_by":0,"name":"Marly Iskander","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIiWNgGAWjYHACxgMMDBJACCIZbIBUDhCzwaWwAmQtaShaGPBoYYBpOUxYi2772QeHeRgs7CXbzx688XHP+Xz+9tyDj3nKDkfzN/AewKbF7Ey6AVCLROJsnrxkyxnPblvOOPMu2Zjn3OHcGQf4ErBqOZDGANKSIMeQYybNc+C2AcMNIIO37XDuBgYeA6xazj8Da7GX439jJv3nwDkDeYJabkBsYZwtAVTJcOCAgQFhLc8YDs4xkEicOeONsWXPgWQDQ6BfDOecS8+dcRiXw9IYH7ypqLOXOJ9jeOPHATsDueO5Bx+8KbPO7W/vMXyARQsIMPEYYBVnxqEeCBh/4JYbBaNgFIyCUcDAAADP4GlFTRGsOwAAAABJRU5ErkJggg==","orcid":"","institution":"Radboud University Nijmegen","correspondingAuthor":true,"prefix":"","firstName":"Marly","middleName":"","lastName":"Iskander","suffix":""},{"id":613571250,"identity":"d3c4ef87-ed71-47e6-b97c-6f9dac882d3e","order_by":1,"name":"Frederike J. C. Haverkamp","email":"","orcid":"","institution":"Radboud University Nijmegen Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Frederike","middleName":"J. C.","lastName":"Haverkamp","suffix":""},{"id":613571252,"identity":"0c2095be-5331-4c77-af6a-88dab8b57e93","order_by":2,"name":"Leo M. G. Geeraedts","email":"","orcid":"","institution":"Amsterdam University Medical Centers","correspondingAuthor":false,"prefix":"","firstName":"Leo","middleName":"M. G.","lastName":"Geeraedts","suffix":""},{"id":613571253,"identity":"994ad86d-d65d-4cd1-9f7f-9bb68fee381e","order_by":3,"name":"Sef J. A. van Bilsen","email":"","orcid":"","institution":"Elisabeth-TweeSteden Ziekenhuis","correspondingAuthor":false,"prefix":"","firstName":"Sef","middleName":"J. A. van","lastName":"Bilsen","suffix":""},{"id":613571254,"identity":"a2cf5909-be63-41ea-95ec-bceecf96090a","order_by":4,"name":"Edward C. T. H. 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H.","lastName":"Tan","suffix":""}],"badges":[],"createdAt":"2026-03-24 17:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9214728/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9214728/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105718975,"identity":"9670a8ba-7fc1-4ca2-8e2d-66f7186af2d8","added_by":"auto","created_at":"2026-03-30 09:15:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":62370,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9214728/v1/25251111ee8ee4d201699dea.png"},{"id":105718820,"identity":"a3756be8-9596-4a5a-93c5-c0b7672d5c53","added_by":"auto","created_at":"2026-03-30 09:14:48","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":260907,"visible":true,"origin":"","legend":"\u003cp\u003eLongitudinal self-assessed confidence in general skills in the traditional versus blended-learning DSATC course\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9214728/v1/4f952848c7d9db3ef73a49b1.jpeg"},{"id":105729233,"identity":"7527cb60-dfe6-4e45-9978-dbc520445a17","added_by":"auto","created_at":"2026-03-30 11:13:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1270391,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9214728/v1/136c8abe-e5d1-4990-8623-163d71e004f1.pdf"},{"id":105718832,"identity":"87ad952a-32eb-40b2-9a9a-ede1affcc4f1","added_by":"auto","created_at":"2026-03-30 09:14:54","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21917,"visible":true,"origin":"","legend":"\u003cp\u003eFor appendix A: please see the additional Microsoft Word document (.docx) “Additional file Appendix A”. The title of the data in this file is: “Comparison of the traditional and blended-learning DSATC course formats”. The file contains two tables outlining the timeline of each course and the preparation material for each of the main professions in both course formats.\u003c/p\u003e","description":"","filename":"AdditionalfileAppendixA.docx","url":"https://assets-eu.researchsquare.com/files/rs-9214728/v1/f9038208b2dccfae10544eb9.docx"},{"id":105718830,"identity":"6879b68c-6cf3-496d-a176-5a51510a5eca","added_by":"auto","created_at":"2026-03-30 09:14:54","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":18029,"visible":true,"origin":"","legend":"\u003cp\u003eFor appendix B: please see the additional Microsoft Word document (.docx) “Additional file Appendix B”. The title of the data in this file is: “Questionnaire of the blended-learning DSATC course”. The file contains all questions included in the questionnaires distributed to the blended-learning DSATC course participants.\u003c/p\u003e","description":"","filename":"AdditionalfileAppendixB.docx","url":"https://assets-eu.researchsquare.com/files/rs-9214728/v1/8cad1fd627da67f3f5977e04.docx"},{"id":105718871,"identity":"f64de4a2-38ba-45b0-8553-dbc847b2a132","added_by":"auto","created_at":"2026-03-30 09:15:05","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":19786,"visible":true,"origin":"","legend":"\u003cp\u003eFor appendix C: please see the additional Microsoft Word document (.docx) “Additional file Appendix C”. The title of the data in this file is: “Respondent distribution”. 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ECTHT is vice chair of the DSATC course.","formattedTitle":"A Blended-Learning Two-Day Trauma Course Compared with the Traditional Three-Day Trauma Course: A Retrospective Non-Inferiority Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe effective treatment of critically injured patients requires an integrated set of technical and non-technical skills, such as acute surgical skills, communication, and teamwork [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Educational opportunities aimed at the treatment of polytrauma patients are crucial to improve the readiness and competence of medical professionals in trauma care, since this influences the quality of care provided to patients [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, learning opportunities in the clinical work environment are often limited by factors such as increased nonoperative management and the unpredictable and time-sensitive nature of trauma cases, which complicate the planning and delivery of educational initiatives, resulting in a lack of on-the-job learning opportunities [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn recognition of the need for trauma care education, various courses have been developed. Examples include Advanced Trauma Life Support (ATLS), Advanced Surgical Skills for Exposure in Trauma (ASSET), Definitive Surgical Trauma Care (DSTC) and Definitive Anaesthetic Trauma Care (DATC) courses [\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Participation in such courses can enhance self-assessed competence, clinical performance, knowledge, and the efficiency of team-based patient care [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Dutch DSTC and DATC courses were the first to be combined into one multidisciplinary course: the Definitive Surgical and Anaesthetic Trauma Care (DSATC) course [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The Dutch DSATC course has been in place since 2009 and provides learning opportunities to national and international participants involved in trauma care, such as intensivists, scrub nurses, anesthesia nurses, surgeons and anesthesiologists. The intention is to equip participants with knowledge and skills regarding the application of damage control principles to polytrauma patients through interactive workshops, group discussions, and lectures [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Hands-on experience with trauma cases is offered through simulation in a regulated environment, enabling skill development while eliminating risks for individual patients [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The unique multidisciplinary approach, which distinguishes the DSATC course, improves teamwork and team-based care for severely injured patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2020, the traditional three-day on-site DSATC course was redesigned into a blended-learning format that combines online modules with two days of in-person training, while maintaining the amount of hands-on experience. This shift, prompted by the COVID-19 pandemic and guided by previous faculty and participant feedback, can enhance learning by offering greater flexibility for individual learners\u0026rsquo; needs, reinforcing theoretical knowledge, and improving preparation for practical training [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The preparation for the previous course consisted mainly of theoretical preparation through course manuals, whereas the current format provides preparatory material through the renewed DSATC manual [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and an online learning environment, comprising pre-recorded lectures, e-learnings and virtual simulation (Appendix A). Online learning complements traditional methods but cannot replace hands-on learning [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Given the significance of educational quality for participant development and, consequently, its potential implications for patient outcomes, it is essential to evaluate how differences in course design influence educational quality and learners\u0026rsquo; self-efficacy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, the objective of this study is to compare self-assessed confidence in skills between participants who attended a previous traditional DSATC course and those who completed the new blended-learning DSATC course. With this approach, the study aims to generate actionable learning points applicable to the DSATC and similar courses. To our knowledge, few studies have examined both technical and non-technical skills within such multidisciplinary settings. Previous studies also highlighted the need for research on the multidisciplinary aspects of trauma care courses. These points have been identified as gaps in research [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], which this study seeks to address.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis retrospective non-inferiority cohort study included two cohorts of attendees from the DSATC course at the Radboud University Medical Centre (Radboudumc) in Nijmegen, the Netherlands. Cohort 1 consisted of participants from traditional DSATC courses between 2016 and 2019. Cohort 2 consisted of participants who took part in the new blended-learning DSATC course between 2021 and 2024.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe study population comprised all participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;843) in the DSATC course at Radboudumc between 2016 and 2024. The participants included were mainly attending and resident surgeons and anesthesiologists, scrub nurses and anesthesia nurses from various countries.\u003c/p\u003e \u003cp\u003eCourse participants were informed about the conduction of research throughout the DSATC courses and were requested to complete the corresponding questionnaires. Subsequently, consent to participate in this study was implied by the voluntary completion of the questionnaires. This study was determined to be exempt from the Dutch Medical Research Involving Human Subjects Act (WMO) by a Medical Ethics Committee.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eAll course participants received an invitational email to anonymously fill out quantitative digital questionnaires at five instances: one day before the course, and one day, three months, one year, and two years after the course. Reminders were sent four weeks later. The participants from the 2024 blended-learning DSATC course group received an additional questionnaire before receiving access to the individual preparatory materials. Answers were automatically collected and organized yearly into secure data files on Radboudumc servers by the Department of Surgery. Participants who wished not to participate could opt to be unsubscribed to future invitations and withdraw at any time.\u003c/p\u003e \u003cp\u003eThe questionnaires were identical at each timepoint (Appendix B) and data from the questionnaires were analyzed to reveal actionable learning points for the DSATC and similar multidisciplinary courses. The questions encompassed participant characteristics, including sex, age, and profession, as well as technical skills (e.g. trauma laparotomy, treating head trauma) and non-technical skills (communication, teamwork, leadership). Participants assessed their confidence in each skill using a five-point Likert scale (1 not confident \u0026ndash; 5 very confident). Skills questions concerned general skills that applied to all participants, as well as specific skills for each of the main professions, namely surgeons (including orthopedic surgeons), anesthesiologists and anesthesia/scrub nurses. The questionnaires were based on previous resources consisting of course objectives and content, expert opinions, and a similar questionnaire utilized in a study by Gaarder et al. in 2005 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Previous studies have utilized and published on the questionnaire [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Minor differences existed between the traditional and blended-learning course questionnaires, mainly regarding the newly developed individual preparations. The previous questionnaire was published in the 2020 study by Tan et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eParticipant characteristics and mean evaluation grades, collected from annual digital course evaluations, were analyzed descriptively. These are presented as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or as numbers with percentages. Participant characteristics were analyzed comparatively between the traditional and blended-learning cohorts via a chi square test for categorical data and an independent samples t-test or one-sample t-test for numerical data. Prominent participant feedback from the evaluations and overall self-assessed skills progression observed throughout the surveys were also reported descriptively.\u003c/p\u003e \u003cp\u003eThe primary outcome measures were the mean changes in self-assessed confidence in general technical and non-technical skills, compared between the cohorts. For the comparative analysis, self-assessed confidence ratings of general skills questions were combined to compute the primary outcome variables: confidence in general technical and non-technical skills. Mean confidence ratings were calculated from the pre-course and one-day post-course questionnaires for each cohort. The data had been previously collected.\u003c/p\u003e \u003cp\u003eAdditional sub-analyses were conducted. One sub-analysis compared the mean change in self-assessed confidence in skills between the cohorts for each of the main professions: surgeons (including orthopedic surgeons), anesthesiologists and anesthesia/scrub nurses. The outcome variables were computed from specific skills questions from the pre-course and one-day post-course questionnaires. Surgeons\u0026rsquo; non-technical skills covered leadership and teamwork, while nurses\u0026rsquo; and anesthesiologists\u0026rsquo; non-technical skills exclusively covered teamwork. A second sub-analysis compared the mean change in self-assessed confidence from pre-course to one-day post-course between attending and resident physicians within each cohort. A final sub-analysis was conducted using data from the 2024 DSATC course group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;49), to assess how individual preparations might have influenced self-assessed confidence in general technical and non-technical skills before the on-site training.\u003c/p\u003e \u003cp\u003eParticipants who completed both the pre-course and one-day post-course questionnaires were included in the statistical analysis. Those who did not complete both or only completed them partly were excluded (Fig.\u0026nbsp;1). The questionnaires beginning three-months post-course were not analyzed statistically because of low response rates. Furthermore, participants of whom it was unclear which questionnaire they intended to complete were excluded, and missing answers were excluded per analysis.\u003c/p\u003e \u003cp\u003eAn independent samples t-test was deemed the appropriate statistical method for all analyses except the final sub-analysis, for which a paired samples t-test was used. All inferential statistics were conducted using IBM SPSS Statistics (version 29). For the primary analysis, a one-sided 97.5%-confidence interval (CI) was used to test the hypothesis that the results after the blended-learning course are not inferior to those of the traditional course, with a non-inferiority margin of -0.5 based on previous findings [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. For the sub-analyses and analysis of participant characteristics, a two-sided α\u0026thinsp;\u0026le;\u0026thinsp;0.05 was used.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eParticipation and response rates\u003c/h2\u003e \u003cp\u003eAn overview of the study population before and after the application of the inclusion criteria is depicted in Fig.\u0026nbsp;1. Participants of whom it was unclear which questionnaire they intended to complete were labeled non-respondents in the figure (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4). Among the 843 DSATC course participants between 2016 and 2024, 180 (21%) participants completed both the pre-course and one-day post-course questionnaires. The number of participants who completed each subsequent questionnaire declined, with 85 (10%) responses up to three-months post-course, 31 (4%) responses up to one-year post-course, and 9 (1%) responses up to two-years post-course. In total, 667 (79%) individuals completed at least one questionnaire. A comprehensive respondent distribution can be consulted in Appendix C.\u003c/p\u003e\n\u003ch3\u003eDescriptive analysis\u003c/h3\u003e \u003cp\u003eTable 1 presents the background characteristics of the respondents who completed both the pre-course and one-day post-course surveys. Compared with the traditional course cohort, the blended-learning course cohort included a greater number of male participants (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021) and had a different distribution of professional roles: the blended-learning course cohort had a lower proportion of nurses (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15% vs. \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;27%) and a greater number of orthopedic surgeons (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;31 vs. \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.048). The blended-learning course cohort also included more resident physicians (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;35, 31%) than did the traditional course cohort (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9, 18%) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003e\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraditional \u003c/p\u003e \u003cp\u003eDSATC course\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBlended-learning DSATC course\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;67\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;113\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;180\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex \u003cem\u003e(n, %)\u003c/em\u003e \u003cb\u003e*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80 (71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e116 (64%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64 (36%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge in years \u003cem\u003e(mean, SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.3 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.3 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.3 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfession \u003cem\u003e(n, %)\u003c/em\u003e \u003cb\u003e*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgeon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57 (32%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (19%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnesthesiologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49 (27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopedic surgeon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent clinical work position\u003csup\u003ea\u003c/sup\u003e \u003cem\u003e(n, %)\u003c/em\u003e \u003cb\u003e*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttending physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e101 (56%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResident physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (24%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of work experience\u003csup\u003eb\u003c/sup\u003e \u003cem\u003e(mean, SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.2 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.8 (7.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital of employment \u003cem\u003e(n, %)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcademic or military\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72 (40%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeripheral or teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67 (59%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100 (56%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed at a level 1 trauma center (\u003cem\u003en, %\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92 (51%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54 (30%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (19%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e Background characteristics of respondents\u003c/p\u003e \u003cp\u003e \u003cem\u003eSD\u003c/em\u003e standard deviation, \u003cem\u003eN.A.\u003c/em\u003e not applicable, \u003cem\u003en\u003c/em\u003e number of respondents\u003c/p\u003e \u003cp\u003ePercentages are rounded\u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003e Only applicable to surgeons, orthopedic surgeons and anesthesiologists\u003c/p\u003e \u003cp\u003e \u003csup\u003eb\u003c/sup\u003e Only applicable to anesthesia nurses and scrub nurses\u003c/p\u003e \u003cp\u003e \u003cb\u003e*\u003c/b\u003e Statistical analysis on the variable demonstrated significant differences between the cohorts\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e depicts the longitudinal effect of both course formats on participants\u0026rsquo; self-assessed confidence in skills. Compared with the blended-learning DSATC cohort, the traditional DSATC cohort consistently demonstrated higher confidence levels, but the mean self-assessed confidence levels remained higher than the pre-course confidence levels throughout the follow-up period in both cohorts. However, this was not analyzed statistically.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAdditionally, participants in the blended-learning course cohort were asked to rate their level of agreement with the statement \u003cem\u003e\u0026lsquo;individual preparation is not necessary prior to the course\u0026rsquo;\u003c/em\u003e on a five-point Likert scale (1 completely disagree \u0026ndash; 5 completely agree). The respondents demonstrated a mean change in agreement of -0.04 (SD 1.1) toward greater disagreement with the statement after completing the course than before the course (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). The mean preparation time in this cohort was 14.2 hours (SD 7.9) for the online preparation modules and 18.3 hours (SD 11.8) in total, including course manuals and additional preparation.\u003c/p\u003e\n\u003ch3\u003ePrimary analysis\u003c/h3\u003e\n\u003cp\u003eFor the primary analysis, the mean changes in self-assessed confidence in general technical and non-technical skills were compared between the traditional learning DSATC group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;67) and the blended-learning DSATC group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;113) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). For general technical skills, the mean difference (MD) between the groups was 0.07, with a greater increase in self-assessed confidence in the blended-learning DSATC group. The lower bound of the 97.5%-CI was \u0026minus;\u0026thinsp;0.14 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). For general non-technical skills, the MD between the groups was 0.09, again with a greater increase in self-assessed confidence in the blended-learning DSATC group. The lower bound of the 97.5%-CI for this difference was \u0026minus;\u0026thinsp;0.09 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Neither of the lower limits of the 97.5%-CI exceeded the pre-specified non-inferiority margin of -0.5.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelf-assessed confidence in general skills compared between two DSATC course formats\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGeneral skills\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eTraditional DSATC\u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;67\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eBlended-learning DSATC \u003c/p\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;113\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMean difference (CI)\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eMean rating (SD)\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eMean rating (SD)\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-course\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOne-day \u003c/p\u003e \u003cp\u003epost-course\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean change (SE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePre-course\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOne-day\u003c/p\u003e \u003cp\u003epost-course\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMean change (SE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-technical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.9 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.25 (0.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.8 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.36 (0.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.11 (-0.08,0.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeamwork\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.6 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.51 (0.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.5 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.0 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.52 (0.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.01 (-0.20,0.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTechnical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrauma laparotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.94 (0.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.5 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.7 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.19 (0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.26 (-0.08,0.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDamage control surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.2 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.81 (0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.5 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.5 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.01 (0.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.20 (-0.13,0.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.0 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.6 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.55 (0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.8 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.2 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.42 (0.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;0.13 (-0.43,0.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeck trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.6 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.73 (0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.7 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.4 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.70 (0.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;0.03 (-0.34,0.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlast injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.97 (0.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.2 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.2 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.96 (0.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;0.01 (-0.29,0.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBallistic/penetrating injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.7 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.79 (0.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.4 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.5 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.07 (0.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.28 (0.02,0.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurn injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.8 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.6 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.75 (0.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.7 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.4 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.66 (0.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;0.09 (-0.33,0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePooled non-technical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.8 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.32 (0.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.7 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.1 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.41 (0.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.09 (-0.09,0.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePooled technical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.7 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.80 (0.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.5 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.4 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.86 (0.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.07 (-0.14,0.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.4 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.9 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.56 (0.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.8 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.64 (0.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.08 (-0.07,0.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eSD\u003c/em\u003e standard deviation, \u003cem\u003eSE\u003c/em\u003e standard error of the mean, \u003cem\u003en\u003c/em\u003e number of respondents\u003c/p\u003e \u003cp\u003eLevel of significance α\u0026thinsp;\u0026le;\u0026thinsp;0.025\u003c/p\u003e \u003cp\u003e \u003csup\u003ec\u003c/sup\u003e Absence of questions about teamwork, trauma laparotomy, damage control surgery and burn injury in the traditional course of 2019 reduced the number of respondents to \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;64 for these general skills\u003c/p\u003e \u003cp\u003e \u003csup\u003ed\u003c/sup\u003e Scale: 1 completely disagree \u0026ndash; 5 completely agree\u003c/p\u003e \u003cp\u003e \u003csup\u003ee\u003c/sup\u003e Mean difference between cohorts in the change in self-assessed confidence in skills from pre-course to one-day post-course, with negative values indicating a greater change in self-assessed confidence among traditional DSATC participants compared to blended-learning DSATC participants\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSub-analysis\u003c/h2\u003e \u003cp\u003eThe first sub-analysis revealed no significant differences between the cohorts in self-assessed confidence in either technical or non-technical skills for each of the main professional groups.\u003c/p\u003e \u003cp\u003eThe second sub-analysis examined differences in the mean change in self-assessed confidence between residents and attending physicians. In both cohorts, residents demonstrated a greater increase in self-assessed confidence in both technical and non-technical skills than did attending physicians, although the difference was not statistically significant. In the traditional DSATC group, the mean increase for residents exceeded that of attending physicians by 0.14 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.498) for technical skills and 0.28 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.175) for non-technical skills. In the blended-learning DSATC group, the differences were 0.20 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.134) and 0.07 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.518) for technical and non-technical skills, respectively.\u003c/p\u003e \u003cp\u003eThe final sub-analysis assessed the impact of completing the online individual preparations on participants\u0026rsquo; self-assessed confidence prior to the on-site sessions of the 2024 blended-learning DSATC course. For both general technical and non-technical skills, self-assessed confidence declined after completing individual preparations. While the decline in confidence in technical skills was not significant (MD -0.06, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.597), the decline in self-assessed confidence in non-technical skills was indeed significant (MD -0.21, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.042).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCourse evaluations\u003c/h2\u003e \u003cp\u003eThe evaluation scores for the DSATC courses are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The 2017 traditional course received the lowest grade (mean 8.37\u0026thinsp;\u0026plusmn;\u0026thinsp;SD 1.46), whereas the 2024 blended-learning course received the highest (mean 8.67\u0026thinsp;\u0026plusmn;\u0026thinsp;SD 0.74). Generally, the blended-learning courses received higher grades than the traditional courses did.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnnual DSATC course evaluation grades with response rates\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"8\" nameend=\"c9\" namest=\"c2\"\u003e \u003cp\u003eCourse year\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade \u003c/p\u003e \u003cp\u003e(mean, SD)\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.50\u003c/p\u003e \u003cp\u003e(0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.37\u003c/p\u003e \u003cp\u003e(1.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.49\u003c/p\u003e \u003cp\u003e(0.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.41\u003c/p\u003e \u003cp\u003e(0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.56\u003c/p\u003e \u003cp\u003e(0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.63\u003c/p\u003e \u003cp\u003e(0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8.50\u003c/p\u003e \u003cp\u003e(0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8.67 \u003c/p\u003e \u003cp\u003e(0.74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponse rate (%, n/total)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96% (53/55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67% (41/61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92% (82/89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91% (79/87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e64% (90/140)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e54% (73/134)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e72% (101/141)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e63%\u003c/p\u003e \u003cp\u003e(85/136)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eSD\u003c/em\u003e standard deviation, \u003cem\u003e(n/total)\u003c/em\u003e number of respondents/number of invitees\u003c/p\u003e \u003cp\u003ePercentages are rounded\u003c/p\u003e \u003cp\u003e \u003csup\u003ef\u003c/sup\u003e Scale: 1 very poor \u0026ndash; 10 excellent\u003c/p\u003e \u003cp\u003eParticipants highlighted the importance of practical surgical skills and problem-solving across all evaluations. Despite this, participants from both course formats noted that the integration of crew resource management (CRM) principles into the individual preparation and on-site training remains underdeveloped. These principles cover non-technical skills such as problem-solving, leadership, situational awareness and decision-making [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While some found the anatomy and operative porcine laboratories morally challenging, they were considered indispensable by traditional course participants and very beneficial by blended-learning course participants. Practical workshops were consistently rated as the best feature, whereas the quantity and quality of presentations were rated lower. Language barriers hindered the effective application of CRM principles.\u003c/p\u003e \u003cp\u003eParticipant feedback on the individual preparation of the blended-learning course revealed mixed views. While some found it useful and interactive, others, particularly nurses, indicated that it was too extensive, beyond their expertise and mostly aimed at surgeons. Non-technical skills preparation was seen as insufficient. Moreover, disparities in professional backgrounds affected perceptions of course relevance: nurses felt inadequately involved, anesthesiologists expressed a wish for more depth or cross-disciplinary insights, and orthopedic surgeons and lower-level trauma center participants reported feeling out of place. Despite this, practical workshops increased confidence in trauma management for some participants. Suggestions for course improvement differed by cohort, with traditional DSATC course participants favoring a reduction in on-site training by one day, whereas blended-learning DSATC course participants favored less individual preparation or an additional on-site training day.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the impact of transitioning a multidisciplinary trauma care course from a three-day, traditional learning format to a two-day, blended-learning format on participants\u0026rsquo; self-assessed confidence in their technical and non-technical skills. The findings indicate that the blended-learning format is at least as effective as the traditional format in enhancing Dutch DSATC course participants\u0026rsquo; self-assessed confidence, with both cohorts reporting increased confidence following course completion. Notably, participants in the blended-learning cohort reported greater gains in non-technical skills and several technical skills.\u003c/p\u003e \u003cp\u003eThe effectiveness of blended learning in healthcare education has been well established, with its success often attributed to factors such as personalized learning, enhancement of knowledge, facilitation of skill acquisition, and the reinforced connection between theory and practice [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. For example, a study by Bergmans et al. demonstrated the non-inferiority of a blended-learning approach in the context of technical skill acquisition and retention in the European Trauma Course (ETC) compared with traditional face-to-face teaching [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Even so, however, the effectiveness depends on course design, skill complexity and participant characteristics such as motivation, time management and digital experience [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The mixed perceptions expressed in the DSATC course participants\u0026rsquo; feedback highlight how differences in the design, delivery and individual engagement with blended-learning programs can lead to varied educational outcomes. This underscores the idea that online education \u0026ndash; despite its benefits \u0026ndash; cannot fully replace all aspects of in-person curricula and that both should be customized with the individual learner in mind [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe individual preparations of the blended-learning DSATC course further illustrate both the potential and challenges of blended learning. The cohort that completed the newly developed individual preparatory material presented lower baseline confidence in non-technical skills (i.e., prior to the on-site training sessions). According to Kolb\u0026rsquo;s Learning Theory, the preparatory phase may have primarily engaged participants in reflective observation and abstract conceptualization, as they were exposed to theoretical material without the benefit of hands-on experience [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This could have increased the perceived complexity of the material or heightened participants\u0026rsquo; awareness of their knowledge gaps, which, in turn, may have contributed to lower pre-course confidence ratings [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNevertheless, this phase is a necessary and effective component of the learning process, as it encourages active and critical reflection on one\u0026rsquo;s understanding. This facilitates the recognition and formulation of learning needs and goals, laying the foundation for goal-directed actions [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Smyth et al. (2012) reported that postgraduate students in a blended-learning program described developing an increased sense of responsibility for their own learning [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In support of this, participants in the blended-learning DSATC cohort \u0026ndash; despite the initial report of lower self-assessed confidence before the on-site training \u0026ndash; showed greater gains in self-assessed confidence after the course. Following the on-site training, respondents from this cohort also deemed individual preparation to be more necessary than they had initially deemed it before the course. In contrast, the traditional preparatory course manual, which was also distributed prior to the pre-course questionnaire, was reported to be underutilized and likely had minimal impact on participants\u0026rsquo; learning process and self-perceived readiness.\u003c/p\u003e \u003cp\u003eFinally, some of the findings could be explained by differences between the cohorts. The blended-learning cohort included more resident physicians than attending physicians. Although not statistically significant, resident physicians had a greater increase in self-assessed confidence in both technical and non-technical skills. Experience may influence self-efficacy, as less experienced participants often exhibit lower pre-course self-efficacy but are just as likely to achieve competence as more experienced participants [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Another source of heterogeneity was sex: compared with the traditional learning cohort, the blended-learning cohort comprised significantly more male participants than female participants. Differences in sex have been shown to influence self-perception in clinical education, with some studies indicating that women may underestimate their competence despite their performance being equivalent or superior to the performance of male colleagues [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis study extends previous observations by investigating how course modifications affect participants\u0026rsquo; self-assessed confidence in skills in a multidisciplinary educational setting. As recommended by other studies, all trauma team members [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and various technical and non-technical skills were included (Appendix B) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Additionally, the inclusion of attending physicians is noteworthy since they can also benefit from such courses due to the scarcity of on-the-job learning opportunities, but there is a paucity of literature reporting on attending physicians as trainees [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The diversity of participants in terms of profession and professional experience enhances the potential generalizability of the findings to other multidisciplinary trauma training contexts, particularly those aiming to integrate blended learning.\u003c/p\u003e \u003cp\u003eWith 180 participants in the primary analysis, this study is among the larger evaluations of trauma professionals\u0026rsquo; self-assessed confidence in skills following a multidisciplinary trauma course. Despite the group sizes, comparisons between the cohorts were sometimes challenging, resulting in missing answers (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This was mainly due to simplifications and alterations made to the questionnaires, although the overall intent remained the same. Heterogeneity between the cohorts also played a role.\u003c/p\u003e \u003cp\u003eFinally, the results were based on self-assessments, which should be considered with some caution when interpreting them. Self-assessments are essential in adult educational processes to enhance learning but are subject to various factors that influence accuracy, such as work experience and self-perceived competence [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Objective assessments using procedure-specific checklists or global rating scales, or the use of video playback could be more reliable [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Moreover, the effectiveness of trauma care education on performance through, for example, increased confidence and teamwork has been observed [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], but it is unknown exactly to what extent and precisely how increased confidence translates to improved performance in daily practice and, most importantly, improved patient outcomes [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. To our knowledge, few studies have proven the effectiveness of such training in reducing patient morbidity and mortality [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While improved patient outcomes are the main goal of trauma care courses, such as the DSATC course, they remain a challenging area to investigate because of the many environmental variables [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the potential advantages of a blended-learning model in multidisciplinary trauma education, as demonstrated by the Dutch DSATC course. Both the traditional and blended-learning cohorts showed increased confidence following the course, with the blended-learning format proving to be at least as effective as the traditional format. The quantitative data and participant feedback offer complementary insights into the educational effectiveness of this approach, emphasizing the role of individual learner backgrounds and preferences in cultivating self-efficacy in both technical and non-technical skills.\u003c/p\u003e \u003cp\u003eGiven the critical importance of a multidisciplinary approach in preparing trauma teams for the effective treatment of critically injured patients, current educational methods, particularly the individual preparation component, may need further alignment with the needs of individuals from diverse professional backgrounds. Future research should explore the influence of participant characteristics and incorporate long-term follow-up to evaluate the impact of blended learning on skill retention and patient outcomes in trauma care courses.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eATLS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdvanced Trauma Life Support\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eASSET\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdvanced Surgical Skills for Exposure in Trauma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDSTC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDefinitive Surgical Trauma Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDATC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDefinitive Anaesthetic Trauma Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDSATC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDefinitive Surgical and Anaesthetic Trauma Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eRadboudumc\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRadboud University Medical Center\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eWMO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDutch Medical Research Involving Human Subjects Act\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003estandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003econfidence interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emean difference\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCRM\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCrew Resource Management\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eETC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEuropean Trauma Course\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study was reviewed by METC Oost-Nederland (Medical Research Ethics Committee), which determined it does not fall under the Dutch Medical Research Involving Human Subjects Act (WMO) as participants are not subjected to WMO-relevant procedures or burdens.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eAll data generated or analyzed during this study are included in the published article and its supplementary information files. The primary research data are not publicly available and are owned by the Department of Surgery of the Radboud University Medical Center (Radboudumc) in Nijmegen, the Netherlands.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eLMGG and SJAvB are currently the course directors of the Dutch DSATC course. ECTHT is vice chair of the DSATC course.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo funding was utilized for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;MI: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Data curation, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing, Visualization, Project administration.\u003c/p\u003e\n\u003cp\u003eFJCH: Conceptualization, Methodology, Validation, Resources, Data curation, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing, Visualization, Supervision.\u003c/p\u003e\n\u003cp\u003eLMGG: Conceptualization, Investigation, Writing \u0026ndash; review \u0026amp; editing, Supervision.\u003c/p\u003e\n\u003cp\u003eSJAvB: Conceptualization, Investigation, Writing \u0026ndash; review \u0026amp; editing, Supervision.\u003c/p\u003e\n\u003cp\u003eECTHT: Conceptualization, Methodology, Validation, Investigation, Resources, Data curation, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing, Visualization, Supervision.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Dr. Rogier Donders for his assistance with the methodology and statistical analysis and Charles Spronk and Bram Saleming for their assistance in data acquisition and curation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMI, BSc, is currently completing her medical studies at Radboud University, Nijmegen, the Netherlands. Besides her research activities, she is involved in emergency medical education for bachelor students and contributes to the development of educational materials on diversity and culture for master students. Email address: [email protected].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFJCH, MD, PhD, is a surgery resident at Radboud University Medical Center (Radboudumc), in Nijmegen, the Netherlands. She completed her PhD in collaboration with the Dutch Ministry of Defense, focusing on global surgery in conflict settings and medical preparedness for humanitarian and military deployment. In addition to her clinical work, she remains active in research. Email address: [email protected].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLMGG MD, PhD, MSc, is a trauma surgeon and military surgeon at the Amsterdam University Medical Center (AmsterdamUMC), in Amsterdam, the Netherlands. In addition to his clinical work, he is an instructor for medical courses such as the ATLS and ASSET and currently serves as a course director of the Dutch DSATC course. He also initiated the \u0026lsquo;Stop the Bleed \u0026ndash; Save a Life\u0026rsquo; campaign in the Netherlands, aiming to teach bystanders to act as immediate responders in cases of life-threatening blood loss. Email address: [email protected].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSJAvB, MD, is an anesthesiologist at the Elisabeth-TweeSteden hospital (ETZ), in Tilburg, the Netherlands. He is an instructor for several courses, including the Dutch DSATC course, for which he currently serves as course director. Email address: [email protected].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eECTHT, MD, PhD, is a trauma surgeon, HEMS physician and associate professor at Radboud University Medical Center (Radboudumc, in Nijmegen, the Netherlands. He is involved in both prehospital and in-hospital acute care and previously served as a military trauma surgeon. In addition to his clinical work, he is actively involved in the education of medical students and medical professionals and frequently supervises several research projects and PhD candidates. He currently serves as vice chair of the Dutch DSATC educational committee. Email address: [email protected].\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFrengley RW, Weller JM, Torrie J, Dzendrowskyj P, Yee B, Paul AM, et al. The effect of a simulation-based training intervention on the performance of established critical care unit teams. 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Eur J Trauma Emerg Surg. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00068-024-02548-1\u003c/span\u003e\u003cspan address=\"10.1007/s00068-024-02548-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjes","sideBox":"Learn more about [World Journal of Emergency Surgery](http://wjes.biomedcentral.com)","snPcode":"13017","submissionUrl":"https://submission.nature.com/new-submission/13017/3","title":"World Journal of Emergency Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Multidisciplinary trauma course, self-efficacy, blended learning, traditional learning, technical skills, non-technical skills","lastPublishedDoi":"10.21203/rs.3.rs-9214728/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9214728/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDuring the multidisciplinary Definitive Surgical and Anaesthetic Trauma Care (DSATC) course, trauma specialists are trained to apply damage control principles to polytrauma patients. The course transitioned in 2020 from a three-day, traditional format to a two-day format that combines online and traditional learning methods to enhance course quality and learning outcomes. Considering that learning opportunities on the work floor are scarce, continuous course evaluation is crucial to ensure benefits for medical professionals and their patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective non-inferiority study compared self-assessed confidence in technical and non-technical skills between a cohort in the traditional DSATC course and a cohort in the blended-learning DSATC course. Self-assessed confidence ratings were collected through quantitative pre-course and post-course questionnaires. Mean changes in confidence ratings were calculated and compared using independent samples t-tests with a non-inferiority margin of -0.5. Sub-analyses investigated differences between participants of the same profession, between physicians with different levels of experience, and investigated the influence of individual preparation on self-assessed confidence in skills before on-site training.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 180 (21%) participants completed the pre-course and one-day post-course questionnaires completely. Both cohorts showed increased self-assessed confidence in skills following course completion, with the blended-learning DSATC cohort demonstrating non-inferior improvements compared with the traditional cohort in general technical skills (mean difference (MD) 0.07, 97.5%-confidence interval (CI) lower confidence bound\u0026thinsp;\u0026minus;\u0026thinsp;0.14, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and in general non-technical skills (MD 0.09, 97.5%-CI lower confidence bound\u0026thinsp;\u0026minus;\u0026thinsp;0.09, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Self-assessed confidence in non-technical skills declined in the blended-learning cohort following individual preparation (MD -0.21, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.042).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe blended-learning format of the DSATC course is at least as effective as the traditional model in improving self-assessed confidence in technical and non-technical skills. Individual pre-course preparation by participants may increase awareness of learning needs, fostering self-directed learning. The findings underscore the need to move beyond a traditional, one-size-fits-all approach to training and toward competency-based, individualized learning pathways, supported by blended-learning methods. Further research into the effectiveness of such pathways in multidisciplinary trauma education and patient outcomes is needed.\u003c/p\u003e","manuscriptTitle":"A Blended-Learning Two-Day Trauma Course Compared with the Traditional Three-Day Trauma Course: A Retrospective Non-Inferiority Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-30 09:12:07","doi":"10.21203/rs.3.rs-9214728/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-09T13:19:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-07T21:43:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"117635034198486316208656855063214603601","date":"2026-03-30T09:03:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-28T01:40:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"249890199847804902819962111348107690167","date":"2026-03-28T01:11:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-27T09:43:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-25T02:32:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-25T02:32:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Emergency Surgery","date":"2026-03-24T16:53:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjes","sideBox":"Learn more about [World Journal of Emergency Surgery](http://wjes.biomedcentral.com)","snPcode":"13017","submissionUrl":"https://submission.nature.com/new-submission/13017/3","title":"World Journal of Emergency Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7072d226-07be-46bc-8d48-9bafca87c510","owner":[],"postedDate":"March 30th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-17T19:23:35+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-30 09:12:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9214728","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9214728","identity":"rs-9214728","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}